Volume 4, Case 10
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaiʻi John A. Burns School of Medicine
This is a 3-year old male presenting to the E.D. following a 5-minute generalized tonic-clonic seizure at home associated with a high fever. He underwent a surgical procedure to excise a neck mass three days ago and was placed on cephalexin. The operative report indicates that the neck mass is felt to be a calcified masseter muscle, however, the pathology report on the specimen excised is still pending. He developed fever yesterday and was evaluated for a possible wound infection yesterday. However, the wound appeared to be healing well, and his fever was attributed to a viral infection. He vomited twice last night. His fever was noted to be 38.9 degrees at home last night. He was not given any antipyretics after he was put to bed. He experienced a seizure in the morning at 7:30 a.m. and was brought to the E.D. by ambulance. His appetite has been noted to be poor, and his parents also noted that he was complaining of right-sided abdominal pain. He denies any headache or dysuria. His parents have not noted any respiratory symptoms. An acetaminophen suppository is administered by the nursing staff.
Exam: VS T39.7 (oral), P160, R22, BP 114/74, oxygen saturation 98% in room air. He is alert and not toxic. He is not irritable when observed from across the room. He begins to cry when he is approached. Head without evidence of trauma except for the surgical wound of his right jaw region. The wound is healing well without signs of infection. Eyes: PERRL, EOMI, conjunctiva clear. TM's normal. Oral clear and moist. Neck supple. No meningismus. Heart regular without obvious murmurs. Lungs clear. He is not noted to be coughing. Abdomen, soft, flat, bowel sounds active. He is crying a lot, but he appears to have some reproducible tenderness in his right lower quadrant. No hernias. Testes normal. No obvious back tenderness. He ambulates well and uses all his extremities well. When asked to jump or cough, he is too apprehensive to cooperate.
Laboratory studies: CBC WBC 9,000, 14% bands, 72% segs, 7% lymphs, 3% monos, 2% eos, 2% atypical lymphs. Hgb 13.3, Hct 38.0, platelet count 398,000. Glucose 95 mg/dl. Electrolytes 135/4.0/100/21. UA SG 1.035, 1+ ketones, otherwise negative.
An abdominal series is obtained.
View abdominal series: Flat (supine) view.
Upright view.
Consider the differential diagnosis at this time in view of the febrile seizure. Is appendicitis a possibility? Although anything is possible, the diagnosis of appendicitis is not immediately obvious, but it is a possibility. While localization of tenderness to the right lower quadrant is a sign highly predictive of appendicitis, this is not easy to determine in very young children. The tenderness may be poorly localized or its localization may be deceiving. A poorly cooperative child is difficult to examine, but most children with appendicitis prefer to lie still since crying and moving about result in more pain. Our patient's signs and symptoms suggestive of appendicitis include anorexia, fever, vomiting, and right lower quadrant abdominal tenderness. Signs not consistent with appendicitis include a crying and moving child and a normal gait. A leukocyte count of 9,000 is not very high (this does not necessarily rule out appendicitis).
When viewing the abdominal radiographs in a patient suspected of having appendicitis, the findings are often non-diagnostic unless they demonstrate free air or a fecolith. Other radiographic signs suggesting appendicitis include thickening of the cecal wall, indistinct psoas shadows, scoliosis concave toward the right (patient splinting from RLQ pain), focal obliteration of the adjacent properitoneal fat stripe, presence of air in the appendix, sentinel loops in the right lower quadrant (dilated loops in the RLQ in an otherwise relatively gasless abdomen), ileus, etc.
Questions:
Are the radiographic findings helpful in this case?
If so, what radiographic findings are evident?
What diagnostic study, if any, should be ordered next?
This patient's abdominal radiographs demonstrate the presence of a fecolith. There is a spherical calcification in the right lower quadrant. It is easier to appreciate on the flat view. It is difficult to appreciate on the upright view. Turn the room lights down and adjust the contrast and brightness on your monitor
Close-up of the fecolith in the two views:
The presence of a fecolith on an abdominal radiograph is highly predictive of appendicitis. Thus, no other diagnostic studies are indicated at this point. A surgeon should be consulted at this point. It may be difficult to distinguish other RLQ circular densities from a fecolith. A fecolith may display laminations (concentric circles) on magnification. However, I have never been able to appreciate this myself.
While we order many radiographs for possible appendicitis, these radiographs are rarely helpful. In this case, a young child who is difficult to examine presents with a febrile seizure and non-specific symptoms. His surgical procedure three days ago is distracting and totally unrelated to his current illness (a red herring). It is not obbious that he has appendicitis and in such a case, the examiner may not scrutinize the radiographs as carefully as in other cases when the diagnosis of appendicitis seems more likely. Avoid this pitfall. If you're going to order an abdominal series, scrutinize it well. Abdominal films are notorious for revealing an unsuspected serious diagnosis in an occult fashion.
References