Perforated appendicitis without peritonitis in a premature newborn- A case report

Abstract

Introduction: Neonatal appendicitis is extremely rare and lacks specific clinical signs. Given its rarity, lack of specific physical signs and the subsequent low index of suspicion; diagnosis and surgical intervention are often delayed in neonates resulting in significant morbidity and mortality. Case presentation: We describe the case of a premature twin male born via spontaneous vaginal delivery at 22 weeks of gestation. Due to hypoxic respiratory failure and sepsis at birth, he required prolonged ventilator support and intermittent vasopressor support. On the 26th day of life, he developed feeding intolerance with hypotension and was found to have abdominal distension and significant pneumoperitoneum on plain radiograph without signs of peritonitis on physical exam. During an emergent laparotomy with ileocecectomy, he was found to have acute gangrenous appendicitis with large perforation at the base. Pathology examination demonstrated transmural necrosis of the appendix with perforation and an abundance of ganglion cells throughout the length of the examined bowel, excluding the possibility of Hirschsprung's disease. Conclusion: While neonatal appendicitis is historically considered rare, given improved survival of premature babies due to medical advances in perinatal care, it is expected that the incidence of neonatal appendicitis will continue to rise. Our case report describes the unusual presentation of neonatal appendicitis without peritonitis despite significant pneumoperitoneum and it highlights the importance of having a thorough understanding of the nonspecific signs of neonatal appendicitis and a higher index of suspicion with a comprehensive differential diagnosis to facilitate a timely diagnosis and initiate urgent surgical intervention.

Keywords

• Neonatal appendicitis
• Necrotizing enterocolitis
• Hirschsprung's disease
• Neonatal intestinal perforation
• Case report