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July 22, 2020

Image challenge: Just diverticulitis? A very rare complication of a very common disease!

What caused confusion, meningism and spontaneous movement of all extremities in a 68-year-old patient with a history of chronic Leriche syndrome?
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Gastroenterology clinical image challenge: A 68-year-old woman presented to the emergency room of our hospital with reduced consciousness, fever (38.5°C/101.3°F) and abdominal pain. The initial clinical and neurologic examination showed the following findings: the patient was hemodynamically stable, in a confused state, discrete signs of meningism (positive Kernig’s sign), spontaneous movement of all extremities without localizing signs, mild increased tone of all extremities and spontaneous opening of eyes, which were equal and reactive to light. The abdomen was soft with tenderness in both lower quadrants.

Laboratory testing revealed a leukocytosis (16.3/nL; reference, 4.0–9.0/nL), moderate increased C-reactive protein (46.6 mg/L; reference, <5 mg/L), mild increased neutrophils ratio (83.3%; reference, 50%–75%), mild increased glucose (176 mg/dL; reference,70–115 mg/dL), almost normal hemoglobulin value (11.4 g/dL) and normal electrolytes. SpO2 was 89.8% (reference, 95%–98.5%). The patient had been taking over the last three months tilidine (a synthetic opioid analgesic), ibuprofen and prednisolone because of a spinal disc herniation.

The patient’s medical history revealed a chronic Leriche syndrome. A head, chest, abdomen and pelvic contrast-enhanced computed tomography scan revealed following abnormal findings (figure).

What is the diagnosis?

To find out the diagnosis, read the full case in Gastroenterology.

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