PMC9064490_01
(a) Mesoappendix and part of the appendix. Necrotizing vasculitis in mesoappendix small- to medium-sized arteries is evident. There is no inflammation in the appendix mucosa and muscularis propria. Low magnification. H & E stained slide. (b) Segmental transmural necrotizing inflammation. In the involved artery/arteriole, there is fibrinoid necrosis, neutrophils and eosinophils which associated with lumen narrowing. There are no granulomas. High magnification. H & E stained slide.
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The histopathology report showed; Focal peri-appendicular tissue with 3 medium-sized vessels showing necrotizing vasculitis, there were also few small size vessels with the same finding and no evidence of appendicular inflammation (Figures 1(a) and 1(b)).
Ischemic changes involving right coronary territories.
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Nine hours later on the same day, cardiac enzymes kept in trending up (Table 1) and ischemic changes start to appear in the electrocardiogram in form of ST elevation in inferior leads and ST depression in lead I and AVL which is consistent with RCA territory (Figure 2).
(a) Impaired left ventricular systolic function. (b) Left ventricular thrombus (white arrow).
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Urgently repeated echocardiogram showed; impaired left ventricular systolic function involving the septal wall and anterior LV wall; Left anterior descending artery territories (Figure 3(a)). A serial echocardiogram was repeated a few hours later showed multiple echogenic masses at the left ventricular apex (1.5 x 1 cm), LV inferior wall, and in the right ventricle most likely thrombus (Figure 3(b)).
(a) None obstructed coronary arteries. (b) Irregularity of coronary arteries (black arrows).
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Coronary angiography showed no coronary obstruction in both left and right coronary artery systems (Figure 4(a)) but it showed irregularity of the left main coronary artery which indicating vasculitis (Figure 4(b)).
(a) ECG with ischemic changes. (b) Normal ECG on the 4th day after treatment.
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ECG at that time is showing ischemic changes in form of ST elevation in inferior leads and ST depression in lead I and AVL (Figure 5(a)). Follow-up ECG on the 4th day of admission showed no more ischemic changes (Figure 5(b)) and repeated echocardiogram showed improved cardiac function with regression in the size of the left ventricle clot.
Cardiac MRI showed mildly dilated LV.
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There are LV wall motion abnormalities (hypokinesia), abnormal thinning of the apical septal and lateral wall, and diffuse LV mid-wall scarring involving most of the LV mid & apical segments as well as the apical cap with normal coronary arteries (Figure 6).