Clinical Considerations: Atypical Clinical Presentation

Case 1

Perforated appendicitis with leukemia

13 year old girl with acute myelocytic leukemia and neutropenia presented with a history of fever for one week followed by periumbilical pain and tenderness. Initial CT examination (not shown) showed minimal mesenteric infiltration. The patient was discharged home, but experienced persistent pain which worsened as her white count recovered to normal in response to therapy with granulocyte stimulating factor. Repeat CT scan performed one month following onset of symptoms is shown below.

Figure 1. Axial CT image through the upper pelvis demonstrates a complex fluid collection; representing an abscess (arrows), adjacent to the cecum (C).
Figure 2. CT image slightly lower than Figure 1 shows extension of the abscess (arrows) into the right pelvis.
Figure 3. CT image more superior in location than Figure 1, at the level of the lower pole right kidney (K), shows cranial extent of the inflammatory mass, representing a mesenteric abscess(A), anterior to the IVC (C).
Figure 4. CT image more superior in location than Figure 3, at the level of the renal hila, shows dilatation of the right renal pelvis (arrow), resulting from obstruction caused by the abscess.
Surgical findings included an inflamed, perforated appendix and associated abscess.

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Case 2

Crohn's disease with superimposed acute appendicitis.

17 year old girl with right lower quadrant pain and diarrhea for one week duration had an air contrast barium enema , shown below.

Air contrast barium enema shows an abnormal contour of the base of the cecum (C) and nodular, irregular contours of the appendix (arrows). Note extension of the appendix into the right pelvis.
The patient had Crohn's disease involving the cecum and appendix with superimposed acute appendicitis.

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