Introduction
Children’s health can often present a diagnostic challenge, as symptoms may not always point directly to the underlying issue. In a remarkable case reported in ‘The Journal of Emergency Medicine’, a pediatric patient’s severe knee pain was actually a red herring for a serious abdominal condition – ruptured appendicitis with a retrocecal abscess. This case, presented by a team led by Dr. Alan G. Shamrock at The University of Iowa Hospitals and Clinics, underscores why emergency physicians must maintain a broad differential diagnosis even when symptoms seem to indicate a specific, common condition such as septic arthritis.
Case Overview
A 5-year-old boy arrived at the emergency department suffering from right knee pain without a history of trauma, ability to bear weight comfortably, fever, and elevated inflammatory markers. The physical exam and magnetic resonance imaging (MRI) yielded no significant findings in the knee, which significantly reduced the clinical suspicion of knee joint infection. Blood cultures, however, revealed Granulicatella adiacens – a bacterium typically associated with gastrointestinal tracts – suggesting a source of infection originating internally rather than in the knee itself.
Diagnostic Process
The team decided to extend their search to abdominal pathologies commonly associated with referred pain to the lower limbs. Ultrasound and computed tomography (CT) scans duly revealed the true antagonist: a large retrocecal abscess as a result of perforated appendicitis. Such an occurrence is rare but notable and can lead to diagnostic ambiguity.
Treatment and Outcome
A precise, CT-guided drainage alongside intravenous antibiotic therapy was administered to treat the abscess and the underlying appendicitis. The patient responded positively to the treatment. Notably, as the appendicitis was addressed, the musculoskeletal symptoms, including his knee pain, improved, confirming the diagnosis of referred pain from abdominal pathology.
Discussion
Dr. Alan G. Shamrock and colleagues have highlighted through this case that appendicitis may atypically present itself with symptoms mimicking musculoskeletal conditions, such as knee pain, supporting the necessity for emergency physicians to remain vigilant. A high level of suspicion for various conditions, and a willingness to look beyond the obvious, can prevent serious delays in the diagnosis of life-threatening conditions such as appendicitis.
Conclusion
The intriguing case of ruptured appendicitis and a retrocecal abscess revealing as knee pain expands the emergency medicine doctrine that not all presenting symptoms may be as they seem. It mandates a comprehensive diagnostic evaluation that can sometimes turn conventional wisdom on its head, reinforcing the essential need for a broad differential diagnosis in pediatric patients.
DOI: 10.1016/j.jemermed.2019.03.049
References
1. Shamrock, A. G., Bertsch, M. L., Kowalski, H. R., & Weinstein, S. L. (2019). Ruptured Appendicitis and Retrocecal Abscess Masquerading as Knee Pain in a Pediatric Patient: A Case Report. The Journal of Emergency Medicine, 57(1), e21–e25. https://doi.org/10.1016/j.jemermed.2019.03.049
2. Rothrock, S. G., & Pagane, J. (2000). Acute appendicitis in children: emergency department diagnosis and management. Annals of Emergency Medicine, 36(1), 39-51. https://doi.org/10.1067/mem.2000.108882
3. Puylaert, J. (2003). Ultrasound of appendicitis and its differential diagnosis. Medical Ultrasonography, 5(2), 93-101. Retrieved from https://www.umbjournal.org/article/S0301-5629(03)00029-3/fulltext
4. Kaiser, S., Frenckner, B., & Jorulf, H. K. (2002). Suspected appendicitis in children: US and CT—a prospective randomized study. Radiology, 223(3), 633-638. https://doi.org/10.1148/radiol.2233011627
5. Peltola, H., Paakkonen, M., & Kallio, P. (2012). Prospective, randomized trial of 10 days versus 5 days of antibiotic therapy for acute hematogenous osteomyelitis in children. The Pediatric infectious disease journal, 31(8), 798-803. https://doi.org/10.1097/INF.0b013e318258690b
Keywords
1. Pediatric appendicitis symptoms
2. Referred knee pain children
3. Diagnosis of retrocecal abscess
4. Septic arthritis pediatric cases
5. Emergency medicine differential diagnosis