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Shigellosis associated with appendicitis
Shigellosis Associated With Appendicitis By Doris Y. Sanders,
Carolyn
Ray Cort, and Allston
J. Stubbs
T
HE ASSOCIATION of bacterial gastrointestinal infections and appendicitis is not common. However, both ShigelIa and Salmonella infections occurring with appendicitis have been reported with sufficient frequency that the practitioner should be aware of this association. CASE
REPORT
A five-yr-old white girl was admitted to the pediatric service of the North Carolina Baptist Hospital with a history of persistent vomiting and diarrhea of z days’ duration. Her parents and two siblings were being treated with ampicillin for shigellosis at this time. The two siblings had positive stool cultures for Skigella sonnei. This child was also receiving oral ampicillin. On admission, blood pressure was 110/80; pulse, 140; and respirations, 24. Weight was 40 lb. Rectal temperature was 105OF. She had slight nuchal rigidity and appeared seriously ill. She was moderately dehydrated. Abdominal examination revealed generalized tenderness with hypoactive bowel sounds. The remainder of the examination revealed no abnormalities. Admission laboratory studies included a hemoglobin of 15.0 g/loo ml. White-blood-cell count was 7300/cu mm, with a differential count of 52% neutrophils, 34% bands, 10% lymphocytes, and 4% monocytes. Urinalysis was within normal limits, except for 2 + protein. Urine specific gravity was 1.029. Serum electrolytes were within normal limits. Blood urea nitrogen was 1.2 mg/lOO ml. Lumbar puncture revealed normal cerebrospinal fluid. Blood and cerebrospinal fluid cultures had no growth. Stool culture grew no enteric pathogens. Intravenous fluids and intravenous ampicillin in a dosage of 500 mg were given at 6-hr intervals. The following day the child’s condition continued to deteriorate. Examination of the abdomen revealed the absence of bowel sounds and rebound tenderness referred to the right lower quadrant. Rectal examination revealed no masses. The right psoas shadow was not visualized on x-rays of the abdomen. Repeat white-blood-cell count was 18,3OO/cu mm. The dosage of ampicillin was increased to 1 g every 6 hrs intravenously. Kantrex, 150 mg intramuscularly, was initiated at 12-hr intervals. The child failed to improve and the febrile course continued. Forty-eight hours after admission, the child was taken to surgery, where she was found to have a perforated gangrenous appendix. Bacterial culture from the peritoneal fluid grew Skigella sonnei and Esckerickia coli. Ampicillin and Kanamycin were continued for a total of 7 days. The subsequent hospital course was uncomplicated and the child was discharged on the seventh postoperative day.
COMMENT
In the case presented, the tentative diagnosis of Shigella infection doubtedly delayed surgery, although the signs of acute appendicitis
unwith
From the Department of Pediatrics and the Pediatric Service of the North Carolina Baptist Hospital and the Department of Surgery, Bowman Gray School of Medicine, Wiizsfon-Salem, N.C. Doris Y. Sanders, M.D.: Assistant Professor of Pediatrics, Department of Pediatrics, Bowmun Gruy School of Medicine, Winston-Salem, N.C., Carolyn Ray Cort, M.D.: Assistant Resident in Pediatrics, Department of Pediufrics, Bowman Gray School of Medicine, Winston-Salem, N.C. Allston J. Stubbs, M.D.: Chief Resident in Surgery, Depurfmenf of Surgery, Bowman Gray School of Medicine, Winston-Salem, N.C. Journal
of Pediatric
Surgery,
Vol. 7, No. 3 (June-July), 1972
315
316
SANDERS, CORT, AND STUSBS Table 1. Association of Shigella infections and Acute Appendicitis Author
White et al.’
