Fever In Emergency Department Research Articles

Clinical implications of extremely elevated C-reactive protein among febrile immunocompetent children.

To identify the various diagnoses associated with extremely elevated C-reactive protein (CRP) (>30 mg/dL) among immunocompetent children and to evaluate its clinical implications during emergency department (ED) workup and hospital management. Children (3 months-18 years) with fever in ED were included, retrospectively. The cohort was divided into two groups-'extremely elevated CRP' (>30 mg/dL) and 'highly elevated CRP' (15-30 mg/dL). Included were 1173 patients with CRP 15-30 mg/dL and 221 with CRP > 30 mg/dL. Bacterial infection was more prevalent among the extremely elevated CRP group (94.1% vs. 78.5%, respectively, p = 0.002). Specifically, bacterial pneumonia (52%), cellulitis (7.2%) and sepsis (4.1%) were more prevalent among this group. More of these patients were reported as 'Ill appearing' [78 (35.3%) vs. 166 (17.4%), p < 0.001]. They were more often treated with fluids [33 (14.9%) vs. 50 (5.3%), p < 0.001] and a higher portion of them required admission to an intensive care unit [11 (5.0%) vs. 16 (1.7%), p = 0.007]. Febrile children with extremely elevated CRP showed greater illness severity (haemodynamic instability, PICU admissions), thus careful clinical attention is desirable in these cases. More than half of them had bacterial pneumonia, which reinforces the importance of relevant investigation when diagnosis is unclear.

Citrobacter freundii induces sepsis with new-onset status seizure in an adult: A case report and literature review.

Sepsis with brain abscess induced by Citrobacter freundii in adults has rarely been reported and is extremely pathogenic with a high mortality rate. Early diagnosis of the infection still remains challenging. A 27-year-old woman was transferred to our emergency department for fever, status seizure and refractory hypotension. Administration of midazolam, propofol and sodium valproate could not attenuate the seizure except for the addition of vecuronium. The blood white blood cell count was 42.91 (109/L) with 80% neutrophils, and procalcitonin was 22.46ng/mL. Both deoxyribonucleic acid and ribonucleic acid of C freundii were detected in blood by metagenomic next-generation sequencing of pathogens,the diagnosis of septic shock and brain abscess caused by C freundii was highly suspected. On day 1, antibiotics of cefoperazone sodium and sulbactam sodium 6g/day, immunoglobulin, and hydrocortisone were used with suspected septic shock. Continuous renal replacement therapy was used to eliminate excessive lactate, ammonia, myohemoglobin and creatinine. On day 2, a brain computed tomography scan revealed multiple patchy slightly low densities in the brain, antibiotics were adjusted to meropenem intravenously 3g/day. On day 2, a brain computed tomography scan revealed multiple patchy slightly low densities in the brain, she died on day 3. Clinicians should consider the possibility of brain abscess when evaluating a patient with new-onset dizziness, fever, seizure, or other neurologic symptoms or signs, especially for patients whose mental status changes. metagenomic next generation sequencing and resistance genes could be considered when cerebrospinal fluid or blood results are negative and clinical manifestations are highly suspected of infection or when the treatment time is limited.

A teenager with life-threatening abdominal pain

A previously healthy 17-year-old boy was admitted to our emergency department for fever, pharyngitis with cervical lymphadenopathy, abdominal pain, and vomiting for three days. On admission, he was afebrile and his vital signs were normal. Yet, following another vomiting episode, he developed another bout of abdominal pain. C-reactive protein was normal, haemoglobin 14.1 g/dl, WBC 15 x 103/µL, platelets 138 x 103/µL, AST 522 U/L, ALT 341 U/L, total bilirubin 4.75 mg/dl, with direct bilirubin 3.4 mg/dl; LDH level 689 U/L.

The Role of Lung Ultrasound in Diagnosing COVID-19-Related Multisystemic Inflammatory Disease: A Preliminary Experience.

