Patient information: a 2-year-old boy with no known medical illness, initially presented with fever for 8 days, after 2 days he developed bilious vomiting more than 10 episodes per day but still tolerate nourishing fluid, followed by abdomen distension and loose stool 5-10 episodes. Otherwise, none of his family members has any similar symptoms. He has no contact with tuberculosis patients.
Clinical findings: his vital signs are normal except fever spike daily. On inspection, he is active and not septic looking. His abdomen is distended but soft and not tender. There is no mass or hernia.
Diagnostic assessment: his haemoglobin is 7.6 g/dL, total white blood cell is 8.6 x103/uL, the platelet is 380 x103/uL, normal renal profile and liver function test. His chest radiograph noted right pleural effusion and the abdominal radiograph showed prominent small bowels with thickening walls without a transitional point (Figure 1). Ultrasound examination was performed and reported as a duplication cyst (Figure 2) with dilated small bowels and thicken wall but no free fluid.
Therapeutic intervention: he was initially treated with intravenous ampicillin/sulbactam for enteritis and pneumonia. However, the condition was not improved despite medical treatment. Subsequently, an exploratory laparotomy was done and found a 5x5 cm infected omental cyst (arising from greater omentum) with 20 mL frank pus inside the thin cyst wall and adhered to surrounding small bowels. The cyst was severely adhered to and eroded into the ileum (Figure 3) and causes a small perforation of about 1 cm with a healthy edge. Excision of omental cyst (Figure 4) and ileal primary repair were done. Pus was sent for culture and grew Escherichia coli and Klebsiella pneumoniae which were sensitive to gentamicin, amikacin and cefepime. Histopathological examination reported as a benign omental cyst.
Follow-up and outcomes: the patient had recovered well after the surgery except for surgical site infection which needed intravenous gentamicin, wound saline flushing and dressing. After a week, the patient s wound was healed and he discharged home.
Patient perspective: the patient was well taken care of during his hospitalization. The parents were relieved with treatment that was carried out on their child. They were happy to see such improvement from day one of admission until the day of discharge.
Patient s consent: informed consent was obtained from the parents for us to utilize the pictures in this manuscript.