A 36-year-old woman was admitted to the hospital because of fever and abdominal pain of one-week duration. Fever was up to 39 degrees Celsius and was accompanied by chills. The pain was located in the right lower quadrant of the abdomen. She did not complain for other symptoms.
The patient was married to a shipman and had five healthy children, three of whom were delivered by cesarean section. Her past medical history included recurrent cellulitis-like episodes after a glass related injury, which was located in her left forearm.
Physical examination showed elevated temperature (38,8 degrees Celsius). The pulse rate was 90/min and the blood pressure 120/70 mmHg. There were three areas (2X2 cm), on her left forearm, with atrophy and hyperpigmentation. Inflammation was obvious on the right lower quadrant of the abdominal wall, where swelling, tenderness, heat and redness were found in an area of 25X15 cm. Liver, spleen and peripheral lymph nodes were not palpable. The rest of the physical examination did not show any abnormal findings.
Laboratory work-up revealed: Ht=36%, Hb=12,9 g/dl, WBC=9980/mm3 (neutrophils=75%, lymphocytes=18%, monocytes=6%, eosinophils=1%), platelets=210,000/mm3, erythrocyte sedimentation rate (ESR) = 57mm/first hour. The level of C-reactive protein was normal. The biochemical (glucose, renal and liver function, electrolytes, lipid profile, uric acid, amylase, lactate dehydrogenase, creatine kinase, and proteins) and immunological tests of the serum (rheumatoid factor test, antinuclear antibodies, antimitochondrial antibodies, anti-smooth muscle antibodies, cytoplasmic and perinuclear anti-neutrophil cytoplasmic antibodies, serum angioconverting enzyme and complement), were normal, except of the slight elevation of IgM, slight reduction of IgA and low value of C4. Urinalysis did not show abnormal findings. Chest X-rays, ECG, U/S of the abdomen and C/T of the thorax, upper and lower abdomen were normal.