Case 4-2019: An 18-year-old man with abdominal pain and hematochezia

T h e ne w e ngl a nd jou r na l o f m e dicine Pr esentation of C a se Dr. Fabian J. Scheid: An 18-year-old male professional athlete was admitted to this hospital because of fevers, abdominal pain, and hematochezia. The patient had been well until 20 days before this admission, when fevers and pain in the right lower quadrant developed during a trip to the southeastern United States for athletic training. One day later, the patient had mild postpran-dial nausea and loose stools. He presented to a local emergency department for evaluation. In the emergency department of the first hospital, the pulse was 59 beats per minute, the blood pressure 114/65 mm Hg, and the weight 72.1 kg. The results of the rest of the physical examination were not documented. The blood levels of electrolytes, calcium, alkaline phosphatase, total bilirubin, and lipase were normal ; other laboratory test results are shown in Table 1. The results of computed tomography (CT) of the abdomen and pelvis, performed after the administration of oral and intravenous contrast material, were reportedly normal. After 5 hours of observation, the patient was discharged to his hotel without receiving a specific diagnosis. During the next 2 weeks, the abdominal pain diminished and the fevers and loose stools resolved; mild nausea persisted. The patient traveled with his team to the western United States and participated in reduced-intensity athletic training. Four days before this admission, pain in the right lower quadrant recurred and was associated with low-back pain on the right side. In addition, he produced well-formed stools that contained blood. The following day, the abdominal and back pain persisted. Because the patient had not had a bowel movement, his athletic trainer recommended that he take a rectal suppository. After he took the sup-pository, he had a bowel movement that consisted of loose stools admixed with blood and mucus. That evening, a temperature of 39.7°C developed, prompting the From the Department of Medicine, Brigham and Women's Hospital (H.M.S.), the Departments of Medicine (F.