L3: D-dimer

History of Present Illness:

A 32-year-old female with a recent dry cough that has been improving presents to the ED with 6 days of right upper quadrant pain that is worse when she coughs, moves, laughs or takes a deep breath and is associated with nausea but no vomiting.  She has some very mild SOB but denies fever, chest pain, leg swelling, diarrhea, dysuria or any other complaints.

Vital Signs & Physical Exam:

Vital signs are all completely normal.  Physical exam is normal except for RUQ tenderness.

Initial Diagnostic Testing:

  • CBC: normal
  • UA: normal
  • Chem: normal except for AST/ALT of 88/95
  • D-dimer: elevated
  • Imaging: Abdo US, CXR and Pulmonary CTA all normal

What is the most likely cause of the pain?

  • A) Pneumonia
  • B) PE
  • C) Fatty liver
  • D) STI

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ANSWERS: What is the most likely cause of the pain?

  • A) Pneumonia – Unlikely, CXR can miss up to 30%% of pneumonia, but CT would not likely miss it.
  • B) PE – Unlikely, though CT chest can miss up to 15% of smaller PE’s
  • C) Fatty liver – With LFT’s that low and a negative US, liver disease would not likely cause pain.
  • D) STI – CORRECT – The differential diagnosis for elevated D-dimer includes Fitz-Hugh-Curtis, a condition which should always be on the differential for RUQ pain with no other explanation in a sexually active female.

 

1-Minute Consult on this topic: Click HERE and scroll to page 90.

CASE CONCLUSION: This patient tested positive for chlamydia.  It is unusual that the LFT’s were a bit elevated as they are typically normal in Fitz-Hugh-Curtis, which is a perihepatitis.  No baseline LFT’s were available.  The cough is also unusual and may or may not have been related.

CASE LESSONS:

  1. Fitz-Hugh-Curtis syndrome (FHCS) should always be on the differential for RUQ pain with no other explanation in a sexually active female, especially if pleuritic
  2. Most cases of FHCS have normal LFT’s and no pelvic symptoms or signs at all