Appendicitis masquerading as malignancy

J L Baker; S Gull; E C Jesudason; L J Abernethy; P D Losty

doi:10.1136/adc.2002.025817

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Acute paediatrics

Appendicitis masquerading as malignancy

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Diagnosing appendicitis in young children
Francisco Abecasis
Published on: 22 March 2016
Diagnosis of intraabdominal masses prior to biopsy is not alwasy easy
Tom S Walwyn
Published on: 22 March 2016

Published on: 22 March 2016
Diagnosing appendicitis in young children
- Francisco Abecasis, Resident in Paediatrics
- Other Contributors:
  Luisa Carmona, Isabel Vieira, Orlando Cordeiro
Dear editor,
We found this article very interesting, especially because we had a similar case at our Hospital this year.
A 3 year old female presented to the emergency department complaining of dysuria and vague abdominal pain. The urinalysis revealed no signs of infection and she was sent home. A week later she returned with the same complaints. An abdominal ultrasound showed a pelvic mass with solid...
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Dear editor,
We found this article very interesting, especially because we had a similar case at our Hospital this year.
A 3 year old female presented to the emergency department complaining of dysuria and vague abdominal pain. The urinalysis revealed no signs of infection and she was sent home. A week later she returned with the same complaints. An abdominal ultrasound showed a pelvic mass with solid and cystic components and the left ovary could not be visualized. An abdominal computed tomography confirmed the 6x7 cm pelvic mass and showed intralesional calcifications. A diagnosis of probable ovarian teratoma was made. She was referred to paediatric surgery. The studies showed leucocytosis 16500/uL (N 59%; L 35%); CRP 2,6 mg/dL; erythrocyte sedimentation rate 70 mm; Beta–HCG <_10 mui="mui" ml="ml" alpha-="alpha-" fetoprotein="fetoprotein" _39="_39" ng="ng" r.v.10.="r.v.10." at="at" the="the" paediatric="paediatric" surgery="surgery" consult="consult" abdominal="abdominal" pain="pain" was="was" very="very" strong="strong" and="and" urgent="urgent" laparotomy="laparotomy" had="had" to="to" be="be" done="done" with="with" hypothesis="hypothesis" of="of" ovarian="ovarian" teratoma="teratoma" torsion.="torsion." a="a" large="large" pelvic="pelvic" appendiceal="appendiceal" abscess="abscess" drained="drained" appendicectomy="appendicectomy" performed.="performed." patient="patient" discharged="discharged" home="home" on="on" day="day" seven="seven" after="after" completing="completing" _6="_6" days="days" metronidazole="metronidazole" ampicillin="ampicillin" gentamicin.="gentamicin." p="p"/> Our case is very similar to the ones described by Baker et al. except for the much younger age of our patient. Diagnosing appendicitis poses a great challenge in children less than four years old, but one should remember it in the differential diagnosis of abdominal pain even if the complaint is not acute.
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Diagnosis of intraabdominal masses prior to biopsy is not alwasy easy
- Tom S Walwyn, Paediatric Registrar
- Other Contributors:
  Bert Shugg, Edmund Fenton
Dear editor,
We present a case that illustrates the points made by Baker et al, and emphasises the need for care in the diagnosis of mass lesions.
N.B is a 14 year old girl who presented with a 3 week history of diarrhoea, intial vomiting and malaise. She was seen by her general practitioner on the day of admission as the family were concerned about continued loose bowel motions and her ongoing malaise....
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Dear editor,
We present a case that illustrates the points made by Baker et al, and emphasises the need for care in the diagnosis of mass lesions.
N.B is a 14 year old girl who presented with a 3 week history of diarrhoea, intial vomiting and malaise. She was seen by her general practitioner on the day of admission as the family were concerned about continued loose bowel motions and her ongoing malaise. An ultrasound arranged by the GP showed 3 pelvic mass lesions. Examination showed an abdomen moderately distended by the masses, which were tense and only mildly tender. CT showed a 10.5x10x12cm mass in the pouch of douglas, with 2 smaller lesions in the left iliac fossa region measuring 6x3.5x5cm and 5x3.5x7cm. On ultrasound they appeared of mixed echogenicity, and the diagnosis of malignancy was considered, but CT showed them to be of fluid density, raising the possibility of infection. There was evidence of bilateral ureteric obstruction.
Laparotomy confirmed the diagnosis of appendix abscesses, with ongoing concern regarding the lesion on the Pouch of Douglas which includes Uterus, ovaries and loops of bowel.
We are grateful to Baker et al for raising the profile of this differential, as the family had assumed the worst in this case, as do many others (including doctors) when mass lesions are identified on clinical and radiological examination.
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Conflict of Interest:
None declared.
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