An Unusual Surgical Presentation in a Newborn

A 2560 g male infant was born at 38 weeks of gestation via cesarean section due to fetal distress to a 21-year-old G4P3 mother at a community hospital. According to the Fenton growth chart, this birth weight corresponds to approximately the 15th percentile, indicating that the infant is appropriate for gestational age rather than small for gestational age or growth restricted.The maternal prenatal history was unremarkable. No obstetric complications were noted during the pregnancy, and Group B Streptococcus screening was negative.The infant developed respiratory distress shortly after birth. He was intubated and started on nasal synchronized intermittent mandatory ventilation (nasal-SIMV). There was no meconium-stained amniotic fluid, and no signs of meconium aspiration were observed. Given the respiratory findings, early-onset neonatal sepsis was initially suspected.Empirical antibiotic therapy with ampicillin and gentamicin was initiated after obtaining a blood culture sample.The newborn was transferred to a tertiary neonatal intensive care unit within hours of birth. On arrival, he remained on nasal-SIMV, and antibiotic therapy was continued. Initial evaluations, including a blood culture and chest radiograph, were performed. The infant stabilized over the next few days, and respiratory support was successfully weaned to room air by day 5 of life.Enteral feeding with expressed breast milk via an orogastric tube was initiated on day 3, following standard unit protocol. On day 7, the patient developed signs of feeding intolerance, including abdominal distension and passage of bloody stool.Laboratory investigations revealed an elevated white blood cell count and increased C-reactive protein. An abdominal radiograph showed mildly dilated bowel loops. Although the treating team initially noted no evidence of free air, retrospective review with the radiology team revealed subtle findings consistent with portal venous gas and possible early pneumoperitoneum (Figure 1). A preliminary diagnosis of necrotizing enterocolitis (NEC) was made.Enteral feeds were discontinued, and intravenous antibiotics were escalated to teicoplanin and cefepime, following the collection of repeat blood and urine cultures. The initial blood culture obtained on admission prior to antibiotics was negative, and repeat cultures also showed no bacterial growth.A Replogle tube was inserted for continuous gastric decompression. Despite initial conservative management, 6 hours later, a repeat abdominal radiograph shows pneumoperitoneum (Figure 2). Because of progressive clinical deterioration and concern for bowel perforation, an emergency laparotomy was performed.In neonates, acute abdominal symptoms often suggest the following conditions:NEC: A common diagnosis in premature infants, presenting with abdominal distension, bloody stools, and feeding intolerance. NEC remains a leading cause of neonatal abdominal emergencies, requiring prompt recognition and management.1Intestinal Atresia: Obstruction due to congenital malformations, manifesting as bilious vomiting and failure to pass meconium. Early surgical intervention is crucial to prevent complications.2Malrotation with Volvulus: This condition presents with sudden abdominal pain and distension, often necessitating urgent surgical correction. It remains a key differential diagnosis in neonates presenting with an acute abdomen.3Spontaneous Perforation: Occurs secondary to ischemia or congenital defects, presenting with signs of peritonitis. It is particularly common in preterm neonates and carries a significant risk of mortality without timely intervention.4In this case, surgical exploration reveals acute perforated appendicitis (Figure 3), an exceedingly rare diagnosis in neonates, with an incidence of 0.04% to 0.2%.5,6 Symptoms often mimic NEC, leading to delayed recognition.7 This highlights the importance of maintaining a broad differential diagnosis when evaluating neonatal abdominal emergencies.Neonatal appendicitis remains a diagnostic challenge due to overlapping symptoms with other neonatal abdominal conditions. The nonspecific presentation, including feeding intolerance and abdominal distension, often delays surgical intervention. Such delays can increase the risk of perforation and peritonitis, as seen in this case.4,8 The rarity of neonatal appendicitis further complicates timely diagnosis.9,10Timely surgical intervention is critical. In this case, perforated appendicitis was successfully treated with appendectomy.6,8 Broad-spectrum antibiotics were continued postoperatively to address peritonitis, and parenteral nutrition supported recovery until enteral feeding resumed.10Histopathological examination confirmed acute appendicitis with perforation. The infant’s recovery was uneventful, and he was discharged on full enteral feeds.Consider broad differential diagnoses: NEC is common but not the sole cause of neonatal abdominal symptoms.Radiological vigilance: Repeat imaging may reveal critical findings, such as pneumoperitoneum.Early surgical consultation: Essential for timely intervention in neonates with worsening abdominal signs.Awareness of rare entities: Include appendicitis in differential diagnoses, even in neonates.Multidisciplinary approach: Collaboration among neonatologists, radiologists, and surgeons improves outcomes.American Board Of Pediatrics Neonatal–Perinatal Content SpecificationUnderstand Perioperative care of newborn infants (eg, respiratory, fluid, temperature, antibiotics, pain management).Understand necrotizing enterocolitis and gastrointestinal perforation.The authors would like to thank Dr. Ayşe Bülbül Adam, Pediatric Surgeon, for performing the surgery and kindly providing the intraoperative image of the appendix.