Doctors Thought This Three-Year-Old Had Appendicitis—Until the Surgery Started
To their surprise, little Daniel's appendix looked perfectly healthy. It was when they started moving the camera through his intestines that things got really weird...
A Medical Mystery
The patient: Daniel (name changed), a three-year-old boy
The symptoms: Worsening belly pain and fever
The doctor: Dr. Saar Hashavya, head of the pediatric ER at Hadassah Medical Center in Jerusalem, Israel
Daniel’s parents weren’t surprised at first when their little boy started complaining that his tummy hurt. It was late March, 2019, not long after the Jewish holiday Purim, and the three-year-old had overindulged in candy. But when Daniel started refusing food and throwing up, they brought him to a clinic. The doctor assured them it was likely gastroenteritis from a stomach virus, and that it would run its course in three days. They were advised to give him rest and fluids.
By the morning of day four, however, the pain was much worse. Instead of playing with his toys as usual, Daniel was hunched over and feverish, and he couldn’t defecate. He was eating almost nothing. His worried parents brought him to the pediatric emergency room at Hadassah Medical Center’s Ein Kerem campus.
“For us, as pediatricians, there’s a very clear line between a well-appearing child and an ill-appearing child,” says Dr. Saar Hashavya. “It’s a lot of small things—his colour, the way he holds his body, the way he speaks with you—that make the larger picture of a child who is not well.” This boy had no ordinary gastroenteritis, Hashavya intuited.
Another tipoff that Daniel’s condition was serious was tenderness in the right lower quadrant of his abdomen. You don’t usually see that with a simple stomach bug, says Hashavya. Meanwhile, Daniel’s blood work showed a high white blood cell count and inflammatory markers, suggesting the presence of an infection.
The Misdiagnosis
To the doctors, these symptoms and signs all pointed to acute appendicitis, which occurs when the appendix, a slim pouch attached to the colon, becomes infected from a blockage. This isn’t common in preschoolers, but can sometimes happen. Treatment is surgical removal of the appendix. “We were stunned and anxious,” says Daniel’s dad, Adam. “We imagined all the worst-case scenarios.” If an infected appendix ruptures, the bacteria can spread throughout the gut.
An ultrasound appeared to confirm the diagnosis. The technician couldn’t get a proper view of the appendix—the tiny organ doesn’t always show up well—but there was definitely a lot of extra fluid present, which indicated inflammation in the intestine.
“All the puzzle pieces were in place for appendicitis,” says Hashavya. “At the time, there was no reason to think something else would pop up.”
There was also no convincing reason to run more tests. A CT scan would have given doctors a better look at Daniel’s abdomen, but exposing him to unnecessary radiation wouldn’t change the fact that he urgently needed surgery. “We knew something wrong was going on, and we needed to work fast,” says Hashavya.
Within three hours of arriving at the hospital, Daniel was in the operating room, and the surgical team was making a small incision in their young patient’s abdomen. They inserted a camera to hunt for the infected appendix. As the surgeons explored the abdominal cavity and looked on their monitor, they could see a great deal of pus. Unexpectedly, they also saw adhesions—some tissues were literally stuck together—and, to their surprise, a normal-looking appendix.
Then things got even weirder. Moving the camera around, the surgeons suddenly discovered a group of strange little ball-shaped objects in the intestines. They were smooth and shiny, and appeared in various colours—red, violet, blue and green. These pretty little balls, it seemed, were wreaking havoc inside Daniel’s abdomen.
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A Magnetic Danger
Unbeknownst to his parents, about a week before Daniel’s symptoms started, one of the other boys at his preschool had brought in a magnet game to show his friends. To a small child who loves Purim candy, the colourful magnetic balls looked tempting, and he couldn’t resist swallowing them.
One magnet on its own would have passed through the body harmlessly, but Daniel had consumed 18. The magnets had come together in two bunches, and had lodged in different parts of his digestive system—the duodenum at the top of his small intestine, and lower in his bowel. The strong magnetic attraction had then pulled the two parts of his body together, squeezing the delicate tissues between them, cutting off their blood supply and eventually perforating them.
Daniel had a version of Valentino syndrome, in which a rare rupture of the duodenum causes signs and symptoms that perfectly mimic acute appendicitis. The condition is usually due to a complication from a peptic ulcer, and it’s named after the silent-movie star of the 1920s, Rudolph Valentino—the infection caused his death. “Just like in our case, doctors went to take out Valentino’s appendix, and discovered it was normal,” Hashavya says. “Now it’s a cautionary tale for medical students: what looks like appendicitis may actually be a perforation.”
The magnets were removed from Daniel’s abdomen, and the damaged tissue was repaired with sutures. Infections this extensive don’t always heal perfectly, and the patient can develop a post-surgical leak in the bowel. But fortunately, the repair was successful. Daniel needed antibiotics for a week, and gradually started eating again. His parents say that although it took about two months before he was completely himself again, there were no lasting effects.
“He feels great now,” says his dad, adding: “We had no idea that magnets were such a danger for children.”
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