Extensive retroperitoneal and right thigh abscess in a patient with ruptured retrocecal appendicitis: an extremely fulminant form of a common disease

Abstract

As a disease commonly encountered in daily practice, acute appendicitis is usually diagnosed and managed easily with a low mortality and morbidity rate. However, acute appendicitis may occasionally become extraordinarily complicated and life threatening. A 56-year-old man, healthy prior to this admission, was brought to the hospital due to spiking high fever, poor appetite, dysuria, progressive right flank and painful swelling of the thigh for 3 d. Significant inflammatory change of soft tissue was noted, involving the entire right trunk from the subcostal margin to the knee joint. Painful disability of the right lower extremity and apparent signs of peritonitis at the right lower abdomen were disclosed. Laboratory results revealed leukocytosis and an elevated C-reactive protein level. Abdominal CT revealed several communicated gas-containing abscesses at the right retroperitoneal region with mass effect, pushing the duodenum and the pancreatic head upward, compressing and encasing inferior vena cava, destroying psoas muscle and dissecting downward into the right thigh. Laparotomy and right thigh exploration were performed immediately and about 500 mL of frank pus was drained. A ruptured retrocecal appendix was the cause of the abscess. The patient fully recovered at the end of the third post-operation week. This case reminds us that acute appendicitis should be treated carefully on an emergency basis to avoid serious complications. CT scan is the diagnostic tool of choice, with rapid evaluation followed by adequate drainage as the key to the survival of the patient.

Figure 1

Retroperitoneal and right thigh abscess in a patient with ruptured retrocecal appendicitis. A: Retroperitoneal abscess with mass effect, demonstrating the upward-pushed duodenum and pancreatic head as well as compressed and encased inferior vena cava (white arrowheads); B: suspicious septic thrombus inside inferior vena cava (white arrow); C: reconstructed coronal image demonstrating extensive involvement of the abscess (short black arrows); D: dissection of the abscess in the right thigh via the femoral canal just beneath the femoral vessels (long black arrow).