1 Ultrasound images of groin pain in the athlete: a pictorial essay PM&R, February 7, 2014
2 Ultrasound revealing secrets of deadly abdominal aortic aneurysms Purdue University Research news, October 16, 2014
3 Effect of abdominal resistance exercise on abdominal subcutaneous fat of obese women: a randomized controlled trial using ultrasound imaging assessments Journal of Manipulative and Physiological Therapeutics, April 1, 2015
4 Ultrasound imaging in the management of bleeding and pain in early pregnancy Best Practice & Research Clinical Obstetrics & Gynaecology, May 8, 2014
5 Ultrasound images of groin pain in the athlete: a pictorial essay PM&R, August 15, 2014
Question: Recall that a 20-year-old male presented for evaluation of abdominal pain x 6 weeks and weight loss. The pain had an insidious onset and was intermittent, but daily; he characterized it as crampy, generally confined to the RLQ. On most days, the pain was 8 out of 10. He has had non-bloody diarrhea, as well as bouts of constipation. The patient, who was a full-time university student and worked part-time in a convenience store, estimated he has lost 15 pounds.
On examination, he was 74 inches tall and weighed 155 pounds. Temperature: 99.2oF; BP: 100/60 mmHg; HR: 62; RR: 18. He appeared uncomfortable, but in no acute distress. The abdomen was soft, mildly distended, and the RLQ was full. There was diffuse tenderness to deep palpation, but no rebound or guarding. The rectal examination did not reveal masses and was guaiac-negative.
The flat and upright radiographs of the abdomen showed an abundance of stool in the colon, but no masses, no free air, and no ascites. A CBC, chemistry panel, lipase and amylase, and urinalysis were normal. An upper GI series with small bowel follow-through confirmed stool in the colon and revealed an irregular luminal narrowing in the cecum. An esophagogastroduodenoscopy revealed normal esophageal and gastric mucosa with mild inflammation in the second portion of the duodenum. A colonoscope could not be advanced beyond the sigmoid colon. Temperature taken after workup was 101.6oF.
The differential diagnosis included appendicitis, peritonitis and Crohn’s disease; it would not include pyelonephritis, as it is unlikely with a normal urinalysis.
Over the ensuing 4 days, he had fevers to 102.4oF and night sweats. An abdominal CT with contrast revealed peritoneal implants with mesenteric lymphadenopathy, but no masses. A CXR revealed a mediastinal mass (5 x 2 x 5 cm) with patchy air-space opacities (up to 10 mm in diameter) in both lungs, which was confirmed with a CT of the chest.
The differential diagnosis at this point included peritoneal carcinomatosis, tuberculosis or lymphoma, but not incarcerated diaphragmatic hernia.
The PPD was 20 mm in diameter 48 h after planting. The patient believes he had a negative PPD when he enrolled in college 2 years ago, and denies known contact with TB patients, although he acknowledges there is a large homeless population that frequents his place of employment. The HIV test was negative.
Biopsy and sputum cultures revealed resistance to rifampin. Which of the following antibiotics would you choose as a replacement for rifampin?
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