Right Upper Quadrant Pain and Fever in a Patient with Pulmonary Sarcoidosis

CASE REPORT

A 47-year-old female, originally from French Guyana, with stage II pulmonary sarcoidosis and multiple hospital admissions for fever, cough, and hemoptysis, presented to the emergency department with complaints of fever to 102°F, nonproductive cough, right upper quadrant pain, emesis, and diarrhea for 10 days.

The patient's past medical history was significant for sarcoidosis diagnosed 7 years previously by biopsy via fiber-optic bronchoscopy and Kveim test, steroid-induced diabetes mellitus for 7 years secondary to treatment of her sarcoidosis, and recently diagnosed hypertension. In the emergency department she was resting comfortably with mild tachypnea, fever, and right upper quadrant pain exacerbated by palpation. Given her history of diabetes and long-term maintenance on steroids, acute cholecystitis was ruled out with a normal hepatobiliary scan. Surgical consultation recommended a computed tomography (CT) scan to exclude the possibility of an abscess as the source of her pain and fever.

On admission her temperature was 102.5°F, pulse rate was 100 beats/min and regular, respirations were 28 breaths/min, and blood pressure measured 156/90 mmHg. Physical exam revealed crackles and wheezes in both bases, right greater than left; normal active bowel sounds; minimal guarding with right upper quadrant palpation; and no hepatosplenomegaly or icteris. Laboratory tests demonstrated a white blood cell count of 7500 (nl = 4800-10,800), hematocrit of 37.3% (nl = 34-48), platelets of 342,000 (nl = 150,000- 450,000), total bilirubin of 0.4 mg/dL (nl = 0.1-1.2), total protein of 7.7 g/dL (nl = 6.0-8.3), alkaline phosphatase 123 U/L (nl = 30-110), AST 20 U/L (nl = 1-50), ALT 19 U/L (nl = 1-53), LDH 206 U/L (nl = 100-220), prothrombin time of 12.2 sec (nl = 11.0- 13.2), activated partial throboplastin time of 25.7 sec (nl = 25.0-33.0), and a serum glucose level of 285 mg/dL (nl = 60-120).

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