A 21-year-old Caucasian woman, previously healthy and asymptomatic with no family history of abdominal disease, presented with 2 months of recurrent, dull abdominal pain in the upper part of her abdomen with no radiation that lasted for 1–2 days approximately twice a week. The pain was often accompanied by fever and 2–3 times by nausea and vomiting and was not associated with defecation or urination. There were no known aggravating or alleviating factors of the abdominal pain. The symptoms initially began with 1 week of gastroenteritis starting the day of her return from a backpacking holiday to the Maldives, Sri Lanka, Bali, and Singapore. After the first week, she had no recurrent episodes of diarrhea and no weight loss, but continued with recurrent episodes of abdominal pain and fever. She had no complaints of abdominal pain prior to her holiday. On examination, we found distinct abdominal tenderness in the right lower quadrant with no palpable tumors. She had a leukocyte count of 7.9 × 109/L (normal range: 3.5–8.8 × 109/L), C-reactive protein (CRP) 37 mg/L (normal range: < 10 mg/L), and normal hemoglobin and liver-parameters. Urine human chorionic gonadotropin (U-hCG) was negative and fecal calprotectin < 30 × 10−6 (normal range: < 50 × 10−6). Given the initial suspicion of traveler's diarrhea or another tropical infectious disease, several microbiological examinations were undertaken, including malaria testing × 3, blood cultures; fecal cultivation and polymerase chain reaction (PCR) for pathogenic bacteria, virus, and parasites (Table 1); fecal samples for analyses of intestinal worms, eggs, and cysts; and tests for human immunodeficiency virus (HIV), hepatitis A/B/C, cytomegalovirus, and Epstein–Barr virus. All tests were negative. An ultrasonic scan was performed, displaying a thickened, hypoechoic, and hyperemic appendix with edema of the surrounding fat (Figure 1). Due to the patient history, the diagnosis of chronic appendicitis was suggested, but as the findings were considered controversial, an additional computed tomography (CT) scan was performed confirming the suspicion of chronic appendicitis with segmental thickening and increased contrast uptake of the appendix. No antibiotics were prescribed. Elective surgery was planned, but due to worsening of the abdominal pain the patient underwent acute surgery 1.5 months after the first hospital visit, hence 3.5 months after her symptoms began.
Patient 1. Ultrasound of lower right quadrant. Ultrasound of the right lower quadrant (area of maximum tenderness) displaying layering and thickening (10 mm) of the distal appendix with increased vascularity and moderate periappendicular edema. No abscess or signs of perforation
The pathological examination of the appendix showed signs of previous perforation, transmural chronic inflammation including fibrosis, and non-necrotizing granulomas. Testing for tuberculosis and fungal and specific microorganisms (periodic acid-Schiff stain for fungal organisms and parasites) were negative.
Eighteen months after the appendectomy, the patient was symptom-free.
A 34-year-old Caucasian man, previously healthy with no family history of abdominal disease, was referred to the specialist fast-track department to rule out possible malignancy due to unintended weight loss of 8 kg during the past 9 months despite no changes in his usual diet. In the same time period he had experienced four episodes, lasting approximately 1 week, of fever and lower abdominal pain, accompanied by vomiting on the first day. The episodes were self-limiting without any antibiotic treatment. On examination, the patient had abdominal tenderness in the left lower quadrant. Hemoglobin level was 8.5 mmol/L, leukocyte count of 7.2 × 109/L, CRP 160 mg/L, and D-dimer 1.4 U/L (normal range: < 0.5 U/L). Other blood results included thrombocytes, liver enzymes, creatinine, thyroid stimulating hormone, hemoglobin A1c, M-component, and antinuclear antibodies—all normal. Fecal calprotectin was 37 × 10−6, no fecal occult blood testing was performed. HIV testing and fecal cultivation and PCR for pathogenic bacteria were negative (Table 1). Blood cultures became positive after 1 day of incubation with growth of Bacteroides fragilis and Streptococcus intermedius. 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) showed increased diameter and signal of the appendix corresponding to inflammation of the appendix and thrombosis in the superior mesenteric veins (Figure 2. Colonoscopy was normal.
Patient 2. 18F-FDG PET/CT. A CT-scan with intravenous and per oral contrast (transaxial plane) of the abdomen at the level of the appendix showing increased diameter of the appendix. B 18F-FDG PET (transaxial at the same level as the CT scan) coincides with the increased diameter of the appendix observed on the CT scan. C Combined 18F-FDG PET/CT showing the increased signal in the appendix corresponding to inflammation of the appendix. D Maximum intensity projection (MIP)
The patient was treated with antibiotics for 7 days (meropenem 1 g intravenously 3 times daily for 3 days followed by moxifloxacin 400 mg orally for 4 days, in conjunction with metronidazole 500 mg orally 3 times daily for the full 7 days ) and the symptoms resolved. The thrombosis was treated with warfarin for 6 months. 18F-FDG PET/CT 1 month later showed regression of the previous findings and hence appendectomy was not undertaken.
Nineteen months later, during which time he had been symptom free, the patient was admitted with acute abdominal pain with localized rebound tenderness on palpation in the right lower quadrant. He was afebrile, with a leukocyte count of 11.9 × 109/L and CRP of 18 mg/L. No radiological imaging was undertaken. Laparoscopic appendectomy revealed a phlegmonous, gangrenous appendix with adherences to the adjacent terminal ileum mesentery. The pathology report described an ulcerated surface with acute transmural inflammation, no granuloma, and no malignancy.
Eight months after the appendectomy the patient was symptom-free.
J Med Case Reports. 2022;16(51) © 2022 BioMed Central, Ltd.