Case 4-2013

"A 50-Year-Old Man with Acute Flank Pain", a CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL by Anna Greka and colleagues.
A 50-year-old man was admitted to this hospital because of left flank pain and fever.
Approximately 6 a.m. on the day of admission, pain in the left flank occurred while he was bicycling. The pain was localized, without radiation, and increased during the next 7 hours from 3 to 8 on a scale of 0 to 10, with 10 indicating the most severe pain.
At a routine annual visit 4 days before admission, the patient reported feeling well. A tetanus–diphtheria–pertussis vaccine booster was administered. During the next 4 nights, he noted mild nausea and temperatures to 38.1°C, without chills, which he attributed to the vaccination.
Fifteen years earlier, a diagnosis of Hodgkin's lymphoma had been made, and the patient had received chemotherapy as well as radiation therapy and splenectomy.
On examination, the patient was alert and oriented and appeared uncomfortable. A holosystolic soft murmur, grade 2/6, was heard at the apex, with radiation to the axilla, and a crescendo–decrescendo systolic murmur, grade 2/6, also was heard at the base, especially at the left upper sternal border.
CT of the abdomen and pelvis showed a focal wedge-shaped defect in the left inferolateral kidney.
Fever in an asplenic patient carries a specific differential diagnosis that is central to the understanding of this case. Another important feature was the presence of heart murmurs.