A young man, aged 16 years, has constant periumbilical pain (with occasional cramping), extreme weakness, anorexia, nausea, constipation, and orthostasis. His symptoms recur each winter after an episode of typical viral upper-respiratory-infection symptoms (i.e., fever, cough). The episode typically lasts throughout the winter and resolves spontaneously. He also experiences some mild and shorter-lived episodes during the summer.

Acetaminophen and ibuprofen provide no relief; ondansetron (Zofran) or dicyclomine (Bentyl) as needed provide minimal relief. Daily bowel training combined with polyethylene glycol (Miralax) and Lactobacillus GG relieve constipation but none of the other symptoms.

The patient’s first episode was in 2009 and kept him out of school all winter. He had a somewhat spontaneous recovery and was well until the following fall, when another fever and cough developed. The cycle resumed for the next two winters.

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This September, the symptoms recurred and he is once again unable to attend school. Depression and school stress/anxiety were fully explored and ruled out. The patient has no history of tobacco, social drug or alcohol use or other risky behaviors.

The only slightly abnormal labs were immunoglobulin (Ig)G (1,586 mg/dL) and mean platelet volume (12.9 fL). Abdominal x-ray showed stool but was otherwise normal. Where can I go from here? — Clarita Coles, PA-C, Bethlehem, Pa.

The reactive cycle of symptoms along with the elevated IgG levels point to an immune phenomenon. The location of the symptoms point toward mesenteric adenitis. The pain and systemic malaise can lead to self-perpetuated constipation and anorexia.

A plain film would not be helpful. A CT scan to more directly visualize the lymph tissue of the abdomen, especially if done during the height of symptoms, may be helpful. It will be interesting to see what is found. — Claire Babcock O’Connell, MPH, PA-C (170-1)