Surgical approach for appendicitis in neutropenia: a case report and review of the literature

Abstract

Background Acute appendicitis is a common abdominal pathology, particularly in younger patients presenting with abdominal pain. The clinical presentation is typically characterized by right lower quadrant pain (with local peritonitis) accompanied by fever and nausea. In neutropenic patients it is challenging to diagnose acute appendicitis. It is much more challenging because the characteristic symptoms are different, and diagnosis may be delayed or missed. Case presentation We present the case of a 33-year-old Caucasian male patient with fever, abdominal pain, and an absolute granulocyte count of 0 × 109/L. Abdominal CT demonstrated an uncomplicated acute appendicitis. We initiated a conservative in-hospital treatment with intravenous antibiotic therapy and simultaneous bone marrow stimulation, with close monitoring. On day three, there was evidence of monocyte increase, one of the first signs of bone marrow regeneration, and delayed laparoscopic appendectomy was performed. The perioperative and postoperative course was uneventful. Conclusion We discuss the different treatment strategies in patients with neutropenia presenting with acute appendicitis (i.e., conservative management, delayed appendectomy, and immediate appendectomy) based on our experience and a review of the literature. In summary, delayed laparoscopic appendectomy at the onset of granulocyte regeneration under antibiotic and G-CSF therapy represents a viable surgical option for adults as well as for children and should be discussed compared with conservative therapy.

Acute Gangrenous Appendicitis in A 70-Year-Old Patient with Multiple Myeloma

“…Cecitis or thyphlitis as it is also known is usually treated conservatively and due to the particularity of the disease, plenty of questions are raised regarding the differential diagnosis. The major question that has to be answered, is when there is a real appendiceal infection and when the surgical treatment via exploratory laparotomy is the only option [11,12]. At the time of differential diagnosis, one of the main problems that appears is the occasion in which there is an inflammatory reaction in the appendix and the surrounding area [10][11][12][13].…”

“…The major question that has to be answered, is when there is a real appendiceal infection and when the surgical treatment via exploratory laparotomy is the only option [11,12]. At the time of differential diagnosis, one of the main problems that appears is the occasion in which there is an inflammatory reaction in the appendix and the surrounding area [10][11][12][13]. Taking this into consideration, the decision for surgical invasion will be based on the clinical appearence, as well as, the imaging finding (free intraperitoneal air, intraperitoneal fluid diffusion, inflammation of the cecal base) [7].…”

“…One of the most essential questions raised from this discussion is if the appendicectomy will be interpreted immediately or in a later phase in patients with aplastic crisis, especially those who underwent treatment with bone marrow transplantation [11,12]. Uthayanan et al support the theory of second-phase treatment when the bone marrow takes over with or without the use of growth factors.…”

“…The index which is taken into account for this type of therapy is the count of monocytes and leukocytes as they increase, indicating, improvement of the bone marrow function. To be more informative we have to mention the existence of the management algorithm [11]. On the other side, Forghieri et al describe the therapeutic process of appendicectomy in phase one, at the time of diagnosis, showing off the safety and low complication risk, even in patients with autologous bone marrow transplantation during the aplastic crisis [12].…”