Letters to the Editor
893
2. Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. Am. J. Roentgenol. 2007; 188: 1604–13.
Reizal Mohd Rosli,* MBBS, BSc (Med) Devinder Raju,* FRACS, MBBS Andrew Luck,* FRACS Smita Raju,† FRANZCR, MBBS Divisions of *Surgery and †Radiology, The Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia doi: 10.1111/ans.12750
Dear Editor, Very rare cause of sepsis We review a 58-year-old woman who had an occult infective source. She initially presented to a regional hospital with fever and groin pain. There, she had a non-contrast computed tomography (CT). She was diagnosed with uncomplicated diverticulitis and discharged with antibiotics. After a week without improvement, she came to our tertiary hospital complaining of the same symptoms. Relevant background history included stepping down heavily from a ladder, ‘pulling a groin muscle’. On examination, she was febrile and tender in the right inguinal region. The abdomen was soft and minimally tender in the lower quadrants. Her white cell count was normal and the C-reactive protein was 270. When the previous non-contrast CT was reviewed, the diagnosis of diverticulitis was questioned and a contrast-enhanced CT was performed. This was reported showing thickening of sigmoid colon with adjacent inflammation. Diverticula were present but not inflamed. A flexible sigmoidoscopy followed; the mucosa was normal.
Despite broad-spectrum antibiotics she deteriorated, developing a limp and suprapubic pain. Repeated reviews of the imaging revealed an ill-defined obturator internus abscess, measuring 65 × 20 mm (Fig. 1), associated with pubic symphysis osteomyelitis. CT-guided percutaneous drainage yielded purulent fluid containing Enterococcus faecalis. The original CT was also diagnostic in retrospect, showing asymmetry of the pelvic musculature. She began to improve after the procedure and was discharged on intravenous antibiotics. Obturator internus pyomyositis (OIP) is very rare in adults, with only three recorded cases in the literature. It is more common in tropical paediatric populations; Viani et al.1 reviewed seven paediatric cases of OIP. Typical presentation was with fever, hip pain and abdominal pain following trauma or strenuous activity. Trauma in this case was the likely precipitant causing pyomyositis. The rarity of primary pyomyositis in temperate climes can lead to delayed diagnosis.2,3 Repeated reviews of imaging in occult cases are indicated. References 1. Viani RM, Bromberg K, Bradley JS. Obturator internus muscle abscess in children: report of seven cases and review. Clin. Infect. Dis. 1999; 28: 117–22. 2. Hadjipavlou M, Butt DA, McAllister J. Primary Pyomyositis: an unusual presentation in an older patient with no recognised risk factors. BMJ Case Rep. 2012; 2012: pii: bcr1220115342. 3. Bertrand SL, Lincoln ED, Prohaska MG. Primary pyomyositis of the pelvis in children: a retrospective review of 8 cases. Orthopedics 2011; 34: e832.
Kang Ler Fong,* MBBS Alistair Spiers,† MBBS Roshanak Kamyab,‡ MBBS, FRACS *JMO, †General Surgery and ‡Breast Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia doi: 10.1111/ans.12769
Dear Editor, Case report: a rare incidental finding during laparoscopic appendicectomy
Fig. 1. An axial view of computed tomography scan showing pyomyositis obturator internus.
© 2014 Royal Australasian College of Surgeons
A 37-year-old gentleman presented with severe abdominal pain to Canterbury Hospital, Sydney, NSW, Australia. He was referred into hospital by his general practitioner with a computed tomography (CT) scan and was reviewed by the on-call surgical registrar. Otherwise, he is a fit and healthy individual with no concurrent co-morbidities. Past medical history included that at the age of 18, he was involved in a motor vehicle accident (MVA) that resulted in head trauma, fractured left orbit, comminuted nasal bones and a ruptured spleen. He subsequently underwent a laparotomy splenectomy with nil complications in Lebanon. Diagnosis of acute appendicitis was made and he was urgently consented, and theatre was arranged for emergency laparoscopic appendicectomy, fearing sepsis in this splenectomized patient. The
894
Letters to the Editor
(a)
(b)
(c)
(d)
CT images were not available for review during time of assessment; however, the report documented features suggestive of acute appendicitis. Intraoperatively, it was noted with sighting concern multiple, of varying sizes, vascular-like lesions along the mesenteric, antimesenteric borders of the bowel as well as within the mesentery and retroperitoneal (Fig. 1) regions, dissimilar in appearance to previously published splenosis nodules.1 Tissue biopsy was obtained of the lesions and of the appendix with histopathology results yielding splenosis, along with his confirmed perforated acute appendicitis. Surgical splenosis is a rare benign condition manifested by the autotransplantation and subsequent proliferation of displaced splenic tissue following traumatic injury to the spleen and has been reported to occur in 50–75%2 of all patients who undergo splenectomy for traumatic injury however has been reported in postsplenectomy patients for haematological reasons.3 In 1939, Buchbinder and Lipkoff introduced the term ‘splenosis’.4 The splenic remnant implants onto serosal surfaces and derives its blood supply from the surrounding tissues and is indistinguishable from normal spleen histologically. In this case, the lesions were initially a concerning visualization, but considering the asymptomatic patient and history of splenectomy, a presumptive diagnosis of surgical splenosis was made while awaiting formal histopathology results. Retrospective review of the CT scan images illustrated minor non-reported lesions in the mesentery and round lesions in the left upper quadrant, suggestive of splenosis. Upon further discussion with the patient regarding the findings and histopathology results, he informed us that his aunty whom also was involved in a separate MVA underwent emergency splenectomy for splenic trauma has surgical splenosis, raising the question, is there a family or heredity predisposition to surgical splenosis considering up to 30% of patients do not develop splenosis?