Background: To date, there are no data regarding the systematic application of Point-of-Care Lung Ultrasound (PoC-LUS) in children with Multisystem Inflammatory Syndrome in Children (MIS-C). The main aim of this study is to show the role of Point-of-Care Lung Ultrasound as an additional aid in the diagnosis of COVID-19-related Multisystem Inflammatory Syndrome in Children (MIS-C). Methods: Between April 2020 and April 2021, patients aged 0–18 years referred to our emergency department for fever, and later hospitalized without a specific diagnosis, underwent PoC-LUS. Ultrasound images of patients with a final diagnosis of MIS-C were retrospectively evaluated. Results: Ten patients were enrolled. All were described to have pleural irregularities and B-lines. In particular: 8/10 children presented with isolated B-lines in at least half of the lung areas of interest; 8/10 presented with multiple B-lines and 3/8 had them in at least 50% of lung areas; 5/10 had a white lung appearance in at least one lung area and 1/5 had them in half of the areas of interest. Pleural effusion was described in 9/10. Conclusions: During the ongoing COVID-19 pandemic, we suggest performing PoC-LUS in febrile patients with high levels of inflammatory indices and clinical suspicion of MIS-C, or without a certain diagnosis; the finding of many B-lines and pleural effusion would support the diagnosis of a systemic inflammatory disease.

The Fever in the Emergency Department: before Versus after COVID-19

A high body temperature, i.e. fever, is a crucial vital sign, and suggests the patient’s infection or inflammation. COVID-19 has changed the lifestyle, and led to the changes in medical use behavior of febrile patients. We investigated the change in etiologies of fever in the emergency department (ED) before and after COVID-19. The medical records of patients with fever who visited the ED of a university hospital before and after the outbreak of COVID-19 in Daegu metropolitan city, South Korea. The cause of fever and its classification were carefully decided and established by agreement through a discussion among board-certified clinicians in emergency medicine, neurology, general surgery, and internal medicine. The etiology of fever and its prevalence in ED were compared between before and after COVID-19. A total of 3,041 patients with fever (> 37.7°C) in the ED were investigated, with 1,400 men (46.0%). Their mean age was 55.88 ± 20.59, and the average number of patients with fever in ED was 8.16 ± 3.94 per a day. The most common etiology before COVID-19 was respiratory system infection (n = 535, 30.5%), followed by gastrointestinal (n = 313, 17.8%) and urinary tract infection (n = 209, 11.9%). However, after COVID-19, gastrointestinal cause became the most common (n = 247, 27.3%), followed by respiratory system (n = 126, 13.9%) and urinary tract infection (n = 102, 11.3%). There has been paradigm-shifting in fever etiology in the emergency department. It is necessary to cope with the changed fever etiology in the COVID-19 era. Keywords: COVID-19, Emergency service, hospital, Etiology, Fever

Infrared thermometers and infants: The device is hot the baby maybe not.

The risk of serious illness in febrile infants (<60 days old) is high, and so fever often warrants aggressive management. Infrared thermometers are unreliable in young infants despite their ubiquity. We aim to describe the: (i) frequency of infrared thermometer usage; (ii) progression to documented fever in the emergency department (ED) and (iii) rate of serious illness (meningitis, urinary tract infection and bacteremia). In this single-centre retrospective chart review at The Royal Children's Hospital, Melbourne, we audited medical records of infants (<60 days old) presenting to the ED with pre-hospital fever on history over a 12-month period. We described the type of thermometer used at home (tympanic or forehead, 'infrared' vs. axillary or rectal, 'direct') correlated to peak temperature in ED, investigations, treatment and diagnosis. The primary outcome was subsequent fever in ED. Of 159 infants, two of three had infrared temperature measurement at home. Fifty-one (32.1%) developed fever in ED (direct 28/54, 52% vs. infrared 23/105, 22% RR 2.36 (95% CI 1.52-3.69)). Investigations (75%) and admission (60%) were common. Pre-hospital fever alone was less likely to be associated with serious illness, with fever in ED a much stronger predictor. In young infants, infrared thermometer use is common and less likely to predict subsequent fever. Twenty-two percent of infants with fever via infrared measurement had fever in ED. History of fever without confirmation is less likely to signal serious illness. Education to public and health-care providers is required to avoid usage of infrared devices in this population.

