ORIGINAL ARTICLE
Acute Appendicitis in Patients with Acquired Immunodeficiency Syndrome Kuo-Ying Liu1, Jia-Fwu Shyu2, Yih-Huei Uen3, Tien-Hua Chen1,2*, Yi-Ming Shyr1, Cheng-Hsi Su1, Chew-Wun Wu1, Wing-Yui Lui1 Department of Surgery, Taipei Veterans General Hospital, 2Department of Anatomy, National Yang-Ming University School of Medicine, and 3Division of Surgery, Chi Mei Medical Center, Tainan, Taiwan, R.O.C. 1
Background: We report our experience with patients who had acquired immunodeficiency syndrome (AIDS) and who presented with signs and symptoms suggesting acute appendicitis. Methods: Observational data are documented for 9 patients with AIDS who underwent surgery for acute appendicitis. Results: Of the 9 patients, 6 (66.7%) had acute appendicitis without perforation, while the other 3 (33.3%) had perforated appendicitis. An elevated preoperative temperature was found in 4 patients without perforation (66.7%), and in 1 patient with perforation (33.3%). An elevated white blood cell count was found in all 6 patients without perforation (100%), but in none with perforation (0%). The mean interval from surgical referral to laparotomy was 61.1 hours, the mean hospital stay was 9.3 days, and the perioperative mortality rate was 22.2%. Conclusion: Our experience should alert emergency medical staff who care for AIDS patients to the need for early diagnosis and prompt surgical treatment of appendicitis. [J Chin Med Assoc 2005;68(5):226–229] Key Words: acquired immunodeficiency syndrome, AIDS, appendicitis
Introduction Acquired immunodeficiency syndrome (AIDS), which is caused by infection with human immunodeficiency virus (HIV), may turn out to be the largest lethal epidemic of infection ever seen. In 2002, the estimated number of adults with HIV infection in Taiwan was 1 4,000. HIV infection and AIDS are relevant to surgeons in terms of the general surgical management of AIDS patients, the increasingly long list of surgical complications specific to AIDS, and the risks of patient-to2–5 surgeon and surgeon-to-patient HIV transmission. Some surgeons reserve the right to select patients on whom they operate, except in emergencies. Emergency operations become necessary to treat AIDSindependent conditions, such as acute cholecystitis and appendicitis, or AIDS-related life-threatening conditions; however, delays and errors in diagnosis are
frequent. 6 By applying sound judgment, and by selecting appropriate management, the surgeon has the ability to prolong life and improve quality of life for 7–9 AIDS patients requiring emergency surgery. The current study describes our observational data from patients with AIDS who presented with signs and symptoms suggesting acute appendicitis. Preoperative evaluation, operative findings and operative course are discussed.
Methods Study population Records were reviewed for 9 patients with AIDS who underwent emergency appendectomy between 1996 and 2003 at Veterans General Hospital, Taiwan. Recorded patient details included age, gender, sexual orientation, duration of AIDS, presenting signs and
*Correspondence to: Dr. Tien-Hua Chen, Department of Surgery, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan, R.O.C. E-mail:
[email protected] Received: June 18, 2004 Accepted: January 21, 2005
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Appendicitis in AIDS patients
Statistical analysis A non-parametric, Mann-Whitney test was used to compare patients with acute appendicitis and perforation with patients having acute appendicitis without perforation. A p value less than 0.05 was considered statistically significant.
