The n e w e ng l a n d j o u r na l of m e dic i n e
Case Records of the Massachusetts General Hospital
Founded by Richard C. Cabot
Eric S. Rosenberg, M.D., Editor
Virginia M. Pierce, M.D., David M. Dudzinski, M.D., Meridale V. Baggett, M.D.,
Dennis C. Sgroi, M.D., Jo‑Anne O. Shepard, M.D., Associate Editors
Allison R. Bond, M.D., Case Records Editorial Fellow
Emily K. McDonald, Sally H. Ebeling, Production Editors
Case 24-2017: An 8-Month-Old Girl
with Fever and an Abdominal Mass
Uzma Shah, M.D., Allan M. Goldstein, M.D., Michael S. Gee, M.D., Ph.D.,
and Vikram Deshpande, M.D.
Pr e sen tat ion of C a se
From the Departments of Pediatrics (U.S.), Dr. Rajitha Venkatesh (Pediatrics): An 8-month-old girl was admitted to this hospital
Pediatric Surgery (A.M.G.), Radiology because of fever and an abdominal mass.
(M.S.G.), and Pathology (V.D.), Massa‑
chusetts General Hospital, and the De‑ The patient had been in her usual good health until approximately 6 days before
partments of Pediatrics (U.S.), Surgery admission, when she passed a large stool surrounded by clotted blood. During the
(A.M.G.), Radiology (M.S.G.), and Pa‑ next 4 days, she had intermittent fevers with associated irritability, as well as de-
thology (V.D.), Harvard Medical School
— both in Boston. creased oral intake without emesis. She continued to produce 6 to 8 wet diapers
per day and to pass soft, brown stools. During the day before admission, a mild
N Engl J Med 2017;377:574-82.
DOI: 10.1056/NEJMcpc1616393 cough developed. The patient was evaluated in the office of her pediatrician, and
Copyright © 2017 Massachusetts Medical Society. abdominal ultrasonography was scheduled for the next day. That evening, her
temperature rose to 40.3°C; her parents administered ibuprofen and took her to
the emergency department of another hospital.
On examination at the other hospital, the patient appeared to be in mild dis-
comfort. The temperature was 39.4°C, the blood pressure 102/58 mm Hg, the pulse
170 beats per minute, the respiratory rate 32 breaths per minute, and the oxygen
saturation 99% while she was breathing ambient air. The weight was 9.53 kg (93rd
percentile). The fontanelle was open, soft, and flat. The abdomen was moderately
distended, with normal bowel sounds and no apparent tenderness on palpation;
the remainder of the examination was normal. Acetaminophen was administered,
and the temperature decreased to 36.1°C. Analysis of a urine specimen obtained by
means of catheterization revealed a pH of 5.0, a specific gravity of 1.005, a small
amount of blood, and a urobilinogen level of 0.2 mg per deciliter and was other-
wise normal. A blood specimen could not be obtained.
Dr. Michael S. Gee: Abdominal radiography (Fig. 1A), performed with the patient
in an upright position, revealed the absence of bowel gas in the midabdomen and
peripheral displacement of multiple bowel loops, findings suggestive of an ab-
dominal mass; there was a nonobstructive bowel-gas pattern and no free intra-
peritoneal air or abnormal calcifications. Abdominal ultrasonography (Fig. 1B)
revealed a large, thick-walled complex cystic mass in the midabdomen that had
574 n engl j med 377;6 nejm.org August 10, 2017
The New England Journal of Medicine
Downloaded from nejm.org on July 30, 2019. For personal use only. No other uses without permission.
Copyright © 2017 Massachusetts Medical Society. All rights reserved.
, Case Records of the Massachuset ts Gener al Hospital
internal dependent debris and multiple mural the administration of intravenous and oral con-
satellite cysts. The mass was located predomi- trast material, revealed a complex cystic mass
nantly to the left of the midline, displaced the (measuring 14.5 cm in greatest dimension) in
left kidney laterally, and did not have internal the midabdomen. The mass filled the left side of
vascularity on Doppler imaging. the abdomen and was separate from the bowel.
Dr. Venkatesh: The patient was transferred to Several loculations of the cyst abutted the pan-
this hospital 4.5 hours after her arrival at the creatic body and tail. The mass did not contain
other hospital. enteric contrast material, and the attenuation
The patient had been born after an uncompli- values of the contents of the mass were consis-
cated gestation of 41 weeks’ duration. When she tent with fluid.
was 6.25 months of age (7.5 weeks before this Ultrasound-guided percutaneous drainage of
evaluation), she was seen in the emergency de-
partment of the other hospital because she had A
four episodes of vomiting over a 3-hour period;
she had associated grunting that was suggestive
of abdominal pain but had no constipation, fever,
or bleeding. On examination at that time, she was
afebrile and weighed 8.15 kg (84th percentile);
she had mild abdominal distention and volun-
tary guarding but had no palpable mass or organo-
megaly. Abdominal radiography revealed a non-
specific bowel-gas pattern. She was able to
receive several feedings without complication,
and she returned home.
