Ruptured Appendiceal Abscess Presen@ng as a UTI in a Pediatric Pa@ent Rachel E. Herdes, MS4
Jennifer Weber, MD
John M. Taylor, PhD
Kansas City University of Medicine and Biosciences
Phoenix Children’s Hospital
Kansas City University of Medicine and Biosciences
Introduction
Pelvic Ultrasound
Appendici@s is the most common cause of emergent abdominal surgery in the pediatric popula@on. It presents most frequently during the second decade of life, but has an incidence of up to 28 per 10,000 children younger than 14 years of age. The rate of ruptured appendici@s has been reported to be higher in children than adults, but is oHen difficult to diagnose due to frequent atypical physical exam findings and presen@ng symptoms that overlap with other common pediatric illnesses such as gastroenteri@s. The classical presenta@on of appendici@s includes findings such as anorexia, early periumbilical abdominal pain migra@ng to the right lower quadrant, vomi@ng, fever, and signs of peritoneal irrita@on. These signs, however, are most oHen seen in adult pa@ents and can be absent or variable in pediatric pa@ents. Observa@onal studies of school-­‐age children (ages 5-­‐12 years) have shown that these pa@ents will oHen present with difficulty walking, anorexia, abdominal tenderness in the right lower quadrant, and involuntary guarding if perfora@on has already occurred. Discussion
Midline abdominal mass measuring 9.1 x 6.7 x 13.1 cm which demonstrates posterior acous@c enhancement and mul@ple internal air bubbles, concerning for abscess forma@on. Case Report
We present the case of a 9-­‐year-­‐old previously healthy female who presented with a 10-­‐day history of intermi:ent low-­‐grade fevers, dysuria, generalized abdominal pain, and suprapubic tenderness, which was exacerbated by urina@on. A complete review of systems was posi@ve for a decrease in appe@te and nausea without associated vomi@ng. The pa@ent had no past surgical history and was up-­‐to-­‐date with her immuniza@ons. She had been prescribed Keflex four days prior to admission for a suspected urinary tract infec@on. Subsequent physical exam revealed a well nourished, comfortable appearing female with a soH, non-­‐distended abdomen, normal bowel sounds, and mild suprapubic tenderness upon deep palpa@on. Pa@ent had no abdominal guarding or rigidity, no CVA tenderness, and no rebound or peritoneal signs. She was able to walk and jump without visible signs of discomfort. CBC revealed a WBC of 34.1 with 82% neutrophils and 3% lymphocytes. CMP and liver enzymes were unremarkable. A urinalysis demonstrated moderate leukocyte esterase, 56 WBCs, and few bacteria. A pelvic ultrasound unexpectedly revealed a midline mass measuring 9.1 x 6.7 x 13.1 cm. A CT of the abdomen and pelvis with contrast was then ordered, showing an abscess within the lower abdomen and pelvis measuring 12.9 cm with mild right lower quadrant and pelvic free fluid. These results, together with the clinical examina@on and a lack of improvement of symptoms with Keflex therapy, were probable evidence to conclude that the pa@ent had a ruptured appendiceal pelvic abscess. Signs and Symptoms of Acute Appendici@s in Children (Emergency Medicine Prac@ce, 2000) © 2015 Kansas City University of Medicine and Biosciences
Signs and Symptoms of Urinary Tract Infec@ons (Mayo, 2015) CT Abdomen and Pelvis with Contrast
While it is widely known that the pediatric popula@on is at a high risk of developing appendici@s, the variability in presenta@on can present a diagnos@c dilemma. Up to 82% of school aged children with underlying appendici@s will have right lower quadrant abdominal tenderness; however, there is a small cohort of pediatric pa@ents who will not present with pain in this loca@on. Thus, while careful abdominal examina@on can be per@nent to the discovery of appendici@s, a high index of suspicion must also be present for those pa@ents who do not present with the typical clinical findings of appendici@s, but whom may present with symptoms of other common pediatric illnesses such as gastroenteri@s or urinary tract infec@ons. This case represents an unexpected presenta@on of a ruptured appendiceal abscess in a previously healthy pediatric female with no dis@nct clinical features of appendici@s. It provides evidence that clinicians should maintain the possibility of appendici@s and ruptured appendiceal abscesses in their differen@al diagnoses for pa@ents who present with signs and symptoms of urinary tract infec@ons, which may be refractory to an@bio@c treatment. Pa#ent Outcome: Pa@ent was placed on IV an@bio@cs during hospitaliza@on and had the pelvic abscess drained by interven@onal radiology. AHer several days, she was discharged home with oral an@bio@cs and a drain in place. Outpa@ent follow-­‐up with surgery a few days later found the pa@ent to be doing well and she was able to have her drain removed. References
Abscess within the lower abdomen and pelvis measuring 12.9 cm with mild right lower quadrant and pelvic free fluid. Amin P, Cheng D. Management of Complicated Appendici@s in the Pediatric Popula@on: When Surgery Doesn’t Cut It. Seminars in Interven-onal Radiology. 2012;29(3):231-­‐236. Brown C, Kang L, Kim ST. Percutaneous Drainage of Abdominal and Pelvic Abscesses in Children. Seminars in Interven-onal Radiology. 2012;29(4):286-­‐294. Brown L, Jones J. Acute Abdominal Pain in Children: “Classic” Presenta@ons vs. Reality. Emergency Medicine Prac@ce. 2000; 2(12): 1-­‐24. Clinical Manifesta@ons in Children with Ruptured Appendici@s. Pediatric Emergency Care. 28(5):433-­‐435, May 2012. Urinary Tract Infec@on (UTI): Symptoms. Mayo Clinic. Web. 16 Apr. 2015. h:p://
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