An Anterior Abdominal Abscess as the Initial Presentation of a Perforated Duodenal Ulcer: A Case Report

Duodenal perforation most commonly presents with life-threatening symptoms of acute abdomen. However, in rare cases, a perforation may have an indolent course due to subclinical progression, and the patient may present with complications at the first visit. We present a case of an anterior abdominal abscess as the initial presentation of a duodenal perforation in a 65-year-old female with no pre-morbidities. The patient presented with a painful mass in the right upper quadrant associated with fever. Physical examination revealed a tender, erythematous swelling in the right hypochondrium and lumbar regions with no signs of peritonitis. Contrast-enhanced CT (CECT) of the abdomen showed a subcapsular hepatic abscess with parietal extension, but no signs of hollow viscus perforation were visible. Empirical antibiotics were given, and incision and drainage (I&D) were performed to drain around 100 mL of pus. However, drain on postop day one demonstrated bile suggesting a hollow viscus perforation, which was confirmed by a Gastrografin study.

Extraintestinal Clostridioides difficile Infection (CDI): A Recurrent Battle with Resilient Abdominal Wall Abscess

Clostridioides (formerly Clostridium) difficile infection is a common and costly healthcare-associated infection. Extraintestinal C. difficile infection is rarely encountered, especially in isolation. We present a unique case of abdominal wall abscess presenting six months following gastrointestinal (GI) surgery. The patient was managed with computed tomography (CT) guided drainage of the abscess, placement of a drainage catheter, and aggressive broad-spectrum antibiotic treatment for a prolonged duration over multiple admissions.

LEARNING POINTS

Risk factors for extraintestinal CDI include prior hospital stay, prolonged antibiotic therapy, proton pump inhibitor (PPI) use, relative state of immunodeficiency such as malnutrition and diabetes mellitus, previous abdominal surgery especially following perforation and leak of intestinal content.Presentation can be late following surgery with mesh repair (foreign body implantation) for intestinal perforation as they have high risk of colonisation, which later leads to infection.For extraintestinal CDI in the presence of a foreign body, removal is the desired course of action. But it is not always possible given the presence of comorbidities in this population, thus resulting in a prolonged course of antibiotics.

Abdominal wall abscess resembling urachal carcinoma caused by ileal diverticulitis

Introduction

We report a rare case of abdominal wall abscess caused by ileal diverticulitis that developed along the midline below the umbilicus and resembled a urachal carcinoma.

Case presentation

A 76-year-old woman with diabetes presented with abdominal enlargement below the umbilicus. Computed tomography revealed a well-enhanced mass, which was visualized on magnetic resonance imaging as a continuous mass connected to the restiform structure, extending from the umbilicus to the bladder. As the mass showed high uptake on 18F-fluorodeoxyglucose positron emission tomography, urachal carcinoma was suspected, and surgery was subsequently performed. As the tumor adhered to the ileum, partial resection of the small intestine was required. The pathological diagnosis was abdominal wall abscess associated with ileal pseudodiverticulitis.

Conclusion

Although abdominal wall abscess caused by ileal diverticulitis is rare, it should be considered as a differential diagnosis of urachal carcinoma.

Acute appendicitis complicated with necrotizing fasciitis in a patient with adult-onset Still's disease: A case report

RATIONALE

Adult-onset Still disease (AOSD) is a rare systemic inflammatory disease of unknown etiology characterized by evanescent salmon-pink rash, spiking fever, arthralgia/ arthritis, and lymphadenopathy. AOSD sometimes was fatal when it is complicated by macrophage activation syndrome (MAS) or hemophagocytic lymphohistiocytosis (HLH). Nonetheless, the literature provides no recommendations for treatment of AOSD patients with severe sepsis.

PATIENT CONCERNS

A previously healthy 65-year-old man with history of AOSD was referred to our hospital for persistent right lower quadrant abdominal pain for 2 days. One week later, an abdominal wall abscess and hematoma developed by extravasation from the inferior epigastric vessels, complicated by necrotizing fasciitis of the right thigh and groin region. To our best knowledge, this case was the first reported case of a perforated appendix complicated with necrotizing fasciitis in a patient with AOSD.

DIAGNOSES

The patient was diagnosed as acute appendicitis complicated with necrotizing fasciitis and abdominal wall abscess.

INTERVENTIONS

This case received intravenous tigecycline injection and daily 10 mg prednisolone initially, and shifted to daily intravenous hydrocortisone 200 mg for suspected MAS or HLH. This patient underwent surgical intervention and debridement for necrotizing fasciitis.

OUTCOMES

The patient's symptoms progressed worse rapidly. He died from cytomegalovirus viremia and bacterial necrotizing fasciitis complicated by septic shock.

LESSONS

(1) The steroid dose was difficult to titrate when AOSD complicated by sepsis. The differential diagnosis from MAS/HLH with bacterial/viral infection related severe sepsis was difficult but critical for decision making from clinicians and rheumatologists. (2) The conservative treatment with antibiotics for perforated appendix is safe but has a higher failure rate in immunocomprised patients such as systemic lupus erythematosus and AOSD. Early surgical intervention might contribute to better outcome. (3) The abdominal wall abscess can be spread from intra-abdominal lesion through the inferior epigastric vessels which were as weak points of abdominal wall. Imaging examinations contribute to acute diagnosis and help surgeons perform surgical interventions to prevent morbidity and mortality.