Basilar Pneumonia Simulating Acute Appendicitis in Children Juda Z. Jona, MD, Robert P. Belin, MD
\s=b\ Twelve children with acute abdominal pain, which was suspected of being acute appendicitis, were subsequently found to have lower lobe pneumonia. Diagnostic barium enema or operative exploration failed to demonstrate any appendiceal abnormality. The abdominal symptoms and the ileus subsided soon after the initiation of antibiotic therapy. Contrary to common belief, it was observed that left-sided pneumonia is capable of mimicking appendicitis almost as frequently as right\x=req-\ sided pneumonia. Since the likelihood of acute appendicitis accompanying pneumonia is small, operative intervention is rarely indicated and should be undertaken only after careful and intensive investigation. (Arch Surg 111:552-553, 1976)
Temperature elevation was also present in all children, and it was particularly high (>39 C) in two. Symptoms of upper respiratory infection were frequently mild and were totally absent in four patients. Nausea and vomiting were reported in nine children. Examination of the chest showed rales in only two children. Signs of peritoneal irritation were, however, present in the entire group. With the paucity of the chest symptoms and the frequent localiza¬ tion of the abdominal findings on the right side, it is easy to understand why acute appendicitis was strongly suspected.
Laboratory
Tests
Hematological studies disclosed a white blood cell count of 9,800 to
29,400 cells
per cubic millimeter. Shift to the left of the
neutrophilic series is known to mimic
intra-abdom¬ pneumonia Lower conditions, frequently appearing Children manifesting pain,
lobe inal abdomen.1-'
as
an
acute
elevated and of are temperature, leukocytosis having suspected acute appendicitis. This may be true even in the presence of pneumonia, especially when the abdominal symptoms are intense and the chest examination is nonrevealing. This article describes our experience with a group of such children. They were seen primarily for abdominal pain, clinically suspected of being caused by appendicitis. However, basilar pneumonia was subsequently implicated as the cause of their symptoms. abdominal
SUBJECTS AND METHODS
'
During a 30-month period (December July 1975), more than 250 children were examined for acute abdomen. Of those, 12 patients were found to have basilar pneumonitis as the sole cause of their abdominal symptoms. These children compose the basis of this report. There were seven boys and five girls, aged 3 to 18 years, in this series. Three were examined and treated in the outpatient clinic; the remaining nine were admitted for observation, further stud¬ ies, or operative exploration. Abdominal and chest roentgeno¬ grams were obtained on all children, and in six, additional diagnostic barium enema was employed. Operative exploration of the appendix was carried out on three occasions. 1972 to
Clinical Presentation Abdominal pain was the cardinal presenting symptom in the entire group. The pain varied in its intensity and localization, but it was severe enough to suggest acute appendicitis in each case.
Accepted
for publication Dec 16, 1975. From the Division of Pediatric Surgery,
University of Kentucky
was seen in all but one patient. Radiologie studies included abdominal films with the patient in supine and upright positions and frontal and lateral chest views. Intestinal distention, the hallmark of ileus, was noted on roentgenograms in eight children; in three of them, it was severe enough to suggest an advanced disease. Chest roentgenograms showed seven cases of right-sided and five cases of left-sided basilar pneumonia. In three children, the pulmonary abnormality was inapparent on the frontal views, and in each case the pneumonia was located behind the dome Of the diaphragm, in the posterior sulcus, in such a way that it was visualized only on the lateral chest projection (Fig 1 and 2). Despite the presence of abnormal chest roentgenograms and mainly because of the intensity of the abdominal symptoms, the possibility of appendicitis accompanying the pneumonia could not be excluded in six children, and diagnostic barium enema was obtained. In all six, however, a normal study excluded the possi¬ bility of acute appendicitis,' and the children were treated only for their pneumonia. Bactériologie cultures of the sputum were obtained in ten children. Diplococcus pneumoniae was found in four, Staphylo¬ coccus aureus in three, Haemophilus influenzae in two, and no pathogenic organism was recovered in the remaining child.
