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Uncommon Differential Diagnosis of Acute Right-Sided Abdominal Pain – Case Report

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Uncommon Differential Diagnosis of Acute Right-Sided Abdominal Pain – Case Report CASE REPORT SURGERY // RADIOLOGY Uncommon Differential Diagnosis of Acute Right-sided Abdominal Pain – Case Report Cédric Kwizera1, Benedikt Wagner2, Johannes B. Wagner3, Călin Molnar1 1 Department of Surgery, Emergency County Hospital, Târgu Mureș, Romania 2 Student, Faculty of General Medicine, University of Medicine, Pharmacy, Science and Technology, Târgu Mureș, Romania 3 Department of General, Abdominal and Endovascular Surgery, District Hospital Landsberg am Lech, Germany CORRESPONDENCE ABSTRACT Cédric Kwizera The appendix is a worm-like, blind-ending tube, with its base on the caecum and its tip in Str. Gheorghe Marinescu nr. 50 multiple locations. Against all odds, it plays a key role in the digestive immune system and 540136 Târgu Mureș, Romania appendectomy should therefore be cautiously considered and indicated. We report the case Tel: +40 729 937 393 of a 45-year-old male with a known history of Fragile-X syndrome who presented to the emer- E-mail: [email protected] gency department with intense abdominal pain and was suspected of acute appendicitis, after a positive Dieulafoy’s triad was confirmed. The laparoscopic exploration showed no signs of ARTICLE HISTORY inflammation of the appendix; nonetheless, its removal was carried out. Rising inflammatory laboratory parameters led to a focused identification of a pleural empyema due to a tooth inlay Received: February 22, 2019 aspiration. Our objective is to emphasize the importance of a thorough anamnesis, even in Accepted: March 27, 2019 cases of mentally impaired patients, as well as to highlight a rare differential diagnosis for ap- pendicitis. Acute appendicitis is an emergency condition that requires a thorough assessment and appropriate therapy. Clinical examinations are important, but in this particular case, imaging methods had a much more important role in establishing the right treatment approach. Further- more, the signs of acute appendicitis are mimicked by several medical conditions including respiratory tract infections. Keywords: appendicitis, pleural empyema, differential diagnosis, tooth inlay aspiration INTRODUCTION The appendix or vermiform process is a worm-like, blind-ending tube connect- ed to the caecum, about 2 cm beneath the Bauhin valve. Its average dimensions are 7–8 mm wide and 9 cm long, but its length can range from 2 to 20 cm, the longest ever recorded appendix being 26 cm long, discovered postmortem in a 72-year-old Croatian patient (Guinness World Record 2006). Its base is attached to the cecum, but the position of its tip can vary, as it can be retrocecal, subcecal, pre-ileal, retroileal, pelvic, or ectopic.1 The appendix has long been considered worthless due to the absence of noticeable reactions post appendectomy, hence the assumption of its vestigial characteristics.2 Nevertheless, William Parker et Benedikt Wagner • Str. Gheorghe Marinescu nr. 38, 540139 Târgu Mureș, Romania. Tel: +40 265 215 551 al. suggested that it may act as a storage unit of beneficial microbiome, activated Johannes B. Wagner • Bürgermeister-Dr.-Hartmann- especially after the reduction of normal intestinal bacteria following infectious Straße nr. 50, 86899 Landsberg am Lech, Germany. Tel: +49 8191 3330 Călin Molnar • Str. Gheorghe Marinescu nr. 38, 540139 Târgu Mureș, Romania. Tel: +40 265 215 551 Journal of Interdisciplinary Medicine 2019;4(1):33-36 DOI: 10.2478/jim-2019-0004 34 Journal of Interdisciplinary Medicine 2019;4(1):33-36 FIGURE 1. Thoracic X-ray, coronal view: aspect of encapsulated, FIGURE 2. Thoracic CT, coronal view: expanding serous pleural presumably interlobular eff usion, component of the right lung with eff usion on the right side (no distinct empyema criteria), with basal ventilatory dysfunction. Unidentifi able, radiopaque, foreign adjacent partial ventilatory dysfunction, particularly in the lower body of approximately 1.3 cm in diameter, in the right cardiophrenic right lobe. Presumably intrabronchial aspirate lying in a proximal angle. segmental bronchus. diseases,3 because the immune system participates in the of his caregiver and a laboratory evaluation which revealed formation of the benefi cial microbiome due to the location a CRP of 3.41 mg/dL and leucocytes of 15.3 × 10^3/L, a of the appendix and its histological structure with immune laparoscopic exploration was performed on the same day tissues.4 Research has shown that patients were four times of admission. Although the appendix presented no major more prone to a recurrent Clostridium diffi cile colitis fol- signs of infl ammation or other pathological characteristic lowing an appendectomy.5 Its structure contains B cells, upon laparoscopic inspection, it