I know that some infections can stay silent for days, even weeks. In one of my stories that I am writing, I have a patient who comes in with severe abdominal pain, nausea and vomiting, and a high fever. He is later found to be vomiting blood.

The doctor did an abdominal CT along with the usual vital signs, blood tests, and urine tests. Nothing abnormal came up on the urine tests. Abdominal CT showed late stage appendicitis.

However, the WBC count was high, too high to be simply appendicitis. The fever at 104°F also seemed a bit too high to only be explained by the appendicitis. The doctor is suspecting an infection. Since the patient is only complaining of GI symptoms, some form of gastroenteritis is suspected.

I'm thinking that the high fever would point towards bacterial gastroenteritis. But, is gastroenteritis one of those infections that can stay silent for a while? If so, how long can it stay silent?

  • I'm thinking the doctor is going to say screw it and refer the patient to surgery to have the hot appendix removed and that's going to be the end of the problem. – Carey Gregory Jan 8 at 5:07
  • What are the crucial details of this event: do all the symptoms and lab results need to be as you presented them? In what circumstances this happened and what is desired timing and what needs to be the outcome? In short: In which way should this event affect/change the whole story? – Jan Jan 8 at 8:13
  • As for the circumstances in which this happened, the character that became the patient, was going about his daily business when suddenly, he was in a lot of pain and felt like laying down on the floor. The medic got called and it was decided that he should get transferred to the ER. Not all the symptoms and labs need to be as presented, like the vomiting of blood for example is optional. Within the first hour of being in the ER, the patient goes from just being nauseous and in pain, maybe with a low grade fever to having a high fever. – Caters Jan 8 at 8:42
  • I haven't really thought about the outcome other than that i want the patient to be able to survive and recover from the infection in my story. I know the patient is going to survive the appendectomy(appendectomy is one of the lowest risk surgeries), so the surgery for the appendicitis itself doesn't concern me. – Caters Jan 8 at 8:47
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    @Caters Then why not...have them have appendicitis? Why do they need appendicitis "plus"? – Bryan Krause Jan 8 at 8:54

Symptoms of appendicitis (NIDDK.NIH.gov, AAFP):

The first symptom of appendicitis is usually a sudden pain around the belly button that moves to the lower right abdomen within hours. Pain is constant (not crampy) but worsens within hours and is aggravated by coughing and moving around. It often makes a person to lie down on the back (supine) with knees bent to decrease the tension in the abdomen.

Other symptoms that typically develop after pain can include nausea, vomiting (without blood), constipation and diarrhea.

Diagnosis of appendicitis

Blood test shows increased leukocytes (WBC): >10-15,000/μL. If WBC is significantly higher and accompanied with higher temperature than usual for appendicitis (>39 °C) (BMC Surgery - Table 3), the perforation of the appendix or other abdominal organ should be suspected, in which case, the first next imaging investigation would be an abdominal X-ray (AAFP - Fig 6). Abdominal X-ray is not enough for the diagnosis of perforated appendix, so a CT would be needed afterwards. (Ultrasound is usually the first imaging investigation when uncomplicated appendicitis is suspected (Insight Imaging, 2016). The realistic timing between the onset of the first symptoms and worsening of symptoms due to appendix rupture would be 18 hours to 14 days (Annals of African Medicine, 2019), for example, between 24 and 48 hours.

If the worsening of symptoms needs to occur within 2-3 hours, it can be just worsening of appendicitis, because it's unlikely that the appendix would rupture in such a short time. This is also much more realistic than being diagnosed with appendicitis and having a severe GI infection at the same time.

WBC in infections does not need to be as high as you might expect: In one study, WBC in most individuals with pneumococcal pneumonia was 6,000-25,000/mm3 (as compared to 10,000-20,000 in appendicitis).

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