Ann Thorac Surg 2004;78:1086-1088
© 2004 The Society of Thoracic Surgeons
Case report
Pericarditis as complication of appendicitis
Edward C. T. H. Tan, MD*,a,
Paul N. M. A. Rieu, MD, PhDa,
Aagje Nijveld, MDa,
Ad P. C. M. Backxa,
Jacques F. G. M. Meis, MD, PhDa,
René S. V. M. Severijnen, MDa
a Department of General Surgery, Pediatric Surgery, Pediatric Cardiology and Cardiothoracic Surgery, University Medical Center Nijmegen, Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
Accepted for publication July 3, 2003.
* Address reprint requests to Dr Tan, Department of Surgery, 410, PO Box 9101, University Medical Center St. Radboud, 6500 HB Nijmegen, the Netherlands.
e.tan{at}chir.umcn.nl
 |
Abstract
|
|---|
Pericarditis as a complication of appendicitis is a rare event. In a 25-year period we encountered two pediatric cases with this severe complication due to (a)typical presentation of appendicitis resulting in small bowel obstruction, intraabdominal abscesses, constrictive pericarditis, and purulent pericarditis.
|
Introduction
|
|---|
Appendicitis is a common presentation especially affecting patients between 15 and 30 years of age. The lifetime appendicitis risk amounts to 8.6% for men and 6.7% for women in the USA [1]. The classic presentation of appendicitis is well known. However children present often with several nonspecific complaints resulting sometimes in a delayed diagnosis or, worse, a misdiagnosis. We present two children with severe complications due to an acute appendicitis.
|
Case reports
|
|---|
Patient 1
Patient 1, a 12-year-old girl, presented in another hospital with abdominal pain, joint pain, pain in the right thigh and back, and diarrhea existing for 8 days. After 4 days the abdominal pain was diminished, but a fever developed (39°C) with shivers. On admittance she was sick and collapsed several times when sitting up right. The heart sounds were normal and no murmurs or pericardial friction were heard. Her abdomen was tender and distended with minimal bowel movement. Laboratory investigations showed a white blood cell count of 27.1 x 109/l and an erythrocyte sedimentation rate (ESR) of 41 mm in the first hour. On abdominal radiograph there were signs of bowel obstruction and a chest radiograph revealed pleural effusion and probably an infiltrative process. The abdominal sonography was normal. She was started on ceftriaxone (100 mg/kg/d) for a suspected pneumonia that same day. A control chest radiograph showed pleural effusion and also an enlarged cardiac silhouette. Blood cultures became positive with Bacteroides fragilis and Streptococcus milleri. Metronidazole was added. She continued having fever despite broad-spectrum antibiotic coverage and remained tachypneic. On echocardiographic examination progressive pericardial effusion was seen. The decision was then made to insert a pericardial drain percutaneously, which produced 600 mL serosanguinolent fluid, and she improved clinically. Culture of the pericardial fluid showed Escherichia coli, Viridans streptococci, and Candida albicans, but no anaerobes were detected. Antibiotic treatment was switched to amoxicillin/clavulanic acid and fluconazole. Moreover dexamethasone was started. After 4 days the drain was removed, but the same day the pericardial fluid returned again. She was transferred to our university hospital. On echocardiography a pneumo-hydropericard was seen without signs of a cardiac tamponade. A chest and abdominal computed tomogram (CT) scan confirmed the pneumo-hydropericard and demonstrated an abscess in the right lung (Figure 1) and a process in the right abdomen suggesting a psoas abscess (Figure 2). Our hypothesis was that the clinical signs could be attributed to a retrocecal perforated appendix, followed by abdominal and pericardial effusion. No acute abdominal operation seemed indicated at that time. Corticosteroids were tapered down and stopped. Because of a developing septicemia with increasing abdominal pain she was operated 12 days later. We performed an appendectomy and surgically drained the abdominal abscess. Pathologic examination demonstrated severe active peri-appendicitis.
View larger version (138K):
[in this window]
[in a new window]
|
Fig 1. Contrast-enhanced chest computed tomogram from patient 1 showing a pneumohydropericard and a right-sided abscess in the lung.
|
|
View larger version (128K):
[in this window]
[in a new window]
|
Fig 2. Contrast-enhanced abdominal computed tomogram from patient 1 showing a process in the lower right abdomen suggesting a psoas abscess.
|
|
Abdominal cultures showed aerobic gram-negative rods, anaerobic positive cocci, and enterococci. She continued receiving amoxicillin/clavulanic acid and recovered quickly after the surgery. Nine days later she collapsed when getting upright. A new echocardiogram showed a markedly thickened pericardium with little pericardial effusion. The inferior caval vein and the hepatic veins were dilated with low flow velocities. There was antegrade pulmonary blood flow in diastole during atrial contraction with a maximal velocity (Vmax) of 0.39 m/s (0.50 m/s in systole) not seen before. Apparently, in a short period of time, the right ventricle has developed a resistance to filling thereby acting as a conduit between right atrium and pulmonary artery. The most logical explanation for this patient is the development of constrictive pericarditis. Because of the hemodynamic unstable situation emergency cardiac surgery was deemed necessary. Partial pericardial resection and decortication of the epicard was performed through a median sternotomy. No cultures were taken at this time. Her further recovery was uneventful and she was discharged home 1 month later.
