A case of acute appendicitis presenting with mild symptoms on a routine diabetes follow-up visit

Background: Worldwide, acute appendicitis is one of the most common reasons for emergency abdominal surgeries; incidence is approximately 100 per 100,000 person-years. Presenting symptoms, such as abdominal pain and nausea, can resemble many other disorders and although rare, can be diagnosed incidentally during routine office visits for other complaints. Case Presentation: A 57-year old African-American female presented for a routine follow up visit for diabetes mellitus at an outpatient clinic. During the visit, the patient stated that she had been experiencing generalized abdominal pain (with nausea) that had later localized to the right lower quadrant. Vitals were within normal limits. Pain was described as waxing and waning and worse with movement. Physical exam revealed pain elicited on deep palpation of the right lower quadrant, maximal at McBurney's point, and the patient was advised to go to the emergency room due to suspicion of acute appendicitis. Workup at the emergency room revealed no leukocytosis, fever, or systemic inflammatory response syndrome. CT scan revealed a focal outpouching arising from the cecum due to possible appendiceal origin or diverticulum with surrounding inflammatory changes and an appendicolith concerning for inflammatory process, without associated fluid collections or free air. Emergency appendectomy was performed and patient made a full recovery. Conclusion: This case illustrates a unique presentation of acute appendicitis diagnosed incidentally at a routine outpatient visit for diabetes follow up, and emphasizes the unique role of primary care physicians in recognizing this disease even in well-appearing patients with mild symptoms.