2. 9 y/o girl H/o of JRA treated with methotrexate and enbrel 4 day h/o abdominal pain Nausea/emesis Urinary retention

3. Presented to PCP 3 days before admission Started on PO abx for UTI Continued emesis and abdominal pain Temp of 100.2 two days after clinic visit

4. Presented to outside ED Temp > 38.5 Continued abdominal pain Abdominal CT with oral and rectal contrast Fecalith vs ureteric stone Free fluid in abdomen Transferred to Children’s Hospital

5. ED Evaluation Vitals Temp 39.1 HR 128 BP 128/54 RR 24

6. ED Evaluation Physical Exam Gen: Abdominal pain CV: RRR Pulm: CTA B Abd: Distension, R sided tenderness, + psoas sign, + Rovsing sign, + rebound

7. ED Evaluation Labs WBC 13.7 Hct 36 CRP 26 E-lytes WNL

8. ED Evaluation Abdominal US Noncompressible mass in RLQ Complicated fluid collection at tip Diameter of 14mm Mild R pelviectasis

9. A/P Started on IV abx IVF started To OR for presumed appendicitis and appendectomy Perforated appendicitis with frank puss in RLQ Fluid collection in pelvis Enflamed loops of small bowel

10. RLQ Pain in Immunosuppressed Patient DDx Appendicitis Typhlitis Enteritis Pancreatitis Perforated viscus Graft vs. Host PID Splenic rupture Intussuception

11. Diagnosis Difficult Delay in diagnosis approx 4 days Sxs Fever Nonspecific bowel pain Chan-Hon Chui et al. Appendicitis in immunosuppressed children: Still a diagnostic and therapeutic dilemma? Pediatric Blood & Cancer 50: 6, pgs 1282- 1283

12. Tx Typhlitis Bowel rest IV abx Non operative Appendicitis IV abx Operative treatment

13. Data Typhlitis and appendicitis found in equal quantities in ALL patients Up to 26% in kids with ALL and RLQ pain 53% chance of sepsis 40-70% mortality for ALL kids with sepsis 8% mortality postoperatively (most due to infection and sepsis) Skibber JM, Matter GJ, Pizzo PA, et al. Right lower quadrant pain in young patients with leukemia. A surgical perspective. Ann Surg 1987; 206: 711-716.

14. Diagnosis and Treatment CT to evaluate bowel Laproscopy if still doubt about diagnosis IV abx if typhlitis or inflammation of ceacum that includes appendix Surgery if fecalith visualized or isolated appendiceal inflammation McCarville MB, Thompson J, Li C, et al. Significance of appendiceal thickening in association with typhlitis in pediatric oncology patients. Pediatr Radiol 2004; 24: 245-249 Urbach DR, Rotstein OD. Typhlitis. Can J Surg 1999; 42: 415-419.