Results Nine patients with AIDS (8 males and 1 female) underwent emergency laparotomy during the 8-year period up to August 2003. Seven patients were homosexual men (77%), 1 was a heterosexual woman who was infected with HIV from her husband (11.1%), and 1 was a man who acquired HIV from a blood transfusion (11.1%). The mean patient age was 40.3 years (range, 32–50 years). Data on comorbid conditions, pathology, duration of hospital stay and mortality are shown in Table 1. Six of 9 patients (66.7%) had acute suppurative appendicitis, and 3 (33.3%) had perforated appendicitis. One patient with acute appendicitis also had a typhoid infection. The mean hospital stay was 9.3 days (range, 7–12 days). Two deaths occurred in 3 patients with perforated appendicitis (Table 1). The initial presenting symptom was lower abdominal pain in all patients. Pain was localized in the right lower quadrant in 4 patients, and became
diffuse abdominal peritonitis in 2. Of the remaining 3 patients, all developed nausea and vomiting; 1 also had diarrhea. All patients were diagnosed by computed tomography (CT) scans of the abdomen. Fever (temperature ≥ 38.0°C) was noted in 5 patients (55.5%), and a raised preoperative temperature was noted in 66.7% of patients with acute appendicitis and 33.3% of those with perforated appendicitis. An elevated white blood cell count (WBC ≥ 10,000/mm3) was found in 6 patients (66.7%), all of whom had acute appendicitis without perforation (Figure 1). The mean interval from surgical referral to laparotomy was 61.1 hours (range, 10 hours to 12 days). Patients with acute appendicitis were operated on within 10–24 hours (mean, 17.1 hours), whereas patients with perforated appendicitis were operated on
100% 100 Temperature ≥ 38°C WBC ≥ 10,000/mm3
80 66.7%
60
%
symptoms, radiographic findings, laboratory data, preoperative diagnosis, operative findings, definitive diagnosis, and postoperative survival.
33.3%
40
20 0% 0 Acute
Perforated
Figure 1. Body temperature and white blood cell count (WBC) in 9 patients with AIDS who underwent appendectomy.
Table 1. Clinical data for 9 patients with AIDS who underwent emergency appendectomy Patient number 1 2 3 4 5 6 7
8 9
Critical comorbidity
Preoperative diagnosis
Pathology
None None PCP; CMV infection Disseminated tuberculosis lymphadenitis None None Tuberculosis; PCP; CMV retinitis; herpes zoster
Ruptured appendicitis Acute appendicitis Acute appendicitis Ruptured appendicitis Acute appendicitis Acute appendicitis Ruptured appendicitis with SMV thrombosis and liver abscess Ruptured appendicitis with abscess formation Ruptured appendicitis
Tuberculosis; CMV retinitis; interstitial pneumonia None
Hospital LOS (d)
Mortality
Ruptured appendicitis Suppurative appendicitis Suppurative appendicitis Acute appendicitis
12 7 11 7
Alive Alive Alive Alive
Suppurative appendicitis Suppurative appendicitis Ruptured appendicitis
7 9 –
Alive Alive Dead
Ruptured appendicitis
–
Dead
12
Alive
Typhlitic appendicitis
CMV = cytomegalovirus; LOS = length of stay; PCP = Pneumocystis carinii pneumonia; SMV = superior mesenteric vein.
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within 16 hours to 12 days (mean, 181 hours/7.5 days). Delayed diagnosis and exploratory surgery occurred in 2 patients with perforated appendicitis after a mean of 9 days. Two of the 3 patients with perforated appendicitis died perioperatively. After the first postoperative day, WBC and temperature became normal in all 6 patients with acute appendicitis. However, 2 of 3 patients (66.7%) with perforated appendicitis had fever, which persisted for up to 12 days postoperatively, accompanied by leukocytopenia (Figures 2 and 3).
16,000
WBC (per mm3)
14,000
Acute appendicitis Perforated appendicitis
*
12,000 10,000 8,000 6,000 4,000 2,000 PRE-OP
OP1
OP2
OP3
OP4
OP5
OP6
OP7
OP8
Postoperative days Figure 2. White blood cell count (WBC) in 9 patients with AIDS who underwent appendectomy. A non-parametric, Mann-Whitney test was used to compare data from patients with acute appendicitis and perforation with data from patients with acute appendicitis without perforation; *p < 0.05.
39.0
*
Acute appendicitis Perforated appendicitis
Temperature (°C)
38.5
* 38.0
*
37.5 37.0
36.5 36.0 PRE-OP OP1
OP2
OP3
OP4
OP5
OP6
OP7
OP8
OP9
Postoperative days Figure 3. Body temperature in 9 patients with AIDS who underwent appendectomy. A non-parametric, Mann-Whitney test was used to compare data from patients with acute appendicitis and perforation with data from patients with acute appendicitis without perforation; *p < 0.05.