Medical
Center, Lexington, Ky. Reprint requests to Division of Pediatric Surgery, University of Kentucky Medical Center, Lexington, KY 40506 (Dr Jona).
Therapy As mentioned earlier, three children were not hospitalized. Once infection was implicated as the sole source of their abdominal symptoms, they were given oral antibiotic treatment and released. The remaining children were hospitalized, initially for further evaluation, which was later followed by appropriate therapy. Despite the identification of pneumonia, three children were subjected to surgical exploration of the appendix without the benefit of diagnostic barium enema. Based on clinical findings alone, the examining surgeon was unable to exclude the possibility of concomitantly occurring acute appendicitis. None of these three, however, were found to have any intraperitoneal abnormal¬ ity. A fasting regimen was prescribed for all of the hospitalized children, and they received intravenous infusions until they recovered from the ileus. An appropriate intravenous antibiotic was administered as soon as the possibility of appendicitis was excluded. The abdominal symptoms improved, and the ileus
pulmonary
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Fig 1.—Frontal chest view. Posterior basal ent. Note associated ileus.
pneumonia
not appar¬
resolved within 12 to 18 hours after the initiation of the antimi¬ crobial treatment. On full recovery, oral antibiotic treatment was prescribed, and the patients were discharged. Recurrent abdom¬ inal problems were not encountered on follow-up examinations in the clinic.
COMMENT
Basilar pneumonia is listed among the more frequent extra-abdominal conditions that may produce symptoms of an acute abdomen."' We have found this to be particularly true in children, since our experience shows that nearly 5% of the children, who are thought to have acute appendicitis, have, in fact, basilar pneumonia as their sole pathological process. The dominance of the abdominal symptoms over the thoracic findings contributes toward this diagnostic error. This is indeed a strong argument for obtaining chest roentgenograms on all children who have symptoms of an acute abdomen. The chest films must include a lateral view, lest limited posterior-inferior pneumonia be overlooked. It is certainly possible for acute appendicitis to accompany pneumonia. The relationship between seasonal variations, the occurrence of upper respiratory infections, and the increased incidence of appendicitis have been suggested." We suspect, however, that this association is rare and, therefore, every effort, short of operation, must be made to ascertain whether indeed an intra-abdominal problem exists. When the examining physician strongly suspects acute appendicitis, even in the presence of
Fig 2.—Lateral chest (arrow).
view. Posterior basal
pneumonia apparent
abnormal chest roentgenograms, a diagnostic barium enema can assist him in excluding this possibility, thus eliminating the need for exploratory operation in the face of pulmonary infection.1 By employing the barium enema, we were able to dismiss three children receiving only oral medications, follow them closely in the outpatient clinic, and witness prompt and complete resolution of their abdominal symptoms. One should remember, however, that premature administration of antibiotics may mask the symptoms and alter the course of early acute appendicitis. For that reason, antibiotics should not be prescribed to children with abdominal pain and pneumonia until the physician can assure himself that appendicitis is not present. The rapid resolution of the abdominal symptoms, once treatment of the pneumonia has begun, serves to reaffirm the surgeon's judgement to withhold operation. '
References 1. Botsford TW, Wilson RE: The Acute Abdomen. Philadelphia, WB Saunders Co, 1969, p 33. 2. Cope Z: The Early Diagnosis of the Acute Abdomen, ed 13. Oxford, England, Oxford University Press, 1968. 3. Jona JZ, Selke AC, Belin RP: Radiologic aids in the diagnosis of appendicitis in children. South Med J 68:1373-1376, 1975. 4. Schey WL: Use of barium in the diagnosis of appendicitis in children. Am J Roentgenol Radium Ther Nucl Med 118:95-103, 1973. 5. Schwartz SI (ed): Principles of Surgery. New York, McGraw-Hill Book
Co. Inc, 1969, p 833.
