A 21-year-old male, professional soldier, with no medical or surgical history of interest who came to the emergency department of our Hospital due to unspecific abdominal discomfort due to medical-military evolution.
The patient was carrying out a survival maneuver in the situation.
For 18 hours, initially diffuse pain had focused on the right iliac fossa (RLF) and increased its intensity.
He had progressive anorexia, with no gastrointestinal transit alterations.
Examination showed a blushing and depressible abdomen, very painful to deep pressure in the RIF with defense and a marked peritoneal reaction.
The axillary temperature was 38.5°, with no other remarkable findings.
Pathologic studies of thorax and abdomen did not reflect.
Analytical: leukocytes, 14,000 x 109 /l (78% neutrophils); hemoglobin, 14.46 mg /dl; platelets, 268,000 x 109 /l.
Rest, including clinical chemistry, liver function and coagulation study: normal.
Abdominal ultrasound showed intense bloating of the small intestine that prevented visualization of the cecum and vermiform appendix.
No significant amount of free fluid was observed between the wings or the bottom of the bag of Douglas.
An urgent exploratory laparotomy was indicated under the suspicion of acute colitis.
The patient was premedicated with amoxicillin and clavulanic acid 1,000/200 mg intravenous, respectively, single dose.
Through the McBurney incision, a large cecal tumor of hard consistency and multiple lymphadenopathies are observed.
After closing the incision, the cavity is again approached through a supra-infraumbilical midline laparotomy.
The mass, with the appearance of a perityphilitis, encompassed cecum, appendix and terminal ileum.
Mesocolic lymph nodes were visualized and fixed.
In the retroperitoneum, in contact with the right parietocolic gout, a creamy abscess, blanc and inodorus containing about 100 or 150 c were found.
Samples were taken from patients infected with tioglycolate agar, blood and chocolate agar and subsequently analyzed using a BEC 9240® system.
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Having doubts about the cancerous origin of the tumor, a regulated right hemicolectomy was performed with oncological intention, resecting the affected parietal peritoneum and all palpable adenopathy in the surgical specimen.
The reconstruction of the digestive tract was performed by manual laterolateral ileocolic anastomosis.
In the immediate postoperative period, the patient presented a fever peak in the evening, with a temperature above 38.5o.
Blood cultures were extracted and microbiologically sterile.
On the fifth postoperative day, we report the growth in the culture of the biological fluid sample of a Gram-positive bacillus Lis spp.
Through laboratory techniques and serotyping, by means of the agglutination method, the pathogen was definitely identified as a common serotype 4b lysate specie isolated.
In the antibiogram the germ was ampicillin, sensitive cefoxime, vancomycin, rifampin, and trimethoprim, cotrimoxazole, ciprofloxacin and amoxicillin plus clavulanic acid.
Given the good clinical evolution of the patient, with the disappearance of fever, the antibiotic regimen was maintained, consisting of 3,000/600 mg amoxicillin and clavulanic acid, respectively, three intravenous doses daily.
On the sixth day oral feeding tolerance begins and progresses, with positive results.
On the 14th postoperative day, as a measure prior to discharge, intravenous antibiotic therapy is suspended and replaced by an oral regimen of 1,500/375 mg amoxicillin and clavulanic acid every 24 weeks, maintained for more hours.
The patient was discharged three days later.
One year after surgery the patient was asymptomatic and developed normal activity.
Complete laboratory tests and CT scans of the abdomen were requested, but no pathological findings or suggestive of inflammatory bowel disease were reported.
