Immunocompromise and Appendicitis

The immunocompromised state alters the normal response to acute infection and wound healing. Appendicitis affects all types of patients and must be considered in those who have undergone organ transplantation, are receiving chemotherapy, have hematological malignancy, or are infected with the human immunodeficiency virus. The differential diagnosis of abdominal pain in this population is broad and includes hepatitis, pancreatitis (from medications or cytomegalovirus infection), acalculous cholecystitis, intra-abdominal opportunistic infections (cytomegalovirus colitis or mycobacterial ileitis), secondary malignancies (lymphoma or Kaposi’s sarcoma), graft-versus-host disease, and typhlitis. This broad differential diagnosis often results in delay in diagnosis and late presentation to surgical evaluation, at which time perforation may be more likely.

Appendicitis in patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) presents unique challenges. Abdominal pain is not an uncommon symptom in these patients, making differentiation between surgical and nonsurgical causes difficult. Nonetheless, immunocompromised patients with appendicitis present with symptoms similar to those of the general population, and appendicitis should be considered in patients with right lower quadrant pain, nausea, and anorexia. Fever and white blood cell count may not be helpful in this population, so imaging studies, particularly CT, have been supported by some authors.There is no specific contraindication to operation in immunocompromised patients, so once diagnosed with appendicitis, appendectomy should be performed promptly.