medicina Case Report An Unusual Case of Meckel Diverticulitis Misdiagnosed as an Infected Urachal Cyst Ioana Anca Stefanopol 1 , Magdalena Miulescu 2,*, Liliana Baroiu 3 , Aurelian-Dumitrache Anghele 4, Dumitru Marius Danila 4 and Zina Tiron 3 1 Department of Morphological and Functional Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, 800216 Galat, i, Romania; ancafl[email protected] 2 Cardiorespiratory and Neuromotor Functional Exploration Laboratory, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, 800216 Galat, i, Romania 3 Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, 800216 Galat, i, Romania; [email protected] (L.B.); [email protected] (Z.T.) 4 Clinical Surgical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, 800216 Galat, i, Romania; [email protected] (A.-D.A.); [email protected] (D.M.D.) * Correspondence: [email protected]; Tel.: +40-746608771 Abstract: Introduction: Meckel’s diverticulum (MD), a remnant of the omphaloenteric duct, is among the most frequent intestinal malformations. Another embryonic vestige is the urachus, which obliterates, becoming the median umbilical ligament; the failure of this process can lead to a urachal cyst formation. We present a case of Meckel diverticulitis misdiagnosed as an infected urachal cyst. Presentation of case: A 16-year-old girl presented with hypogastric pain, fever and vomiting. She had undergone an appendectomy 6 years prior and no digestive malformation had been documented. In the last 2 years, she had 3 events of urinary tract infections with Escherichia coli, and anabdominal ultrasound discovered a 28/21 mm hypoechogenic preperitoneal round tumor, anterosuperior to Citation: Stefanopol, I.A.; Miulescu, the bladder. We established the diagnosis of an infected urachal cyst, confirmed later by magnetic M.; Baroiu, L.; Anghele, A.-D.; Danila, resonance imaging. Intraoperative, we found MD with necrotic diverticulitis attached to the bladder D.M.; Tiron, Z. An Unusual Case of dome. Discussions: Meckel’s diverticulum and urachal cyst (UC) are embryonic remnants. Both Meckel Diverticulitis Misdiagnosed conditions are usually asymptomatic, being incidentally discovered during imaging or surgery as an Infected Urachal Cyst. Medicina performed for other abdominal pathology. Imaging diagnosis is accurate for UC, but for MD they are 2021, 57, 495. https://doi.org/ 10.3390/medicina57050495 low sensitivity and specificity. For UC treatment, there is a tendency to follow an algorithm related to age and symptoms, but there is no general consensus on whether to perform a routine resection of Academic Editor: Jan Bilski incidentally discovered MD. Conclusion: Preoperatory diagnosis of MD represents a challenge. We want to emphasize the necessity of a thorough inspection of the small bowel during all abdominal Received: 22 March 2021 surgical interventions and MD surgical excision regardless of its macroscopic appearance. These two Accepted: 12 May 2021 actions seem to be the best prophylaxis measures for MD complications and consequently to avoid Published: 13 May 2021 emergency surgery, in which case more extensive surgical procedures on an unstable patient may be needed. Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in Keywords: Meckel’s diverticulum; urachal cyst; children; embryology; management published maps and institutional affil- iations. 1. Introduction Both UC and MD are embryologic vestiges originating in the yolk sac (endoderm). Copyright: © 2021 by the authors. The umbilical cord contains various elements such as the allantois and the omphaloenteric Licensee MDPI, Basel, Switzerland. duct. The allantois obliterates, forming the urachus, while the omphaloenteric duct resorbs This article is an open access article completely [1,2]. If these processes fail, some anomalies may arise, including UC or distributed under the terms and MD [3]. While MD is one of the most frequent bowel malformations, with a 2% incidence, conditions of the Creative Commons UC is exceedingly rare (1 in 300,000 births) [4]. Clinically, both conditions are usually Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ asymptomatic, being discovered incidentally during imaging investigations or abdominal 4.0/). surgery; they become symptomatic when they complicate [4,5]. Medicina 2021, 57, 495. https://doi.org/10.3390/medicina57050495 https://www.mdpi.com/journal/medicina Medicina 2021, 57, 495 2 of 6 Medicina 2021, 57, 495 2 of 6 usually asymptomatic, being discovered incidentally during imaging investigations or abdominal surgery; they become symptomatic when they complicate [4,5]. Regarding the imaging diagnosis methods, UC can be found on an abdominal ul- Regarding the imaging diagnosis