Case Presentation:
A 71 year old man with history of multiple sclerosis and gout (on Methylprednisolone) presented with weakness. Patient was diagnosed with a UTI on a recent hospital admission for fever and weakness. He improved on IV antibiotics and was discharged home to complete a 7-day PO course, but returned 9 days later after his symptoms recurred along with 2-3 episodes of emesis. On exam, patient had a temperature of 100.3 and a benign abdomen. Labs were significant for a WBC count of 16.46. Patient was started on IV Ceftriaxone for suspected undertreated UTI, but his weakness progressed despite treatment. Blood and urine cultures and urinalysis were negative. On hospital day (HD) 6, patient became unresponsive with a fever of 103.4 and rigors. Labs showed a lactate of 3.0. His mental status improved to baseline and his fever resolved with IV Vancomycin and Zosyn, and 1 liter of fluids. On HD 7, patient was well appearing. He denied abdominal pain and reported a normal bowel movement the night prior. Repeat lactate was 0.9. A CT Abdomen & Pelvis was ordered to evaluate for sources of infection and a perforated loop of jejenum was identified. Patient underwent exploratory surgery with bowel anastomosis and wash-out, and had an uneventful post-op recovery. Surgical pathology report confirmed diagnosis of diverticulitis.
Discussion:
In our patient without any history of gastrointestinal disease or recent trauma, determining the underlying etiology of his jejunal perforation required some detective work. Review of patient‘s imaging with a radiologist revealed that our patient likely had jejunal diverticuli that ruptured and walled off. Jejunal diverticulosis is a rare process that most commonly affects males between 60-70 years old and poses a vast diagnostic challenge because it usually presents with non-specific symptoms. In up to 15% of cases, it progresses to complications such as diverticulitis and perforation. Small bowel perforation has an up to 40% mortality rate because it is so difficult to diagnose. Given the complexity of its presentation, biomarkers that can aid in diagnosis are especially useful. A CRP > 200mg/L can strongly correlate to a diagnosis of acute diverticulitis complicated by perforation. Also, fecal calprotectin, which is commonly used in patients with IBD, is closely associated with subclinical intestinal inflammation, serving as a useful marker of diverticular disease. Use of chronic steroids, as in this case, can further complicate diagnosis by masking the typical signs of bowel perforation, such as chest or abdominal pain, which are mediated by inflammatory immune response.
Conclusions:
A high degree of clinical suspicion is needed to diagnose jejunal perforations, especially in cases confounded by steroid use. Vigilant consideration of risk factors and past medical history is required when working up sepsis of unknown etiology. The clinician should utilize imaging and targeted laboratory tests when standard work-up provides inconclusive answers.