Fig. 1. Intraoperative laparoscopic images of surgical splenosis in various shaped, forms and locations. (a) Single intra-mesenteric lesions. (b) Singular nodules along antimesenteric ileum border. (c) Retroperitoneal lesions along iliac vessels and in pelvis. (d) Multinodular lesions along ileum antimesenteric border.
In conclusion, despite the rarity of splenosis and the different forms the lesions may appear even potentially mimicking malignancy,2 a high level of suspicion of its existence in post-traumatic splenectomy patients should be made. Despite the presumptive presence of surgical splenosis, further non-invasive, preferably, investigations like 99mTc heat-damaged red blood cell scintigraphy1 with or without CT scan4,5 should be obtained and results documented in medical records for future references. References 1. Garaci FG, Grande M, Villa M et al. What is a reliable CT scan for diagnosing splenosis under emergency conditions? World J. Gastroenterol. 2009; 15: 3684–8. 2. Koh J, Lin M, Lin P et al. Splenosis presenting as multiple intraabdominal masses mimicking malignancy. ANZ J. Surg. 2008; 78: 406–7. 3. Nielsen JL, Ellegaard J, Marqversen J, Hansen HH. Detection of splenosis and ectopic spleens with 99mTc-labelled heat damaged autologous erythrocytes in 90 splenectomised patients. Scand. J. Haematol. 1981; 27: 51–6. 4. Buchbinder JH, Lipkoff CJ. Splenosis: multiple peritoneal splenic implants following abdominal injury: a report of a case and review of the literature. Surgery 1939; 6: 927–34. 5. Gunes I, Yilmaziar T, Sarikaya I, Akbunar T, Irgil C. Scintigraphic detection of splenosis: superiority of tomographic selective spleen scintigraphy. Clin. Radiol. 1994; 49: 115–7.
James Salinas, BSc, MBBS Jay Abeysinghe, FRACS Department of General Surgery, Canterbury Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12798
© 2014 Royal Australasian College of Surgeons
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
893
2. Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. Am. J. Roentgenol. 2007; 188: 1604–13.
Reizal Mohd Rosli,* MBBS, BSc (Med) Devinder Raju,* FRACS, MBBS Andrew Luck,* FRACS Smita Raju,† FRANZCR, MBBS Divisions of *Surgery and †Radiology, The Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia doi: 10.1111/ans.12750
Dear Editor, Very rare cause of sepsis We review a 58-year-old woman who had an occult infective source. She initially presented to a regional hospital with fever and groin pain. There, she had a non-contrast computed tomography (CT). She was diagnosed with uncomplicated diverticulitis and discharged with antibiotics. After a week without improvement, she came to our tertiary hospital complaining of the same symptoms. Relevant background history included stepping down heavily from a ladder, ‘pulling a groin muscle’. On examination, she was febrile and tender in the right inguinal region. The abdomen was soft and minimally tender in the lower quadrants. Her white cell count was normal and the C-reactive protein was 270. When the previous non-contrast CT was reviewed, the diagnosis of diverticulitis was questioned and a contrast-enhanced CT was performed. This was reported showing thickening of sigmoid colon with adjacent inflammation. Diverticula were present but not inflamed. A flexible sigmoidoscopy followed; the mucosa was normal.
Despite broad-spectrum antibiotics she deteriorated, developing a limp and suprapubic pain. Repeated reviews of the imaging revealed an ill-defined obturator internus abscess, measuring 65 × 20 mm (Fig. 1), associated with pubic symphysis osteomyelitis. CT-guided percutaneous drainage yielded purulent fluid containing Enterococcus faecalis. The original CT was also diagnostic in retrospect, showing asymmetry of the pelvic musculature. She began to improve after the procedure and was discharged on intravenous antibiotics. Obturator internus pyomyositis (OIP) is very rare in adults, with only three recorded cases in the literature. It is more common in tropical paediatric populations; Viani et al.1 reviewed seven paediatric cases of OIP. Typical presentation was with fever, hip pain and abdominal pain following trauma or strenuous activity. Trauma in this case was the likely precipitant causing pyomyositis. The rarity of primary pyomyositis in temperate climes can lead to delayed diagnosis.2,3 Repeated reviews of imaging in occult cases are indicated. References 1. Viani RM, Bromberg K, Bradley JS. Obturator internus muscle abscess in children: report of seven cases and review. Clin. Infect. Dis. 1999; 28: 117–22. 2. Hadjipavlou M, Butt DA, McAllister J. Primary Pyomyositis: an unusual presentation in an older patient with no recognised risk factors. BMJ Case Rep. 2012; 2012: pii: bcr1220115342. 3. Bertrand SL, Lincoln ED, Prohaska MG. Primary pyomyositis of the pelvis in children: a retrospective review of 8 cases. Orthopedics 2011; 34: e832.
