Rice and Sutter Journal of Medical Case Reports 2010, 4:353 http://www.jmedicalcasereports.com/content/4/1/353 of trauma, including compression or blast injuries. He remained inside the base perimeter for the duration of deployment, had no contact with the local human or animal population and denied consuming local food or beverages. He reported using DEET (N,N-Diethyl- meta-toluamide) insect repellant and wearing perme- thrin-treated uniforms and denied insect bites. He was not aware of any sick contacts. Over the next 24 hours, the patient noted worsening abdominal pain and subjec- tive fevers, as well as several episodes of watery diarrhea. He presented to the emergency department (ED) the morning after his arrival in the United States of America. In the ED, the patient described his abdominal pain as diffuse and aching, unrelated to positional changes or oral intake. He denied anorexia, nausea and vomiting. His vital signs were stable and within normal limits, and the patient was afebrile at that time. Examination demonstrated mild tenderness to palpation in all quad- rants without rebound or guarding. Bowel sounds were normal, his abdomen was soft and no organomegaly or distension was appreciated. The remainder of his physi- cal examination was normal. The complete blood count (CBC) was unremarkable, with a white blood cell (WBC) count of 5,440/μL. The chemistry panel and urine analysis were normal. Liver function tests (LFTs) revealed mild transaminitis, with aspartate aminotrans- ferase (AST) of 82 u/L and alanine aminotransferase (ALT) of 89 u/L but were otherwise unremarkable. The heterophile antibody test result was negative. Chest radiography results were normal. The appendix was not completely visualized on abdominal computed tomogra- phy (CT), but the study was otherwise unremarkable, with the remainder of bowel, liver, spleen and kidney appearance normal for technique. The patient was diag- nosed with gastroenteritis at that time and discharged with conservative treatment. Five days later, the patient returned to the ED. He reported resolution of diarrhea two days earlier but complained of persistent fevers and chills and worsening abdominal pain that was exacerbated by movement. He also reported a sore throat, rhinorrhea, cough and head- ache over the preceding two days, as well as occasional dizziness and lightheadedness. He noted one episode of nonbloody, nonbilious emesis three days earlier but otherwise denied nausea and vomiting. He reported mild anorexia but was tolerating a bland diet. He reported headache relief with ibuprofen and denied photophobia and neck stiffness. Vital signs were stable from his prior visit, with a temperature of 99.4°F. Mild bilateral anterior cervical lymphadenopathy was present, but the results of the head, eye, ear, nose and throat examination were otherwise unremarkable. Abdominal examination revealed increased tenderness to palpation in all quadrants but was otherwise unchanged from Page 2 of 5 prior findings. He had normal rectal tone without evidence of bleeding, and guaiac testing results were negative. The remainder of his physical examination findings were normal. The CBC revealed a five-day decrease in hemoglobin and hematocrit, from 15.0 g/dL and 43.4% to 11.0 g/dL and 31.2%, respectively, and an increase in platelets from 105,000/μL to 200,000/μL. The WBC count was unchanged from the prior value. LFTs revealed an increase in AST to 111 u/L and ALT to 178 u/L. Review of urine cultures obtained in the ED five days prior revealed no growth. Repeat heterophile antibody testing results were negative. Flat and upright abdominal films revealed a nonspecific abnormal bowel gas pattern but were otherwise unremarkable. After eva- luation and recommendations from general surgeons, the patient was admitted to the internal medicine ser- vice for further work-up and observation with serial abdominal examinations. The following morning, the patient appeared pale, described worsening abdominal pain and orthostatic symptoms and was in obvious discomfort with move- ment. He was moderately tachycardic and tachypneic, with a temperature of 101.9°F. Abdominal examination revealed moderate distension, significantly increased and more localized tenderness to palpation in the left upper quadrant (LUQ), rebound tenderness and involuntary guarding. Serum laboratory testing demonstrated persis- tent transaminitis, increasing thrombocytosis and a further decrease in hemoglobin and hematocrit to 9.9 g/ dL and 28.0%, respectively. Repeat abdominal CT demonstrated a fluid-filled abdomen consistent with hemoperitoneum, and after consultation with the sur- geons, the patient was emergently taken to the operating room. Open exploratory laparotomy was performed via midline incision, with more than one litre of dark blood and clots visualized in the peritoneum, localized predo- minately in the LUQ. Inspection of the spleen revealed a tense, ruptured capsule with active bleeding. The gross appearance was otherwise normal, with no perisplenic adhesions visualized. The stomach, liver, small bowel and colon were examined, with no evidence of pathol- ogy. Splenectomy was performed without complication, with two units of packed red blood cells (RBCs) trans- fused intraoperatively. The patient recovered well post- operatively, with gradual resolution of symptoms and normalization of laboratory parameters. He was dis- charged on postoperative day seven with hemoglobin and hematocrit of 10.9 g/dL and 32.5%, respectively. He was started on daily aspirin for secondary thrombocyto- sis and received Pneumococcus, Meningococcus and H. influenzae immunizations before discharge. Pathologic investigation was performed locally and by the Armed Forces Institute of Pathology Depart- ment of Hematopathology in consultation with the