Appendicitis in an Uncommon Location

A 37-year-old woman presented to the emergency department with 12 hours of gradually worsening left lower quadrant pain with anorexia, vomiting, and diarrhea. She also reported intermittent fever and chills. On exam, her initial vital signs were 102/68, pulse of 102, respirations 18, temperature of 97.5° F. She was mildly anxious secondary to pain. Abdominal exam revealed a soft abdomen with left lower quadrant tenderness with voluntary guarding and mild rebound tenderness. Pelvic exam and urinalysis were normal. Urine pregnancy test was negative. The WBC returned at 15.3x103/μL with 78% neutrophils. A computed tomography scan was performed and showed a left-sided appendicitis with situs inversus totalis (Figure 1 and 2). Situs inversus totalis is a complete mirror reversal of the organs. The yearly incidence of acute appendicitis alone is approximately 1:1000 with approximately 6-7% of the population having appendicitis at some point during their lives. The total incidence of left-sided acute appendicitis is 0.04%, with 0.024% having abdominal viscera situs inversus and 0.016% having situs inversus totalis, as in this patient’s case.1 Her diagnosis of situs inversus was previously undiagnosed. This is only the ninth case report in the literature. Address for Correspondence: JM. Tyson Pillow, MD, Section of Emergency Medicine, Depart. of Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX, 77030. Email [email protected]