Appendicitis in the Infant Population: A Case Report and Review of a Four-Month Old With Appendicitis

BackgroundAppendicitis is uncommon in children <6 months old, with few observational studies reporting cases of children younger than 5 years old with the diagnosis. The classic periumbilical pain that migrates to the right lower quadrant, followed by the onset of fever and vomiting, is present in approximately 40% of pediatric patients under 12 years of age with appendicitis.Case ReportA 4-month-old girl presented to the Emergency Department (ED) with acute onset of grunting, pallor, fussiness, emesis, and diarrhea. The patient was initially afebrile, tachycardic, and tachypneic with a soft, nondistended, nontender abdomen and active bowel sounds. The patient became febrile, with a maximum temperature of 39.3°C (102.7°F), and remained tachycardic despite receiving fluids and antipyretics. Laboratory studies were notable for mild dehydration and sterile pyuria. Chest x-ray study was negative for infectious etiologies. Initial abdominal ultrasound found no clear etiology of the patient's symptoms. The patient was admitted to inpatient pediatrics for dehydration, fever, and presumed pyelonephritis. Twenty-four hours later the patient's abdomen became distended and diffusely tender to palpation, with obstipation and increasing episodes of emesis. Abdominal x-ray study demonstrated mild gaseous distension of multiple bowel loops with repeat abdominal ultrasound notable for a focal 8-mm, noncompressible hyperemic structure in the right lower quadrant. The patient was taken to the operating room for a laparoscopic appendectomy.Why Should an Emergency Physician Be Aware of This?Appendicitis is a potentially life-threatening condition. In the infant population it frequently presents without the features typically seen in older children.