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DOI: 10.1055/s-2007-966704
© Georg Thieme Verlag KG Stuttgart · New York
Infected appendiceal mucocele presenting as pyrexia of unknown origin
U. Dutta, MD, DM
Department of Gastroenterology
Postgraduate Institute of Medical Education and Research
Chandigarh 160012
India
Fax: +91-172-2744401
Email: ushad@satyam.net.in
Publication History
Publication Date:
08 May 2008 (online)
A mucocele of the appendix is defined as dilatation of the appendiceal lumen secondary to a variety of underlying pathological processes. Its presentation as pyrexia of unknown origin (PUO) has not been reported before. A 65-year-old man presented with a 3-month history of high-grade fever. Clinical examination and initial work-up for PUO was unremarkable. Contrast-enhanced abdominal computed tomography detected a well-defined, smooth, hypodense lesion at the base of the cecum ([Fig. 1]). A smooth filling defect, 1.5 cm × 1.5 cm in size, was seen on barium meal and follow through ([Fig. 2]). At colonoscopy, a smooth, indentable bulge (1.5 cm × 1.5 cm) was seen in the base of cecum with normal overlying mucosa ([Fig. 3]); the appendiceal opening was not visualized. When we took a biopsy from the lesion there was a gush of mucopurulent fluid. Culture of this fluid yielded growth of Gram-negative bacteria and anaerobes. The lesion collapsed and the appendiceal opening was then visible and found to be normal ([Fig. 4]). Biopsies of the lesion showed chronic inflammation. After drainage of the fluid and treatment with appropriate antibiotics the patient showed a dramatic reduction in his fever. Histopathological examination of tissue obtained from the appendectomy that was performed 2 weeks later was reported as suggestive of mucocele ([Fig. 5]).
An appendiceal mucocele may be detected incidentally at surgery, during imaging, or at colonoscopy. Barium studies usually reveal a sharply circumscribed, smooth, submucosal or extrinsic mass indenting the cecum without overlying ulceration [1]. An echo-poor mass with an onion-skin appearance is seen on ultrasound [2]. Computed tomography shows a hypodense lesion at the base of the cecum, indenting it on the medial side [3]. The classic colonoscopic appearance is that of the “volcano sign”, where there is a mound with a central appendiceal orifice [4].
Colonoscopy has been of limited use for appendiceal disorders. This is possibly the first time that it has had a therapeutic role. This case exemplifies the detection and management of an appendiceal mucocele presenting as a PUO.
Endoscopy_UCTN_Code_CCL_1AD_2AG
#References
- 1 Dachman A, Lichtenstein J, Friedman A. Mucocele of the appendix and pseudomyxoma peritonei. AJR Am J Roentgenol. 1985; 144 923-929
- 2 Caspi B, Cassif E, Auslender R. et al . The onion skin sign: a specific sonographic marker of appendiceal mucocele. J Ultrasound Med. 2004; 23 117-121
- 3 Horgan J, Chow P, Richter J. et al . CT and sonography in the recognition of mucocele of appendix. AJR Am J Roentgenol. 1984; 43 959-962
- 4 Hamilton D L, Stormont J M. The volcano sign of appendiceal mucocele. Gastrointest Endosc. 1989; 35 453-456
U. Dutta, MD, DM
Department of Gastroenterology
Postgraduate Institute of Medical Education and Research
Chandigarh 160012
India
Fax: +91-172-2744401
Email: ushad@satyam.net.in
References
- 1 Dachman A, Lichtenstein J, Friedman A. Mucocele of the appendix and pseudomyxoma peritonei. AJR Am J Roentgenol. 1985; 144 923-929
- 2 Caspi B, Cassif E, Auslender R. et al . The onion skin sign: a specific sonographic marker of appendiceal mucocele. J Ultrasound Med. 2004; 23 117-121
- 3 Horgan J, Chow P, Richter J. et al . CT and sonography in the recognition of mucocele of appendix. AJR Am J Roentgenol. 1984; 43 959-962
- 4 Hamilton D L, Stormont J M. The volcano sign of appendiceal mucocele. Gastrointest Endosc. 1989; 35 453-456
U. Dutta, MD, DM
Department of Gastroenterology
Postgraduate Institute of Medical Education and Research
Chandigarh 160012
India
Fax: +91-172-2744401
Email: ushad@satyam.net.in