My second patient of the morning was Bradley, a five-year-old boy who was brought in for abdominal pain. Mom said the school had called her yesterday because he was in the office with a fever of 101.4 and he didn’t feel good. Picking him up, he did have a fever, but no other symptoms. He hardly ate anything for dinner and went to bed early. At 3 o’clock in the morning Bradley woke her saying he had a stomach ache. With no diarrhea or vomiting she made him try to go to the bathroom, thinking that he might be constipated. But his bowel movement was normal. His pain was in the middle of the abdomen so she wasn’t too concerned about an appendicitis. She gave him some ibuprofen and he was able to go back to sleep.
In the morning he had a fever of 102 degrees. Now he did complain of pain in the right lower quadrant. With this she called the office for the first available appointment. Bradley’s temperature was now 101.9 and his pulse was a bit fast, possibly from the fever. When I entered the room he was sitting hunched over, clearly not feeling well. The history revealed that there was no cough, congestion, vomiting or diarrhea. On exam his ears were clear, his throat was not red, his lungs were clear, and his abdominal exam was quite impressive. His bowel sounds were normal which I did not expect if he had had appendicitis. But he was tender in the right lower quadrant where the appendix is located. This location is known as McBurney’s point. Not only was he tender there, but when I gently pressed and then let my hand go the pain seemed to be magnified. This is referred to as “rebound tenderness” which typically signifies intra-abdominal inflammation. All of this was looking very suspicious for appendicitis. I had him stand up, then get into a squat like a baseball catcher. He said this made the pain worse. Finally I asked him to jump up and down. He did it once but refused a second time because of the pain. These are maneuvers that one will often see with appendicitis. With that, I told mom I was going to have Bradley go to the emergency room to start the work up for a possible, if not probable appendicitis. I called the ER doctor and told him of my concerns. He assured me he would get Bradley in ASAP.
In the ER they did the standard labs. His urine was clear, ruling out a urinary tract infection. His white blood count was elevated at 19,500 (normal is 5000-10000). This was concerning for appendicitis. They did an abdominal ultrasound but this did not visualize the appendix. The ER doctor called to keep me informed and said that he was sure that Bradley had an appendicitis. He was going to call the surgeon in. Before they would commit him to surgery they wanted to get a CT of the abdomen.
The ER doctor informed me when the CT was done that it showed Bradley’s appendix was normal and they found a small round pneumonia in his right lower lung. It is not that uncommon for a pneumonia to be discovered by CT of the abdomen when looking to confirm an appendicitis.
It turned out that Bradley did have a pneumonia resulting in his high fever, not feeling well and having abdominal pain. Pneumonias are caused by different bacteria. Usually they are accompanied with a fever, bad cough and “crackles or rales” when you listen to the lungs with a stethoscope. An exception to this is a particular bacteria called strep pneumonia. While it does cause fever and a high white blood count, it does not necessarily cause a cough. Depending on where the pneumonia is located, it can cause right lower quadrant pain mimicking an appendicitis. Or if it is located in the upper lung it may cause a stiff neck and mimic meningitis. All without much of a cough. This presents a clinical challenge to clinicians. Prior to the era of ultrasounds and CT scans, it used to be that a surgeon would not take a patient to the operating room for an appendicitis without a chest x-ray for this very fact.
Mom was thrilled that Bradley did not need surgery. The ER doctor gave him an antibiotic injection and put him on an oral medication. He was already much improved the next day. He no longer had fever, did not have abdominal pain and said he felt much better. Of note, when I listened to his lungs, he now did have some rales (or crackles) on the right side. When I re-checked him after he completed the antibiotics, he was back to baseline and his lungs were 100% clear. Another case of a pneumonia looking just like appendicitis!