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Discussion A recent report by the Taiwan AIDS Society stated that, although the total number of known AIDS cases in Taiwan in 2002 was 4,000, the number is expected 1 to increase rapidly in the near future. Thus, surgeons are likely to increasingly encounter patients with AIDS. The presentation of right lower quadrant abdominal pain in patients with HIV/AIDS poses a difficult diagnostic dilemma because the differential diagnosis must include surgical conditions, such as acute appendicitis, and gastrointestinal opportunistic 10–12 infections. Clinical history, symptoms and physical findings suggestive of acute appendicitis may also be produced by cytomegalovirus (CMV) enterocolitis or acute typhlitis, both of which are common enteric 10–12 infections in AIDS patients. Acute appendicitis affects 0.1–0.2% of the population, but the rate is probably higher in HIVinfected patients. A study of 36 AIDS patients requiring emergency laparotomy reported that 6 (16.7%) had appendicitis. Another study involving 1,725 consecutive hospitalized HIV-infected patients re13,14 ported 9 cases (0.5%) of acute appendicitis. The causes of acute appendicitis in most HIV/AIDS patients are similar to those in the general population. However, in some HIV/AIDS patients, the cause of appendicitis is an underlying opportunistic infection, particularly CMV infection or neoplastic obstruction of the base of the appendix by Kaposi’s sarcoma. In our patients, no CMV infection of the appendix was found, but one patient had typhoid appendicitis. Diagnostic laparoscopy, CT scans and ultrasonography are advocated by many surgeons for a 15 more accurate diagnosis of appendicitis. In our study, all patients had diagnosis confirmed by CT scan. Although it is important to avoid unnecessary surgery in patients with AIDS, such a conservative strategy may delay a diagnosis of appendicitis until a more advanced stage of the condition has developed. In our study, the 2 deaths that occurred were both attributable to delays in the diagnosis and treatment of appendicitis. Our data reveal very few differences between AIDS patients and general patients with acute appendicitis. Our AIDS patients were significantly older (mean age, 40.3 years) than patients in the general population 16 (mean age, 25.5 years in 1 study ), most probably because of the age distribution of HIV infection. Preoperative WBC is usually not elevated in the presence of acute inflammation in AIDS patients, probably because of an impaired immune response.17 In the general population, however, 90% of patients with
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appendicitis (acute or perforated) have an elevated 16 preoperative leukocyte count. In our study, all patients with acute appendicitis had an elevated preoperative WBC, whereas none with perforated appendicitis did. In the general population, patients with appendicitis (acute or perforated) typically present with an elevated 16 body temperature (15% or 40% of cases, respectively). In our series, 66.7% of patients with acute appendicitis had an elevated preoperative temperature, whereas only 33.3% of patients with perforated appendicitis had a fever. Further, the proportions of patients with an elevated WBC or fever were significantly greater in patients with acute rather than perforated appendicitis. Postoperatively, a marked decrease in WBC and absence of fever was often observed in patients with AIDS. Compared with other patients, HIV-infected patients have a clinically different presentation of perforated appendicitis because of underlying opportunistic infection of other organs and a weak intensity of the disease ascribed to ongoing AIDS or antiretroviral drug therapy. In the general population, the incidence of normal, acute and perforated appendicitis is 13%, 63% and 24%, respectively, based 16 on surgical findings. In our series of 9 AIDS patients with acute appendicitis, 6 had acute appendicitis without perforation (66.7%) and 3 had perforated appendicitis (33.3%). A conservative approach to lower abdominal pain in AIDS patients may result in surgery at a more advanced stage of acute appendicitis, a higher incidence of perforated appendicitis, and subsequently, an 6 increased rate of complications. Indeed, the 2 deaths in our study occurred among the 3 patients with perforated appendicitis. One of the 2 patients who died had a history of tubercular infection, Pneumocystis carinii pneumonia, CMV infection, and herpes zoster, th and died on the 15 postoperative day; the other had a history of tubercular infection, CMV infection, and interstitial pneumonia, and died of septic shock 56 days after surgery. Thus, in the absence of typical characteristics, preoperative diagnosis of appendicitis in HIV/AIDS patients should be based on clinical judgment, low WBC or low-grade fever. It is our impression that a significant delay in diagnosis can be avoided with a more deliberate laparoscopic examination under general anesthesia.
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In conclusion, we emphasize the need for prompt exploration and early removal of the infected appendix when acute appendicitis is suspected in a patient with AIDS.
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