methods, UC can be found on an abdominal ul- trasound (US), but in MD cases, the correct diagnosis is provided by laparotomy or lap- trasound (US), but in MD cases, the correct diagnosis is provided by laparotomy or la- aroscopy [3–5]. Because MD is relatively frequent, and its positive diagnosis is extremely paroscopy [3–5]. Because MD is relatively frequent, and its positive diagnosis is extremely difficult, a deliberate search for MD is advised during all abdominal surgical interven- difficult, a deliberate search for MD is advised during all abdominal surgical interventions. tions. For incidentally discovered MD, prophylactic resection still remains controversial, For incidentally discovered MD, prophylactic resection still remains controversial, but but other studies advise it for all pediatric patients [6,7]. other studies advise it for all pediatric patients [6,7]. We report a challenging case of a 16-year-old girl, presenting with symptoms and We report a challenging case of a 16-year-old girl, presenting with symptoms and imagingimaging investigations investigations matching matching with with an an infected infected UC, UC, but but during during surgical surgical intervention, intervention, we foundwe found Meckel Meckel diverticulitis diverticulitis attached attached to the to bladder. the bladder. 2.2. Case Case Presentation Presentation AA 16-year-old 16-year-old girl girl showed showed up up at at a a general general practitioner practitioner with with a a fever fever (39 (39◦ C),°C), median median subumbilicalsubumbilical pain pain and and dysuria. dysuria. In In the the last last 2 years, 2 years, she she had had experienced experienced 3 events 3 events of urinary of uri- tractnary infection tract infection (UTI) with (UTI) Escherichia with Escherichia coli. Associated coli. Associated reno-urethral reno-urethral malformations malformations were not documentedwere not documented during an US.during The recommendationan US. The recommendation was to start treatment was to start with treatment ciprofloxacin with andciprofloxacin ibuprofen. and Because ibuprofen. her fever Because and pain her persistedfever and afterpain 5persisted days, she after was 5 referred days, she to ourwas hospital.referred Sheto our complained hospital. ofShe hypogastric complained pain ofwith hypogastric fever (39 pain◦C), nauseawith fever and (39 vomiting. °C), nausea She hadand been vomiting. operated She on had 6 years been prioroperated for acute on 6 appendicitisyears prior for (open acute surgery) appendicitis and no (open digestive sur- malformationgery) and no wasdigestive documented. malformation The menarche was documented. was at the The age menarche of 14 years, was but at during the age the of last14 years, 6months, but sheduring had experiencedthe last 6months, menstrual she had irregularity experienced (vaginal menstrual bleeding irregularity every 2 weeks) (vagi- andnal dysmenorrhea.bleeding every 2 Affirmatively weeks) and dysmenorrhea. she had no sexual Affirmatively activity. The she physicalhad no sexual examination activity. revealedThe physical hypogastric examination tenderness revealed without hypogastric peritoneal tenderness signs, with without median peritoneal subumbilical signs, with warmthmedian andsubumbilical erythema, warmth but no drainageand erythema, from thebut umbilicus no drainage was from ever the seen. umbilicus Laboratory was investigationsever seen. Laboratory found a highinvestigations level of CRP found (11.60 a high mg/dl), level andof CRP urinalysisrevealedproteinuria (11.60 mg/dl), and urinaly- (albumin:sisrevealedproteinuria 140.02 mg/dl) (albumin: and many 140.02 epithelial mg/dl) cells, and many but the epithelial urine culture cells, but was the sterile. urine The cul- Addis–Hamburgerture was sterile. The test Addis–Hamburger showed high levels test of show reded and high white levels blood of red cells and and white the rapidblood testcells forand the the detection rapid test of for fecal the occultdetection blood of fecal in stool occult was blood positive. in stool was positive. TheThe abdominal abdominal ultrasound ultrasound (US) (US) discovered discovered a a 28/21 28/21 mm mm hypoechogenic hypoechogenic round round tumor tumor inin the the midline midline of of the the hypogastric hypogastric region, region, anterosuperior anterosuperior to the to bladderthe bladder and and posterior posterior to the to abdominalthe abdominal wall, wall, with with diffuse diffuse mural mural thickening. thickening. The The uterus uterus and and both both ovaries ovaries appeared appeared to beto normal.be normal. We decidedWe decided to perform to perform a pelvic a pe MRIlvic which MRI which showed showed a 16/18/32