Author Affiliations:Departments of Surgery (Drs Garg and Ramamoorthy) and Pathology (Dr Bakhtar), University of California, San Diego.
A 66-year-old man originally from the Philippines with a history of amyotrophic lateral sclerosis came to our emergency ward with suprapubic pain localizing to the right lower quadrant, a low-grade fever (temperature, 38.1°C), and tachycardia (heart rate, >100 beats/min). Initially, he was minimally communicative and dependent on a gastrostomy tube for his feedings. Given the debilitation from his neurologic disease, a broad workup including laboratory and radiologic studies was initiated. His chemistry panel, urinalysis, and blood culture results were normal. His liver enzyme panel revealed a mildly elevated total bilirubin level of 22 μmol/L (1.3 mg/dL). His white blood cell count was mildly elevated at 10 300 cells/mL. He had a left shift with 83 neutrophils, bandemia (14%), and no eosinophils. His radiologic workup revealed a normal abdominal series. A computed tomographic scan was performed, demonstrating a hyperemic appendix and pericecal fluid without abscess (Figure 1). The patient was taken to the operating room and a routine laparoscopic appendectomy was performed. There was significant periappendiceal fibrosis. The appendix was noted to be purulent and grossly perforated. The appendix was removed successfully. The pathologic analysis of the specimen contained mineralized eggs throughout the appendix (Figure 2).
A computed tomographic image of the abdomen showing a hyperemic appendix (arrow) and pericecal fluid without abscess.
The infiltrate consists of plasma cells, lymphocytes, neutrophils, and rare egg-containing giant cells. The eosinophils commonly seen in acute infections are absent. The eggs (arrow) have inconspicuous spines (paraffin-embedded specimen, hematoxylin-eosin, original magnification ×40).
A. Perforated schistosomal appendicitis
B. Perforated appendiceal cryptosporidiosis
C. Perforated appendiceal cancer
D. Perforated cecal diverticulosis
Thank you for submitting a comment on this article. It will be reviewed by JAMA Surgery editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 2
Customize your page view by dragging & repositioning the boxes below.
Care at the Close of Life EDUCATION GUIDES
Palliative Care for Patients with Amyotrophic Lateral Sclerosis
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.