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JAMA Surgery Clinical Challenge
July 2018

Elderly Man With Left Iliac Fossa and Inguinal Pain

Author Affiliations
  • 1Second Department of General Surgery, “Sismanoglio” General Hospital of Attika, Athens, Greece
JAMA Surg. 2018;153(7):683-684. doi:10.1001/jamasurg.2018.0600

An elderly man presented to the emergency department describing unremitting pain in the left iliac fossa with accompanying tenderness, fever, and tachypnea. He also noted swelling in his left inguinofemoral region, left scrotum, and left femur. His symptoms started 2 days before admission and the pain was progressively worsening. The patient did not report vomiting, constipation, or change in his bowel habits. His history was significant for hypertension and hypothyroidism; his last colonoscopy, 4 years ago, revealed diverticulosis of the sigmoid colon. The patient’s condition was stable (blood pressure, 130/85 mm Hg, heart rate, 88 beats/min), but he was febrile (temperature, 38.6°C). Physical examination showed cellulitis in his left inguinal canal, scrotum, and femur along with sensitivity in the left lower quadrant of the abdomen. Initial laboratory test findings exhibited white blood cell count of 16 700/μL (to convert to 109/L, multiply by 0.001) and C-reactive protein of 340 mg/L (to convert to nanomoles per liter, multiply by 9.524). Chest roentgenogram was negative for free air under the diaphragm but was remarkable for some air-fluid levels. The patient underwent a computed tomography (CT) scan of the abdomen and pelvis with oral contrast (diatrizoate meglumine and diatrizoate sodium solution) (Figure, A and B).

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