HighlightsThe combination of physical exam findings and imaging is usually sufficient for the diagnosis of Spigelian hernias.Patient with chronic lower abdominal pain and with normal physical exam and imaging studies revealed to have a Spigelian hernia.Diagnostic laparoscopy of patient with chronic lower abdominal pain reveals Spigelian hernia with omentum.The omentum is reduced and the hernia defect is repaired.

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A woman in her 60s with diabetes presented to our institution with altered mental status. Preceding symptoms included headaches, nausea and vomiting. One month prior to presentation, she cut her left thumb and developed a pustule, which she occasionally manipulated with a non-sterile needle. On arrival, the patient was in shock, with a Glasgow Coma Scale of 3, requiring emergent intubation and intensive care unit admission. Her initial imaging studies revealed a large pericardial effusion and cerebral subcortical hypodensities. She suffered from a cardiopulmonary arrest with return of spontaneous circulation, with bedside echocardiogram revealing cardiac tamponade. She underwent emergent pericardiocentesis which revealed purulent drainage. Blood, pericardial fluid, cerebrospinal fluid, sputum and urine cultures returned positive for methicillin-sensitive Staphylococcus aureus. The hospital course was further complicated by refractory septic shock and fulminant multiorgan failure, ultimately leading to her demise.

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