Community-acquired infection to Raoultella ornithinolytica presenting as appendicitis and shock in a healthy individual

Community-acquired infection to Raoultella ornithinolytica presenting as appendicitis and shock... Journal of Surgical Case Reports, 2018;5, 1–3 doi: 10.1093/jscr/rjy097 Case Report CASE REPORT Community-acquired infection to Raoultella ornithinolytica presenting as appendicitis and shock in a healthy individual 1, 2 3 2 Roy Hajjar *, Frank Schwenter , Shih-Hann Su , Marie-Christine Gasse , and Herawaty Sebajang Université de Montréal, Programme de Chirurgie Générale, Centre Hospitalier de l’Université de Montréal (CHUM), Service de Chirurgie Oncologique, Hôpital Notre-Dame, Montréal, Québec, Canada H2L 4M1, Centre Hospitalier de l’Université de Montréal (CHUM), Service de Chirurgie Oncologique, Hôpital Hôtel-Dieu, Montréal, Québec, Canada H2W 1T8, Centre Hospitalier de l’Université de Montréal (CHUM), Département de microbiologie médicale et infectiologie, Hôpital Notre-Dame, Montréal, Québec, Canada H2L 4M1, and Centre Hospitalier de l’Université de Montréal (CHUM), Service de Chirurgie Oncologique, Hôpital Notre-Dame, Montréal, Québec, Canada H2L 4M1 *Correspondence address. Université de Montréal, Programme de Chirurgie Générale, Centre Hospitalier de l’Université de Montréal (CHUM), Service de Chirurgie Oncologique, Hôpital Notre-Dame, Montréal, Québec, Canada H2L 4M1. Tel: +1-438-989-8113; E-mail: roy.hajjar@umontreal.ca ABSTRACT Raoultella ornithinolytica and Raoultella planticola are histamine-producing bacteria that are usually found in fish and water. They are associated with scombroid syndrome that presents with vomiting and flushing. A wide range of infections with these germs is reported, but mainly in fragile hospitalized patients with multiple comorbidities. We report the case of a 54-year-old healthy patient who presented with 24-hours abdominal pain, vomiting, flushing and shock. The abdominal examination showed guarding in the right lower quadrant (RLQ), and the abdominal CT scan images showed a thickened terminal ileum and a distended appendix. The patient underwent a surgical exploration revealing a normal terminal ileum but an inflamed appendicular base. Raoultella ornithinolytica was found in blood cultures and in the liquid retrieved from the RLQ. To the best of our knowledge, this is the first report of a severe life-threatening intra-abdominal presentation due to a community-acquired R. ornithinolytica infection. include this germ along with Klebsiella planticola and Klebsiella INTRODUCTION terrigena [1]. Raoultella ornithinolytica and Raoultella planticola are Raoultella ornithinolytica is a Gram-negative, oxidase-negative, recognized as histamine-producing bacteria that convert histi- aerobic, encapsulated, non-motile rod, belonging to the Entero- dine to histamine, due to their pyridoxal phosphate-dependent bacteriaceae family [1, 2]. It is commonly found in fish, water histidine decarboxylase [3]. Their presence in fish, especially and soil. Raoultella ornithinolytica was previously classified as a in Scomberesocidae families, has been linked to histamine fish Klebsiella specie, but in 2001, the genus Raoultella was created to poisoning, also known as scombroid syndrome [3]. It usually Received: March 3, 2018. Accepted: April 27, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy097/4996198 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 R. Hajjar et al. presents with flushing, vomiting, diarrhea, and sometimes oral Pathological analysis of the appendectomy specimen showed swelling and respiratory compromise [2, 3]. It resembles a self- acute inflammation of the appendicular muscularis, with no limited allergic reaction that usually resolves after a few hours, inflammation of the mucosa. No perforation was objectified. but can also occasionally persist for several days. Periappendicular inflammation of the fatty tissue was also Acute appendicitis is characterized by transmural appen- noted. dicular inflammation usually due to the obstruction of the lumen. Since the inflamed appendix displays usually a different