Phillips’ Saev4 Rabin’ Thompson and White’
Age (yr)and 3ex of Patient 6, male 6. male 9, male 5, male 6, male 5, female 5, male 6, male 12, male 2, female 6, male 9, male 15, female 9, female 20, female 11 ? Adult, male Adult. male
soecies
S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sohnei
S. sonnei S. sonnei S. sonnei S. sonnei S. flexneri S. sonnei S. flexneri
Graham’
30, male 25, male Adult, male
S. flexnerl S. newcastle
Rose’
30, male 29, male 5, female
S. flexneri S. shtga S. sonnei
Sanders et al.
Sites of Cufture
Appendix, rectal swab Appendix, rectal swab Appendix, rectal swab Rectal swab Appendix, rectal swab Appendix, rectal swab Appendix, rectal swab Appendix Appendix, rectal swab Appendix Appendix Appendix, rectal swab Appendix Appendix, feces Feces Feces Appendicitis occurred during epidemic of gastroenteritis; specific cultures on these two patients are not stated Appendicitis occurred during epidemic of gastroenteritis; specific cultures on these patients are not stated Feces Appendix Peritoneal fluid
*Reported in this paper.
guarding and rebound tenderness in the right lower quadrant were present. In 1961, White et a1.l reported on their experience with the association of Shigellu infections and appendicitis. Twelve of 160 patients with acute appendicitis had positive appendiceal ctiltures for Shigella sonnei. Seventeen per cent of the children in this series presented with diarrhea as an early sonnei symptom of appendicitis, including all 12 children with S&Ala infections. They emphasize that diarrhea is often overlooked as an initial manifestation of acute appendicitis. In 1958, Cowan2 reported teil cases of appendicitis among 345 patients with clinical dysentery. Unfortunately, bacterial investigations were not made. The association of Shigella infections and appendicitis has been observed by others, as summarized in Table 1. The association of Salmonellu infections and appendicitis has been reported even more frequently. Frequently, in patients with shigellosis, symptoms mimicking appendicitis may occur. The diagnosis of appendicitis is difficult and ultimately depends on the physical examination. Laboratory studies, including the white blood cell count and differential count, may be of little value. However, the awareness of the association of bacterial gastroenteritis and acute appendicitis should
SHIGELLOSIS IN APPENDICITIS
317
be remembered. The definitive diagnosis of bacterial gastroenteritis certainly should not exclude consideration of the diagnosis of appendicitis. This is probably best expressed by a quotation from Sir Zachary Cope and Dr. M. Spark, “The diseased vermiform appendix is the most frequent disturber of abdominal peace.. . . And it does not care who got there first.” SUMMARY
Shigellosis and acute appendicitis presented concomitantly in a s-yr-old girl. The literature regarding the association of Shigellu infections and acute appendicitis is reviewed briefly. REFERENCES 1. White, M. E. E., Lord, M. D., and Rogers, K. B.: Bowel infection and acute appendicitis. Arch. Dis. Child. 36:394, 1961. 2. Cowan, D. J.: Appendicitis and acute terminal ileitis during an outbreak of gastroenteriti samong british troops in Port Said. Brit. Med. J. 1~~8, 1958. 3. Phillips, T. J.: Appendicitis associated with Shigella sonnei infection. Alaska Med. 11~74, 1969. 4. Saev, S.: Case of acute phlegmonous appendicitis in dysentery. Khirurgiia (Sofia) 10:1039,1957. 5. Rabin, A. G.: Differential diagnosis of acute appendicitis and dysentery in chil-
dren. Vop. Okhr. Materin Dets. 8:82, 1963. 6. Thompson, C. M., and White, B. V.: Shigellosis studies, clinical observations on dysentery caused by Shigella jlerneri III. U.S. Naval Med. Bull. 46:901, 1946. 7. Graham, W. H.: Diagnosis of appendicitis with gastroenteritis. Milit. Surg. 95: 296, 1944. 8. Rose, T. F.: The clinical differentiation of appendicitis and the dysenteries. Med. J. Aust. 2~72,1945. 9. Spark, M.: Acute appendicitis occurring in the already sick child. Amer. Practit. Dig. Treatment 8:1222, 1957.