Patient 2
Patient 2, a 13-year-old girl without medical history, presented with epigastric discomfort for one day (note: this patient was seen and treated 25 years ago). Later this pain was more localized in the right lower quadrant. She was nauseated and vomited during the night. She had no diarrhea. Palpation of the abdomen disclosed localized tenderness and rebound tenderness in the right lower quadrant. Her temperature was 37.7°C, her white blood cell count 11.5 x 109, and she had an ESR of 17 mm in the first hour. Appendicitis was diagnosed and an appendectomy was performed. During surgery the appendix perforated. The appendiceal stump was inverted and tied with a purse string. A faecolith was found in the appendix. Antibiotic treatment was started with amoxicillin, but after 1 day treatment was switched to methicillin for 5 days. A persisting fever developed and abdominal sonography revealed multiple intraabdominal abscesses. Pus evacuation through her vagina occurred and culture showed Escherichia coli, anaerobic rods (Bacteroides vulgatus), and Peptostreptococcus species. A relaparotomy was performed after 11 days and a Douglas abscess was evacuated. Antibiotic treatment was changed to doxycycline and metronidazole. After the second surgical intervention she recovered, but slowly. On physical examination a systolic and diastolic murmur was found with crepitations and ascites was also present. The liver could be palpated and a chest radiograph demonstrated an enlarged heart contour with low voltage changes on an electrocardiogram. Pericarditis was suspected and furosemide treatment was started. However she did not improve and became septic. Echocardiography showed a purulent pericarditis and an abdominal sonography demonstrated a subphrenic abscess and a Douglas abscess.
The cardiac surgeon performed a partial pericardectomy 25 days after the appendectomy through an anterolateral left thoracotomy. The pericardium and left pleural space were drained and cultures remained negative. This was followed by relaparotomy to evacuate all abscesses. Antibiotics were switched to flucloxacillin, gentamicine, and lincomycin. Three days later a relaparotomy was necessary due to a postoperative cecum perforation. A small bowel resection was necessary (20 cm) and a split ileostomy was made. Several abscesses were drained. After a slow recovery 2 months later the ileostomy was closed. Seven years later she had surgery for a small bowel obstruction with strangulation. Many adhesions were removed and two small bowel resections (50 cm) were necessary. Nine years later she experienced a period of passage problems which resolved spontaneously. Now 25 years later she has one healthy child and is again pregnant by in vitro fertilization.
|
Comment
|
|---|
Even in the 21st century it is sometimes difficult to diagnose appendicitis in children correctly. A delayed diagnosis is often responsible for severe morbidity and even mortality in children [2, 3]. Here we describe two children with pericarditis as a severe complication of a perforated appendix. Only two cases were reported previously in the literature of this rare complication of appendicitis: one in a 7-year-old child [4] and the other in a 58-year-old adult [5]. The classic presentation of appendicitis, poorly localized peri-umbilical pain, followed by nausea and vomiting with subsequent shift of pain to the right lower quadrant occurs only in 50%–60% of patients [1]. For patient 1 making the correct diagnoses was very difficult. Pericarditis was diagnosed 14 days from the start of the symptoms and the cause of this, a perforated appendix, was made 19 days from the beginning of the symptoms. The reasons for misdiagnosis include the difficulty of interpreting the aspecific symptoms in the young child, communication problems with the child, and the presence of diarrhea which can mimic gastroenteritis. Additional laboratory investigations, like white blood cell count, ESR and C-reactive protein, are nonspecific. Specific radiologic evaluations include sonography and CT although in patient 1 the first abdominal sonography did not reveal intraabdominal problems.
For patient 1 the clinical course suggested a perforated appendix during the prehospital phase of her illness. This perforation led to transient bacteremia and hematogenous seeding of the pericardium and the formation of small asymptomatic abscesses. The onset of acute abdominal pain correlated with the subsequent cecal perforation. For patient 2 the symptoms seemed clear in diagnosing appendicitis. Because only amoxicillin was started anaerobic bacteria were not covered which could have caused the purulent pericarditis.
Clinically pericarditis presents with fever, tachycardia, dyspnea, and shallow respiration with chest pain which are almost always present. Some children even complain of abdominal pain. On physical examination neck vein congestion, liver enlargement, and hypotension can be found if a cardiac tamponade is developing. A typical pulsus paradoxus (difference of more then 20 mm Hg) can be felt. Depending on the amount of pericardial fluid it is difficult to hear a pericardial friction rub. Muffled heart sounds may be the only finding on auscultation.
