Acute appendicitis coexisting with acute pyelonephritis causing diagnostic dilemma in a pediatric patient: a case report

Authors: Fadi Ali Jamaleddin Ahmad1, MPH., BS, Nukhba Syed1, BS, Meghan Mangal1, BS, Kirstie Venegas1, Emily Dill1, and Maryna Al-Fauri1, MD., PhD.

Affiliation: American University of the Caribbean Medical School1

A 2 y/o F UTD on vaccinations with no past surgical history, hospitalizations, or family hx presents to the emergency department with her mother for abdominal pain with associated vomiting. The patient was found to be febrile (39.9C) and hypotensive (100/77) with a lethargic appearance and an acutely tender abdomen. Two days ago the patient had one episode of emesis and yesterday her mother noted that she was walking with her hands on her belly. The patient has had no bowel movements in the past 2 days. Her symptoms worsened and she had not urinated since 2 pm. Initial KUB showed air-fluid levels and no distal colon gas concerning malrotation with volvulus. She was started on NS bolus, zosyn, flagyl, and got an NGT that returned scant pale yellow fluid. Ultrasound showed bladder distention to immeasurable proportions. After foley cather insertion, urinary retention resolved. UA shows moderate leukocytes, high WBCs in clumps, and few squams. UGIS showed no volvulus, improving bowel gas pattern with no air-fluid levels, and positive distal colon air. The patient appeared improved; resting comfortably, non-tender abdomen. 

            The mother describes the patient’s diet as regular. No known allergies noted. GI/GU examination shows distended abdominal pain with rebound and decreased bowel sounds, constipation, nausea, vomiting, and urinary retention with bladder distension. The patient was admitted to inpatient with a diagnosis of suspected malrotation and intestinal volvulus. The patient was given toradol and Zofran. UGIS ruled out bowel obstruction/malrotation and labs show symptoms have improved. The patient was given IV fluids and had multiple abdominal exams. The patient tolerated a normal diet well and show sign of more energy. The day after the visit the patient was positive for mycobacterium infection.

Differential diagnosis led to malrotation, intestinal obstruction, mycoplasma, and appendicitis with pyelonephritis complications. Four days later, the patient was confirmed to have appendicitis with a large inflammatory process and pyelonephritis/urinary retention. Specialists decided to treat non-operatively with antibiotics. Clinical presentation and complications of appendicitis vary among patients, particularly in children under 5, especially when the genitourinary tract is involved. Appendicitis may mimic urological disorders and vice versa. Awareness of differential diagnosis and proper diagnostic techniques is important in preventing delayed diagnosis and possible complications. 

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