An unexpected severe complication after a negative laparoscopic appendectomy.

A 67-year-old woman with a history of myelodysplastic syndrome (MDS) was on holiday in another country when abdominal pain developed. Her MDS had been stable over the previous 2 decades, and her outpatient monitoring had been cancelled. She went to the local emergency department with pain in the right lower quadrant. Laboratory results showed elevated C-reactive protein (CRP) and white blood cell (WBC) counts. The patient underwent a diagnostic laparoscopy for suspected acute appendicitis. At laparoscopy, her appendix was not inflamed and there was no other cause for her abdominal pain. Postoperatively, what at first looked like a wound infection developed at the trocar opening in lower left abdomen. The wound turned necrotic. Surgeons performed a necrotectomy of the wound and placed a central venous catheter in her left subclavian vein. The patient was started on antibiotics. Since she was on holiday in a foreign hospital, she requested a transfer to a hospital in her home country. Arrangements were made to transfer the patient to our ward. On admission, she had a fever (39°C), elevated CRP (3038.16 nmol/L) and WBC counts (14.7 × 109/L) and refractory anemia secondary to myelodysplastic syndrome. She had a large wound in her lower left abdomen with some debris (Fig. 1A). She also had thoracic pain at the site where the central venous catheter had been placed; the former access site was slightly red and swollen. A skin incision for suspected wound infection did not reveal any pus. The next day, she became clinically septic and was admitted to our intensive care unit. A thoracic and abdominal computed tomography (CT) scan revealed no focus Steve M.M. de Castro, MD, PhD Ilfet Songun, MD, PhD Boudewijn J. Dwars, MD, PhD