P0731 / #2140: SARS-COV-2-RELATED MULTISYSTEM INFLAMMATORY SYNDROME IN FAMILIAL REFRACTORY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A CASE REPORT

AIMS & OBJECTIVES: To describe how the clinical course of children positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tested with reversetranscriptase polymerase chain reaction (RT-PCR) has changed lately from non-severe to life threatening cases. METHODS: Case report. A 2-month-old baby arrived at the emergency department for fever, anemia, leukopenia and thrombocytopenia, he was hospitalized and diagnosed with severe dengue. A week later, he started with respiratory symptoms and fever, he was positive for SARS-CoV-2 based on RT-PCR. Two weeks later, persistent fever, C-Reactive protein and D-dimer elevation, lymphocytopenia, anemia and thrombocytopenia integrated diagnosis of multisystem inflammatory syndrome (MIS-C) treated with intravenous immune globulin, systemic glucocorticoid and anticoagulation therapy in the intensive care unit. Nevertheless, he had persistent fever, hepatosplenomegaly, pancytopenia, hypertriglyceridemia and high serum IL-6 levels;bone marrow aspiration revealed an hemophagocytic lymphohistiocytosis (HLH), so treatment with steroid, cyclosporine and cytarabine was administrated. Antibiotic therapy was added because of clinical symptoms for septic shock. Multiple transfusions because of refractory anemia and thrombocytopenia, vasopressor management and mechanical ventilation were needed. However, because of his insidious clinical course and history of infection with SARS-CoV-2, management with inhibitor of JAK signalling was added. Physical examination revealed silver hair, suggestive for a familial HLH secondary to Griscelli syndrome type 2. RESULTS: In the end, multiple organ dysfunction (cardiovascular, hematologic, respiratory, renal, neurologic). CONCLUSIONS: MIS-C was secondary to an immunemediated injury triggered by viral infections with an overall mortality greater than 50% in previously healthy children, however additional HLH resulted in fatal outcome.

Triage of patients with fever: The Manchester triage system's predictive validity for sepsis or septic shock and seven-day mortality.

Up to 15% of patients arrive in the emergency department suffering from fever. Triage is their first contact and is responsible for the stratification of patients according to the severity of the condition for which they are presenting at the emergency department. The aim of this study is to assess the predictive validity of the Manchester Triage System in patients with fever for sepsis or septic shock and seven-day mortality. The sensitivity, specificity and negative predictive value of the Manchester Triage System was assessed by priority code allocation towards seven-day mortality and the diagnosis of sepsis or septic shock. A total of 3831 patients were evaluated in the emergency department for fever between 1 January 2017 and 30 June 2019. Of these, 1.9% were diagnosed with sepsis or septic shock. Using the Manchester Triage System to predict diagnosis of sepsis or septic shock provided a sensitivity of 88.7%, a specificity of 50.1% and a negative predictive value of 99.5%. For seven-day mortality, sensitivity was 44.4%, specificity was 92.3% and the negative predictive value was 99.3%. The Manchester Triage System has demonstrated high sensitivity and negative predictive value in patients with fever diagnosed with sepsis or septic shock. For patients with sepsis or septic shock one-third of cases with an incorrectly assigned priority code were caused by incorrect application of the Manchester Triage System.

474 Isolated pulmonary endocarditis

Abstract INTRODUCTION Isolated pulmonary endocarditis is a rare entity, especially in patients without predisposing factors, being its current incidence less than 1% of the total cases of infectious endocarditis. This is due to the lower right heart pressures and a decrease of intravenous drug-consum, being most of the cases nowadays, related to congenital right-heart diseases or pacemakers and defibrillators implants. CLINICAL CASE A 35 year-old man, tobacco smoker and intravenous cocaine consumer since he was 25, was admitted to our Emergency Department for fever up to 40ºC, cough and dyspnea started three days before admission. In the anamnesis he refereed intravenous consum of cocaine and sharing of syringes the last week. On physical examination he was tachycardic and signs of heart right failure were present such as jugular ingurgitation and peripheral edema. No murmurs were heard. No respiratory failure was detected at any time. Blood test analysis showed high levels of protein C reactive and leukocytosis. Blood cultures were positive for S. aureus (OXA-S) in the first 24h. Chest X-ray (image 1) showed a necrotizing bilateral pneumonia that was confirmed with the presence of cavitated images in the pulmonary CT (image 2). Antibiotic treatment was started with daptomicine + cloxaciline. With the suspicion of right endocarditis a transthoracic echocardiography was performed, showing the presence of a big vegetation (4x1cm) on the pulmonary valve that caused moderate pulmonary insufficiency (images 3, 4). Neither tricuspid nor left side valves were involved. Biventricular function was conserved and hyperdynamic. Endocarditis diagnosis was definitive and due to the presence of multiple right embolisms and the big size of the vegetation, the patient underwent cardiac surgery. Intra-surgical finding demonstrated a big vegetation of almost 5 cm (image 5) depending of the posterior pulmonary valve that was removed; the posterior valve needed to be repaired. Posterior clinical evolution was correct without complications, completing 17 days of i.v. antibiotics (cloxaciline) before discharge. CONCLUSIONS Right endocarditis is a rapidly progressive disease due to the fact that staphylococcus are the most frequent microorganisms involved. Valvular destruction and secondary embolic phenomena are the rule. Tricuspid valve is involved most of the times being the isolated pulmonary valve affection very uncommon. Abstract 474 Figure. CT, Echo and surgical images

