Worsening Abdominal Pain and Rash Following Laparoscopic Appendectomy

Case at a Glance

A 30-year-old female presented with a spreading skin rash and worsening lower abdominal pain ten days following a laparoscopic appendectomy. While initially treated for a suspected skin infection, the progression of her symptoms, including new urinary discomfort, prompted further evaluation for an intra-abdominal complication versus a secondary infection.

Patient's Story

The patient is a 30-year-old female with a past medical history of Polycystic Ovary Syndrome (PCOS), Hashimoto's thyroiditis, Postural Orthostatic Tachycardia Syndrome (POTS), and ADHD. Ten days prior to presentation, she underwent an emergency laparoscopic appendectomy for non-perforated appendicitis. The initial post-operative course was marked by significant pain but was otherwise unremarkable. She reported an incident of minor blunt trauma two days after surgery when her dog jumped onto her lower abdomen.

Initial Assessment

Approximately six days post-operatively, the patient noticed the surgical glue detaching from her incisions and the development of an intensely pruritic, erythematous, and warm rash around all three laparoscopic port sites. The rash was raised and had spread beyond the immediate incision boundaries. The incisions themselves appeared to be healing well, without signs of drainage or dehiscence.

Eight days post-operatively, she was evaluated by her primary care physician who, concerned about the warmth of the rash, diagnosed a possible cellulitis and prescribed a course of oral doxycycline. The patient began the antibiotic immediately.

The Diagnostic Journey

Despite starting doxycycline, the patient's condition worsened over the next 48 hours. Her lower abdominal pain, which had been gradually improving, became more severe, with sharp pains elicited by changing positions, such as moving from sitting to standing. The pain began to radiate from the right lower quadrant across her entire lower abdomen. She also developed new symptoms of pelvic pressure and discomfort during urination. While she felt subjectively hot, she remained afebrile on home temperature checks.

Concerned about a potential intra-abdominal abscess, she sought further advice. A remote physician consultation suggested the rash was more characteristic of an allergic contact dermatitis, likely from surgical dressings or skin prep, given its presence around all three incisions. The new urinary symptoms, in the context of a recent surgery where a Foley catheter is often placed, raised high suspicion for a Urinary Tract Infection (UTI). The possibility that an intra-abdominal inflammatory process was causing irritation to the bladder was also considered. The patient was advised to seek immediate in-person evaluation at an urgent care center for a physical exam, urinalysis, and blood work.

Final Diagnosis

1. Allergic Contact Dermatitis secondary to surgical dressings.
2. Post-operative Urinary Tract Infection (UTI).
3. Post-surgical intra-abdominal pain, exacerbated by the UTI.

Treatment Plan

The patient presented to an urgent care facility for evaluation.

1. Dermatitis: She was advised to discontinue the doxycycline, as the rash was deemed non-infectious. She was instructed to apply over-the-counter 1% hydrocortisone cream to the affected skin 2-3 times daily.
2. UTI: A urinalysis was positive for leukocyte esterase and nitrites. She was prescribed a course of antibiotics appropriate for an uncomplicated UTI, pending culture results.
3. Pain Management: She was advised to continue with her prescribed post-operative pain regimen and to follow up closely with her surgeon.

Outcome and Follow-up

Within 48 hours of starting the new antibiotic for the UTI and using topical steroids, the patient's symptoms improved markedly. The pruritic rash began to fade, and her lower abdominal pain and urinary discomfort significantly decreased. At her scheduled surgical follow-up appointment three days later, her incisions were well-healed, the dermatitis was nearly resolved, and her abdominal pain had returned to a level expected for her stage of recovery. A physical exam revealed no signs of an intra-abdominal abscess, and no further imaging was deemed necessary.