Image of the Week: Severe Abdominal Pain and Knee Swelling


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A 19-year-old exchange student presents to the emergency department with severe abdominal pain and swelling of the right knee. She has experienced recurrent episodes of abdominal pain for the past 5 years that persist for 2 to 3 days before resolving spontaneously. Previous investigations, including radiography, computed tomography, endoscopy, and an exploratory laparoscopy have all failed to identify a cause. She mentions that several family members who still reside in Turkey experience similar symptoms. On examination, she has a temperature of 39.4°C and a heart rate of 125 beats per minute. Her abdomen is diffusely tender with rebound tenderness. Effusion of the right knee is present, and a raised, tender, erythematous lesion on the lower portion of her left leg is noted. Laboratory testing reveals an elevated white cell count with a neutrophilic predominance as well as an elevated erythrocyte sedimentation rate, C-reactive protein, and serum amyloid A protein.

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