Epiploic Appendagitis Masquerading As Pulmonary Embolism

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CMIG Extra: Cases 28 (2004) 1–3 www.elsevier.com/locate/compmedimag Case report Epiploic appendagitis masquerading as pulmonary embolism

V. Sites, C. Wald*, F. Scholz

Department of Diagnostic Radiology, Lahey Clinic Medical Center, Burlington, MA 01805, USA

Received 13 February 2003; accepted 6 August 2003

Abstract There has been recent interest in the radiological literature regarding the various clinical manifestations of epiploic appendagitis, which may mimic many acute abdominal and pelvic conditions. We present a case of appendagitis masquerading as pulmonary embolism; to our knowledge the first reported such presentation with primary thoracic symptoms and findings prompting an initial workup for suspected pulmonary thrombembolism. Radiographic findings, differential diagnosis and the pertinent literature are briefly discussed. q 2003 Elsevier Ltd. All rights reserved.

Keywords: Epiploic appendagitis; Atelectasis; Pulmonary thrombembolism

1. Introduction the proximal descending colon. A water-soluble contrast enema revealed no abnormality. An abdominal CT scan There has been recent interest in the radiological demonstrated a left pleural effusion and basal atelectasis literature regarding the abdominal manifestations of epi- (Fig. 1). A lung scan was low probability for pulmonary ploic appendagitis. The most common clinical manifes- embolus. A bilateral lower leg extremity ultrasound was tation is lower abdominal pain simulating diverticulitis, negative. Review of the CT scan showed inflammatory appendicitis and gynecologic disease in women. Since change in the fat of the left upper quadrant adjacent to the epiploic appendages are distributed throughout the colon, left hemidiaphragm and a small focus of oval fat surrounded upper abdominal symptoms are possible. We report a case by a rim of soft tissue in the region of the inflamed fat which presented with upper abdominal and lower thoracic (Fig. 2). The patient was treated with broad-spectrum symptoms, clinically difficult to distinguish from a primary antibiotics and pain medication and became afebrile with a pulmonary process and which prompted initial workup for normal white count after three days. All symptoms pulmonary embolus. completely subsided over several days. The discharge diagnosis was epiploic appendagitis of the splenic flexure causing sympathetic pleural effusion. The patient has 2. Clinical case remained asymptomatic with subsequent normal CT scan.

Case report. The patient was a 49 year old white male with a 24 h history of sudden onset of severe left shoulder 3. Discussion and left posterolateral ﬂank pain. There was no associated nausea or vomiting. There was slight tenderness to deep palpation in the left upper quadrant and some discomfort Most authors believe that epiploic appendagitis is due to over the left posterior chest with percussion. White Blood torsion and secondary thrombosis of the epiploic appen- Cell count was 13,000 with a shift to the left. The patient’s dages, although some have considered the possibility temperature was 100.58. There was no prior history of of spontaneous venous or arterial thrombosis in the etiology abdominal or pulmonary disease. [1,2]. It is a self-limited disease with a course of Initial chest X-ray demonstrated bibasilar atelectasis. An approximately one week, requiring only symptomatic abdomen ﬁlm revealed distension of the colon to the level of treatment for pain [3]. The exact incidence is unclear, although recent use of CT scanning suggests that it is more * Corresponding author. Tel.: þ1-781-744-8170; fax: þ1-781-744-5232. common than previously suspected [3,4]. Epiploic appen- E-mail address: [email protected] (C. Wald). dagitis is most common from ages 25 to 50 years with no

have been reported occurring in the transverse colon, hepatic and splenic flexures [9,11,12]. There have been no cases reported of pulmonary manifestations of EA. Because of the proximity to the diaphragm, EA in the more superior aspects of the colon, especially the splenic flexure, would be more likely to cause pulmonary manifestations than the more frequently reported lower abdominal cases. This case presented with symptoms and initial radiological findings suggestive of a pulmonary process, either pneumonia or pulmonary embolus. The abdominal CT demonstrated the classical findings of EA with fat lucency, containing a central area of high attenuation, surrounded by a high attenuation rim and surrounding fat edema. With no other etiology for pulmonary disease in this patient, the inflammation arising from the splenic flexure appendagitis is believed to have Fig. 1. Left pleural effusion and partial atelectasis of lower lobe. resulted in irritation and inflammation of the left hemi- sexual predilection. Patients complain of sudden onset of diaphragm causing ‘sympathetic’ pleural effusion and sharp abdominal pain, usually lasting less than one week secondary atelectasis. [5]. Nausea and vomiting occur in approximately 20–40% Pleural effusions have been noted in 49% of patients [6]. Mild fever and elevation of WBC is usually present. undergoing abdominal surgery [13], 20% of patients with hepatic abscess [14], 80% of patients with subphrenic and There is often a disparity between the patients’ complaints upper abdominal abscesses (exclusive of the liver) [15], and of severe pain and the relatively benign clinical findings. 18% of patients with perinephric abscess [16].The There is usually only mild to moderate focal tenderness overwhelming majority of these ‘sympathetic’ pleural without clinical signs of peritonitis. A palpable mass is effusions are sterile. Various mechanisms of formation uncommon. Spontaneous resolution of the symptoms occurs have been suggested including irritation of the diaphragm, within 1–2 weeks with no sequelae. direct passage across defects in the diaphragm, and the Classical CT findings of EA have been described as development of pleural fluid secondary to atelectasis caused 1–4 cm oval or round mass of fat density surrounded by a by the upper abdominal process. Whatever the actual hyperattenuating peripheral rim and often containing a mechanism, processes in the upper abdomen produce central hyperattenuating focus, contiguous with the serosal pulmonary changes, including sterile effusions, in a large surface of the adjacent colon [4,7,8]. Induration and proportion of patients. This case is believed to be the first thickening of the adjacent peritoneal lining and surrounding case of sympathetic effusion associated with EA. fat is usual present. Previous reports have documented approximately 90% of EA to be in the lower abdomen. Reports are varied as to the predominance of right lower versus left lower abdomen [9,10]. Only 10–15% if the cases References

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Francis Scholz, MD, FACR graduated from Georgetown University School of Medicine, interned at Boston City Hospital and did his Vincent Sites, MD initially attended Dartmouth Medical School, and residency at Lahey Clinic. After two years on staff at Brigham and completed his studies at Harvard Medical School. Initially, his two Women’s Hospital, he joined the staff at Lahey Clinic in 1975 and PGY years were devoted to internal medicine at St Luke’s Hospital has practiced there since, serving 10 years as Chairman from 1979 center in NYC and at the Peter Bent Brigham in Boston, respectively. to 1989, and served as president of the staff association, member of He then spent two years with the centers for disease control as an the governing board, the board of trustees, and the board of epidemiologist. He then completed a residency in diagnostic radiology overseers. He served as president of the Massachusetts Radiological at the Massachusetts General Hospital. He entered private practice as a Society and of the New England Roentgen Ray Society. He has general radiologist with subspecialty interest in angiography and written numerous papers and chapters in gastrointestinal radiology interventional radiology. He joined the Lahey Clinic in 1996 and is and has been a oral board examiner in gastrointestinal radiology for presently the vice chairman of the Department of Radiology. over 20 years.