Although acute appendicitis is the major cause of emergency surgery in the pediatric population, diagnosing this condition in children remains challenging due to the fact that symptoms are not always typical and are often mistaken for gastroenteritis [2, 3]. A delayed diagnosis can lead to an increased risk of complications and associated morbidity and mortality [3, 8]. Cardiac tamponade is a life-threatening condition that is caused by cardiac compression secondary to fluid or gas accumulation in the pericardial space [4]. Major causes of tamponade include pericardial effusion, chest trauma, cardiac wall rupture, and aortic dissection. Additionally, pericardial effusion can be idiopathic or secondary to pericarditis, malignancy, uremia, infection, radiation, post-acute myocardial infarction, autoimmune disorders, collagen vascular disease, and hypothyroidism [4, 8].
To our surprise, the first reported case that detailed the rare relationship between pericardial disease and appendicitis in the pediatric population occurred in 1901 and 5/7 cases were reported after 2000 (Table 1). Additionally, the vast majority of cases were reported in developed countries (Table 1). Taken together, this may suggest that pericardial disease may be a more common complication of pediatric appendicitis but was under reported in the 1900s and in developing countries. Although in most of the cases, appendicitis was diagnosed prior to pericardial disease, which is in accordance with the idea that pericardial disease develops as a complication of appendicitis, in 2/7 cases, pericardial disease was diagnosed before appendicitis. Therefore, in the presence of pericardial disease, especially with symptoms associated with appendicitis, a workup of appendicitis may be warranted. Pleural effusions and abdominal abscesses were the other common complications of the appendicitis (Table 1).
The main finding of the current study was that we were able to characterize the association between pediatric appendicitis and pericardial disease. However, one limitation of our study is that we were unable to propose a definitive mechanism that explains the connection between these two conditions. Nevertheless, here, we describe a few possible mechanisms. First, the pericardium may have simply been directly infected due to bacteremia secondary to appendicitis. However, a majority of the cases we presented herein had negative cultures of the pericardial fluid (Table 1). While we were unable to assess 2/7 cases for the presence of SIRS due to a lack of information, the remaining cases all met the diagnostic criteria (Table 1). Therefore, SIRS secondary to the appendicitis may have been contributory to the pericardial disease. Similarly, in our previous case report, we attributed SIRS secondary to perforated appendicitis as the cause of the cardiac tamponade after ruling out/providing evidence against other likely etiologies which included autoimmune/rheumatologic diseases, malignancy, infection, and trauma [5]. Additionally, another mechanism contributing to the etiology of pericardial disease may have been the contiguous spread of inflammation and/or infection from the retroperitoneal space to the mediastinum [12,13,14]. Finally, 71% of the cases were females (Table 1), and this may have been because women are more commonly affected by systemic inflammatory diseases (SID) than men and are more commonly affected by pericarditis related to SID [15].
With regard to our secondary objective to summarize anesthetic management of a child with a pericardial disease in the context of appendicitis, all cases, but our own, did not report the anesthetic management from a hemodynamic point of view (Table 1). Therefore, given the lack of data, we were unable to summarize such anesthetic management.
In conclusion, diagnosis of acute appendicitis may be difficult and, therefore, delayed in the pediatric population resulting in a perforated appendix and associated rare complications. We should consider the presence of life-threatening pericardial disease when anesthetizing children with appendicitis. Pericardial diseases associated with pediatric appendicitis may be due to direct infection, SIRS, or the contiguous spread from retroperitoneal space to the mediastinum. Awareness of this uncommon association may have prognostic value as this may facilitate appropriate management of pericardial effusions, tamponade, and/or appendicitis.