Kang Ler Fong,* MBBS Alistair Spiers,† MBBS Roshanak Kamyab,‡ MBBS, FRACS *JMO, †General Surgery and ‡Breast Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia doi: 10.1111/ans.12769
Dear Editor, Case report: a rare incidental finding during laparoscopic appendicectomy
Fig. 1. An axial view of computed tomography scan showing pyomyositis obturator internus.
© 2014 Royal Australasian College of Surgeons
A 37-year-old gentleman presented with severe abdominal pain to Canterbury Hospital, Sydney, NSW, Australia. He was referred into hospital by his general practitioner with a computed tomography (CT) scan and was reviewed by the on-call surgical registrar. Otherwise, he is a fit and healthy individual with no concurrent co-morbidities. Past medical history included that at the age of 18, he was involved in a motor vehicle accident (MVA) that resulted in head trauma, fractured left orbit, comminuted nasal bones and a ruptured spleen. He subsequently underwent a laparotomy splenectomy with nil complications in Lebanon. Diagnosis of acute appendicitis was made and he was urgently consented, and theatre was arranged for emergency laparoscopic appendicectomy, fearing sepsis in this splenectomized patient. The
894
Letters to the Editor
(a)
(b)
(c)
(d)
CT images were not available for review during time of assessment; however, the report documented features suggestive of acute appendicitis. Intraoperatively, it was noted with sighting concern multiple, of varying sizes, vascular-like lesions along the mesenteric, antimesenteric borders of the bowel as well as within the mesentery and retroperitoneal (Fig. 1) regions, dissimilar in appearance to previously published splenosis nodules.1 Tissue biopsy was obtained of the lesions and of the appendix with histopathology results yielding splenosis, along with his confirmed perforated acute appendicitis. Surgical splenosis is a rare benign condition manifested by the autotransplantation and subsequent proliferation of displaced splenic tissue following traumatic injury to the spleen and has been reported to occur in 50–75%2 of all patients who undergo splenectomy for traumatic injury however has been reported in postsplenectomy patients for haematological reasons.3 In 1939, Buchbinder and Lipkoff introduced the term ‘splenosis’.4 The splenic remnant implants onto serosal surfaces and derives its blood supply from the surrounding tissues and is indistinguishable from normal spleen histologically. In this case, the lesions were initially a concerning visualization, but considering the asymptomatic patient and history of splenectomy, a presumptive diagnosis of surgical splenosis was made while awaiting formal histopathology results. Retrospective review of the CT scan images illustrated minor non-reported lesions in the mesentery and round lesions in the left upper quadrant, suggestive of splenosis. Upon further discussion with the patient regarding the findings and histopathology results, he informed us that his aunty whom also was involved in a separate MVA underwent emergency splenectomy for splenic trauma has surgical splenosis, raising the question, is there a family or heredity predisposition to surgical splenosis considering up to 30% of patients do not develop splenosis?
Fig. 1. Intraoperative laparoscopic images of surgical splenosis in various shaped, forms and locations. (a) Single intra-mesenteric lesions. (b) Singular nodules along antimesenteric ileum border. (c) Retroperitoneal lesions along iliac vessels and in pelvis. (d) Multinodular lesions along ileum antimesenteric border.
In conclusion, despite the rarity of splenosis and the different forms the lesions may appear even potentially mimicking malignancy,2 a high level of suspicion of its existence in post-traumatic splenectomy patients should be made. Despite the presumptive presence of surgical splenosis, further non-invasive, preferably, investigations like 99mTc heat-damaged red blood cell scintigraphy1 with or without CT scan4,5 should be obtained and results documented in medical records for future references. References 1. Garaci FG, Grande M, Villa M et al. What is a reliable CT scan for diagnosing splenosis under emergency conditions? World J. Gastroenterol. 2009; 15: 3684–8. 2. Koh J, Lin M, Lin P et al. Splenosis presenting as multiple intraabdominal masses mimicking malignancy. ANZ J. Surg. 2008; 78: 406–7. 3. Nielsen JL, Ellegaard J, Marqversen J, Hansen HH. Detection of splenosis and ectopic spleens with 99mTc-labelled heat damaged autologous erythrocytes in 90 splenectomised patients. Scand. J. Haematol. 1981; 27: 51–6. 4. Buchbinder JH, Lipkoff CJ. Splenosis: multiple peritoneal splenic implants following abdominal injury: a report of a case and review of the literature. Surgery 1939; 6: 927–34. 5. Gunes I, Yilmaziar T, Sarikaya I, Akbunar T, Irgil C. Scintigraphic detection of splenosis: superiority of tomographic selective spleen scintigraphy. Clin. Radiol. 1994; 49: 115–7.
James Salinas, BSc, MBBS Jay Abeysinghe, FRACS Department of General Surgery, Canterbury Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12798
© 2014 Royal Australasian College of Surgeons
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
