A 47-year-old man went to the doctor with abdominal pain and fever, but he did not get better after symptomatic treatment. The clinical pharmacist suggested to do so...

*It is only for medical professionals to read and think that it is just a simple gastroenteritis, but the result is surprising! Clinically, it is believed that many doctors find that patients have symptoms such as fever and abdominal pain.
When blood routines indicate increased white blood cells, C-reactive protein, and erythrocyte sedimentation rate, first consider bacterial gastroenteritis, and then patients take antibacterial drugs
.

But is leukocytosis necessarily a bacterial infection? What does the increase in eosinophils in the white blood cells imply? Let us look at a special case
.

 Medical history review: No obvious cause for abdominal pain, abdominal distension, fever.
.
.
The patient, a 47-year-old male, was admitted to the hospital on October 14 due to "abdominal pain and abdominal distension for half a year, aggravated with fever for 10+ days"
.

 History of present illness: Half a year ago, there was no obvious cause for repeated upper abdominal pain with abdominal distension, intermittent episodes, no obvious radiating pain and involved pain, obvious abdominal distension and discomfort after eating, sometimes acid reflux, gas, retching, discomfort, no chills, fever , No chest pain, hemoptysis, no palpitation, shortness of breath, dyspnea, no hematemesis and melena, no diarrhea, mucus pus and blood in the stool and other discomforts
.

It has not been paid attention to and treated.
10+ days ago, the above symptoms were significantly worsened, the abdominal distension was transferred to the lower abdomen, and the right lower abdomen was obvious, and he felt feverish, which was low fever
.

There is still no obvious cough, sputum expectoration, nausea, vomiting, diarrhea, mucus pus and blood in the stool, no skin rash and joint swelling
.

At that time, oral medications at the local health center were ineffective, so I went to our hospital for further clarification of diagnosis and treatment
.

 Past history: Perianal pain, bleeding after defecation for 5+ years, pinky-sized masses prolapsed after defecation for 2+ years, perianal itching with frequent defecation for 10+ years, up to 15 times/day, a little each time Yellow, dry and hard stool, and it improves slightly after applying hot water on its own
.

1 month+before, she went to the hospital for right back pain and radiating pain in the right hip and lower limbs.
He did not get better after conservative treatment.
The specific treatment is unknown
.

No coronary heart disease, high blood pressure, kidney disease, diabetes and so on
.

 Admission examination: T 37.
4℃, P 89 beats/min, R 19 beats/min, BP 108/76mmHg, weight 52kg
.

Normal development, moderate nutrition, well-proportioned body, stepping into the ward, acute appearance, automatic posture, clear mind, slight tenderness in the upper abdomen and right lower abdomen, and the rest of the cardiothoracic, abdomen, and nerves are normal
.

 ▌ Laboratory blood test: white blood cell count (WBC) 10.
32×109/L, neutrophils accounted for (N%) 66.
9%, eosinophil count (EOS) 1.
92×109/L, eosinophils percentage (EOS%) 18.
6%
.

Erythrocyte Sedimentation Rate (ESR): 73mm/h
.

C-reactive protein (CRP): 136.
19mg/L
.

Blood biochemistry: Alanine aminotransferase 52U/L
.

There were no obvious abnormalities in blood coagulation function, amylase, urine and stool, A/B/C/syphilis/HIV
.

 ▌ Auxiliary examination of ECG: sinus rhythm, HR 69bpm, unbiased electric axis
.

Plain radiographs of standing abdomen: 1.
Plain radiographs of standing abdomen showed no abnormal X-line signs; 2.
Lumbar degeneration
.

Chest and abdomen CT: 1.
Thickening of the peritoneum, consider peritonitis; 2.
Structural disorder of the right appendix area, which cannot be excluded from appendicitis; 3.
Slightly thickened rectal wall with circular high-density shadows; 4.
Consider the upper and lower lobes of the right lung and the upper left lobe Infection
.

 CT of the lungs showed multiple nodules; CT of the abdomen showed obvious thickening of the mesenteric appendix + peripheral color Doppler ultrasound: no obvious mass and effusion in the appendix area▌ Initial diagnosis of admission 1.
Chronic gastritis; 2.
Cause of fever: appendicitis? Others; 3.
Internal hemorrhoids; 4.
Lumbar disc herniation
.

▌ Amoxicillin/ Potassium Clavulanate and Vitamin B6 Injection for the initial treatment plan
.

After admission to the hospital, the fever continued.
October 15: The patient still has a fever with a Tmax of 38.
7°C.
The fever is irregular throughout the day.
After taking the ibuprofen suspension, the body temperature can drop, and he still feels abdominal distension and abdominal pain in the upper and right lower abdomen.
, Occasionally acid reflux, belching discomfort
.

