PHYSICAL EXAMINATION

VS: T 37.0°C, P 110/min, R 16/min, BP 136/80 mmHg

PE: An ill-appearing male in mild distress due to abdominal pain; enlargement of the liver and spleen, with mild tenderness, was noted.

LABORATORY STUDIES

Blood

Hematocrit: 32%

WBC: 9400/μL

Differential: 54% PMNs, 20% lymphs, 18% eosinophils

Serum chemistries: AST 78 U/L, ALT 92 U/L, bilirubin 3.2 μmol/L, albumin 3.1 g/dL

Imaging

Abdominal ultrasound showed enlarged liver and spleen with evidence of portal hypertension.

Table 52-1 lists the likely causes of the man’s illness (differential diagnosis). Diarrheal stool specimens may be positive for blood. Routine enteric investigation may be a good start to rule out enteric bacterial causes of diarrhea; however, further investigation for specific microbiologic diagnosis may include

• Blood culture. Can aid in ruling out typhoid fever or other blood-borne agents that cause febrile illness

• Ova and parasite examination of stool

TABLE 52-1 Differential Diagnosis and Rationale for Inclusion (consideration)

Dysentery syndrome

Entamoeba histolytica

Shigella dysenteriae

Infectious gastroenteritis (Salmonella)

Inflammatory bowel disease

Schistosomiasis

Typhoid fever

Viral hepatitis

Rationale: In a person from a superendemic area, infectious gastroenteritis must always be considered. Diarrhea is very common and is not very useful by itself for narrowing the differential diagnosis. Other symptoms, such as hepatosplenomegaly, are helpful because most common causes of diarrhea do not lead to this complication. Schistosomiasis is one of the causes that should be considered; it is very common in endemic areas. Typhoid fever is always a consideration in patients with fever and abdominal pain who have recently been in a developing country. Acute viral hepatitis should be considered in patients who have fever and right-upper-quadrant pain, although hematemesis would not be expected.