Abdominal pain and leukocytosis in an immunosuppressed patient

Patient 25-year-old Hispanic woman. Chief Complaint Abdominal pain. History of Present Illness The patient presented to her regular renal clinic appointment complaining of decreased appetite and midepigastric abdominal pain for 2 weeks. She described the pain as episodic in nature, occurring approximately twice daily, and resolving spontaneously. The pain was associated with bloating, but there was no accompanying nausea, vomiting, or diarrhea. The patient had a history of gastroesophageal reflux disease (GERD), but stated that her current pain was different from the pain she experienced during an episode of GERD. Additionally, her pain was not positional and was unchanged by eating. Past Medical History Systemic lupus erythematosis (SLE) diagnosed 7 months prior to presentation, stage IV lupus nephritis, steroid-induced diabetes mellitus, hypertension, and a history of GERD. Past Surgical History Removal of a benign axillary mass. Drug History Prednisone, 60 mg, once daily; hydroxychloroquine, 200 mg, twice daily; lisinopril 20 mg, once daily; glimepiride, 1 mg, once daily; esomeprazole, 40 mg, once daily. Family/Social History The patient had no significant family medical history. She has 1 child and denied any history of alcohol, tobacco, or drug abuse. She had a single blood transfusion 7 months prior to presentation. Physical Examination Vital signs: temperature, 36.9°C; heart rate, 80 beats per minute; respiratory rate, 20 breaths per minute; blood pressure, 94/63 mmHg. The patient was in no acute distress. She had a cushingold appearance with moon facies. The remainder of the physical exam was normal. Of note, the patient's abdomen was soft, non-tender, and non-distended with normoactive bowel sounds. Principal Laboratory Results (Table 1). Results of Additional Diagnostic Procedures and Tests A bone marrow biopsy revealed a hypocellular bone marrow with increased megakaryocytes, mild anemia, and leukemoid reaction with moderate eosinophilia. Blood and urine cultures were negative for microorganisms. Stool cultures grew normal gastrointestinal tract (GI) flora, but the bacteria were spread between the colonies in a lacy, web-like pattern on the solid growth medium, giving the appearance of "tracks" (Image 1A). A selenite broth culture that had been inoculated with the stool sample was centrifugea and a sample of the sediment was analyzed for ova and parasites (O&P) (Image 1B-1D).