46-Year-Old Man With Abdominal Pain and Hypotension

Abstract

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Jacksonville, FL (O.A.W., D.F.S.); Adviser to residents and Consultant in Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL (N.L.D.). A 46-year-old man with a history of type 2 diabetes, tetralogy of Fallot, and a bioprosthetic pulmonary valve replacement presented to the emergency department feeling generally unwell after eating a meal at a restaurant. The patient was in his usual state of health until starting dinner at the restaurant. The meal included cooked seafood, which consisted of different types of fish, shrimp, and scallops. A few minutes into his meal, he was overtaken by a sudden onset of severe back pain and cramping that radiated to his abdomen, mainly in the periumbilical region. He rated the pain as 8 of 10 on the severity scale. The pain was followed by progressively worsening dizziness and blurry vision. He also experienced intense palpitations, giving him the sensation of “wanting to pass out.” The patient had no known allergies to fish, seafood, or iodine. He had never experienced any of these symptoms before. None of his colleagues who ate with him had any similar symptoms. He had not recently traveled. On arrival at the emergency department, he became nauseated and vomited 6 times. He appeared to be moderately distressed. He was afebrile, his heart rate was 115 beats/min, and his blood pressure was 78/ 56 mm Hg. Physical examination yielded unremarkable findings except for erythema on his cheeks and mild wheezing on pulmonary examination. Laboratory tests, including complete blood cell count, metabolic profile, and liver function tests, revealed normal values except for a lactate level of 2.1 mmol/L (reference range, 0.6-2.3 mmol/L). Electrocardiography detected sinus tachycardia, and computed tomography of the abdomen with contrast medium revealed diffuse small-bowel wall thickening, edema, and mesenteric fluid with engorgement of the vasa recta. He was admitted to the hospital for further evaluation and treatment.