On physical examination, the abdomen was slightly swollen, and the upper abdomen and right lower abdomen were slightly tender
.

October 16th: The patient still has a fever, Tamx is 38.
4℃, and the antibacterial drug is changed to piperacillin/tazobactam
.

Gastrointestinal surgery consultation: appendicitis is not excluded
.

October 17: still fever, Tmax 38.
5℃, abdominal distension and abdominal pain have not been relieved
.

October 19: Fever for 5 consecutive days, the highest body temperature in the evening and early morning, Tmax 39.
2℃, can be relieved after taking ibuprofen, there is no change in physical examination, and the spirit, diet and sleep are normal
.

[Laboratory examination] Blood routine: WBC 10.
93×109/L, N% 44.
8%, EOS 4.
58×109/L, EOS% 41.
9%; blood biochemistry: ALT 64U/L, AST 47U/L, ALb 29.
12g/L ; CRP 100.
35mg/L; Mycobacterium tuberculosis antibody is negative
.

▌ Auxiliary examination of chest and abdomen CT: 1.
Double pneumonia infection is more than before; 2.
No obvious change in peritoneal thickening than before; 3.
Structural disorder of the right appendix area; 4.
Rectal wall is slightly thickened and ring-shaped high-density shadow; 5.
CT scan of liver, spleen, pancreas and kidneys showed no obvious space-occupying lesions
.

In order to confirm the diagnosis, consult the opinion of the clinical pharmacist.
Considering that the patient still has fever after admission for treatment, in order to clarify the cause of the fever, the clinical pharmacist is invited for consultation
.

The consultation opinion is as follows: the patient's occupation is a forest ranger, combined with the clinical manifestations of fever, abdominal pain, abdominal distension, perianal itching, and elevated eosinophils, erythrocyte sedimentation rate, C-reactive protein and ALT, lung CT suggests the presence of multiple nodules.
The use of antibacterial drugs is not effective.
Considering the possibility of parasitic infections such as parasites and Mycobacterium tuberculosis, it is recommended to perform a full set of parasite inspections, and actively arrange colonoscopy and bronchoscopy.
During the period, pathological examinations of intestinal wall tissue and bronchopulmonary tissue are possible.
In the presence of eosinophil infiltration and other conditions, after the parasite infection is clear, pizaviridone or albendazole can be given to the specific parasite
.

At the same time, the specific cellular immune response of Mycobacterium tuberculosis was checked to rule out the infection of Mycobacterium tuberculosis
.

 The use of antibacterial drugs is ineffective, and it is recommended to stop piperacillin/tazobactam
.

Next, in accordance with the opinions of the clinical pharmacist, is it sufficient to complete the examination and perform treatment? What do you want to know? Please continue to pay attention to the digestive liver disease channel in the medical community, the next part (tomorrow) will bring you more exciting content, so stay tuned! Reference materials: [1] Brito-BzbapulleF.
The eosinophilias, including the idiopathic hypereosinophilic syndrome [J].
Br J Haematol.
2003, 121(2): 203-223 [2] Zhang Sali, Xu Chuanhui, Mu Rong.
2012 edition Consensus on the standard of eosinophilia and related syndromes [J].
Chinese Journal of Rheumatology, 2013, 17(1): 58-59.
[3] Reimert CM, Fitzsimmons CM, Joseph S, et al.
Eosinophil activity in Schistosoma mansoni infections in vivo and in vitro in relation to plasma cytokine profile pre -and posttreatment with praziquantel.
[J].
Clinical and Vaccine Immunology, 2006, 13(5):584-593.
[4] Ren Yi, Gu Junchao.
Central nervous system parasite infection[J].
Chinese Tropical Medicine, 2011, 11 (4): 503-506.
[5] Pharmacology (Third Edition), Qian Zhiyu, China Medical Science and Technology Press [6] HsuSC, LanRR, TsengCC, et al.
Extrapulmonary tuberculous infection manifested as peritoneal fluid eosinophilia in continuous ambulatory peritoneal dialysis patient[j].
Nephrol Dial Transplant, 2000, 15(2): 284-285.
[7] Jia Erna, Gao Chenmao, Liu Yang, etc.
Chinese Physician Journal, 2016, 18 (supplement): 202-203.
DOI:10.
3760/cma.
j.
issn.
1008-1372.
2016.
z1.
1103 [8] Twomey JJ, LeavellBS.
Leukemoid reactions to tuberculosis[J].
Arch Intern Med, 1965, 116: 21-28.