6. Boyce FF: Acute Appendicitis and Its Complications. Oxford, England, Oxford University Press, 1949, p 46.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/01/2015
\s=b\ Twelve children with acute abdominal pain, which was suspected of being acute appendicitis, were subsequently found to have lower lobe pneumonia. Diagnostic barium enema or operative exploration failed to demonstrate any appendiceal abnormality. The abdominal symptoms and the ileus subsided soon after the initiation of antibiotic therapy. Contrary to common belief, it was observed that left-sided pneumonia is capable of mimicking appendicitis almost as frequently as right\x=req-\ sided pneumonia. Since the likelihood of acute appendicitis accompanying pneumonia is small, operative intervention is rarely indicated and should be undertaken only after careful and intensive investigation. (Arch Surg 111:552-553, 1976)
Temperature elevation was also present in all children, and it was particularly high (>39 C) in two. Symptoms of upper respiratory infection were frequently mild and were totally absent in four patients. Nausea and vomiting were reported in nine children. Examination of the chest showed rales in only two children. Signs of peritoneal irritation were, however, present in the entire group. With the paucity of the chest symptoms and the frequent localiza¬ tion of the abdominal findings on the right side, it is easy to understand why acute appendicitis was strongly suspected.
Laboratory
Tests
Hematological studies disclosed a white blood cell count of 9,800 to
29,400 cells
per cubic millimeter. Shift to the left of the
neutrophilic series is known to mimic
intra-abdom¬ pneumonia Lower conditions, frequently appearing Children manifesting pain,
lobe inal abdomen.1-'
as
an
acute
elevated and of are temperature, leukocytosis having suspected acute appendicitis. This may be true even in the presence of pneumonia, especially when the abdominal symptoms are intense and the chest examination is nonrevealing. This article describes our experience with a group of such children. They were seen primarily for abdominal pain, clinically suspected of being caused by appendicitis. However, basilar pneumonia was subsequently implicated as the cause of their symptoms. abdominal
SUBJECTS AND METHODS
'
During a 30-month period (December July 1975), more than 250 children were examined for acute abdomen. Of those, 12 patients were found to have basilar pneumonitis as the sole cause of their abdominal symptoms. These children compose the basis of this report. There were seven boys and five girls, aged 3 to 18 years, in this series. Three were examined and treated in the outpatient clinic; the remaining nine were admitted for observation, further stud¬ ies, or operative exploration. Abdominal and chest roentgeno¬ grams were obtained on all children, and in six, additional diagnostic barium enema was employed. Operative exploration of the appendix was carried out on three occasions. 1972 to
Clinical Presentation Abdominal pain was the cardinal presenting symptom in the entire group. The pain varied in its intensity and localization, but it was severe enough to suggest acute appendicitis in each case.
Accepted
for publication Dec 16, 1975. From the Division of Pediatric Surgery,
University of Kentucky
was seen in all but one patient. Radiologie studies included abdominal films with the patient in supine and upright positions and frontal and lateral chest views. Intestinal distention, the hallmark of ileus, was noted on roentgenograms in eight children; in three of them, it was severe enough to suggest an advanced disease. Chest roentgenograms showed seven cases of right-sided and five cases of left-sided basilar pneumonia. In three children, the pulmonary abnormality was inapparent on the frontal views, and in each case the pneumonia was located behind the dome Of the diaphragm, in the posterior sulcus, in such a way that it was visualized only on the lateral chest projection (Fig 1 and 2). Despite the presence of abnormal chest roentgenograms and mainly because of the intensity of the abdominal symptoms, the possibility of appendicitis accompanying the pneumonia could not be excluded in six children, and diagnostic barium enema was obtained. In all six, however, a normal study excluded the possi¬ bility of acute appendicitis,' and the children were treated only for their pneumonia. Bactériologie cultures of the sputum were obtained in ten children. Diplococcus pneumoniae was found in four, Staphylo¬ coccus aureus in three, Haemophilus influenzae in two, and no pathogenic organism was recovered in the remaining child.