Any patient with a rapidly increasing heart size in the absence of increasing pulmonary vascular markings should be suspected of having a pericardial effusion. The electrocardiogram (ECG) sometimes shows typical low voltages of the QRS (ventricular complex on ECG) complexes resulting from a damping effect of the pericardial fluid. Mild segment (ST) elevation and T-wave inversion may appear later. No abnormalities were found in either of our patients. A considerable amount of pericardial effusion must be present to cause an enlarged cardiac shadow on a chest roentgenogram. Sometimes a water-bottle configuration can be found [6]. In most cases, as was seen in our patients, pericarditis is detected due to a cardiomegaly. Treatment consists of pericardial drainage and appropriate intravenous antibiotic therapy. Closed pericardial aspiration can be lifesaving in the case of severe cardiac compression, but without open surgical drainage and removal of adhesions, tamponade almost always recurs. Complications can occur such as arrhythmias resulting from myocardial injury, laceration of the coronary arteries leading to hemopericardium, tamponade, and pneumothorax.
Open pericardial drainage is indicated for treatment of purulent pericarditis. The left anterolateral thoracotomy through the fourth or fifth intercostal space achieves good exposure for removal of a portion of the pericardium (pericardial window) to allow drainage. A subxiphoid approach is another approach mostly reserved for patients too ill for the above [7]. The only effective therapy for constrictive pericarditis is pericardectomy with decortication of the epicardium over a wide area of the heart as was performed in our patient. Controversy exists regarding the approach and the extent of surgery. A variety of surgical approaches have been described including the left anterior thoracotomy, bilateral thoracotomy, or median sternotomy. The best exposure is provided by the latter also giving opportunity to utilize cardiopulmonary bypass [8]. Good results can be obtained with either operative approach. The long-term prognosis is usually good. Most children recover fully with a return to normal activity.
The most common organisms implicated in purulent pericarditis are which are rare causes of purulent pericarditis. For patient 2 the culture remained negative, probably due to the antibiotics which were started before. Broad spectrum antibiotics directed toward gram-negative rods and anaerobes should be given before surgery or at the time of abscess drainage.
Pericarditis frequently arises hematogenously from a distant focus of infection. When pericarditis is reactive the signs and symptoms develop over some time after initial Staphylococcus aureus (26%), Hemophilus influenza type B, Neisseria meningitidIs, and streptococci (20% pneumococci, 10% streptococci) [5, 6]. Patient 1 had polymicrobial flora consisting of Escherichia coli, Viridans streptococci, and Candida albicans. Antibiotics are started as was seen in both patients 1 and 2. Constrictive pericarditis normally occurs months or years after the initial pericarditis but occasionally it may be a rapidly progressive process as in patient 1.
In summary appendicitis can be difficult to diagnose in children. Pericarditis is a serious life-threatening complication. Although rare it can be a sequel of acute appendicitis and may even develop after initial treatment of appendicitis.
|
References
|
|---|
- Rothrock SG, Pagane J. Acute appendicitis in children: emergency department diagnosis and management. Ann Emerg Med. 2000;36:39–51[Medline]
- Bachoo P, Mahomed AA, Ninan GK, Youngson GG. Acute appendicitis: the continuing role for active observation. Ped Surg Int. 2001;17:125–128
- Kokoska ER, Silen ML, Tracy-TF J, Dillon PA, Cradock TV, Weber TR. Perforated appendicitis in children: risk factors for the development of complications. Surgery. 1998;124:619–625[Medline]
- Khristov K, Boicheva A, Kostova S, Mikhova M, Todorov A, Mikhailova V, et al. (Subphrenic abscess and suppurative pericarditis as complications in children with perforated appendicitis)Kum vuprosa za subfrenichniia abstses i gnoiniia perikardit kato uslozhnenie pri detsa s perforativen apenditsit Khirurgiia Sofiia. 1990;43:21–24
- Skiest DJ, Steiner D, Werner M, Garner JG. Anaerobic pericarditis: case report and review. Clin Infect Dis. 1994;19:435–440[Medline]
- Diseases of the pericardium. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson Textbook of Pediatrics. W.B. Saunders: Philadelphia, PA, 2002:1436–9
- Miller JI, Mansour KA, Hatcher CR Jr. Pericardiectomy: current indications, concepts, and results in a university center. Ann Thorac Surg. 1982;34:40–45[Abstract]
- DeValeria PA, Baumgartner WA, Casale AS, Greene PS, Cameron DE, Gardner TJ, et al. Current indications, risks, and outcome after pericardiectomy. Ann Thorac Surg. 1991;52:219–224[Abstract]
Top
Abstract
Introduction
