Case Report |
Corresponding author: Ioannis Katsaros ( ioankats@med.uoa.gr ) © 2022 Anargyros Bakopoulos, Nikolaos Koliakos, Ioannis Katsaros, Natasha Hasemaki, Dimitrios Tsapralis, Diamantis I. Tsilimigras, Dimitrios Moris, Dimitrios Schizas.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Bakopoulos A, Koliakos N, Katsaros I, Hasemaki N, Tsapralis D, Tsilimigras DI, Moris D, Schizas D (2022) An extremely rare clinical manifestation of acute appendicitis in a nonagenarian patient: lessons still to be learned. Folia Medica 64(3): 527-531. https://doi.org/10.3897/folmed.64.e62008
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Abstract
Acute appendicitis is associated with a relatively high mortality rate among elderly patients due to the unusual clinical presentation that often leads to misdiagnosis and, in turn, severe complications.
This report describes an extremely uncommon clinical manifestation of acute appendicitis in an elderly patient - a subcutaneous abdominal wall abscess initially treated as cellulitis. Despite the initial misdiagnosis, contrast-enhanced computed tomography revealed a circumscribed inflammatory process of the appendix that was in close proximity to the abdominal wall. The patient underwent a surgical drainage of the abscess, received broad-spectrum antibiotics, and was discharged on day 12 following an uneventful course.
Diagnosis of acute appendicitis in elderly patients is challenging due to the atypical clinical presentation and co-existing comorbidities that can be misleading. Early application of high-resolution imaging techniques is necessary to identify the cause of acute abdomen in the elderly population.
appendicitis, case report, nonagenarian
Acute appendicitis remains one of the most frequent causes of acute abdomen with a lifetime risk reaching up to 7%.[
Complicated appendicitis is more frequently encountered in the elderly population and is associated with increased morbidity and mortality rates.[
Herein, we present a case of an elderly woman treated for acute appendicitis after presenting with a subcutaneous abscess of the abdominal wall.
This case presentation was carried out following the Declaration of Helsinki and CARE Guidelines (Consensus-based Clinical Case Reporting Guideline Development) and an informed patient’s consent was obtained. [
At the time of admission, her vital signs were normal, whereas physical examination revealed a painful redness of the skin covering the right iliac region and the hypogastrium (Fig.
Empirical antibiotic therapy with vancomycin (1 g b.i.d.) and piperacillin/tazobactam (4+0.5 g t.i.d.) was initiated combined with parenteral nutrition. The patient underwent a surgical exploration of the abscess cavity. Drainage of the abscess was performed and necrotic subcutaneous tissue was excised. A 10-cm incision was conducted both at the right and left lower abdomen, as the combined image of a subcutaneous abscess along with the surrounding abdominal wall fasciitis warranted surgical drainage and an extensive debridement as well. Surgical procedure was not extended in the abdominal cavity and no appendectomy was performed due to the extensive inflammation of the area. The wound was left open and dressings were changed on daily basis. The culture of the abscess was positive for Staphylococcus warneri and Escherichia coli, therefore adjusting the antibiotic therapy accordingly for the remaining hospitalization period. A vacuum assisted closure (VAC) device was applied to the wound four days later.
A computed tomography was repeated five days after initial admission that showed a remarkable remission of the abdominal wall inflammation (Figs
The abdominal wall of the patient during the drainage operation. A red swelling extends from right anterior superior iliac to the pubic symphysis.
CT-scan demonstrates an abscess in the subcutaneous tissue of the hypogastrium. The inflamed appendix (black arrow) is in close proximity to the abscess. Sagittal reconstruction shows inflamed appendix as the cause of the subcutaneous abscess.
CT-scan at the level of the anterior superior iliac spine demonstrates the subcutaneous abscess with gas bubbles (white arrow) before the drainage and five days following the drainage.
Acute appendicitis is one of the most frequent surgical emergencies, with an overall lifetime risk of 7%–8% in general population, while the same percentage falls to 3%-4% in elderly patients.[
Literature search yielded three cases of appendicular abscess of the abdominal wall, one extending to the superior lumbar triangle[
Due to the usually atypical presentation in elderly patients, the diagnosis of acute appendicitis is particularly challenging in this age group. A variety of physiological changes in the elderly such as lower baseline body temperature, attenuated response to pyrogens, and compromised T-cell response may alter patient inflammatory response in the setting of acute appendicitis. The existing co-morbidities and the absence of the hallmark signs of acute appendicitis in these patients may also complicate the diagnostic process. Indeed, elderly patients are more likely to present with delayed signs and symptoms, which usually leads to the development of severe complications such as perforation, abscess formation, and sepsis.[
Current evidence suggests that 50% to 70% of elderly patients with appendicitis are correctly diagnosed on admission and approximately 5% of elderly patients are diagnosed intra-operatively.[
In a recent cohort study, Segev et al.[
No consensus has been reached regarding the preferred treatment approach for elderly patients diagnosed with acute appendicitis.[
In conclusion, the current case represents an uncommon clinical manifestation of acute appendicitis - subcutaneous abscess of the lower abdominal wall. The atypical presentation of acute appendicitis in this age group may delay diagnosis and compromise patient outcomes. The high rates of misdiagnosis highlight the importance of a high index of suspicion and the use of contrast-enhanced computed tomography early in the diagnostic process to prevent severe complications in this challenging group of patients.
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Competing Interests
The authors have declared that no competing interests exist.