An Unusual Presentation of Acute Appendicitis With Mobile Cecum Syndrome

Abstract

A 13-year-old boy presented to our emergency department with nausea and hypogastric pain. An initial diagnosis of enteritis was made due to the patient’s relatively unremarkable medical history and physical examinations. Shortly afterward, fever and severe abdominal pain in the left upper quadrant with persistent nausea developed. Laboratory examinations showed an elevated level of Creactive protein. There was left shift of white cells without evident leukocytosis. Because of nonspecific findings in physical examinations and relatively normal laboratory results, the diagnosis initially remained inconclusive. After being admitted for 36 hours, the patient’s fever progressed to 39 C despite partial relief of abdominal pain and improvement of appetite. Tenderness over the left lower quadrant with mild rebound pain over the bilateral lower abdomen was noted. However, obturator sign, psoas sign, and Rovsing sign for acute appendicitis were all negative. With progressive elevation of inflammatory index and abdominal symptoms, intra-abdominal infection was suspected. Abdominal computed tomography revealed ectopic appendicitis with the swollen appendix in the deep lower pelvic cavity (Figure 1). In addition, the duodenum failed to cross to the left side, resembling malrotation (Figure S1), with small intestine