RESUMO
Mycobacterium tuberculosis is primarily known to affect the lungs with cavitary lesions and enlarged lymph nodes as the first telltale sign. However, if the bacteria spread to extrapulmonary areas such as the bones, and lack lymphadenopathy, then the differential diagnosis may become misleading. We present a case of a 68-year-old male patient with a chief complaint of chronic left hip pain upon which computer tomography identified lytic lesions on the left hip. Given the mildly elevated prostate-specific antigen with a family history of prostate cancer, a bone biopsy was warranted. The biopsy revealed non-caseating granulomas and the DNA probe identified the Mycobacterium tuberculosis complex. This case signifies that atypical presentations of Mycobacterium tuberculosis may mimic other diagnoses and more invasive techniques such as a biopsy may be necessary.
RESUMO
INTRODUCTION: Hundreds of thousands of cholecystectomies and appendectomies are performed in the United States annually. Due to the prevalence of cholecystitis and appendicitis, a subset of patients will require both operations. The limited literature describing these patients supports a laparoscopic approach over open surgery; consistent with the advantages of laparotomy over open surgery in the treatment of each condition individually. CASE PRESENTATION: We report two cases where a patient presented with cholecystitis and appendicitis simultaneously. An abdominal computer tomography (CT) scan revealed the presence of the two diagnoses, which was then confirmed by an abdominal ultrasound. A four-access port was utilized for simultaneous appendectomy and cholecystectomy. DISCUSSION: A review of the literature indicates that simultaneous infection with appendicitis and cholecystitis is rare, and thus clinical presentation, lab work, and imaging studies are all needed to support such a diagnosis. Potential findings on imaging in these patients may include distended gallbladder with thickened wall and fluid-filled dilated appendix with mural enhancement. In the event that both clinical presentation and further work-up indicate both pathologies, laparoscopic intervention is suitable. A four-access port is deemed the conservative approach to dealing with such cases. CONCLUSION: Finding a single diagnosis responsible for a patient's illness is a high priority in an acute care setting, a concept known as diagnostic parsimony. However, it is inevitable that very common illnesses will be comorbid in a subset of patients, and physicians should be prepared to consider contemporaneous illness in the isolated circumstances it is warranted.