Carolyn
Ray Cort, and Allston
J. Stubbs
T
HE ASSOCIATION of bacterial gastrointestinal infections and appendicitis is not common. However, both ShigelIa and Salmonella infections occurring with appendicitis have been reported with sufficient frequency that the practitioner should be aware of this association. CASE
REPORT
A five-yr-old white girl was admitted to the pediatric service of the North Carolina Baptist Hospital with a history of persistent vomiting and diarrhea of z days’ duration. Her parents and two siblings were being treated with ampicillin for shigellosis at this time. The two siblings had positive stool cultures for Skigella sonnei. This child was also receiving oral ampicillin. On admission, blood pressure was 110/80; pulse, 140; and respirations, 24. Weight was 40 lb. Rectal temperature was 105OF. She had slight nuchal rigidity and appeared seriously ill. She was moderately dehydrated. Abdominal examination revealed generalized tenderness with hypoactive bowel sounds. The remainder of the examination revealed no abnormalities. Admission laboratory studies included a hemoglobin of 15.0 g/loo ml. White-blood-cell count was 7300/cu mm, with a differential count of 52% neutrophils, 34% bands, 10% lymphocytes, and 4% monocytes. Urinalysis was within normal limits, except for 2 + protein. Urine specific gravity was 1.029. Serum electrolytes were within normal limits. Blood urea nitrogen was 1.2 mg/lOO ml. Lumbar puncture revealed normal cerebrospinal fluid. Blood and cerebrospinal fluid cultures had no growth. Stool culture grew no enteric pathogens. Intravenous fluids and intravenous ampicillin in a dosage of 500 mg were given at 6-hr intervals. The following day the child’s condition continued to deteriorate. Examination of the abdomen revealed the absence of bowel sounds and rebound tenderness referred to the right lower quadrant. Rectal examination revealed no masses. The right psoas shadow was not visualized on x-rays of the abdomen. Repeat white-blood-cell count was 18,3OO/cu mm. The dosage of ampicillin was increased to 1 g every 6 hrs intravenously. Kantrex, 150 mg intramuscularly, was initiated at 12-hr intervals. The child failed to improve and the febrile course continued. Forty-eight hours after admission, the child was taken to surgery, where she was found to have a perforated gangrenous appendix. Bacterial culture from the peritoneal fluid grew Skigella sonnei and Esckerickia coli. Ampicillin and Kanamycin were continued for a total of 7 days. The subsequent hospital course was uncomplicated and the child was discharged on the seventh postoperative day.
COMMENT
In the case presented, the tentative diagnosis of Shigella infection doubtedly delayed surgery, although the signs of acute appendicitis
unwith
From the Department of Pediatrics and the Pediatric Service of the North Carolina Baptist Hospital and the Department of Surgery, Bowman Gray School of Medicine, Wiizsfon-Salem, N.C. Doris Y. Sanders, M.D.: Assistant Professor of Pediatrics, Department of Pediatrics, Bowmun Gruy School of Medicine, Winston-Salem, N.C., Carolyn Ray Cort, M.D.: Assistant Resident in Pediatrics, Department of Pediufrics, Bowman Gray School of Medicine, Winston-Salem, N.C. Allston J. Stubbs, M.D.: Chief Resident in Surgery, Depurfmenf of Surgery, Bowman Gray School of Medicine, Winston-Salem, N.C. Journal
of Pediatric
Surgery,
Vol. 7, No. 3 (June-July), 1972
315
316
SANDERS, CORT, AND STUSBS Table 1. Association of Shigella infections and Acute Appendicitis Author
White et al.’
