A woman of age 49 was presented to the emergency room of a hospital where she complained of dull abdominal pain. She pointed towards the right lower quadrant, the appendix, where the intensity of pain increased gradually. She was suffering from gradual but constant pain for last 5 days. Although the intensity of pain increased yet it didn’t radiate towards surrounding regions. She had a history of breast cancer and hysterectomy as well as bilateral salpingo-oophorectomy. Her breast cancer had metastasized to liver for which she was undergoing IBRANCE® chemotherapy. Upon conducting physical examination, there was no apparent factor to favor the condition. There was no tenderness and she was afebrile. Close observation revealed that the pain was located around McBurney’s point. The location of severe pain around McBurney’s point indicated the occurrence of appendicitis.
CT Scan Results
The CT scan of abdomen revealed a dilated and inflamed appendix. The results of imaging scan confirmed that patient had pain due to appendicitis. The only treatment criterion for appendicitis is appendectomy. The patient underwent appendectomy. Since it is a simple surgical procedure therefore she was discharged the same day.
Pathological analysis
This middle aged woman did not have a severe surgical case but the cause underlying her appendicitis was quite appalling. After surgical removal of appendix the pathologists observed and studied it. A normal appendix has an average length of 9 cm whereas its diameter is 9 mm. In this case, the appendix had a length of 6.5 cm and a diameter of 2.6 cm. Gross examination demonstrated a brownish yellow lumen with a layer of scanty fatty tissue. To understand the accurate cause of appendicitis, the pathologists examined deeper sections of appendix. Surprisingly, the morphology of organ indicated the presence of Actinomyces specie. There was no other substance or debris, neither neoplastic nor non-neoplastic.
The fragment of nail found in appendix of this patient was contaminated Actinomyces. It usually develops in the nail bed of gardeners. There is a possibility that the patient was a gardener as well as a frequent nail-biter.
How did a nail fragment interfere?
Nail-biting can become a cause of appendicitis in any age group. In adult appendicitis any foreign body, which in this case is a nail, blocks the lumen of appendix causing ischemia and infection. The obstruction of lumen of appendix by a foreign body, and that too a nail, is extremely rare. This happens when the bolus is passing through the large intestine. Only when the foreign body is heavier than the bolus it causes the bolus to slow down and stop temporarily in the intestines. During that time the foreign body, such as nail, enters the lumen of appendix. As soon as the substance enters the appendix it is unable to get back into the colon due to negligible peristalsis. After the entry it remains dormant for some hours, even some years, and becomes actively painful without any warning.
