Case Presentation: 52-year-old male with no past medical history, presents to the emergency room for complaints of worsening diffuse abdominal discomfort of one-day duration. Pain was located in lower part of abdomen, dull in character, non-radiating, 10/10 in intensity associated with nausea, and subjective fever .Vital signs were significant with a temperature of 101.1 degrees Fahrenheit with rest of them being normal. Abdominal exam was remarkable for diffuse tenderness on deep palpation mostly localized in right iliac fossa and umbilical area with rebound tenderness. Complete blood count showed elevated white count of 20000, hemoglobin of 12.2g/dl with hematocrit 35.8 % and platelet count was 321000, segmented neutrophils were 83% with noted bandemia .Urinalysis showed no signs of urinary tract infection. Lipase was 58 with AST and ALT being 45U/Land 18U/L respectively. Basic metabolic panel was within normal limits.. A CT abdomen and pelvis showed heterogeneous low attenuation in the right lobe of the liver with amorphous hyper attenuation of the lumen of the gallbladder. Differential diagnosis included infection with multiple pyogenic amoebic abscesses and gallbladder carcinoma with necrotic hepatic metastasis .With the preliminary findings of possible amoebic /pyogenic abscess as evidenced by CT scan he was started on IV antibiotics including Ceftriaxone and Flagyl. During the first day of hospitalization, he spiked a temperature of 103.F and was treated with antipyretics. Viral serology returned positive for Hepatitis BsAg with Alpha feto protein of 466.6 ng/ml . He was further worked up for possible Hepatocellular carcinoma and was seen by Hepatobiliary surgeon. Over the course of next couple of days patient significantly improved with disappearance of abdominal symptoms, stopped spiking temperature and white count normalized. Patient was scheduled for a right trisegmentectomy of the liver. Per operatively he was found out to have inflammed appendex, which was resected, and the biopsy retuned positive for acute inflammation that may have explained patients’ clinical presentation of fever, elevated white count and right iliac fossa pain with rebound tenderness.
Discussion: Diagnosis of Acute Appendicitis was missed in a 52 year old gentleman with classic signs and symptoms when incidentally a liver mass was found on abdominal imaging .This case demonstrates how the most likely clinical diagnosis is being discarded due to principle of Occam’s razor which advocates for one explanation and a unifying diagnosis where in fact multiple diagnoses co-exist (Hickam’s dictum).
Conclusions: Due to the inappropriate use of the principle of Occam’s Razor the most probable clinical diagnosis of acute appendicitis was excluded that could have let to devastating consequences such as perforation of appendex and peritonitis .Initiation of antibiotics for differential diagnosis of hepatic abscess had most likely delayed further progression of acute appendicitis .This is one of the examples where imaging led to a fixation bias and an oversight leading to a miss- diagnosis.