Medical
Center, Lexington, Ky. Reprint requests to Division of Pediatric Surgery, University of Kentucky Medical Center, Lexington, KY 40506 (Dr Jona).
Therapy As mentioned earlier, three children were not hospitalized. Once infection was implicated as the sole source of their abdominal symptoms, they were given oral antibiotic treatment and released. The remaining children were hospitalized, initially for further evaluation, which was later followed by appropriate therapy. Despite the identification of pneumonia, three children were subjected to surgical exploration of the appendix without the benefit of diagnostic barium enema. Based on clinical findings alone, the examining surgeon was unable to exclude the possibility of concomitantly occurring acute appendicitis. None of these three, however, were found to have any intraperitoneal abnormal¬ ity. A fasting regimen was prescribed for all of the hospitalized children, and they received intravenous infusions until they recovered from the ileus. An appropriate intravenous antibiotic was administered as soon as the possibility of appendicitis was excluded. The abdominal symptoms improved, and the ileus
pulmonary
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/01/2015
Fig 1.—Frontal chest view. Posterior basal ent. Note associated ileus.
pneumonia
not appar¬
resolved within 12 to 18 hours after the initiation of the antimi¬ crobial treatment. On full recovery, oral antibiotic treatment was prescribed, and the patients were discharged. Recurrent abdom¬ inal problems were not encountered on follow-up examinations in the clinic.
COMMENT
Basilar pneumonia is listed among the more frequent extra-abdominal conditions that may produce symptoms of an acute abdomen."' We have found this to be particularly true in children, since our experience shows that nearly 5% of the children, who are thought to have acute appendicitis, have, in fact, basilar pneumonia as their sole pathological process. The dominance of the abdominal symptoms over the thoracic findings contributes toward this diagnostic error. This is indeed a strong argument for obtaining chest roentgenograms on all children who have symptoms of an acute abdomen. The chest films must include a lateral view, lest limited posterior-inferior pneumonia be overlooked. It is certainly possible for acute appendicitis to accompany pneumonia. The relationship between seasonal variations, the occurrence of upper respiratory infections, and the increased incidence of appendicitis have been suggested." We suspect, however, that this association is rare and, therefore, every effort, short of operation, must be made to ascertain whether indeed an intra-abdominal problem exists. When the examining physician strongly suspects acute appendicitis, even in the presence of
Fig 2.—Lateral chest (arrow).
view. Posterior basal
pneumonia apparent
abnormal chest roentgenograms, a diagnostic barium enema can assist him in excluding this possibility, thus eliminating the need for exploratory operation in the face of pulmonary infection.1 By employing the barium enema, we were able to dismiss three children receiving only oral medications, follow them closely in the outpatient clinic, and witness prompt and complete resolution of their abdominal symptoms. One should remember, however, that premature administration of antibiotics may mask the symptoms and alter the course of early acute appendicitis. For that reason, antibiotics should not be prescribed to children with abdominal pain and pneumonia until the physician can assure himself that appendicitis is not present. The rapid resolution of the abdominal symptoms, once treatment of the pneumonia has begun, serves to reaffirm the surgeon's judgement to withhold operation. '
References 1. Botsford TW, Wilson RE: The Acute Abdomen. Philadelphia, WB Saunders Co, 1969, p 33. 2. Cope Z: The Early Diagnosis of the Acute Abdomen, ed 13. Oxford, England, Oxford University Press, 1968. 3. Jona JZ, Selke AC, Belin RP: Radiologic aids in the diagnosis of appendicitis in children. South Med J 68:1373-1376, 1975. 4. Schey WL: Use of barium in the diagnosis of appendicitis in children. Am J Roentgenol Radium Ther Nucl Med 118:95-103, 1973. 5. Schwartz SI (ed): Principles of Surgery. New York, McGraw-Hill Book
Co. Inc, 1969, p 833.
6. Boyce FF: Acute Appendicitis and Its Complications. Oxford, England, Oxford University Press, 1949, p 46.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/01/2015
