Patient Case Discussion
Case Summary
The team discussed several cases of abdominal pain and inflammation, including a rare case of perforated appendicitis that was initially managed conservatively. They also explored the histopathological analysis of an appendix and the diagnosis of a rare medical condition called low-grade appendiceal, mucinous neoplasm. The importance of diligence, detail, and shared decision-making in pathology and treatment decisions was emphasized, with a focus on the potential for significant consequences and the need for follow-up on certain practices.
Unusual Presentation of Perforated Appendicitis
A case was presented of a 12-year-old female patient with Courland syndrome who presented with right lower quadrant pain, nausea, vomiting, and loose stool. The patient had been symptomatic for 6 days and was initially treated with analgesia. Upon arrival at the emergency department, the patient's blood pressure was normal, but she was borderline tachycardic and had tenderness in the right lower quadrant. An ultrasound revealed acute perforated appendicitis with collection. The team discussed the patient's unusual presentation, considering the possibility of a mist perforation where the patient perforated but walled off the infection. They emphasized the importance of imaging in such cases to guide treatment decisions.
Possible Acute Perforated Appendicitis
A recent ultrasound was discussed that revealed an inflamed appendix with a diameter of up to 2 cm. The appendix was surrounded by hyperechoic fat and free fluid, with complex debris present. No frank appendicular or encapsulated collection was observed, but the complex free fluid suggested a possible acute perforated appendicitis.
Patient With Perforated Appendicitis
The team discussed the case of a patient with perforated appendicitis who was initially managed conservatively with antibiotics. The patient improved and was scheduled for an interval appendectomy, which was performed 3 months later. The moderators emphasized the importance of shared decision-making in such cases, considering factors such as the patient's social situation and access to healthcare. Also discussed were the risks of recurrence, noting that the best literature suggests a 15% to 20% chance. Dr. Sherif Emil questioned the findings on ultrasound that would warrant a strong recommendation for an appendectomy and mentioned lateral adhesions in the patient's case. The pathology results revealed a neuroendocrine tumor of the appendix, which was a surprise finding.
Appendix Histopathological Analysis Discussion
The team discussed the histopathological analysis of an appendix, noting its thinned walls and absence of a distinct mass. The appendix showed dissecting mucin, flattened epithelium, and acellular mucin near the surgical margin. A focal area of fibrous obliteration was also noted, with foreign body-type giant cells reacting to the mucin. The appendix had areas of hyperplasia and crowded cells. The presence of small diverticula and areas of mucin perforation was mentioned.
Low-grade Appendiceal Mucinous Neoplasm Diagnosis
The team discussed a rare medical condition called low-grade appendiceal, mucinous neoplasm, which predominantly affects adults in their 3rd to 8th decade and has a female predominance. The presentation can vary from incidental to abdominal pain because of rupture and abdominal dissemination. Treatment typically involves a simple appendectomy with negative margins, but more extensive treatment may be required depending on the stage. The prognosis is generally good for lesions confined to the appendix and completely resected, but worsens with spread and high-grade cytologic grade. The differential diagnosis for this condition was discussed, including non-neoplastic appendiceal rupture, reactive change, true hyperplastic polyps, and serrated lesions. The team shared the initial diagnosis of the condition as a low-grade appendiceal, mucinous neoplasm, which was later revised to interval appendicitis or interval appendectomy with reactive changes after consultation with other pathologists and the surgical team.
Smooth Muscle Staining Importance Discussed
A case was discussed where there was no loss of muscularis mucosa or lamina propria, even with hyperplastic change. It was noted that inflammation and cellular musing could mimic other conditions. This highlighted the importance of smooth muscle staining to assess epithelial integrity, emphasizing the need for diligence and detail in pathology to avoid mistakes.
Pathology Diagnosis and Treatment Discussion
The diligence and humility of the pathologists was noted for revising the diagnosis, highlighting the rarity of such pathology. Dr. Emil, who presented the case, confirmed that even with a positive lymph node and extension into the meso appendix, the neuroendocrine tumor behaves differently in children, and appendectomy is often curative. He also emphasized the potential significant consequences of a previous perforation. The team discussed the practice change in handling carcinoids, with most believing in a right hemicolectomy, but it was suggested that the evidence now supports that appendectomy is sufficient, regardless of the carcinoid's involvement. They agreed to follow up on this matter and review the available evidence.