Perforated retroperitoneal appendicitis presented with right thigh abscess: case report and literature review

Abstract

The typical clinical presentation of acute appendicitis is initial diffuse abdominal pain that shifts to right iliac fossa, nausea, vomiting supported with elevated white blood cell count [3]. It is reported that there are atypical presentation of acute appendicitis approximately 20%-30%. Retroperitoneal perforated appendix can cause retroperitoneal and psoas abscess. After abscess formation, inflammation and pus may extend to pelvis and extra-abdominal compartments through certain routes and tissue plains. Reported routes in literature such as deep to inguinal ligament (through psoas sheath, femoral sheath and femoral canal), fibro-osseus canals (through sacrosciatic notch and Obturator foramen). We report a 67 years old patient with initial presentation of right thigh abscess and psoas abscess caused by perforated retroperitoneal appendicitis. He was managed with vertical drainage of the thigh abscess and laparoscopic appendectomy with psoas abscess drainage. There are several reports that diagnostic modalities such as CT of the abdomen and pelvis or MRI could direct the management to surgical or non-surgical plans. The early surgical intervention to the intra-abdomen pathology with sufficient drainage of the psoas and thigh abscess is the definite treatment. It is suggested that in unexplained thigh or groin pain/soft tissue infection with fever and leukocytosis a gastrointestinal pathology should not be overlooked.