DISCUSSION flora than its normal counterpart, an infectious process has been suggested to contribute to this disease. Terminal ileum We report the case of a healthy 54-year-old male who pre- sented with R. ornithinolytica septic shock, associated with can also be involved in the inflammatory reaction. However, ileitis is more commonly due to inflammatory bowel disease or appendicitis. To our knowledge, this clinical presentation has not been previously described in the literature with R. ornithino- infectious agents, such as Mycobacterium spp., Yersinia spp., Salmonella spp. or cytomegalovirus in immunocompromised lytica nor R. planticola. Previous reports of R. ornithinolytica and R. planticola infections patients [4]. We present here the first case in the literature of a healthy include cases of bacteremia, pneumonia, urinary tract infection, cellulitis, surgical site infection and necrotizing fasciitis [5, 6]. patient with appendicitis and shock caused by R. ornithinolytica. Freney et al. [7]reported the first clinical manifestations related to these organisms in the 1980s as septicemia to Klebsiella trevisa- nii in patients hospitalized for cardiac comorbidities. CASE PRESENTATION Regarding gastrointestinal infections to R. ornithinolytica, chol- A 54-year-old man, with no significant past medical or surgical angitis and pancreatitis were described [6]. One recent case of history and no recent travel, presented to the emergency room spontaneous peritonitis in a healthy individual was published [8]. with a 24-h history of nausea, vomiting, diarrhea and abdom- As for R. planticola, reports included cases of pancreatitis, cholan- inal pain. The patient denied any ingestion of fish, contami- gitis, hepatic abscess, acute cholecystitis and peritoneal dialysis- nated food or water. He had generalized skin flushing and his associated peritonitis [5, 9]. A case of gastroenteritis-associated vital signs were as follow: blood pressure 60/39 mmHg, heart bacteremia has been described in a patient who recovered rate 131/min and temperature 37,8°C. Aggressive fluid resusci- uneventfully with antibiotics [10]. A recent case of a necrotizing tation and intravenous ciprofloxacin and metronidazole were appendicitis managed with an uneventful laparoscopic append- initiated. ectomy was also described [11]. Blood tests’ results were as follow: white blood count 18.9 × The majority of the reports on R. ornithinolytica and R. planti- 9 9 10 /L, neutrophils 17,63 × 10 /L, hemoglobin 162 g/L, platelets cola describe nosocomial infections in patients with significant 120 × 10 /L, creatinine 445μmol/L and an estimated glomerular systemic comorbidities such as chronic kidney disease, dia- filtration rate (GFR) of 12 mL/min. The venous blood gas (VBG) betes and cancer. It has even been suggested that infection displayed metabolic acidosis with a pH of 7,29. with these organisms occurs mainly in patients with impaired A non-injected computed tomography (CT) scan of the abdo- defense mechanisms and weakened immune system. Our men and pelvis showed a thickened terminal ileum and a dis- patient was a healthy middle-aged man with no recent hospi- tended appendix reaching 13 mm, with mild stranding of the talizations, infections nor impaired immune system that could surrounding fat. explain the severity of his clinical presentation. Moreover, ini- Hemodynamic instability and a suspected intra-abdominal tial imaging and surgical exploration failed to reveal any signifi- source warranted surgical exploration. Turbid fluid retrieved cant gastrointestinal injury that would properly explain the from the right lower quadrant (RLQ) was sent for Gram stain septic shock and severe acute kidney failure. Although signifi- and culture. A 1 cm necrotic zone was noted at the base of the cant vasodilation has been described in scombroid syndromes, appendix, without any other significant signs of appendicular the patient did not present symptoms of an allergic reaction, or ileal inflammation. Appendectomy and peritoneal lavage such as bronchospasm, oral swelling or respiratory distress were performed. that could suggest