(P05) My Back Hurts. but I am Too Young for Back Problems

Chief Complaint : Left lower back pain that radiated to his left groin and knee.

History of Present Illness : The patient is a 35-year-old male with no significant past medical history who presents with left lower back pain, that radiates to the left groin and knee, he states the pain commenced approximately three weeks before his presentation, and there was no inciting event that contributed to his pain. He described it as sharp, 10 out of 10 in severity, radiating, progressively worsening, exacerbated by sitting, and had never occurred previously, he adds that the pain is associated with nausea, vomiting, and melena, which he admits has been sporadic. He also reported an unintentional 7kg weight loss over six months, he however denied fever, chills, hematochezia, changes in bowel habits, or palpable masses. The patient also denies any associated saddle anesthesia, numbness, tingling, weakness, or any focal neuromusculoskeletal deficits.

Pertinent Physical Exam: GENERALIZED APPEARANCE: Patient is awake and oriented, in moderate discomfort
VITAL SIGNS: Tachypnea is most likely due to pain
EYES: (-) conjunctival pallor, (-) scleral icterus
ABDOMEN: Soft, non-distended, non-tender, (-) guarding, (-) organomegaly, (-) rebound tenderness
CHEST AND RESPIRATORY: (-) rales, (-) rhonchi, (-) wheezes; breath sounds equal bilaterally
HEART AND CARDIOVASCULAR: (-) irregularity; (-) murmur, (-) gallop
VASCULAR: (+) distal pulses, (+) symmetric

Pertinent Laboratory Data: Lab work was notable for a white blood cell count of 13,700 (normal range: 5000 – 10,000/ uL) and elevated alkaline phosphatase levels of 2,005 IU/L (normal range: 44-147 IU/L).

Case Discussion: Intussusception is rare in the adult population, and it has been noted that the major cause in this population is a lead point that is either caused but abdominal adhesions or intraabdominal malignancy. In our patient it was also noted on the Contrast-enhanced computed tomography of the abdomen and pelvis, was remarkable for a 48.9 mm long segment of the ileoileal intussusception in the left upper quadrant, enlarged retroperitoneal lymph nodes, intraperitoneal fat stranding, and evidence of diffuse osseous metastatic disease. The patient was admitted for surgical evaluation, serial abdominal examinations, and further oncologic workup. The patient was evaluated by the surgical team the following day who recommended repeat CT imaging and conservative therapy. Repeat imaging revealed complete resolution of the intussusception 48 hours later. During the admission, the patient’s pain was managed by a pain management consultant. In addition, elevated tumor markers required a gastroenterology consult, and subsequent esophagogastroduodenoscopy (EGD) was performed to collect a distal esophageal biopsy and survey for abnormalities in the upper gastrointestinal tract. CT findings of lymphadenopathy also required a cardiothoracic consult for supraclavicular lymph node biopsy and robotic video-assisted thoracic surgery (VATS) mediastinoscopy. Following the procedures, the surgical pathology results indicated poorly differentiated adenocarcinoma with mucinous and signet ring-type pathognomonic features, along with lymphoproliferative changes that suggest an upper gastrointestinal origin of malignancy. Upon completion of the procedures, the patient was later discharged from the hospital and advised outpatient follow-up with hematology/oncology, pain management, and palliative care.

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