Barthel et al. Journal of Medical Case Reports 2012, 6:229 http://www.jmedicalcasereports.com/content/6/1/229 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Giant cystic meconium peritonitis presenting in a neonate with classic radiographic eggshell calcifications and treated with an elective surgical approach: a case report Erik R Barthel1, Allison L Speer1, Daniel E Levin1, Bindi J Naik-Mathuria2 and Tracy C Grikscheit1* Abstract Introduction: Giant cystic meconium peritonitis is relatively rare. Patients often present with nonspecific physical findings such as distension and emesis. Plain abdominal films remain invaluable for identifying the characteristic calcifications seen with a meconium pseudocyst, and large eggshell calcifications are pathognomonic for the giant cystic subtype. Case presentation: We present classic plain X-ray findings and an intraoperative image of a premature low birth weight two-day-old Hispanic male baby treated for giant cystic meconium peritonitis with a staged procedure involving peritoneal drainage, ostomy creation and closure. Conclusion: Pediatric surgeons have a range of potential therapeutic approaches for giant cystic meconium peritonitis. A delay of definitive surgical management in the setting of massive abdominal soiling is a safe and acceptable strategy if adequate temporizing drainage is performed in the early perinatal period. Introduction Reports of meconium peritonitis appear in the English- language literature beginning in the early 20th century [1,2]. Infants may present with the failure to pass meco- nium, abdominal distension, emesis and symptoms of peritonitis [3]. Meconium pseudocyst occurs as a result of in utero or postnatal intestinal perforation. This perforation is often secondary to ischemia or obstruction and although meconium is sterile, chemical irritation of the peritoneum can ensue [4]. As the body attempts to wall off the source of inflammation, dystrophic calcifi- cation occurs, resulting in the classic eggshell calcifica- tions seen on abdominal radiography, demonstrated in Figure 1 [5]. Case presentation A 2.2 kg Hispanic boy was born vaginally to a 21 year- old primigravida woman at 31 weeks and one day of * Correspondence: tgrikscheit@chla.usc.edu 1Children’s Hospital Los Angeles Division of Pediatric Surgery, 4650 Sunset Boulevard Mailstop 35, Los Angeles, CA 90027, USA Full list of author information is available at the end of the article gestation after prolonged rupture of membranes. He had a prenatal history of dilated bowel loops and hydrops on ultrasonography, as well as fetal anemia requiring an intrauterine blood transfusion 18 days prior to delivery. Our patient was intubated at 11 minutes of life for poor respiratory effort. Analysis of his cord arterial blood gas on transfer to the neonatal intensive care unit revealed a pH of 7.32, partial pressure of CO2 50 torr, and partial pressure of O2 20. His abdomen was markedly dis- tended, exhibited progressive erythema, and radiographs showed dilated bowel loops and significant, well- demarcated bilateral calcifications (Figure 1A, arrows). Our patient was diagnosed with a giant meconium pseudocyst, a walled-off collection of meconium that can cause neonatal peritonitis, which is distinguished from other forms of meconium peritonitis by the persist- ence of a communication between the digestive lumen and the peritoneal cavity leading to the entire abdomen becoming filled with meconium [6]. On the second day of life, he was taken to the operating room, placed in the supine position, and an exploratory laparotomy was per- formed. At surgery, extensive soiling and inflammation © 2012 Barthel et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.