histamine poisoning rather than a septic As these findings were deemed insufficient to explain the process. He presented however with unexplained cutaneous severity of the patient’s presentation, intraoperative short colon- flushing for several days. oscopy and transesophageal echocardiography were performed. In conclusion, R. ornithinolytica, along with R. planticola, have Both were normal. The patient was then admitted to the inten- long been believed to be harmless environmental organisms, sive care unit (ICU) where support with vasopressors continued usually found in water or soil. The present report along with for 2 days. He developed disseminated intravascular coagulation other recent papers suggest rather a wide spectrum of life- (DIC). After 7 days of empirical intravenous treatment with cipro- threatening clinical presentations even in healthy individuals. floxacin and metronidazole, the patient received an additional 7 days course of oral amoxicillin/clavulanic acid. The flushing syn- CONFLICT OF INTEREST STATEMENT drome persisted for 6 days. The patient left the ICU after 6 days, and recovered uneventfully before being discharged on post- None declared. operative Day 10. Blood drawn at arrival and liquid from intraoperative RLQ REFERENCES fluid were analyzed using the MALDI-TOF MS technique (Matrix-Assisted Laser Desorption/Ionization Time-of-Flight 1. Drancourt M, Bollet C, Carta A, Rousselier P. Phylogenetic Mass Spectroscopy). Results indicated the presence of R. ornithi- analyses of Klebsiella species delineate Klebsiella and nolytica, which was multisensitive, notably to ciprofloxacin and Raoultella gen. nov., with description of Raoultella ornithi- amoxicillin/clavulanic. nolytica comb. nov., Raoultella terrigena comb. nov. and Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy097/4996198 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Community-acquired infection to Raoultella ornithinolytica presenting as appendicitis 3 Raoultella planticola comb. nov. Int J Syst Evol Microbiol 2001; literature. Int J Infect Dis 2016;45:65–71. doi:10.1016/j.ijid. 51:925–32. 2016.02.014. 2. Puerta-Fernandez S, Miralles-Linares F, Sanchez-Simonet 7. Freney J, Gavini F, Alexandre H, Madier S, Izard D, Leclerc H, MV, Bernal-Lopez MR, Gomez-Huelgas R. Raoultella planti- et al. Nosocomial infection and colonization by Klebsiella cola bacteraemia secondary to gastroenteritis. Clin Microbiol trevisanii. J Clin Microbiol 1986;23:948–50. Infect 2013;19:E236–7. doi:10.1111/1469-0691.12102. 8. Sibanda M. Primary peritonitis caused by Raoultella 3. Bjornsdottir-Butler K, Bowers JC, Benner RA Jr.. Prevalence ornithinolytica in a 53-year-old man. JMM Case Rep 2014;1: and characterization of high histamine-producing bacteria e002634. in Gulf of Mexico fish species. J Food Prot 2015;78:1335–42. 9. De Campos FP, Guimarães TB, Lovisolo SM. Fatal pancreatic doi:10.4315/0362-028×.JFP-15-012. pseudocyst co-infected by Raoultella planticola: an emer- 4. Goulart RA, Barbalho SM, Gasparini RG, de Carvalho AC. ging pathogen. Autops Case Rep 2016;6:27–31. doi:10.4322/ Facing terminal ileitis: going beyond Crohn’s disease. acr.2016.034. Gastroenterology Res 2016;9:1–9. Epub 2016 Mar 8. Review. 10. Kim SW, Kim JE, Hong YA, Ko GJ, Pyo HJ, Kwon YJ. 5. Ershadi A, Weiss E, Verduzco E, Chia D, Sadigh M. Emerging Raoultella planticola peritonitis in a patient on continuous pathogen: a case and review of Raoultella planticola. ambulatory peritoneal dialysis. Infection 2015;43:771–5. Infection 2014;42:1043–6. doi:10.1007/s15010-014-0638-9. doi:10.1007/s15010-015-0788-4. 6. Seng P, Boushab BM, Romain F, Gouriet F, Bruder N, Martin 11. Naganathan G, Amin NK. Raoultella planticola associated C, et al. Emerging role of Raoultella ornithinolytica in necrotizing appendicitis: a novel case report. Int J Surg Case human infections: a series of cases and review of the Rep 2018;44:38–41. doi:10.1016/j.ijscr.2018.01.021. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy097/4996198 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Community-acquired infection to Raoultella ornithinolytica presenting as appendicitis and shock in a healthy individual

