Presse Med. 2015; 44: 241–254
A rare cause of appendicular syndrome Une cause rare de syndrome appendiculaire Case report A 72-year-old woman was admitted to the emergency department for suspected appendicitis. Physical examination showed a temperature of 38 8C and lower right abdominal quadrant tenderness without contracture. Laboratory tests showed a C-reactive protein level of 100 mg/L and a white-cell count of 14,000 per cubic millimetre. Since abdominal ultrasonography could not visualize the appendix, an abdominal computed tomographic (CT) scan was performed and showed focal pericecal fat stranding and a hyperdense foreign body perforating the colic wall (figure 1 A, B). Emergency surgery revealed a cecal toothpick (figure 2). She was discharged after ten days of hospitalization.
Discussion Cecal perforation by a toothpick is a very rare differential diagnosis of acute appendicitis. Very few cases have been reported in the literature [1–3]. Ingested foreign bodies are uncommon causes of perforation of the gastrointestinal tract. A wide variety of foreign bodies find their way into the gastrointestinal tract, including coins, toys, keys, batteries, jewellery, pins, needles, razor blades, nails, clips, and bones. Most of them do not cause intestinal perforation and are evacuated. However, hard or sharp objects, such as fish bones, chicken bones, and toothpicks may cause perforation. A clinical history of foreign body ingestion is rarely available. CT findings include visualization of foreign body in or through the gastrointestinal tract, thickening of the bowel wall, localized pneumoperitoneum and adjacent fat stranding [4]. In case of ingested toothpick, bowel perforation is usually contained by the greater omentum or the adjacent intestinal or mesenteric structures. Thus, peritonitis is rarely generalized [5].
Letters to the editor
en ligne sur / on line on www.em-consulte.com/revue/lpm www.sciencedirect.com
Figure 1 Computed tomographic (CT) scan
tome 44 > n82 > février 2015
241
Axial (A) and sagittal (B) unenhanced CT reformations showing pericecal fat stranding surrounding a hyperdense sharp foreign body (arrow).
Lettres à la rédaction
Letters to the editor
Granulome à corps étranger : un diagnostic à ne pas oublier Foreign body granuloma: A diagnosis not to be forgotten
Observation
Figure 2 Laparotomy confirmed the presence of a toothpick penetrating through the cecal wall
Disclosure of interest : the authors declare that they have no conflicts of interest concerning this article.
References [1] [2]
[3]
[4] [5]
Niciforovic D, Spasic A, Turkalj I, Vanhoenacker FM. Toothpick perforation of the caecum. JBR-BTR 2014;97:47. Neumann U, Fielitz J, Ehlert HG. Perforation of the cecum by a toothpick – a rare differential acute appendicitis diagnosis. Case report and review of the literature. Chirurgie 2000;71:1405–8. Hauser H, Pfeifer J, Uranüs S, Klimpfinger M. Perforation of the cecum by a toothpick. Case report and review of the literature. Langenbecks Arch Chir 1994;379:229–32 [Review]. Gayer G, Petrovitch I, Jeffrey RB. Foreign objects encountered in the abdominal cavity at CT. Radiographics 2011;31:409–28. Regent D, Balaj C, Jausset F, Oliver A, Sellal-Aubriot C, Croise-Laurent V. Perforations du tube digestif. EMC–Radiologie et imagerie médicale– abdominale–digestive 2012;7(4):1–21 [article 33-705-A-15].
Un homme de 31 ans, sans antécédent pathologique particulier, consultait pour une lésion ulcéro-crouteuse du cuir chevelu, augmentant progressivement de taille. Cette lésion était apparue 3 mois auparavant sur des cicatrices cutanées de zona ophtalmique survenu il y a six mois. L'état général était excellent. À l'examen, il existait une lésion ulcéro-crouteuse siégeant au niveau fronto-pariétal gauche, mesurant 5 4 cm de diamètre, indolore à la palpation (figure 1). Cette lésion était entourée d'alopécie cicatricielle et de cicatrices atrophiques et achromiques de zona. Les aires ganglionnaires étaient libres. Les diagnostics de carcinome épidermoïde (sur cicatrice de zona), mais également d'ulcération neurotrophique et de leishmaniose cutanée, étaient évoqués. Une biopsie de la lésion était faite, et l'examen histologique révélait un épiderme hyperplasique réactionnel, un derme contenant un infiltrat inflammatoire chronique avec des granulomes fait de plasmocyte, d'histiocyte et de cellules géantes macrophagiques de type résorptif contenant dans leur cytoplasme des corps étrangers biréfringents à la lumière polarisée
Brice Robert1, Lionel Rebibo2 1
Amiens North Hospital, department of radiology, 80054 Amiens cedex 01, France 2 Amiens North Hospital, department of metabolic and digestive surgery, 80054 Amiens cedex 01, France
Correspondence : Brice Robert, University of Picardy, Amiens North Hospital, Department of Radiology, place Victor-Pauchet, 80054 Amiens cedex 01, France [email protected] Received 3 July 2014 Accepted 22 September 2014 Available online: 12 December 2014
242
http://dx.doi.org/10.1016/j.lpm.2014.09.014 © 2014 Elsevier Masson SAS. All rights reserved.
