Acute appendicitis (AA) in neonates and infants is an infrequent event. In day-to-day practice, death due to AA is hardly ever reported to a coroner or a medical examiner. Here, we report on an 8-month-old infant assigned to the medical examiner as the death occurred within 10 days of a surgical procedure. The cause of death was undetermined. Autopsy revealed gross and histologic features of AA. A postmortem review of the medical records showed signs and symptoms consistent with AA. On the other hand, a recent history of upper respiratory tract infection followed by clinical diagnosis and treatment by a community pediatrician probably blindsided the hospital physicians. This case illustrates the challenges of AA in infancy. The literature review revealed that a misdiagnosis of AA is more likely to occur on several occasions. They include patients who present "atypically," patients who are not thoroughly examined, patients receiving antipyretic or analgesic medication and discharged, those diagnosed as having gastroenteritis, and patients who do not receive an appropriate discharge or follow-up instructions.