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JAMA Surgery Clinical Challenge

An Unexpected Find

Image of Figure 1
Image of Figure 2

Figure 1.
Coronal computed tomographic scan of the abdomen/pelvis.

Figure 2.
Findings after surgical resection.

A 64-year-old woman presented to the emergency department with a 1-day temperature of 38.9°C (102°F). The patient had some accompanying cough, nausea, and arthralgias but denied having dyspnea, emesis, and chest or abdominal pain. She had a complicated medical history that was significant for non-Hodgkin lymphoma, chronic diarrhea, myelodysplastic syndrome treated with chemotherapy, and Behçet syndrome treated with prednisone acetate (6 mg daily). Her surgical history was significant for a previous right-sided hemicolectomy due to recurrent right-sided diverticulitis. On examination, she was alert and awake with appropriate mental status. Her vital signs were as follows: blood pressure of 150/59 mm Hg, heart rate of 127 beats per minute, respiratory rate of 20 breaths per minute, temperature of 38.5°C (101.3°F) (oral), and an oxygen saturation as measured by pulse oximetry of 99% in room air. The physical examination was unremarkable. Significant laboratory data included a white blood cell count of 2700/μL (reference range, 4800-10 800/μL; to convert to ×109 per liter, multiply by 0.001), a lactic acid level of 19.8 mg/dL (to convert to millimoles per liter, multiply by 0.111), and a platelet count of 72×103/μL (to convert to ×109 per liter, multiply by 1.0). Urinalysis showed trace blood, positive nitrite, +1 leukocyte esterase, and a white blood cell count of 2000/μL to 5000/μL. A urine culture came back positive for Klebsiella pneumoniae, and a blood culture came back positive for Enterobacter sakazakii (now known as Cronobacter sakazakii). There was concern about the source of the bacteremia, so an infectious disease consult was ordered, and a computed tomographic scan of the abdomen/pelvis with contrast was performed. Figure 1 shows a coronal, reformatted image of the scan. The patient was scheduled for surgery, and the findings are shown in Figure 2.

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