Gastroenterology
Volume 133, Issue 5 , Page 1412, November 2007

Clinical Challenges and Images in GI

Department of Surgical Oncology, University of Tokyo, Tokyo, Japan

David A. Katzka and David L. Jaffe, Section Editors

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Image 1 

Question: A 38-year-old man was admitted to a general hospital with complaints of right lower abdominal pain and fever. Cefotiam was administered, but there was no clinical improvement. Massive hematochezia occurred on day 7, and he was referred to our hospital for further workup and treatment. His body temperature was 39.2°C and marked tenderness was present in the right lower abdomen. Laboratory tests showed anemia (hemoglobin 8.9 g/dL) and an elevated white blood cell count (10,200/mm3). The patient was homosexual. HIV antibody was positive and CD4+ T-cell count was decreased (183/mm3). Computed tomography (CT; Figure A) and colonoscopy (Figure B) showed abnormal findings. What is the most likely diagnosis?

Look on page 1747 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

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Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 1412): Amoebic Appendicitis 

CT showed a markedly swollen appendix (Figure A, arrow) and thickened colonic wall. Appendectomy was performed because perforation was suspected. Histopathologic examination showed gangrenous inflammation associated with hematophagous amoebic trophozoites (Figures C and D), consistent with amoebic appendicitis. The colonoscopic appearance, numerous red-rimmed ulcers with a thick yellowish coat, was typical of concomitant amoebic colitis. Metronidazole 750 mg 3 times a day was given postoperatively, and the patient rapidly recovered.

Amoebic appendicitis is a rare disease, present in 0.5%–2.3% of acute appendicitis even in endemic regions,1, 2 which is frequently observed in patients with HIV infection.3 Preoperative diagnosis of amoebic appendicitis is difficult, because the clinical presentation is often not specific in the absence of dysenteric symptoms.2 Anti-amoebic antibodies or fecal amoebic trophozoites can be negative. Therefore, appendectomy is often indicated for a suspected case of “usual” acute appendicitis. Histopathologic examination is diagnostic, and postoperative administration of metronidazole is usually associated with an excellent outcome.2, 3

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References 

  1. Gupta SC, Gupta AK, Keswani NK, et al. Pathology of tropical appendicitis. J Clin Pathol. 1989;42:1169–1172
  2. Guzman-Valdivia G. Acute amebic appendicitis. World J Surg. 2006;30:1038–1042
  3. Ramdial PK, Madiba TE, Kharwa S, et al. Isolated amoebic appendicitis. Virchows Arch. 2002;441:63–68

 For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).

PII: S0016-5085(07)01763-5

doi:10.1053/j.gastro.2007.09.053

Gastroenterology
Volume 133, Issue 5 , Page 1412, November 2007

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