The patient is a 17-year-old girl who had been sick for 1 week prior to admission to the hospital. She had constant right upper quadrant pain and pleuritic right-sided chest pain. She was seen as an outpatient and treated with Tylenol® with Codeine #3. The pain did not abate so she was again seen by her primary care provider who told her she had costochondritis, and she should take nonsteroidal anti-inflammatory drugs.
Three days later she observed that her skin was yellow, her urine was orange, and she had developed progressive shortness of breath with a productive cough. She was seen in the ER and admitted to the hospital.
She denied having fevers, chills, cough, or other complaints until the day of admission.
History and Physical Examination
History.
The patient’s past medical history was negative. Current social history:
Student: in suburban high school;
Pets: 4 birds, 2 dogs, cat;
Travel: to Eastern Europe 6 months ago; and
Habits: no bad habits; plays the saxophone.
Physical examination.
On physical examination, the following were noted:
General: ill-appearing and jaundiced; splinting when talking;
Vital signs: temperature 39 degrees C; respirations 24 breaths per minute, pulse 110 beats per minute;
HEENT: yellow sclera;
Lungs: decreased breath sounds on right side, with "e" to "a" changes;
Heart: grade 2/6 murmur; and
Abdomen: slight right upper quadrant tenderness to palpation.
Laboratory value and imaging results.
WBC: 25,000 with 36% bands;
Bilirubin 9.2 mg/dL;
ALP 114 U/L; AST 199 U/L; ALT 103 U/L;
CT abdomen: mild hepatosplenomegaly;
Ultrasound: normal gallbladder;
CXR: lemon-sized thick-walled cavity with air-fluid level and large effusion.
What is the diagnosis?
Tuberculosis
Psittacosis
Leptospirosis
Mixed bacterial lung absess
Legionella
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