Acute abdominal symptoms as the first presentation of a patient with mirror-image dextrocardia with situs inverus.

This is the case of a 63 years old female that was admitted with abdominal pain mainly localized in the left lower quadrant, with diffuse radiation to the rest of the abdomen. It persisted for two days and worsened on the day of admission. It was associated with two episodes of vomiting and fever. She had no urinary symptoms or lumbar zone tenderness. There was no familial history of dextrocardia. The physical examination showed discrete abdominal distention; bowel movements diminished in the left lower quadrant with guarding and rebound tenderness at this site. The reminder of the physical examination was normal. The ECG findings in Lead I: P, QRS and T waves inverted or upside down. Lead II: represented the usual lead III and vice versa. AVR and AVL were reversed and prominent negative deflections were seen in AVL rather than in AVR. AVF was unaffected. The V1-V6 complexes showed decreasing amplitude. V1 was the equivalent of the usual V2 and vice versa. The differential diagnosis included dextroposition of the heart, dextroversion of the heart and misplaced electrodes. The chest X-Ray findings were consistent with dextrocardia. Abdominal and pelvic CT showed situs inversus, inflammatory process at the cecum and proximal ascending colon located on the left side of the abdomen, compatible with perforated appendicitis. No abscess or free intraperitoneal air was seen. The patient was started on empiric antibiotic coverage with cleocin and cipro. Surgical intervention was performed with the findings of a perforated and gangrenous appendix and severe inflammation at the left side of the abdomen. The surgical wound was closed by second intention 3 days later without complications. The patient recovered and was discharged home to continue with oral antibiotic therapy. The incidence of dextrocardia with situs inversus is 1:5,000 to 1:10,000. A review of the American medical literature from 1965 to the present revealed only 18 acute presentations of situs inversus with the following distribution: appendix (4 cases), trauma (4 cases), cardiovascular (3 cases), gastrointestinal (3 cases), gallbladder (3 cases), spleen (1 case). The case presented is a typical "after-the-facts-findings" were the initial evaluation overlooked a typical presentation, just side-reversed.