A 13-year-old male was admitted to our hospital with a history of abdominal distension that was neither painful nor associated with vomiting. On examination, he appeared pale and apathetic, but he was hemodynamically stable. A non-tender tennis-ball-sized mass was palpated in the right iliac fossa of his abdomen. Hernia orifices were free, and there was no discoloration of the abdomen. Ultrasonography of the abdomen was not conclusive. Computerized tomography of his abdomen showed thickened bowel walls with features also suggestive of lymphoma. The patient was kept under observation and managed conservatively. The abdominal mass decreased in size over the next week, and the patient was then discharged home. 
Four days later; however, he developed severe abdominal pain while playing football and was again transferred to the hospital. He arrested during transfer but was resuscitated and later revived. Upon arrival, he was unconscious, severely hypotensive and tachycardic, with oxygen saturation of 50%. His abdomen was severely distended, his WBC count was 15000 c/mL, and computerized tomography showed free peritoneal fluid and features suggestive of pneumonia.
Operative exploration showed a huge and perforated appendix (Figure 1). The appendix measured about 55 cm in length, was filled with fecal material, and had a perforation in its center (Figure 2). Histopathological examination of the removed specimen confirmed an inflamed appendicular tissue.