[A rare triple combination of mesenteric panniculitis, acute appendicitis and König´s syndrome in a patient operated for acute febrile intestinal obstruction: a case report].

Mesenteric panniculitis is a primary inflammation of the mesentery with variable necrosis, inflammation and fibrosis of the fatty tissue. It can be idiopathic (primary) or secondary (associated) to other diseases, asymptomatic and accidentally discovered or revealed by abdominal pain or complications (intestinal obstruction or peritonitis). We here report the case of a 53-year-old patient, admitted with acute abdominal pain, cessation of the transit of materials and gases, in a febrile context. Patient's history included chronic abdominal pain suggesting König´s syndrome and epigastralgia lasting several years. Physical examination showed sore face and abdominal examination revealed mild bloating, marked tenderness in the right iliac fossa (RIF) and in the periumbilical region, without guarding or rigidity and borygms heard on auscultation and with normal rectal examination. A diagnosis of bowel obstruction and fever was made, with suspicion of meso-celiac appendicitis. Abdominal X-ray without preparation and ultrasound confirmed the diagnosis of bowel occlusion. Exploratory laparotomy revealed functional stenosis of the ileum (König´s syndrome) at 1.20m from the ileocecal junction, with multiple adhesions. Adhesiolysis revealed hyperemic appendix measuring 15cm long, whose anatomo pathological examination showed a mucous membrane with inflammatory infiltrate and a wall rich in polynuclear cells. Infiltration of the ileal mesentery causing color change (reddish and greyish in some areas) and small nodosities with friability and tearing on simple handling led to suspicion of mesenteric panniculitis, then confirmed by anatomopathological examination, showing inflammatory reaction in the fatty tissue specimen with infiltration by macrophages, associated with necrotic patches and degeneration. Treatment was based on bowel emptying, anterograde appendectomy, and a combination of corticosteroid (Dexamethasone 24 mg/day) and chymotrypsin (10000 IU/day). The patient´s outcome was good and he was discharged in the 10 postoperative day. The patient underwent clinical and paraclinical follow-up (3 months) for another unknown associated pathology or a pathology that may have occurred early.