Presentation
Fever, nausea, left upper quadrant pain radiating to the back.
Patient Data
Enlarged spleen with two small subcapsular wedge-shaped hypodense lesions and several small, ill-defined isodense, hypoenhancing lesions. The former most probably represent infarcts.
Mild hepatogastric ligament lymphadenopathy, substantial hepatic hilar adenopathy, enlarged aortocaval lymph node.
Minuscule amount of pleural fluid bilaterally.
The spleen has returned to normal dimensions and all lesions have vanished.
The previously described adenopathy has regressed considerably in all stations.
Even the pleural fluid has been absorbed.
Case Discussion
A healthy woman arrived at the ER with fever, nausea, and left upper quadrant pain radiating to the back. On examination, left upper quadrant and left costovertebral tenderness were elicited. Chest radiograph and urinalysis were normal. Lab results were remarkable only for lactate dehydrogenase (LDH) 784 IU/L (normal 240-480 IU/L).
As the initial suspicion was of left urolithiasis or renal abscess, CT urography was done, which revealed an enlarged spleen with subcapsular wedge-shaped infarcts and small hypodense lesions (probably granulomas), as well as lymphadenopathy in several abdominal stations. The infarcts may very well have been the cause of the left upper quadrant pain and the reason for the raised LDH. CT chest (not included) was normal except for tiny pleural effusions, seen on the CT abdomen.
All cultures came back negative, as did essays for autoantibodies, and both transthoracic and transesophageal echocardiography were normal. Serology for Bartonella henselae was positive for IgG and IgM antibodies. The patient reported having two cats at home that lick her. She received doxycycline per os and recovered promptly. At 3 weeks follow-up, she was well, with normal lab tests. Her spleen appeared normal at CT.
Splenic infarcts have never been reported in bartonellosis without accompanying endocarditis.
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