Journal of Pediatric Surgery Case Reports 18 (2017) 4e6

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Journal of Pediatric Surgery Case Reports

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A rare presentation of a common entity: Chronic appendicitis in a

patient with back pain
Ekene Onwuka a, c, *, Joseph Drews a, c, Vinay Prasad b, Benedict Nwomeh a, c
a
Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
b
Department of Pathology, Nationwide Children's Hospital, Columbus, OH, United States
c
Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States

a r t i c l e i n f o a b s t r a c t

Article history: Despite being one of the most common pediatric surgical diseases, some cases of appendicitis are far
Received 16 December 2016 from straightforward to diagnose. We present here an interesting case of chronic, retrocecal appendicitis
Received in revised form in a dancer who presented with isolated back pain.
30 December 2016
© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
Accepted 2 January 2017
Available online 3 January 2017
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords:
Chronic appendicitis
Low back pain
Mural fibrosis

1. Introduction tumbling. On the day of presentation, the pain was so severe it

Acute appendicitis classically presents with periumbilical
abdominal pain migrating to the right lower quadrant over 24e48 h
with low-grade fever, anorexia and nausea. Patients have a mild
leukocytosis and ultrasound or cross-sectional imaging demon-
strates periappendiceal inflammation. Rarely, the disease may have
an odd presentation that makes the diagnosis more difficult. We
present the case of an athlete with isolated back pain who under-
went an MRI for suspected spondylolysis and was instead found to
have retrocecal appendicitis. Interestingly, the specimen pathology
was consistent with chronic appendicitis, which is thought to ac-
count for approximately 1.5% of appendicitis cases [1].
2. Case report
A 14-year-old female dancer was referred to a sports medicine
clinic by her pediatrician for back pain. She had a history of two
previous sacral injuries and had suffered from intermittent low
back pain for one year. She was an avid dancer, typically 16e20 h
per week. One week prior to presentation, she experienced onset of
aching pain on both sides of the pelvis that worsened with
caused her to limp. Physical examination was significant for
tenderness of the lumbar paraspinal muscles bilaterally, most se-
vere near L5. Her examination was otherwise negative, as were
spinal x-rays. An MRI of the lumbar spine, performed five days later,
showed no sign of injury to the vertebrae or spinal cord. However, it
revealed an inflamed retrocecal appendix coursing along the psoas
muscle measuring 9 mm with surrounding free fluid (Fig. 1). There
was no evidence of perforation or abscess.
Upon surgical evaluation, the patient reported fatigue but did
not have abdominal pain, fever, nausea or vomiting. She had
stopped dancing after her initial clinic visit, but the back pain
persisted. Her abdomen was soft, nontender and nondistended. She
was afebrile with a white blood cell (WBC) count of 8100 per mm3.
She underwent a laparoscopic appendectomy that confirmed an
inflamed appendix. Her postoperative course was uncomplicated
and she was discharged on postoperative day one. Pathology
showed marked submucosal fibrosis and patchy collections of eo-
sinophils (Fig. 2). Her pain improved and she returned to dancing
on postoperative day 20.
3. Discussion

Appendicitis is one of the most common surgical disorders in

* Corresponding author. 700 Children's Drive Columbus, OH 43205, United States. the pediatric population, with over 500 appendectomies per-
E-mail address: ekene.onwuka@osumc.edu (E. Onwuka). formed annually at our institution (60,000e80,000 across the US)

http://dx.doi.org/10.1016/j.epsc.2017.01.002
2213-5766/© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 E. Onwuka et al. / Journal of Pediatric Surgery Case Reports 18 (2017) 4e6 5

Fig. 1. MRI demonstrating 9 mm, retrocecal appendix (arrow) coursing along psoas muscle (Ps). Bottom right panel demonstrates enlarged cross-sectional view (*).