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Abstract

Journal of Surgical Case Reports, 2018;5, 1–3 doi: 10.1093/jscr/rjy097 Case Report CASE REPORT Community-acquired infection to Raoultella ornithinolytica presenting as appendicitis and shock in a healthy individual 1, 2 3 2 Roy Hajjar *, Frank Schwenter , Shih-Hann Su , Marie-Christine Gasse , and Herawaty Sebajang Université de Montréal, Programme de Chirurgie Générale, Centre Hospitalier de l’Université de Montréal (CHUM), Service de Chirurgie Oncologique, Hôpital Notre-Dame, Montréal, Québec, Canada H2L 4M1, Centre Hospitalier de l’Université de Montréal (CHUM), Service de Chirurgie Oncologique, Hôpital Hôtel-Dieu, Montréal, Québec, Canada H2W 1T8, Centre Hospitalier de l’Université de Montréal (CHUM), Département de microbiologie médicale et infectiologie, Hôpital Notre-Dame, Montréal, Québec, Canada H2L 4M1, and Centre Hospitalier de l’Université de Montréal (CHUM), Service de Chirurgie Oncologique, Hôpital Notre-Dame, Montréal, Québec, Canada H2L 4M1 *Correspondence address. Université de Montréal, Programme de Chirurgie Générale, Centre Hospitalier de l’Université de Montréal (CHUM), Service de Chirurgie Oncologique, Hôpital Notre-Dame, Montréal, Québec, Canada H2L 4M1. Tel: +1-438-989-8113; E-mail: roy.hajjar@umontreal.ca ABSTRACT Raoultella ornithinolytica and Raoultella planticola are histamine-producing bacteria that are usually found in fish and water. They are associated with scombroid syndrome that presents with vomiting and flushing. A wide range of infections with these germs is reported, but mainly in fragile hospitalized patients with multiple comorbidities. We report the case of a 54-year-old healthy patient who presented with 24-hours abdominal pain, vomiting, flushing and shock. The abdominal examination showed guarding in the right lower quadrant (RLQ), and the abdominal CT scan images showed a thickened terminal ileum and a distended appendix. The patient underwent a surgical exploration revealing a normal terminal ileum but an inflamed appendicular base. Raoultella ornithinolytica was found in blood cultures and in the liquid retrieved from the RLQ. To the best of our knowledge, this is the first report of a severe life-threatening intra-abdominal presentation due to a community-acquired R. ornithinolytica infection. include this germ along with Klebsiella planticola and Klebsiella INTRODUCTION terrigena [1]. Raoultella ornithinolytica and Raoultella planticola are Raoultella ornithinolytica is a Gram-negative, oxidase-negative, recognized as histamine-producing bacteria that convert histi- aerobic, encapsulated, non-motile rod, belonging to the Entero- dine to histamine, due to their pyridoxal phosphate-dependent bacteriaceae family [1, 2]. It is commonly found in fish, water histidine decarboxylase [3]. Their presence in fish, especially and soil. Raoultella ornithinolytica was previously classified as a in Scomberesocidae families, has been linked to histamine fish Klebsiella specie, but in 2001, the genus Raoultella was created to poisoning, also known as scombroid syndrome [3]. It usually Received: March 3, 2018. Accepted: April 27, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy097/4996198 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 R. Hajjar et al. presents with flushing, vomiting, diarrhea, and sometimes oral Pathological analysis of the appendectomy specimen showed swelling and respiratory compromise [2, 3]. It resembles a self- acute inflammation of the appendicular muscularis, with no limited allergic reaction that usually resolves after a few hours, inflammation of the mucosa. No perforation was objectified. but can also occasionally persist for several days. Periappendicular inflammation of the fatty tissue was also Acute appendicitis is characterized by transmural appen- noted. dicular inflammation usually due to the obstruction of the lumen. Since the inflamed appendix displays usually a different DISCUSSION flora than its normal counterpart, an infectious process has been suggested to contribute to this