Case 262 -- Diarrhea and Urinary Frequency

Contributed by Irina Pushkar, MD and A. William Pasculle, ScD
Published on line in March 2001


The patient is a 42-year-old African male who presented to the Emergency Department complaining of intermittent fevers, up to 104 degrees of Fahrenheit, occasional chills, night sweats and rigors, periods of diarrhea, dysuria, and generalized malaise. He had a low abdominal discomfort but denied any nausea or vomiting. He had a decreased appetite, but denied any weight loss. He denied any palpitations, chest pain, shortness of breath, or chronic cough. He also denied flank pains.

The patient's illness started two months prior to his presentation to the Emergency Department and was accompanied with a period of watery stools. He was initially seen in an outpatient clinic and treated empirically with a two-week course of ciprofloxacin for presumed bacterial gastroenteritis. One month later, he returned to an outpatient clinic and was noted to have fever, some loose stools, dysuria, and hematuria with large amounts of blood, a proteinuria of 3+ and moderate leukocyte esterase in his urine. A urine culture grew 73,000 CFU of a viridans Streptococcus and he was treated again with a two-week course of ciprofloxacin. Stool cultures, ova and parasites, and Cryptosporidium were negative.

The patient had a past medical history of malaria (species unknown) two years ago, treated with chloroquine. He denies any tobacco use and his alcohol use is occasional. He denied history of intravenous drug use or blood transfusions.

Physical examination demonstrated a cachectic gentleman in no acute distress. The conjunctivae were pale and mucous membranes were dry. There was no jaundice. The neck was supple and free of adenopathy or bruits. The lungs were clear bilaterally. The heart rate was regular and there were no murmurs. The abdomen was soft, non-tender, non-distended, without hepatosplenomegaly, and bowel sounds were present. The patient was noted to have Hemoccult-positive stool, and when a Foley was inserted, it was noted that the Foley could be palpated freely in the rectum, documenting presence of a vesicorectal fistula. The remainder of the review of systems and physical examination was unremarkable.




CHEST X-RAY: Demonstrated abnormal findings of somewhat nodular opacity involving both apices and upper lobes bilaterally, consistent with acute inflammatory process (Figure 1)



PROCTOSCOPY  delineated the large fistulous communication, between urethra and the rectum.

LAPAROTOMY  demonstrated ascites, multiple deposits on the small bowel, suggestive of peritoneal tuberculosis, massively enlarged mesenteric lymph nodes, which were caseating. Small bowel deposits were biopsied and sent for pathological evaluation and culture. A decompression loop ileostomy was constructed.



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