Clinical and epidemiological characteristics of children admitted with fever in emergency department with or without sepsis.

Sepsis is a major cause of childhood death worldwide. In developing countries, epidemiological data about sepsis is scarce. This study describes and compares the frequency of etiological agents and initial sites of infection in children with or without sepsis, identifying risk factors and assessing outcomes. Clinical and demographic data from patients < 13 years of age with reported fever in a pediatric emergency department were collected and registered in forms. Patients were classified as with or without sepsis according to Goldstein et al.'s criteria [6]. Of 254 patients, 120 (47%) did and 134 (53%) did not meet the sepsis definition. Overall, the median age (IQR) was 1.7 (0.8-3.9) years, and 153 (60%) were boys. Patients with sepsis were older (2.8 [1.1-5.3] versus 1.3 [0.6-2.9] years; p < 0.001) and had sickle-cell disease more frequently (7.6% versus 0.8%; p = 0.007). By multiple logistic regression, age and sickle-cell disease were independently associated with sepsis. The most frequent initial infections were pneumonia (43.7%), diarrhea (17.3%) and cellulitis/adenitis (13.0%). The frequency of these did not differ when patients with or without sepsis were compared. Etiology was established in 57 (22.4%) patients, 32 (26.7%), and 25 (18.7%) with or without sepsis, respectively. Four (3.3%) patients died in the sepsis subgroup, whereas none died in the other subgroup. Children who met the 2005 international consensus definition of sepsis showed differences in age and comorbidities (sickle-cell disease) upon admission and were more likely to die.

Delayed diagnosis of 22q11 deletion syndrome due to late onset hypocalcemia in a 11-year-old girl with imperforated anus.

Neonatal hypocalcemia and congenital heart defects has been known as the first clinical manifestation of the chromosome 22q11.2 deletion syndrome (22q11DS). However, because of its wide clinical spectrum, diagnosis of 22q11DS can be delayed in children without classic symptoms. We report the case of a girl with the history of imperforate anus but without neonatal hypocalcemia or major cardiac anomaly, who was diagnosed for 22q11DS at the age of 11 after the onset of overt hypocalcemia. She was born uneventfully from phenotypically normal Korean parents. Imperforate anus and partial cleft palate were found at birth, which were surgically repaired thereafter. There was no history of neonatal hypocalcemia, and karyotyping by GTG banding was normal. At the age of 11, hypocalcemia (serum calcium, 5.0 mg/dL) and decreased parathyroid hormone level (10.8 pg/mL) was noted when she visited our Emergency Department for fever and vomiting. The 22q11DS was suspected because of her mild mental retardation and velopharyngeal insufficiency, and a microdeletion on chromosome 22q11.2 was confirmed by fluorescence in situ hybridization. The 22q11DS should be considered in the differential diagnosis of hypocalcemia at any age because of its wide clinical spectrum.

Caregiver Low Health Literacy and Nonurgent Use of the Pediatric Emergency Department for Febrile Illness

