A 64-year-old woman presented to the emergency department with a 1-day temperature of 38.9°C (102°F). The patient had some accompanying cough, nausea, and arthralgias but denied having dyspnea, emesis, and chest or abdominal pain. She had a complicated medical history that was significant for non-Hodgkin lymphoma, chronic diarrhea, myelodysplastic syndrome treated with chemotherapy, and Behçet syndrome treated with prednisone acetate (6 mg daily). Her surgical history was significant for a previous right-sided hemicolectomy due to recurrent right-sided diverticulitis. On examination, she was alert and awake with appropriate mental status. Her vital signs were as follows: blood pressure of 150/59 mm Hg, heart rate of 127 beats per minute, respiratory rate of 20 breaths per minute, temperature of 38.5°C (101.3°F) (oral), and an oxygen saturation as measured by pulse oximetry of 99% in room air. The physical examination was unremarkable. Significant laboratory data included a white blood cell count of 2700/μL (reference range, 4800-10 800/μL; to convert to ×109 per liter, multiply by 0.001), a lactic acid level of 19.8 mg/dL (to convert to millimoles per liter, multiply by 0.111), and a platelet count of 72×103/μL (to convert to ×109 per liter, multiply by 1.0). Urinalysis showed trace blood, positive nitrite, +1 leukocyte esterase, and a white blood cell count of 2000/μL to 5000/μL. A urine culture came back positive for Klebsiella pneumonia, and a blood culture came back positive for Enterobacter sakazakii (now know as Cronobacter sakazakii). There was concern about the source of the bacteremia, so an infectious disease consult was ordered, and a computed tomographic scan of the abdomen/pelvis with contrast was performed. Figure 1 shows a coronal, reformatted image of the scan. The patient was scheduled for surgery, and the findings are shown in Figure 2.
Mueller K, Eckford J, Watson RW. An Unexpected Find. JAMA Surg. 2013;148(8):791-792. doi:10.1001/jamasurg.2013.308a