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

Vimon Seriburi, MD; Ann F. Fisher, MD


November 14, 2022

Physical Examination and Workup

The physical examination demonstrates a toxic-appearing elderly woman who is actively experiencing rigors, with a temperature of 103°F (39.4°C) and a heart rate of 104 beats/min. Her blood pressure is stable at 120/86 mm Hg. She has pulse oxygenation of 97% while breathing room air. Distant and regular heart sounds are heard, but no murmur is noted.

The lung examination is unremarkable except for an occasional wheeze. The abdomen is soft and nontender, with positive normoactive bowel sounds and no apparent organomegaly. She has a well-healed midline abdominal incision from her prior surgery. The rectal examination reveals several nontender external hemorrhoids, with no evidence of recent bleeding. Guaiac testing of the stool is strongly positive.

Her laboratory findings are notable for a white blood cell count of 23.7 × 103 cells/µL, with 98% neutrophils and 12% bands; a hemoglobin level of 8.2 g/dL; and a hematocrit of 24.6%. At the time of discharge approximately 2 weeks ago, her baseline hemoglobin level was 10 g/dL and baseline hematocrit was 29.4%. The creatinine level is 1.8 mg/dL (reference range, 0.59-1.04 mg/dL). Liver aminotransferase values are within normal limits. Urinalysis is unremarkable.

Chest radiography reveals clear lung fields. Given the patient's relatively recent history of colonic instrumentation, repeat abdominal CT is performed, this time with both oral and intravenous contrast (Figure 1).

Figure 1.

To help in making the diagnosis, additional information from the hospitalization is presented here. Two sets of blood cultures were obtained in the ED, at the time of initial presentation, several hours apart, and the two cultures were noted to be positive for different organisms: alpha-hemolytic Streptococcus and Candida glabrata. In addition, repeat echocardiography was again negative for vegetations.


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