ObjectiveTo examine the association between caregiver health literacy and the likelihood of a nonurgent emergency department (ED) visit in children presenting for fever. MethodsThis cross-sectional study used the Newest Vital Sign to assess the health literacy of caregivers accompanying children with fever to the ED. Visit urgency was determined by resources utilized during the ED visit. Findings were stratified by race and child age. Chi-square and logistic regression analysis controlling for race were conducted to determine the association between low health literacy and ED visit urgency. ResultsA total of 299 caregivers completed study materials. Thirty-nine percent of ED visits for fever were nonurgent, and 63% of caregivers had low health literacy. Low health literacy was associated with a higher proportion of nonurgent ED visits for fever (44% vs 31%, odds ratio 1.8, 95% confidence interval [CI] 1.1, 2.9). Low health literacy was associated with higher odds of a nonurgent visit in white and Hispanic caregivers but not in black caregivers. In regression analysis, children ≥2 years old had higher odds of a nonurgent visit if caregivers had low health literacy (adjusted odds ratio 2.0; 95% CI 1.1, 4.1); this relationship did not hold for children <2 years old (adjusted odds ratio 0.8; 95% CI 0.4, 1.8). ConclusionsNearly two-thirds of caregivers with their child in the ED for fever have low health literacy. Caregiver low health literacy is associated with nonurgent ED utilization for fever in children over 2 years of age. Future interventions could target health literacy skills regarding fever in caregivers of children ≥2 years.

Reduced Use of Occult Bacteremia Blood Screens by Emergency Medicine Physicians Using Immunization Registry for Children Presenting With Fever Without a Source

This study examined whether utilization of the Florida State Health Online Tracking System (SHOTS) immunization registry to determine Haemophilus influenzae type B and heptavalent pneumococcal conjugate (PCV7) vaccine status impacts the protocolized decision to perform a screening blood draw for occult bacteremia (OB) in young children. A convenience sample of children 6 to 24 months of age presenting to the pediatric emergency department with fever of greater than 39°C without a source was enrolled. Physicians were trained to use the SHOTS immunization registry and reviewed the emergency department's fever protocol. A "preregistry" workup plan was documented for each patient based on clinical history, immunization status before accessing SHOTS, and physical examination. A "postregistry" workup plan was then documented based on the SHOTS record. Demographic and registry data were recorded. Preregistry workup plans indicated OB screening blood draws for 100% (n = 91; 95% confidence interval [CI], 96-100) of patients with unconfirmed immunization status. Of those 91 children, 58% (n = 53; 95% CI, 55-61) were documented in SHOTS as having received their primary conjugate vaccine series at ages 2, 4, and 6 months. Registry access reduced the percentage of screening blood draws from 100% (n = 91) to 42% (n = 38; 95% CI, 37-53; P < 0.001). The state immunization registry is an adjunctive tool to caregiver recall, which can be used by emergency medicine practitioners to confirm completion of the primary conjugate vaccine series before making the decision to perform blood screens for OB in children aged 6 to 24 months who present with fever without a source.

Accuracy of Non-contact Infrared Thermometry Versus Rectal Thermometry in Young Children Evaluated in the Emergency Department for Fever

We evaluated the accuracy of a non-contact infrared thermometer compared with a rectal thermometer. Two hundred patients, ages 1 month to 4 years, were included in the study. Each child underwent contemporaneous standard rectal thermometry and mid forehead non-contact infrared thermometry. Clinical features, including chief complaint, recently administered antipyretic agents, and ambient temperature at the time of measurement, were included. Linear models were used to compare agreement between the 2 techniques, as well as to determine bias of infrared thermometry at different rectal temperatures. Multivariate linear models were used to evaluate the impact of clinical variables and ambient temperature. A linear relationship between rectal and infrared temperature measurements was observed; however, the coefficient of determination (r(2)) value between was only 0.48 (P < 0.01). Infrared thermometry tended to overestimate the temperature of afebrile children and underestimate the temperature of febrile patients (P < .01). Ambient temperature and child age did not affect the accuracy of the device. In this study, non-contact infrared thermometry did not sufficiently agree with rectal thermometer to indicate its routine use.

Monitoring the Impact of Influenza by Age: Emergency Department Fever and Respiratory Complaint Surveillance in New York City

