Introduction

Acute appendicitis in infants under two years of age is an exceptionally rare and challenging condition to diagnose. This difficulty arises from the non-specific nature of symptoms and the inability of infants to verbalize pain. This case report presents the successful diagnosis and treatment of a three-month-old baby girl with acute appendicitis, highlighting the critical importance of timely medical intervention.

Presentation and History

A three-month-old baby girl, presented with persistent irritability, constant crying, and an unexplained fever of 39°C. The parents reported two episodes of milky vomiting, refusal to feed, and a lack of bowel movements, accompanied by severe constipation over the past day. Initial assessments at the local children’s hospital did not identify the cause of the symptoms, classifying the condition as a fever of unknown origin.

Diagnostic challenges

Diagnosing acute appendicitis in such a young patient posed significant challenges due to the nonspecific nature of the symptoms. A physical examination revealed abdominal tenderness with generalized muscle guarding. Lung auscultation was clear and symmetrical, and no inguinal hernias were detected. An anal examination showed normal findings, with the rectum found empty.

Laboratory tests indicated an elevated white blood cell count (WBC = 21,000) and a C-reactive protein (CRP) level of 78 mg/L, suggesting an infection. Electrolyte levels were within normal limits. A simple abdominal ultrasound was performed, revealing no signs of obstruction or abnormal gas-fluid levels.

Despite the absence of classical appendicitis symptoms, the medical team proceeded with further evaluations due to the severity of the clinical presentation.

Management

The child was admitted to the hospital. A nasogastric tube (NGT) was placed, and intravenous saline was initiated. Due to the concerning clinical picture, the child was promptly prepared for surgery.

Surgical intervention

This case underscores the importance of considering acute appendicitis in the differential diagnosis of infants presenting with non-specific symptoms and the critical need for a thorough clinical evaluation. Prompt surgical intervention is essential to prevent complications such as perforation or sepsis. The successful management of this case highlights the importance of vigilance and timely action in pediatric care.

Follow-up and treatment:

The child was monitored in the pediatric ward for several days, receiving intravenous rehydration and a three-day course of intravenous antibiotics. Her recovery was uneventful, and she was discharged in good health a few days later. She was prescribed anti-inflammatory medication and a pain reliever as needed.

Key findings

This case underscores the importance of considering acute appendicitis in the differential diagnosis for infants presenting with unexplained fever and discomfort. The successful outcome of this case highlights the critical role of prompt diagnosis and immediate surgical intervention. The vigilance of the medical staff was crucial in preventing severe complications such as appendiceal perforation or septic shock, which could have been life-threatening.

This rare condition emphasizes the need for early diagnosis and ergent surgical treatment for acute appendicitis in infants. It also underscores the importance of raising awareness among healthcare workers and parents about the seriousness of unexplained symptoms in young children.

Discussion about appendicitis in young children

Appendicitis is a prominent medical problem, especially in children, under the age of two, as its symptoms may appear atypical and can lead to serious complications if not diagnosed quickly.

Overview of Pediatric appendicitis

Appendicitis occurs when the appendix becomes obstructed and infected. This condition is a medical emergency due to the risk of appendix rupture, which can lead to severe complications such as peritonitis or sepsis if not addressed promptly.[1]

Symptoms in young children

In children under two years of age, symptoms of appendicitis can be atypical and may not follow the classic presentation seen in older children. Common signs include:

1. Abdominal Pain: Often the first symptom but may not be localized.
2. Vomiting: Frequent vomiting can accompany abdominal pain.
3. Fever: Low-grade fever is common, but a high fever may indicate a ruptured appendix.
4. Swelling: Abdominal swelling may indicate serious complications.
5. Anorexia: Reduced appetite often accompanies other symptoms.

Diagnostic challenges

Diagnosing appendicitis in young children is particularly challenging because[2], [3]:

• Non-Specific Symptoms: Symptoms in infants can be vague and non-specific, making it difficult to identify appendicitis early.
• Limited Communication: Infants cannot verbalize their pain, complicating the clinical assessment.
• Lack of Classical Symptoms: The classic symptoms of appendicitis may not be present, such as localized pain or rebound tenderness.

Early recognition and intervention are crucial to managing appendicitis effectively in young children. Enhanced awareness and diagnostic vigilance are essential for preventing severe outcomes and improving patient outcomes.

Comparison of appendicitis scale systems in children

Several scoring systems have been developed to aid in the diagnosis of appendicitis in children. These systems integrate clinical findings and laboratory test results to predict the likelihood of appendicitis. Here, we compare several of these scales: the Pediatric Appendicitis Score (PAS), the Alvarado Score, the Modified PAS, the Lintula Score, and the Tzanakis Score.

Pediatric Appendicitis Score (PAS) system

The PAS is specifically designed for children and includes the following factors:

• Cough/Knock/Rebound Pain in the Lower Right Quadrant: +2
• Anorexia: +1
• Fever: +1
• Nausea or Vomiting: +1
• Lower Right Quadrant Pain: +2
• Increased Leukocytosis: +1
• Polymorphonuclear Neutrophils: +1
• Migratory Abdominal Pain: +1

A PAS score of more than 7 indicates a high probability of appendicitis. Studies show that the PAS has a sensitivity range of 87-100% and specificity of 59-92%

Alvarado Score

The Alvarado Score is widely used but may be less accurate in younger children. The score includes:

• Symptoms: Migratory right iliac fossa pain (+2), nausea/vomiting (+1), anorexia (+1)
• Signs: Tenderness in right iliac fossa (+2), rebound tenderness (+1), elevated temperature (+1)
• Laboratory Results: Leukocytosis (+2)

An Alvarado score of 7 or more suggests appendicitis. In pediatric patients, the Alvarado Score has demonstrated a sensitivity of 85.5%, specificity of 70%, positive predictive value of 96.5%, negative predictive value of 33.3%, and diagnostic accuracy of 84.11%.