[2]. While the clinical presentation is sometimes so classic that
patients may be taken directly to the operating room without im-
aging, other cases are not as straightforward. We present two
interesting variants of the appendicitis presentation. The first is the
incidental finding of retrocecal appendicitis in a patient who
received an MRI for lower back pain, and the second is the rare
discovery that this patient's history and pathology were consistent
with chronic appendicitis.
The appendix lies in the retrocecal position in 28e68% of cases.
Clinical features of retrocecal appendicitis typically match those of
non-retrocecal appendicitis, but, rarely, patients present with back
pain when the appendix is retrocecal and extraperitoneal [3]. In our

Fig. 2. Pathology specimen showing extensive collagen deposition, or fibrosis (F), encompassing most of submucosal layer (Sm). Eosinophils (* on left panel, red arrowheads on
magnified image) infiltrate the submucosal and epithelial (Ep) layers. Changes are consistent with chronic appendicitis. Lumen (L), muscularis propria (Mp). (For interpretation of
the references to colour in this figure legend, the reader is referred to the web version of this article.)
6 E. Onwuka et al. / Journal of Pediatric Surgery Case Reports 18 (2017) 4e6
case, a dancer with a history of two previous sacral injuries pre-
sented with lower back pain which was worsened by tumbling. This
naturally placed spinal injury high on the differential diagnosis,
leading to the MRI which was negative for spinal pathology but
positive for an inflamed retrocecal appendix. Drezner et al. simi-
larly reported a case of appendicitis which was found in a 23-year-
old female runner who initially presented with lower right-sided
back pain. The patient had no symptoms consistent with appen-
dicitis, such as nausea, vomiting, anorexia, fevers or abdominal
pain. Two weeks of treatment with NSAIDs was unsuccessful, as
was six weeks of symptomatic treatment for renal stones. A CT was
performed to assess for nephrolithiasis, but instead demonstrated a
retrocecal appendix with an appendicolith, mild thickening of the
appendiceal wall and periappendiceal fat stranding consistent with
appendicitis. Appendectomy was performed with improvement of
symptoms and pathology consistent with chronic appendicitis [4].
While this presentation is rare, clinicians should have a high level of
suspicion in patients presenting with lower back pain unrelieved by
typical therapies for musculoskeletal disease.
Appendicitis has traditionally been considered to be a progres-
sive disease process, with untreated cases advancing within a few
days to perforation, peritonitis, and ultimately sepsis. As such, the
existence of chronic appendicitis is somewhat controversial.
Chronic appendicitis is described as a longstanding inflammation of
the appendix which presents clinically as prolonged or intermittent
abdominal pain [5]. It accounts for 1.5% of appendicitis cases and is
thought to be due to a partial and transient obstruction of the ap-
pendix [1,6,7]. Some authors have made a distinction between
recurrent appendicitis (intermittent bouts of pain) and chronic
appendicitis (less severe, nearly continuous abdominal pain that
can last for weeks, months, or even years) [6,7]. A history of fever is
absent in many cases, and the WBC count is often normal [1,5].
Because of the unusual presentation, the diagnosis is often missed
or mistaken for other conditions such as inflammatory bowel dis-
ease, musculoskeletal disease, or even lymphoma in one patient
presenting with night sweats and three months of fever and
abdominal pain [4,8,9]. Imaging is frequently obtained for other
reasons, but may show thickening of the appendix, with echogenic,
thickened mesentery on ultrasound [10], or findings similar to
acute appendicitis on CT, such as pericecal fat stranding, dilated
appendix, or appendicolith [4]. Symptoms are relieved following
appendectomy, and chronic inflammatory changes, such as mural
fibrosis or a mixed inflammatory cell infiltrate, are found on pa-
thology [1,4,8].
4. Conclusion
In summary, despite its high prevalence, appendicitis can be
challenging to diagnose. We present two unusual findings that,
together, contributed to a diagnostic dilemma: a patient with iso-
lated back pain who was found to have retrocecal appendicitis and
pathology findings from the surgical specimen of chronic
appendicitis.
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