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BMJ Case Rep. 2010; 2010: bcr0320102847.
Published online Oct 28, 2010. doi:  10.1136/bcr.03.2010.2847
PMCID: PMC3027958
Rare disease
Amyand's hernia with perforated appendix in a neonate
Gabriel Ngom, Issa Amadou, K A Ibrahima, André Mubake, Oumar Ndour, and Mamadou Ndoye
Department of Pediatric Surgery, Cheikh Anta Diop University Teaching, Aristide Le Dantec Hospital, Dakar, Sénégal
Correspondence to Gabriel Ngom, gngom2004/at/yahoo.fr
Abstract
Inguinal hernia with acute appendicitis known as Amyand's hernia is uncommon. It occurs mostly in adults, older children and infants. The appendix inside the hernial sac is rarely perforated. The authors describe in a neonate aged 14 days an unusual case of inguinal hernia containing a perforated appendix that was clinically considered as a strangulated inguinal hernia. Surgery performed with an inguinal approach permitted us to remove the appendix and close the hernial sac. The postoperative course was uneventful after a follow-up of 1 year.
Background
The case is important because it is very uncommon particularly in a neonate. We decided to publish it because it is the first case in our department (Sénégal) since 50 years and we did not find a similar case in the African literature.
A neonate aged 14 days was referred to our department for a right inguino-scrotal swelling evolving since 18 h associated with excessive crying without vomiting or bowel habit disorders. Physical examination found a good general state, fever and a right inguino-scrotal mass, painful and irreducible. Laboratory revealed leukocytosis and slightly elevated C reactive protein (CRP) level. The preoperative diagnosis was that of a strangulated inguinal hernia. Surgery was performed with an inguinal approach. We discovered a perforated appendix inside the hernial sac (figure 1). Appendectomy was carried out via the hernial sac, which was repaired by high ligation. The postoperative course was uneventful. The follow-up period was 1 year during which the child is free of any symptom.
Figure 1
Figure 1
Perforated appendix exteriorised through a right inguinal incision.
Investigations
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    Blood cell: leukocytosis (13 300/ml)
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    CRP level: 15 mg/l.
Differential diagnosis
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    Strangulated inguinal hernia
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    Testicular torsion
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    Epididymo-orchitis
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    Inguinal lymphadenitis.
Treatment
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    Appendectomy
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    Closure of hernial sac.
Outcome and follow-up
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    Uneventful
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    Follow-up of 1 year.
Amyand's hernia is a rare event estimated at 0.1% of all acute appendicitis.1 It occurs in all ages. But its discovery in the neonatal period as in our case is exceptional.2 3 Pathogenesis is not well understood. The role of microtraumatism and compression of the appendix in the sac disturbing its blood supply has been invoked. Amyand's hernia is rarely diagnosed preoperatively. Few cases have been discovered before surgery.4 Signs are not specific and may mimic strangulated inguinal hernia, testicular torsion, epididymo-orchitis and inguinal lymphadenitis. In these difficult cases, ultrasound or CT may be useful.4 In any case, surgical exploration through inguinal incision must be performed quickly to avoid complications. The postoperative course is usually favourable. Few deaths were reported in the literature.5 For our neonate, preoperative diagnosis was that of a strangulated inguinal hernia because of the frequency of this complication in this age and the irreducibility of the mass on clinical examination.
Learning points
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    Rarity
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    The field: neonate
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    The most important differential diagnosis: strangulated inguinal hernia.
Footnotes
Competing interests None.
Patient consent Obtained.
References
1. Pellegrino JM, Feldman SD. Case report: acute appendicitis in an inguinal hernia. N J Med 1992;89:225–6. [PubMed]
2. Cankorkmaz L, Ozer H, Guney C, et al. Amyand's hernia in the children: a single center experience. Surgery 2010;147:140–3. [PubMed]
3. Iuchtman M, Kirshon M, Feldman M. Neonatal pyoscrotum and perforated appendicitis. J Perinatol 1999;19:536–7. [PubMed]
4. Luchs JS, Halpern D, Katz DS. Amyand's hernia: prospective CT diagnosis. J Comput Assist Tomogr 2000;24:884–6. [PubMed]
5. Inan I, Myers PO, Hagen ME, et al. Amyand's hernia: 10 years’ experience. Surgeon 2009;7:198–202. [PubMed]
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