disease. Terminal ileum We report the case of a healthy 54-year-old male who pre- sented with R. ornithinolytica septic shock, associated with can also be involved in the inflammatory reaction. However, ileitis is more commonly due to inflammatory bowel disease or appendicitis. To our knowledge, this clinical presentation has not been previously described in the literature with R. ornithino- infectious agents, such as Mycobacterium spp., Yersinia spp., Salmonella spp. or cytomegalovirus in immunocompromised lytica nor R. planticola. Previous reports of R. ornithinolytica and R. planticola infections patients [4]. We present here the first case in the literature of a healthy include cases of bacteremia, pneumonia, urinary tract infection, cellulitis, surgical site infection and necrotizing fasciitis [5, 6]. patient with appendicitis and shock caused by R. ornithinolytica. Freney et al. [7]reported the first clinical manifestations related to these organisms in the 1980s as septicemia to Klebsiella trevisa- nii in patients hospitalized for cardiac comorbidities. CASE PRESENTATION Regarding gastrointestinal infections to R. ornithinolytica, chol- A 54-year-old man, with no significant past medical or surgical angitis and pancreatitis were described [6]. One recent case of history and no recent travel, presented to the emergency room spontaneous peritonitis in a healthy individual was published [8]. with a 24-h history of nausea, vomiting, diarrhea and abdom- As for R. planticola, reports included cases of pancreatitis, cholan- inal pain. The patient denied any ingestion of fish, contami- gitis, hepatic abscess, acute cholecystitis and peritoneal dialysis- nated food or water. He had generalized skin flushing and his associated peritonitis [5, 9]. A case of gastroenteritis-associated vital signs were as follow: blood pressure 60/39 mmHg, heart bacteremia has been described in a patient who recovered rate 131/min and temperature 37,8°C. Aggressive fluid resusci- uneventfully with antibiotics [10]. A recent case of a necrotizing tation and intravenous ciprofloxacin and metronidazole were appendicitis managed with an uneventful laparoscopic append- initiated. ectomy was also described [11]. Blood tests’ results were as follow: white blood count 18.9 × The majority of the reports on R. ornithinolytica and R. planti- 9 9 10 /L, neutrophils 17,63 × 10 /L, hemoglobin 162 g/L, platelets cola describe nosocomial infections in patients with significant 120 × 10 /L, creatinine 445μmol/L and an estimated glomerular systemic comorbidities such as chronic kidney disease, dia- filtration rate (GFR) of 12 mL/min. The venous blood gas (VBG) betes and cancer. It has even been suggested that infection displayed metabolic acidosis with a pH of 7,29. with these organisms occurs mainly in patients with impaired A non-injected computed tomography (CT) scan of the abdo- defense mechanisms and weakened immune system. Our men and pelvis showed a thickened terminal ileum and a dis- patient was a healthy middle-aged man with no recent hospi- tended appendix reaching 13 mm, with mild stranding of the talizations, infections nor impaired immune system that could surrounding fat. explain the severity of his clinical presentation. Moreover, ini- Hemodynamic instability and a suspected intra-abdominal tial imaging and surgical exploration failed to reveal any signifi- source warranted surgical exploration. Turbid fluid retrieved cant gastrointestinal injury that would properly explain the from the right lower quadrant (RLQ) was sent for Gram stain septic shock and severe acute kidney failure. Although signifi- and culture. A 1 cm necrotic zone was noted at the base of the cant vasodilation has been described in scombroid syndromes, appendix, without any other significant signs of appendicular the patient did not present symptoms of an allergic reaction, or ileal inflammation. Appendectomy and peritoneal lavage such as bronchospasm, oral swelling or respiratory distress were performed. that could suggest histamine poisoning rather than a septic As these findings were deemed insufficient to explain the process. He