Modified PAS

The Modified PAS is an adaptation of the original PAS, incorporating additional variables or adjusted scoring thresholds to improve diagnostic accuracy. The specific adjustments can vary, but the aim is generally to enhance the sensitivity and specificity of the score.

Lintula Score

The Lintula Score is less commonly used but focuses on similar factors. It combines clinical signs and symptoms with laboratory findings to assess the likelihood of appendicitis. The specifics of this score system may vary and are often tailored to specific clinical settings.

Tzanakis Score

The Tzanakis Score is another tool that combines clinical, physical, and laboratory findings to predict appendicitis. Like other scoring systems, it is used to support clinical decision-making and may vary in its application based on clinical experience and settings.

The use of these different measurement systems, along with clinical judgment and imaging when needed, can help improve the management of suspected appendicitis in pediatric patients.

Treatment options

The primary treatment for appendicitis is an appendectomy, which involves the surgical removal of the appendix. Children, especially those under three years old, are at a significantly higher risk of experiencing perforation of the appendix. Studies indicate that the rates of perforated appendicitis can reach as high as 100% in infants under one year and approximately 69% to 74% in children under five years old. Up to 70% of children under the age of three can develop perforation within 48 hours of symptom onset.[6]

In certain cases, particularly with early or mild appendicitis, non-surgical management using antibiotics may be considered. This approach aims to avoid the need for surgery and involves careful monitoring. However, some children may still require an appendectomy if symptoms do not improve with antibiotic treatment. The necessity of surgery increases with the child’s age, as younger patients are more prone to perforation. Studies show that 70% of children under the age of three can develop perforation within 48 hours of the onset of symptoms. In some cases, particularly with early or mild appendicitis, non-surgical treatment with antibiotics may be considered. This approach can help avoid surgery but requires close monitoring, as some children may eventually need an appendectomy if symptoms do not improve.

• Parental guidance: It is important that caregivers pay close attention to the health of their children. Parents should seek immediate medical attention if their child develops persistent symptoms such as high fever, irritability, or refusal of food, as these symptoms may indicate possible appendicitis.
• Postoperative care: Children after surgery usually need to monitor for complications such as infections or abscesses, especially if appendicitis is advanced at the time of surgery. [5]Antibiotics are often given intravenously to manage any possible infection.

The importance of timely intervention

When appendicitis is suspected, parents should seek immediate medical attention. Delays in diagnosis and treatment can lead to serious complications, including:

The Importance of Promptly intervention

When appendicitis is suspected, parents should seek immediate medical attention. Delays in diagnosis and treatment can lead to serious complications, including:

• Appendix rupture: This can cause extensive intra-abdominal infection.
• Intra-abdominal abscess: pus accumulation can form after perforation.
• Increased morbidity: Complications from delayed treatment can lead to longer hospital stays and more complex medical interventions.

Summary

Although appendicitis is more common in older children and adolescents, it can occur in very young children, presenting unique challenges in diagnosis and treatment. Being aware of symptoms and seeking medical help urgently can significantly improve outcomes for affected children. Parents should remain vigilant and proactive in addressing any signs of discomfort in their young children.

In this case, we documented the rarity, difficulty, and challenges of diagnosing appendicitis in infants. It is crucial to thoroughly examine the child and avoid delaying a visit to the nearest medical facility or children’s hospital if any symptoms arise. Prompt intervention can prevent complications. The primary treatment for this condition involves an appendectomy and abdominal lavage with well-warmed saline solution, ensuring that the solution is adequately heated.

Clarification:

This case was treated at Bab Al-Hawa Hospital, which is supported by  the Syrian American Medical Association – SAMS, where the case was received by Dr. Yasser Al-Hammadi, a resident of pediatric surgery at the Syrian Commission for Medical Specializations Subums, and the case was managed under the direct supervision of the supervising doctor, Dr. Mahmoud Qaddah.

References:

[1]        R. M. Rentea and S. D. St. Peter, “Pediatric Appendicitis,” 2017. doi: 10.1016/j.suc.2016.08.009.

[2]        P. Marzuillo, “Appendicitis in children less than five years old: A challenge for the general practitioner,” World J Clin Pediatr, vol. 4, no. 2, 2015, doi: 10.5409/wjcp.v4.i2.19.

[3]        Z. Pogorelić, J. Domjanović, M. Jukić, and T. Poklepović Peričić, “Acute appendicitis in children younger than five years of age: Diagnostic challenge for pediatric surgeons,” Surg Infect (Larchmt), vol. 21, no. 3, 2020, doi: 10.1089/sur.2019.175.

[4]        E. C. Howell, E. D. Dubina, and S. L. Lee, “Perforation risk in pediatric appendicitis: Assessment and management,” 2018. doi: 10.2147/IDR.S167639.

[5]        M. Knaapen et al., “Outcomes after appendectomy in children with acute appendicitis treated at a tertiary paediatric centre: results from a retrospective cohort study,” Langenbecks Arch Surg, vol. 406, no. 1, 2021, doi: 10.1007/s00423-020-01976-y.

[6]        M. Md. E. L. M. M. Mary L Brandt, “Acute appendicitis in children: Clinical manifestations and diagnosis.” Accessed: Aug. 06, 2024. [Online]. Available: https://www.uptodate.com/contents/acute-appendicitis-in-children-clinical-manifestations-and-diagnosis?search=acute%20appendicitis&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3