Acute represents the part of a type 1-hypersensitivity reaction

Acute appendicitis is well
known as one of the most common surgical emergency. One of the most common
presentations for acute appendicitis is acute abdominal pain. In the Western
countries, the risk for individuals to develop acute appendicitis is 7% during
their lifetimes. (Andrade
et al., 2007). The etiology of acute
appendicitis is not known, but probably it is multifactorial; luminal
obstruction, diet and family factors are responsible. (Humes
& Simpson, 2006). Eosinophilic appendicitis (EA) is
a rare clinical entity. It is characterized by acute presentation and grossly
inflamed appendix with absence of neutrophils in the muscle layer. The
histologic hallmark of EA is eosinophilic infiltration of the muscularis
propria with accompanying edema separating the muscle fibres. (Aravindan,
Vijayaraghavan, & Manipadam, 2010).

 

CASE REPORT

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A 46 years
old woman who lived in Sabah was initially presented at the emergency
department with the history of blunt trauma to the right side of the abdomen
about one week ago. Post trauma sustained pain and bruises over her right
abdomen region but the pain were tolerable. However, there were no evidence of
intra-abdominal injury, thus she was admitted for close observation. After four
days of admissions, she complained of persistent abdominal pain and associated
with vomiting. During the examination, she had some tenderness over right iliac
fossa region. As per history, patient had trauma with suspected aider
peritonism or tear in mesentery. Thus, CT scan was done for further
investigation.  Based on CT scan, it was
concluded that there were evidence of high retro-cecal appendicitis with
regional mesenteric lymphadenitis. Hence, laparoscopic appendecectomy was done.
Intraoperatively, noted that appendix was extremely edematous and inflamed, and
there were no evidence of exudation or suppuration. No postoperative
complication occurred during the follow up period. The appendix was sent for
histopathological examination and revealed eosinophilic infiltration and
lymphocytes extending into the serosa layer.

 

DISCUSSION

 

Esionophilic
appendicitis was first proposed by Aravindan in 1997 and later defined by Aravindan
et al in 2010. He proposed that eosinophilic infiltration is an early event of
appendicitis and represents the part of a type 1-hypersensitivity reaction to
an allergen and primary pathologic changes characterized by eosinophilic
edematous lesion in the appendix. (Aravindan,
Vijayaraghavan, & Manipadam, 2010). Norman J Carr suggested that an
eosinophil count in excess of 10 per mm2 (25 per 10 HPF) could be abnormal. He
also stated that differential diagnosis for this eosinophilic infiltrate as
eosinophilic enteritis and infestation by parasites. (Carr,
2000)

 

The natural
history of acute appendicitis is inflammation leading to perforation in less
than 36 hours. About 60% to 70% of acutely inflamed appendices, obstruction of
the proximal lumen by fecaliths, fibrous bands, parasites, or tumors can be
demonstrated. (Hennington,
Tinsley, Proctor, & Baker, n.d.)

 

In 1904,
Van Zwalenburg suggested that obstruction leads to distension of appendiceal
lumen as a result of mucosal secretion. The association of acute appendicitis
with blunt abdominal trauma is unclear; some have considered an association to
be coincidental. This is because, blunt abdominal trauma and acute appendicitis
both occur with some frequency and largely in the same population. Whether
blunt abdominal trauma can be the inciting event leading to obstruction and
subsequent acute inflammation is difficult to substantiate. It is feasible,
however, that trauma could set into motion the same vicious cycle. (Zwalenburg,
1904)

 

In a study
conducted by Wells, there are no evidences of appendicitis in five rabbits
following direct crush injury to the mucosa in the absence of obstruction. (Wells,
1937). However, in a study conducted by Dennis showed that,
direct trauma might lead to edema formation, hematoma and or hyperplasia of
intrinsic lymphoid tissue and subsequently lead to the obstruction of the
lumen. (Dennis,
Buirge, Varco, & Wangensteen, 1940) 
Based on the two studies conducted, the relationships between trauma and
appendicitis cannot be clearly proved.

 

As the
pathogenesis and etiology of the eosionophilic is not well understood, no
standard for the diagnosis of eosinophilic enteritis exists.

Tally et al
have identified three main diagnostic criteria:

       
i.           
Presence
of gastrointestinal symptoms.

      ii.           
Biopsies
demonstrating eosinophilic infiltration of one or more areas of
gastrointestinal tract (GIT).

   
iii.           
No
evidence of parasitic/extrinsic disease. (Talley,
Shorter, Phillips, & Zinsmeister, 1990)

 

In our case
study, it happened to a women who initially came with history of blunt trauma
to the abdomen, and later on developed the sign and symptoms of acute
appendicitis, thus CT scan was done, and the result suggestive of acute
appendicitis. Appendicectomy was done and histopathological examination
revealed as eosinophilic infiltration.

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