The patient’s childhood immunizations were
current. She took no medications and had no
known allergies. She lived with her parents, a
sibling, and other relatives. Her maternal grand-
father had had colon cancer, and a paternal aunt
had died at 20 years of age because of cancer
that had been initially manifested by an ab- B
dominal cyst; there was no family history of
inflammatory bowel disease.
On examination, the patient was fussy but
consolable. The temperature was 36.3°C, the blood *
pressure 105/52 mm Hg, the pulse 122 beats per
minute, the respiratory rate 32 breaths per min-
ute, and the oxygen saturation 98% while she was
breathing ambient air. The abdomen was soft
and distended. On palpation, there was a firm
fullness above the pubis but no discrete mass.
The remainder of the examination was un-
changed. Blood levels of glucose, calcium, phos-
phorus, total protein, albumin, globulin, lactate Figure 1. Abdominal Imaging Studies Obtained
dehydrogenase, uric acid, amylase, alpha feto- at the Other Hospital.
protein, and human chorionic gonadotropin A radiograph (Panel A) shows the absence of bowel
were normal, as were the results of coagulation gas in the midabdomen and displacement of adjacent
bowel loops. An ultrasound image (Panel B) shows a
and liver-function tests; other test results are
complex cystic mass in the midabdomen, on the left
shown in Table 1. A blood culture was obtained. side, that has internal dependent debris (asterisk) and
Dr. Gee: Computed tomography (CT) of the a thick wall with additional loculations (arrows); the left
abdomen (Fig. 2A and 2B), performed in accor- kidney is displaced laterally (arrowhead).
dance with a pediatric (low dose) protocol after
n engl j med 377;6 nejm.org August 10, 2017 575
The New England Journal of Medicine
Downloaded from nejm.org on July 30, 2019. For personal use only. No other uses without permission.
Copyright © 2017 Massachusetts Medical Society. All rights reserved.
Case Records of the Massachusetts General Hospital
Founded by Richard C. Cabot
Eric S. Rosenberg, M.D., Editor
Virginia M. Pierce, M.D., David M. Dudzinski, M.D., Meridale V. Baggett, M.D.,
Dennis C. Sgroi, M.D., Jo‑Anne O. Shepard, M.D., Associate Editors
Allison R. Bond, M.D., Case Records Editorial Fellow
Emily K. McDonald, Sally H. Ebeling, Production Editors
Case 24-2017: An 8-Month-Old Girl
with Fever and an Abdominal Mass
Uzma Shah, M.D., Allan M. Goldstein, M.D., Michael S. Gee, M.D., Ph.D.,
and Vikram Deshpande, M.D.
Pr e sen tat ion of C a se
From the Departments of Pediatrics (U.S.), Dr. Rajitha Venkatesh (Pediatrics): An 8-month-old girl was admitted to this hospital
Pediatric Surgery (A.M.G.), Radiology because of fever and an abdominal mass.
(M.S.G.), and Pathology (V.D.), Massa‑
chusetts General Hospital, and the De‑ The patient had been in her usual good health until approximately 6 days before
partments of Pediatrics (U.S.), Surgery admission, when she passed a large stool surrounded by clotted blood. During the
(A.M.G.), Radiology (M.S.G.), and Pa‑ next 4 days, she had intermittent fevers with associated irritability, as well as de-
thology (V.D.), Harvard Medical School
— both in Boston. creased oral intake without emesis. She continued to produce 6 to 8 wet diapers
per day and to pass soft, brown stools. During the day before admission, a mild
N Engl J Med 2017;377:574-82.
DOI: 10.1056/NEJMcpc1616393 cough developed. The patient was evaluated in the office of her pediatrician, and
Copyright © 2017 Massachusetts Medical Society. abdominal ultrasonography was scheduled for the next day. That evening, her
temperature rose to 40.3°C; her parents administered ibuprofen and took her to
the emergency department of another hospital.
