9 y/o girl
 H/o of JRA treated with methotrexate and enbrel
 4 day h/o abdominal pain
 Nausea/emesis
 Urinary retention
Presented to PCP 3 days before
admission
 Started on PO abx for UTI
 Continued emesis and abdominal pain
 Temp of 100.2 two days after clinic visit
Presented to outside ED
 Temp > 38.5
 Continued abdominal pain
 Abdominal CT with oral and rectal contrast
 Fecalith vs ureteric stone
 Free fluid in abdomen
 Transferred to Children’s Hospital
ED Evaluation
 Vitals
 Temp 39.1
 HR 128
 BP 128/54
 RR 24
ED Evaluation
 Physical Exam
 Gen: Abdominal pain
 CV: RRR
 Pulm: CTA B
 Abd: Distension, R sided tenderness, + psoas sign, +
Rovsing sign, + rebound
ED Evaluation
 Labs
 WBC 13.7
 Hct 36
 CRP 26
 E-lytes WNL
ED Evaluation
 Abdominal US
 Noncompressible mass in RLQ
 Complicated fluid collection at tip
 Diameter of 14mm
 Mild R pelviectasis
A/P
 Started on IV abx
 IVF started
 To OR for presumed appendicitis and appendectomy
 Perforated appendicitis with frank puss in RLQ
 Fluid collection in pelvis
 Enflamed loops of small bowel
RLQ Pain in Immunosuppressed
Patient
 DDx
 Appendicitis
 Typhlitis
 Enteritis
 Pancreatitis
 Perforated viscus
 Graft vs. Host
 PID
 Splenic rupture
 Intussuception
Diagnosis
 Difficult
 Delay in diagnosis approx 4 days
 Sxs
 Fever
 Nonspecific bowel pain
Chan-Hon Chui et al. Appendicitis in immunosuppressed children: Still a
diagnostic and therapeutic dilemma? Pediatric Blood & Cancer 50: 6, pgs 12821283
Tx
 Typhlitis
 Bowel rest
 IV abx
 Non operative
 Appendicitis
 IV abx
 Operative treatment
Data
 Typhlitis and appendicitis found in equal quantities in
ALL patients
 Up to 26% in kids with ALL and RLQ pain
 53% chance of sepsis
 40-70% mortality for ALL kids with sepsis
 8% mortality postoperatively (most due to infection and
sepsis)
Skibber JM, Matter GJ, Pizzo PA, et al. Right lower quadrant pain in young
patients with leukemia. A surgical perspective. Ann Surg 1987; 206: 711-716.
Diagnosis and Treatment
 CT to evaluate bowel
 IV abx if typhlitis or
 Laproscopy if still doubt
inflammation of ceacum
that includes appendix
 Surgery if fecalith
visualized or isolated
appendiceal
inflammation
about diagnosis
McCarville MB, Thompson J, Li C, et al. Significance of appendiceal thickening in
association with typhlitis in pediatric oncology patients. Pediatr Radiol 2004; 24: 245-249
Urbach DR, Rotstein OD. Typhlitis. Can J Surg 1999; 42: 415-419.