Atypical Presentation of Acute Appendicitis in a Young Adult With Congenital Adrenal Hyperplasia on Chronic Glucocorticoid Therapy

We report the case of a 32-year-old man with congenital adrenal hyperplasia on chronic dexamethasone and fludrocortisone therapy who presented with nausea, diarrhea, and a single episode of vomiting, while denying abdominal pain, fever, anorexia, or right lower quadrant discomfort. Physical examination revealed a completely benign abdomen without tenderness, guarding, rebound, or peritoneal signs. Laboratory evaluation demonstrated hyponatremia and acute kidney injury without leukocytosis. Despite an Alvarado score of 1, CT imaging of the abdomen revealed acute appendicitis, which was later confirmed intraoperatively as a non-perforated, inflamed appendix. This case demonstrates an atypical presentation of acute appendicitis characterized by a benign abdominal examination and normal inflammatory markers in the setting of chronic glucocorticoid therapy. It highlights the importance of maintaining diagnostic vigilance and considering early imaging in steroid-dependent patients with persistent gastrointestinal symptoms, even in the absence of classic clinical findings.