Figure 1 Lésion ulcéro-crouteuse sur cicatrices achromiques et atrophiques de zona ophtalmique
tome 44 > n82 > février 2015
A rare cause of appendicular syndrome Une cause rare de syndrome appendiculaire Case report A 72-year-old woman was admitted to the emergency department for suspected appendicitis. Physical examination showed a temperature of 38 8C and lower right abdominal quadrant tenderness without contracture. Laboratory tests showed a C-reactive protein level of 100 mg/L and a white-cell count of 14,000 per cubic millimetre. Since abdominal ultrasonography could not visualize the appendix, an abdominal computed tomographic (CT) scan was performed and showed focal pericecal fat stranding and a hyperdense foreign body perforating the colic wall (figure 1 A, B). Emergency surgery revealed a cecal toothpick (figure 2). She was discharged after ten days of hospitalization.
Discussion Cecal perforation by a toothpick is a very rare differential diagnosis of acute appendicitis. Very few cases have been reported in the literature [1–3]. Ingested foreign bodies are uncommon causes of perforation of the gastrointestinal tract. A wide variety of foreign bodies find their way into the gastrointestinal tract, including coins, toys, keys, batteries, jewellery, pins, needles, razor blades, nails, clips, and bones. Most of them do not cause intestinal perforation and are evacuated. However, hard or sharp objects, such as fish bones, chicken bones, and toothpicks may cause perforation. A clinical history of foreign body ingestion is rarely available. CT findings include visualization of foreign body in or through the gastrointestinal tract, thickening of the bowel wall, localized pneumoperitoneum and adjacent fat stranding [4]. In case of ingested toothpick, bowel perforation is usually contained by the greater omentum or the adjacent intestinal or mesenteric structures. Thus, peritonitis is rarely generalized [5].
Letters to the editor
en ligne sur / on line on www.em-consulte.com/revue/lpm www.sciencedirect.com
Figure 1 Computed tomographic (CT) scan
tome 44 > n82 > février 2015
241
Axial (A) and sagittal (B) unenhanced CT reformations showing pericecal fat stranding surrounding a hyperdense sharp foreign body (arrow).
Lettres à la rédaction
Letters to the editor
Granulome à corps étranger : un diagnostic à ne pas oublier Foreign body granuloma: A diagnosis not to be forgotten
Observation
Figure 2 Laparotomy confirmed the presence of a toothpick penetrating through the cecal wall
Disclosure of interest : the authors declare that they have no conflicts of interest concerning this article.
References [1] [2]
[3]
[4] [5]
Niciforovic D, Spasic A, Turkalj I, Vanhoenacker FM. Toothpick perforation of the caecum. JBR-BTR 2014;97:47. Neumann U, Fielitz J, Ehlert HG. Perforation of the cecum by a toothpick – a rare differential acute appendicitis diagnosis. Case report and review of the literature. Chirurgie 2000;71:1405–8. Hauser H, Pfeifer J, Uranüs S, Klimpfinger M. Perforation of the cecum by a toothpick. Case report and review of the literature. Langenbecks Arch Chir 1994;379:229–32 [Review]. Gayer G, Petrovitch I, Jeffrey RB. Foreign objects encountered in the abdominal cavity at CT. Radiographics 2011;31:409–28. Regent D, Balaj C, Jausset F, Oliver A, Sellal-Aubriot C, Croise-Laurent V. Perforations du tube digestif. EMC–Radiologie et imagerie médicale– abdominale–digestive 2012;7(4):1–21 [article 33-705-A-15].
Un homme de 31 ans, sans antécédent pathologique particulier, consultait pour une lésion ulcéro-crouteuse du cuir chevelu, augmentant progressivement de taille. Cette lésion était apparue 3 mois auparavant sur des cicatrices cutanées de zona ophtalmique survenu il y a six mois. L'état général était excellent. À l'examen, il existait une lésion ulcéro-crouteuse siégeant au niveau fronto-pariétal gauche, mesurant 5 4 cm de diamètre, indolore à la palpation (figure 1). Cette lésion était entourée d'alopécie cicatricielle et de cicatrices atrophiques et achromiques de zona. Les aires ganglionnaires étaient libres. Les diagnostics de carcinome épidermoïde (sur cicatrice de zona), mais également d'ulcération neurotrophique et de leishmaniose cutanée, étaient évoqués. Une biopsie de la lésion était faite, et l'examen histologique révélait un épiderme hyperplasique réactionnel, un derme contenant un infiltrat inflammatoire chronique avec des granulomes fait de plasmocyte, d'histiocyte et de cellules géantes macrophagiques de type résorptif contenant dans leur cytoplasme des corps étrangers biréfringents à la lumière polarisée
Brice Robert1, Lionel Rebibo2 1
Amiens North Hospital, department of radiology, 80054 Amiens cedex 01, France 2 Amiens North Hospital, department of metabolic and digestive surgery, 80054 Amiens cedex 01, France
Correspondence : Brice Robert, University of Picardy, Amiens North Hospital, Department of Radiology, place Victor-Pauchet, 80054 Amiens cedex 01, France [email protected] Received 3 July 2014 Accepted 22 September 2014 Available online: 12 December 2014
242
http://dx.doi.org/10.1016/j.lpm.2014.09.014 © 2014 Elsevier Masson SAS. All rights reserved.
Figure 1 Lésion ulcéro-crouteuse sur cicatrices achromiques et atrophiques de zona ophtalmique
tome 44 > n82 > février 2015