BackgroundThe importance of understanding age when estimating the impact of influenza on hospitalizations and deaths has been well described, yet existing surveillance systems have not made adequate use of age-specific data. Monitoring influenza-related morbidity using electronic health data may provide timely and detailed insight into the age-specific course, impact and epidemiology of seasonal drift and reassortment epidemic viruses. The purpose of this study was to evaluate the use of emergency department (ED) chief complaint data for measuring influenza-attributable morbidity by age and by predominant circulating virus.Methods and FindingsWe analyzed electronically reported ED fever and respiratory chief complaint and viral surveillance data in New York City (NYC) during the 2001–2002 through 2005–2006 influenza seasons, and inferred dominant circulating viruses from national surveillance reports. We estimated influenza-attributable impact as observed visits in excess of a model-predicted baseline during influenza periods, and epidemic timing by threshold and cross correlation. We found excess fever and respiratory ED visits occurred predominantly among school-aged children (8.5 excess ED visits per 1,000 children aged 5–17 y) with little or no impact on adults during the early-2002 B/Victoria-lineage epidemic; increased fever and respiratory ED visits among children younger than 5 y during respiratory syncytial virus-predominant periods preceding epidemic influenza; and excess ED visits across all ages during the 2003–2004 (9.2 excess visits per 1,000 population) and 2004–2005 (5.2 excess visits per 1,000 population) A/H3N2 Fujian-lineage epidemics, with the relative impact shifted within and between seasons from younger to older ages. During each influenza epidemic period in the study, ED visits were increased among school-aged children, and each epidemic peaked among school-aged children before other impacted age groups.ConclusionsInfluenza-related morbidity in NYC was highly age- and strain-specific. The impact of reemerging B/Victoria-lineage influenza was focused primarily on school-aged children born since the virus was last widespread in the US, while epidemic A/Fujian-lineage influenza affected all age groups, consistent with a novel antigenic variant. The correspondence between predominant circulating viruses and excess ED visits, hospitalizations, and deaths shows that excess fever and respiratory ED visits provide a reliable surrogate measure of incident influenza-attributable morbidity. The highly age-specific impact of influenza by subtype and strain suggests that greater age detail be incorporated into ongoing surveillance. Influenza morbidity surveillance using electronic data currently available in many jurisdictions can provide timely and representative information about the age-specific epidemiology of circulating influenza viruses.

CRITERIA FOR EVALUATING FEBRILE 29- TO 60-DAY-OLD INFANTS: A 3-YEAR RETROSPECTIVE REVIEW FROM BIRMINGHAM.

Purpose This retrospective study examines 29- to 60-day-olds who presented to an emergency department (ED) between 1/1/02 and 12/31/04 with a chief complaint of fever. A set of criteria can predict which patients will not have serious bacterial infections (SBI). Methods Fever is defined as ≥ 100.4°F rectally. Exclusion criteria: previous vaccination (other than hepatitis B), surgeries (other than circumcision), antibiotics, immune deficiency syndromes, non-well appearance, and signs of bacterial infection. Inclusion criteria were well appearance with a complete blood count (CBC) with a white blood cell count (WBC) of 5,000 to 20,000 with a band/neutrophil ratio of 40, and negative Gram stain. A univariate analysis of each variable against predictability of positive cultures and SBIs was performed using EPISTAT. The chi-square of each variable was used to calculate a two-tailed p value. Results Of 552 charts, there were 565 diagnoses; 434 had a fever by our definition. Of these 434, 111 met the inclusion criteria. Of these 111 patients, 110 did not have an SBI (one patient had a urinary tract infection). Of the 323 patients with fever who failed to meet the inclusion criteria, 187 had either a bacterial or serious viral infection. The prevalence of SBI in our study is 15% (83/552) from all causes and 10% (56/552) culture proven. The inclusion criteria have a positive predictive value of 99.1% (110/111), specificity of 98.6% (70/71), sensitivity of 31.2% (110/352), and negative predictive value of 22.4% (70/312) for predicting negative SBI. The inclusion criteria have a positive predictive value of 99.1% (110/111), specificity of 97.8% (44/45), sensitivity of 29.1% (110/378), and negative predictive value of 14.1% (44/312) at predicting negative cultures. Of the criteria, well appearance (p Conclusion A large number of patients are seen in the ED for fever. Many may be safely discharged home without antibiotics.

Presacral mass evaluated with computed tomography and whole-body Tc-99m white blood cell imaging.

A 75-year-old woman was initially examined in the emergency department for fever, elevated leukocyte count, and new-onset right lower extremity tingling for 1 day. Physical examination revealed a large pelvic mass. Abdominal computed tomography (CT) revealed a large presacral mass. A biopsy showed that the mass was not malignant. A whole-body white blood cell (WBC)-labeled study was ordered for further evaluation. Both CT and the leukocyte examinations revealed findings consistent with a pelvic mass that extended posteriorly and laterally in both directions. The patient was taken to surgery and a diagnosis of perforated diverticulitis with an abscess located posterior to the rectum and dissecting laterally in the pelvis was confirmed. The patient recovered from surgery and is now symptom free.