A 66-year-old man originally from the Philippines with a history of amyotrophic lateral sclerosis came to our emergency ward with suprapubic pain localizing to the right lower quadrant, a low-grade fever (temperature, 38.1°C), and tachycardia (heart rate, >100 beats/min). Initially, he was minimally communicative and dependent on a gastrostomy tube for his feedings. Given the debilitation from his neurologic disease, a broad workup including laboratory and radiologic studies was initiated. His chemistry panel, urinalysis, and blood culture results were normal. His liver enzyme panel revealed a mildly elevated total bilirubin level of 22 μmol/L (1.3 mg/dL). His white blood cell count was mildly elevated at 10 300 cells/mL. He had a left shift with 83 neutrophils, bandemia (14%), and no eosinophils. His radiologic workup revealed a normal abdominal series. A computed tomographic scan was performed, demonstrating a hyperemic appendix and pericecal fluid without abscess (Figure 1). The patient was taken to the operating room and a routine laparoscopic appendectomy was performed. There was significant periappendiceal fibrosis. The appendix was noted to be purulent and grossly perforated. The appendix was removed successfully. The pathologic analysis of the specimen contained mineralized eggs throughout the appendix (Figure 2).
A computed tomographic image of the abdomen showing a hyperemic appendix (arrow) and pericecal fluid without abscess.
The infiltrate consists of plasma cells, lymphocytes, neutrophils, and rare egg-containing giant cells. The eosinophils commonly seen in acute infections are absent. The eggs (arrow) have inconspicuous spines (paraffin-embedded specimen, hematoxylin-eosin, original magnification ×40).
A. Perforated schistosomal appendicitis
B. Perforated appendiceal cryptosporidiosis
C. Perforated appendiceal cancer
D. Perforated cecal diverticulosis
Garg J, Bakhtar OR, Ramamoorthy S. Image of the Month—Quiz case. Arch Surg. 2007;142(5):487. doi:10.1001/archsurg.142.5.487