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The Case Files

Welcome to the Case Files!
The Case Files is an anecdotal collection of emergency medicine cases to enable physicians and researchers to find clinically important information on unusual conditions.

Case reports should focus on:

  • Unusual side effects or adverse interactions.
  • Unusual presentations of a disease.
  • Presentations of new and emerging diseases, including new street drugs.
  • Findings that shed new light on a disease or an adverse effect.

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Tuesday, February 26, 2019

A Sneaky Symptom


The progressive suprapubic pain was a cunning symptom.

The 38-year-old man had had five days of that pain and dysuria. By the time he presented to our ED, his pain had spread to the right lower quadrant as well. He had a history of diverticulitis after a laparoscopic left hemicolectomy four years earlier.

He reported no fevers, but complained of nausea and diarrhea. He was afebrile at 36.8°C with a pulse of 76 bpm. All other vital signs were normal. Physical exam was significant for suprapubic pain and right lower quadrant tenderness to palpation without rebound, guarding, or distention.

His workup revealed a normal white blood cell count of 4.2, as well as a normal basic chemistry and urinalysis. A CT of the abdomen and pelvis with intravenous contrast showed a dilated appendix tip measuring 12 mm with mucosal enhancement and fat stranding. The appendix was elongated and overlying the bladder.

case files-lombardo.jpg

Computed tomography of the abdomen and pelvis with intravenous contrast. The yellow arrows show the appendix coursing through the lower abdomen and overlying the bladder.

Our patient was diagnosed with acute appendicitis. He was given antibiotics, intravenous fluids, kept NPO, and admitted to the surgical team. He underwent uncomplicated laparoscopic appendectomy and was discharged the next day.

Suprapubic pain and right lower quadrant pain are typical chief complaints in the emergency department, but it is important to keep a broad differential diagnosis when evaluating patients. In acute appendicitis, migrating right lower quadrant pain, fever, anorexia, nausea, and vomiting are unreliable, occurring consistently in only about half of cases. (Hong Kong Med J 2000; 6[3]:254;

When considering additional diagnoses, it is important to recall anatomical structures near where the pain is reported and to be mindful of variations in appendiceal sizes and locations. The appendix in the retrocecal position can cause inflammation of the retroperitoneal organs, mimicking biliary colic or gastroenteritis. (Adv J Emerg Med 2018;2[2]:e21; A perforated appendix can cause fistula formation to the anterior abdominal wall and present as a palpable mass. (BMJ Case Rep 2016 Nov 10; Our patient's appendix was elongated and overlying the bladder, resulting in suprapubic pain and dysuria.

Dr. Lombardo is a senior resident in emergency medicine, and Dr. Supino is the associate program director of the emergency medicine residency at Jackson Health System/University of Miami.