On examination at the other hospital, the patient appeared to be in mild dis-
comfort. The temperature was 39.4°C, the blood pressure 102/58 mm Hg, the pulse
170 beats per minute, the respiratory rate 32 breaths per minute, and the oxygen
saturation 99% while she was breathing ambient air. The weight was 9.53 kg (93rd
percentile). The fontanelle was open, soft, and flat. The abdomen was moderately
distended, with normal bowel sounds and no apparent tenderness on palpation;
the remainder of the examination was normal. Acetaminophen was administered,
and the temperature decreased to 36.1°C. Analysis of a urine specimen obtained by
means of catheterization revealed a pH of 5.0, a specific gravity of 1.005, a small
amount of blood, and a urobilinogen level of 0.2 mg per deciliter and was other-
wise normal. A blood specimen could not be obtained.
Dr. Michael S. Gee: Abdominal radiography (Fig. 1A), performed with the patient
in an upright position, revealed the absence of bowel gas in the midabdomen and
peripheral displacement of multiple bowel loops, findings suggestive of an ab-
dominal mass; there was a nonobstructive bowel-gas pattern and no free intra-
peritoneal air or abnormal calcifications. Abdominal ultrasonography (Fig. 1B)
revealed a large, thick-walled complex cystic mass in the midabdomen that had
574 n engl j med 377;6 nejm.org August 10, 2017
The New England Journal of Medicine
Downloaded from nejm.org on July 30, 2019. For personal use only. No other uses without permission.
Copyright © 2017 Massachusetts Medical Society. All rights reserved.
, Case Records of the Massachuset ts Gener al Hospital
internal dependent debris and multiple mural the administration of intravenous and oral con-
satellite cysts. The mass was located predomi- trast material, revealed a complex cystic mass
nantly to the left of the midline, displaced the (measuring 14.5 cm in greatest dimension) in
left kidney laterally, and did not have internal the midabdomen. The mass filled the left side of
vascularity on Doppler imaging. the abdomen and was separate from the bowel.
Dr. Venkatesh: The patient was transferred to Several loculations of the cyst abutted the pan-
this hospital 4.5 hours after her arrival at the creatic body and tail. The mass did not contain
other hospital. enteric contrast material, and the attenuation
The patient had been born after an uncompli- values of the contents of the mass were consis-
cated gestation of 41 weeks’ duration. When she tent with fluid.
was 6.25 months of age (7.5 weeks before this Ultrasound-guided percutaneous drainage of
evaluation), she was seen in the emergency de-
partment of the other hospital because she had A
four episodes of vomiting over a 3-hour period;
she had associated grunting that was suggestive
of abdominal pain but had no constipation, fever,
or bleeding. On examination at that time, she was
afebrile and weighed 8.15 kg (84th percentile);
she had mild abdominal distention and volun-
tary guarding but had no palpable mass or organo-
megaly. Abdominal radiography revealed a non-
specific bowel-gas pattern. She was able to
receive several feedings without complication,
and she returned home.
The patient’s childhood immunizations were
current. She took no medications and had no
known allergies. She lived with her parents, a
sibling, and other relatives. Her maternal grand-
father had had colon cancer, and a paternal aunt
had died at 20 years of age because of cancer
that had been initially manifested by an ab- B
dominal cyst; there was no family history of
inflammatory bowel disease.
On examination, the patient was fussy but
consolable. The temperature was 36.3°C, the blood *
pressure 105/52 mm Hg, the pulse 122 beats per
minute, the respiratory rate 32 breaths per min-
ute, and the oxygen saturation 98% while she was
breathing ambient air. The abdomen was soft
and distended. On palpation, there was a firm
fullness above the pubis but no discrete mass.
The remainder of the examination was un-
changed. Blood levels of glucose, calcium, phos-
phorus, total protein, albumin, globulin, lactate Figure 1. Abdominal Imaging Studies Obtained
dehydrogenase, uric acid, amylase, alpha feto- at the Other Hospital.
protein, and human chorionic gonadotropin A radiograph (Panel A) shows the absence of bowel
were normal, as were the results of coagulation gas in the midabdomen and displacement of adjacent
bowel loops. An ultrasound image (Panel B) shows a
and liver-function tests; other test results are
complex cystic mass in the midabdomen, on the left
shown in Table 1. A blood culture was obtained. side, that has internal dependent debris (asterisk) and
Dr. Gee: Computed tomography (CT) of the a thick wall with additional loculations (arrows); the left
abdomen (Fig. 2A and 2B), performed in accor- kidney is displaced laterally (arrowhead).
dance with a pediatric (low dose) protocol after
n engl j med 377;6 nejm.org August 10, 2017 575
The New England Journal of Medicine
Downloaded from nejm.org on July 30, 2019. For personal use only. No other uses without permission.
Copyright © 2017 Massachusetts Medical Society. All rights reserved.