presented however with unexplained cutaneous severity of the patient’s presentation, intraoperative short colon- flushing for several days. oscopy and transesophageal echocardiography were performed. In conclusion, R. ornithinolytica, along with R. planticola, have Both were normal. The patient was then admitted to the inten- long been believed to be harmless environmental organisms, sive care unit (ICU) where support with vasopressors continued usually found in water or soil. The present report along with for 2 days. He developed disseminated intravascular coagulation other recent papers suggest rather a wide spectrum of life- (DIC). After 7 days of empirical intravenous treatment with cipro- threatening clinical presentations even in healthy individuals. floxacin and metronidazole, the patient received an additional 7 days course of oral amoxicillin/clavulanic acid. The flushing syn- CONFLICT OF INTEREST STATEMENT drome persisted for 6 days. The patient left the ICU after 6 days, and recovered uneventfully before being discharged on post- None declared. operative Day 10. Blood drawn at arrival and liquid from intraoperative RLQ REFERENCES fluid were analyzed using the MALDI-TOF MS technique (Matrix-Assisted Laser Desorption/Ionization Time-of-Flight 1. Drancourt M, Bollet C, Carta A, Rousselier P. Phylogenetic Mass Spectroscopy). Results indicated the presence of R. ornithi- analyses of Klebsiella species delineate Klebsiella and nolytica, which was multisensitive, notably to ciprofloxacin and Raoultella gen. nov., with description of Raoultella ornithi- amoxicillin/clavulanic. nolytica comb. nov., Raoultella terrigena comb. nov. and Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy097/4996198 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Community-acquired infection to Raoultella ornithinolytica presenting as appendicitis 3 Raoultella planticola comb. nov. Int J Syst Evol Microbiol 2001; literature. Int J Infect Dis 2016;45:65–71. doi:10.1016/j.ijid. 51:925–32. 2016.02.014. 2. Puerta-Fernandez S, Miralles-Linares F, Sanchez-Simonet 7. Freney J, Gavini F, Alexandre H, Madier S, Izard D, Leclerc H, MV, Bernal-Lopez MR, Gomez-Huelgas R. Raoultella planti- et al. Nosocomial infection and colonization by Klebsiella cola bacteraemia secondary to gastroenteritis. Clin Microbiol trevisanii. J Clin Microbiol 1986;23:948–50. Infect 2013;19:E236–7. doi:10.1111/1469-0691.12102. 8. Sibanda M. Primary peritonitis caused by Raoultella 3. Bjornsdottir-Butler K, Bowers JC, Benner RA Jr.. Prevalence ornithinolytica in a 53-year-old man. JMM Case Rep 2014;1: and characterization of high histamine-producing bacteria e002634. in Gulf of Mexico fish species. J Food Prot 2015;78:1335–42. 9. De Campos FP, Guimarães TB, Lovisolo SM. Fatal pancreatic doi:10.4315/0362-028×.JFP-15-012. pseudocyst co-infected by Raoultella planticola: an emer- 4. Goulart RA, Barbalho SM, Gasparini RG, de Carvalho AC. ging pathogen. Autops Case Rep 2016;6:27–31. doi:10.4322/ Facing terminal ileitis: going beyond Crohn’s disease. acr.2016.034. Gastroenterology Res 2016;9:1–9. Epub 2016 Mar 8. Review. 10. Kim SW, Kim JE, Hong YA, Ko GJ, Pyo HJ, Kwon YJ. 5. Ershadi A, Weiss E, Verduzco E, Chia D, Sadigh M. Emerging Raoultella planticola peritonitis in a patient on continuous pathogen: a case and review of Raoultella planticola. ambulatory peritoneal dialysis. Infection 2015;43:771–5. Infection 2014;42:1043–6. doi:10.1007/s15010-014-0638-9. doi:10.1007/s15010-015-0788-4. 6. Seng P, Boushab BM, Romain F, Gouriet F, Bruder N, Martin 11. Naganathan G, Amin NK. Raoultella planticola associated C, et al. Emerging role of Raoultella ornithinolytica in necrotizing appendicitis: a novel case report. Int J Surg Case human infections: a series of cases and review of the Rep 2018;44:38–41. doi:10.1016/j.ijscr.2018.01.021. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy097/4996198 by Ed 'DeepDyve' Gillespie user on 21 June 2018

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Journal of Surgical Case ReportsOxford University Press

Published: May 15, 2018

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