was removed in order to extra-thymic T cells along with lymphatic vessels, partici- exclude neurogenic appendicopathy. Th e histologic exam- pates in the elimination of gastrointestinal waste, stopping ination showed no signs of malignancy and no signifi cant pathogens and assuring an early immunological defense.6 infl ammatory infi ltrates. Th e initial postoperative course In most of the cases, pain located in the right iliac fossa is proved to be without any complications and without signs usually a sign of acute appendicitis. Th e present case re- of wound infection. Postoperative oral feeding also took port is about a mentally impaired patient admitted and in- place without complications. Nevertheless, on the fi rst advertently operated for acute appendicitis. Subsequently, day following surgery, the laboratory revealed raising in- he was diagnosed and treated for pleural empyema due to fl ammatory parameters such as CRP of 34.09 mg/dL and a foreign body aspiration. leucocytes of 18.2 × 10^3/L, which led to further investi- gation of the patient. Th oracic X-ray (Figure 1) raised the suspicion of a foreign body in the area of the inferior lobe CASE PRESENTATION of the right lung and of an incipient pleural empyema. A 45-year-old male presented to the emergency depart- To complete the records of medical fi ndings, a comput- ment with severe abdominal pain. Due to his mental im- ed tomography (CT) scan of the thorax was performed, pairment with a known diagnosis of Fragile X-syndrome, which confi rmed the suspicion (Figure 2). collecting his past medical record was heavily impeded, Th us, bronchoscopy and video-assisted thoracoscopic and nothing else – besides a positive Dieulafoy’s triad – was surgery (VATS) was indicated. Under general anesthesia determined. Th erefore, an acute appendicitis was suspect- and intubated with a double-lumen tube, a golden tooth ed. An ultrasonography examination was impossible, due inlay was retrieved from the segmental bronchus of the to the lack of compliance. Following the informed consent right inferior lobe with the aid of the bronchoscope. Dur- Journal of Interdisciplinary Medicine 2019;4(1):33-36 35 A B C D FIGURE 3. VATS. A – empyema before decortication; B, C – empyema during decortica- tion; D – finalized decortication ing the first access into the thoracic cavity, putrid liquid acute appendicitis.7 The pain felt in the epigastrium upon was emptied. On investigation of the pleural cavity, a mo- continuous pressure over McBurney’s point is called Aar- bile fibrous block covering the right lung was observed, on’s sign.8 In practice, there are a number of clinical signs and consecutively a progressive decortication of the lung that indicate acute appendicitis: obturator sign, psoas sign, took place (Figure 3). Rovsing’s sign, Blumberg’s sign, Markle’s sign.9–11 Howev- The patient was monitored postoperatively in the inten- er, these clinical signs are encountered in a minority of pa- sive care unit. The postoperative course henceforward was tients. The typical signs of acute appendicitis are: general- without any complications, the drainages were removed in ized abdominal pain, more intense in the umbilical region, time. Under antibiotic therapy with Meropenem, the in- inappetence, nausea, vomiting, leukocytosis and fever. flammatory laboratory parameters regressed, in the end Afterwards, the pain installs in the lower right quadrant/ the serum level of CRP was 3.90 mg/L and leucocytes fossa (same situation in patients with situs inversus with a were 10.8 × 10^9/L. Also, the right lung showed no signs left lengthy appendix). Georges Paul Dieulafoy described of pneumothorax or ventilatory dysfunctions on the con- his famous triad in acute appendicitis: hypersensitivity of trol X-ray. The patient was discharged after 12 days of hos- the skin, tenderness, and muscular contraction at McBur- pitalization with good general status, both clinically and ney’s point.12 However, there are several atypical signs for biologically. Three months later, he is free of symptoms acute appendicitis, with only pain as described above and concerning his pulmonary situation. peritonitis, which requires further investigations such as imaging techniques.13 Our patient presented with gener- alized abdominal pain and elevated inflammatory blood DISCUSSION tests, but due to his mental impairment, we could neither McBurney’s sign, characterized by a deep tenderness in the gather enough details for an appropriate history nor per- right iliac fossa, contributes significantly to the diagnosis of form imaging investigations, thus the case was labeled as 36 Journal of Interdisciplinary Medicine 2019;4(1):33-36 an atypical acute appendicitis. A C-reactive protein level ble number of misdiagnoses, which can be life-threaten- higher than 1 mg/dL is often encountered in acute appen- ing. In mentally healthy
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