Emergency Med Case Challenge: Hemorrhoids, Urinary and Blood Infections in a Woman With Rigors

Vimon Seriburi, MD; Ann F. Fisher, MD


November 14, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 73-year-old woman presents to the emergency department (ED) with fever, chills, and night sweats. Approximately 3 weeks ago, she was hospitalized for hematochezia and fever; urine cultures from that hospitalization had grown Escherichia coli, and the blood cultures were positive for Serratia marcescens.

The workup during that initial hospitalization also included transthoracic echocardiography that revealed no valvular abnormalities; noncontrast abdominal CT, which failed to demonstrate any intra-abdominal pathology; and colonoscopy, which was positive only for polyps. At the time of discharge, the hematochezia was suspected to have been caused by several large external hemorrhoids that were noted on the physical examination as a diagnosis of exclusion. Repeat blood cultures were performed, and they were negative for growth. The patient was discharged to home to complete a 2-week course of levofloxacin after sensitivities from the initial set of cultures were confirmed.

At today's presentation to the ED (3 days after finishing her course of levofloxacin), the patient states that over the past 24 hours, the fever and chills have returned. She denies any rectal bleeding, dizziness, headache, chest pain, hematemesis, abdominal pain, melena, dysuria, or recent weight change. Her medical history includes hypertension; abdominal aortic aneurysm with bilateral iliac artery occlusive disease, treated by aortobifemoral bypass grafting 6 years ago; coronary artery disease, treated with coronary artery bypass grafting 1 year ago; diabetes; chronic renal insufficiency; and diverticulosis. She has an 80–pack-year history of smoking, and she currently continues to smoke. The review of systems is notable only for a chronic cough.


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