Neonatal appendicitis mimicking intestinal duplication: a case report

Fetal Appendiceal Perforation Masquerading as Meconium Peritonitis: A Report of a Rare Case

Intrauterine appendicular perforation leading to meconium peritonitis is exceptionally rare, with few reported cases in the literature. This case underscores the diagnostic challenges and high mortality associated with neonatal appendicular perforation. Neonatal appendicitis and subsequent perforation are uncommon due to the funnel shape of the fetal appendix, which reduces susceptibility to luminal obstruction. While advances in neonatal care and diagnostic modalities have improved outcomes, challenges persist in timely diagnosis and management. We present the case of a preterm infant, one of dichorionic-diamniotic (DCDA) twins delivered via cesarean section, who developed gross abdominal distension and respiratory distress shortly after birth. Diagnostic abdominocentesis revealed meconium-stained fluid, prompting further investigation with imaging and subsequent exploratory laparotomy. Extensive adhesions and cecal perforation were observed, necessitating a cecostomy. Despite interventions, the infant's condition deteriorated, leading to a fatal outcome. Intrauterine appendicular perforation leading to meconium peritonitis is a rare and difficult-to-diagnose condition. Antenatal suspicion and early surgical intervention are crucial for improving outcomes. Factors contributing to neonatal appendicular perforation include ischemia, obstruction, and infective etiologies. Neonatal appendicular perforation is a rare but life-threatening condition requiring a high index of suspicion for prompt diagnosis and management. Advances in diagnostic tools and antenatal monitoring have contributed to improved outcomes, highlighting the importance of considering this diagnosis in cases of unexplained neonatal abdominal distension.

Appendicitis and its associated mortality and morbidity in infants up to 3 months of age: A systematic review

Background and Aims

Although appendicitis is rare in young infants, the reported mortality is high. Primary aim of this systematic review was to provide updated insights in the mortality and morbidity (postoperative complications, Clavien-Dindo grades I-IV) of appendicitis in infants ≤3 months of age. Secondary aims comprised the evaluation of patient characteristics, diagnostic work-up, treatment strategies, comorbidity, and factors associated with poor outcome.

Methods

This systematic review was reported according to the PRISMA statement with a search performed in Pubmed, Embase and Web of Science (up to September 5th 2022). Original articles (published in English ≥1980) reporting on infants ≤3 months of age with appendicitis were included. Both patients with abdominal appendicitis and herniated appendicitis (such as Amyand's hernia) were considered. Data were provided descriptively.

Results

In total, 131 articles were included encompassing 242 cases after identification of 4294 records. Overall, 184 (76%) of the 242 patients had abdominal and 58 (24%) had herniated appendicitis. Two-hundred (83%) of the patients were newborns (≤28 days) and 42 (17%) were infants between 29 days and ≤3 months of age. Either immediate, or after initial conservative treatment, 236 (98%) patients underwent surgical treatment. Some 168 (69%) patients had perforated appendicitis. Mortality was reported in 20 (8%) patients and morbidity in an additional 18 (8%). All fatal cases had abdominal appendicitis and fatal outcome was relatively more often reported in newborns, term patients, patients with relevant comorbidity, nonperforated appendicitis and those presented from home.

Conclusion

Mortality was reported in 20 (8%) infants ≤3 months of age and additional morbidity in 18 (8%). All patients with fatal outcome had abdominal appendicitis. Several patient characteristics were relatively more often reported in infants with poor outcome and adequate monitoring, early recognition and prompt treatment may favour the outcome.

The importance of timely detection and management in neonatal appendicitis

The clinical presentation of cute appendicitis is rarely encountered in neonatology. When it does occur, it is thought to be due to prematurity or develops secondary to coexisting diseases. We present a case of appendicitis in a 10-day-old Middle-Eastern girl, who was born at term and who had no underlying conditions that are typically associated with neonatal appendicitis. This case highlights that certain causes and clinical signs are unreliable when coming to a working diagnosis of neonatal appendicitis, and that regardless of the cause, timely detection and management are necessary in achieving surgical success.