Phillips’ Saev4 Rabin’ Thompson and White’
Age (yr)and 3ex of Patient 6, male 6. male 9, male 5, male 6, male 5, female 5, male 6, male 12, male 2, female 6, male 9, male 15, female 9, female 20, female 11 ? Adult, male Adult. male
soecies
S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sonnei S. sohnei
S. sonnei S. sonnei S. sonnei S. sonnei S. flexneri S. sonnei S. flexneri
Graham’
30, male 25, male Adult, male
S. flexnerl S. newcastle
Rose’
30, male 29, male 5, female
S. flexneri S. shtga S. sonnei
Sanders et al.
Sites of Cufture
Appendix, rectal swab Appendix, rectal swab Appendix, rectal swab Rectal swab Appendix, rectal swab Appendix, rectal swab Appendix, rectal swab Appendix Appendix, rectal swab Appendix Appendix Appendix, rectal swab Appendix Appendix, feces Feces Feces Appendicitis occurred during epidemic of gastroenteritis; specific cultures on these two patients are not stated Appendicitis occurred during epidemic of gastroenteritis; specific cultures on these patients are not stated Feces Appendix Peritoneal fluid
*Reported in this paper.
guarding and rebound tenderness in the right lower quadrant were present. In 1961, White et a1.l reported on their experience with the association of Shigellu infections and appendicitis. Twelve of 160 patients with acute appendicitis had positive appendiceal ctiltures for Shigella sonnei. Seventeen per cent of the children in this series presented with diarrhea as an early sonnei symptom of appendicitis, including all 12 children with S&Ala infections. They emphasize that diarrhea is often overlooked as an initial manifestation of acute appendicitis. In 1958, Cowan2 reported teil cases of appendicitis among 345 patients with clinical dysentery. Unfortunately, bacterial investigations were not made. The association of Shigella infections and appendicitis has been observed by others, as summarized in Table 1. The association of Salmonellu infections and appendicitis has been reported even more frequently. Frequently, in patients with shigellosis, symptoms mimicking appendicitis may occur. The diagnosis of appendicitis is difficult and ultimately depends on the physical examination. Laboratory studies, including the white blood cell count and differential count, may be of little value. However, the awareness of the association of bacterial gastroenteritis and acute appendicitis should
SHIGELLOSIS IN APPENDICITIS
317
be remembered. The definitive diagnosis of bacterial gastroenteritis certainly should not exclude consideration of the diagnosis of appendicitis. This is probably best expressed by a quotation from Sir Zachary Cope and Dr. M. Spark, “The diseased vermiform appendix is the most frequent disturber of abdominal peace.. . . And it does not care who got there first.” SUMMARY
Shigellosis and acute appendicitis presented concomitantly in a s-yr-old girl. The literature regarding the association of Shigellu infections and acute appendicitis is reviewed briefly. REFERENCES 1. White, M. E. E., Lord, M. D., and Rogers, K. B.: Bowel infection and acute appendicitis. Arch. Dis. Child. 36:394, 1961. 2. Cowan, D. J.: Appendicitis and acute terminal ileitis during an outbreak of gastroenteriti samong british troops in Port Said. Brit. Med. J. 1~~8, 1958. 3. Phillips, T. J.: Appendicitis associated with Shigella sonnei infection. Alaska Med. 11~74, 1969. 4. Saev, S.: Case of acute phlegmonous appendicitis in dysentery. Khirurgiia (Sofia) 10:1039,1957. 5. Rabin, A. G.: Differential diagnosis of acute appendicitis and dysentery in chil-
dren. Vop. Okhr. Materin Dets. 8:82, 1963. 6. Thompson, C. M., and White, B. V.: Shigellosis studies, clinical observations on dysentery caused by Shigella jlerneri III. U.S. Naval Med. Bull. 46:901, 1946. 7. Graham, W. H.: Diagnosis of appendicitis with gastroenteritis. Milit. Surg. 95: 296, 1944. 8. Rose, T. F.: The clinical differentiation of appendicitis and the dysenteries. Med. J. Aust. 2~72,1945. 9. Spark, M.: Acute appendicitis occurring in the already sick child. Amer. Practit. Dig. Treatment 8:1222, 1957.