Pumpkin Seed Ingestion and Pediatric Appendicitis: A Unique Case Report

INTRODUCTION

Appendicitis remains a top emergency despite advancements in medical diagnostic and therapeutic methods and is one of the most common causes of acute abdominal pain and is caused mainly by the obstruction of the appendix lumen, as acute appendicitis could be recognized by tumors of the large intestine and appendix in addition to fecalith, lymphoid hyperplasia, and seeds of fruits and vegetables.^[1]

Pumpkin seeds and oil are accepted to be mostly nutraceutical due to their health benefits and used as a food additive in children’s and adults’ food and nutritional products because of its delicious and fully appreciated taste.^[2] Despite the fact that people who consume high amounts of fiber have a very low incidence rate in terms of appendicitis as one of the gastrointestinal disorders. It is commonly occurring in developed countries.^[3]

Histological examination has shown seeds as a very common food material that appears in the appendicectomy specimens. However, the seeds might be explained as worms or their ova in error. Hence, histology should be intended clearly to manage the cause and problem appropriately.^[4]

Interestingly, the typical western diet, which is based on processed carbohydrates and saturated fats, was not found in the geographical distribution of cases. In contrast, it was observed that fresh fruits and vegetables are still a part of Mediterranean dishes and the Middle East as a traditional dietary habit. For instance, during the summer months, the public tends to consume watermelons and prickly pears while sunflower and pumpkin seeds are a favored food among all ages and seasons.^[5]

In fact, the perforation cannot be caused by a medium risk of seed intake, which is not as like as extended, thin, harsh, and sharp materials.^[6] Interestingly, the overgrowth of bacteria within the trapped food material in the appendiceal lumen could be one of the reasons that illustrate the impact of seeds on acute appendicitis.^[1]

Generally, most acute appendicitis should not be caused by fruit seeds and plant residual intake with a minimal ratio of reported cases. However, clinical researches must be done in studying the mechanism of the undigested fruit seed effect and chowing-neglected plants in the appendix as the causes of its pathology remain largely unknown.^[7-9]

Fruit seeds rarely lead to appendicitis as unfortunately, fruit seed subject’s case reports in literature do not meet the publishing criteria, which increases the difficulty to look over publication, unlike the ordinary submitted literature. Moreover, there is a notable lack of hospital-based publications linking the most common general surgical procedure—appendectomy—with the intake of fruit seeds.^[1]

CASE REPORT

The patient, a 4-year-old boy, presented with severe abdominal pain, repeated episodes of vomiting, and a 2-day history of fever. He underwent an exploratory laparotomy and appendectomy due to a diagnosis of acute appendicitis complicated by peritonitis. Postoperatively, the patient experienced a prolonged recovery period characterized by persistent vomiting and poor tolerance of oral intake. Following a 10-day hospital stay, his condition gradually improved, and he was discharged in a stable and satisfactory general condition.

Clinical findings

The patient appeared acutely unwell and in considerable pain. A slight fever of 38°C was documented. Abdominal examination revealed generalized tenderness, distension, and rigidity, accompanied by sluggish bowel sounds. Laboratory investigations demonstrated a white blood cell (WBC) count of 11.6, with neutrophilia accounting for 78%, and a significantly elevated C-reactive protein (CRP) level of 200.3. Results for urea, electrolytes, liver function tests (LFTs), pancreatic enzymes, and coagulation profile were within normal limits. Imaging studies showed colonic gaseous distension on abdominal ultrasound. Computed tomography (CT) scans indicated colonic obstruction as shown in Figure 1 with peritoneal free fluid as shown in Figure 2 and fecal matter impaction as shown in Figure 3. Abdominal X-ray (AXR) revealed distended bowel loops with multiple fluid levels, while the chest X-ray (CXR) was unremarkable. Blood cultures showed no microbial growth in the emergency department (ED) at Riyadh Care Hospital, Saudi Arabia (SA).

Timeline

The timeline of events is as follows: the patient, a 4-year-old boy, consumed pumpkin seeds one to 2 days prior to the onset of symptoms. By the 3^rd day, he developed severe abdominal pain, repeated episodes of vomiting, and fever. On the 5^th day, he presented to the ED at Riyadh Care Hospital, SA, with persistent symptoms. Clinical evaluation and imaging confirmed a diagnosis of acute appendicitis complicated by peritonitis and colonic obstruction. He was subsequently admitted and managed with a nil per oral (NPO) protocol, intravenous (IV) fluids, analgesics, and fresh frozen plasma (FFP). On the same day, he underwent an exploratory laparotomy and appendectomy. Postoperatively, he was transferred to the pediatric intensive care unit (PICU) for management, which included IV fluids, antibiotics, and analgesics such as paracetamol. Following stabilization, he was moved to the pediatric ward for continued monitoring and recovery. Over the subsequent days, his recovery was protracted, with poor tolerance of oral intake and episodes of vomiting. Eventually, his condition showed gradual improvement, and he was discharged in good general condition after a total hospital stay of 10 days.

Diagnostic assessment

The patient appeared acutely unwell, presenting with abdominal tenderness, distension, rigidity, and sluggish bowel sounds. Laboratory investigations revealed a WBC count of 11.6, with neutrophilia at 78%, and a significantly elevated CRP level of 200.3. Other tests, including urea, electrolytes, LFTs, pancreatic enzymes, and coagulation profile, were all within normal limits. Abdominal ultrasound demonstrated colonic gaseous distension, while a CT scan indicated colonic obstruction with peritoneal free fluid and fecal matter impaction. An AXR revealed distended bowel loops with multiple fluid levels, whereas the CXR was unremarkable. The presence of fecal matter and colonic obstruction presented diagnostic challenges. The potential role of bacterial overgrowth and the mechanical obstruction caused by the ingestion of pumpkin seeds were considered contributory factors. The confirmed diagnosis was acute appendicitis complicated by peritonitis and colonic obstruction. Differential diagnoses included other possible causes of acute abdominal pain and obstruction. Postoperatively, the patient experienced a protracted recovery course, characterized by poor oral intake tolerance and vomiting.

Therapeutic intervention

The patient was managed with IV fluids, IV antibiotics, and analgesics, including paracetamol. An exploratory laparotomy and appendectomy were conducted due to a diagnosis of acute appendicitis complicated by peritonitis. To prevent further complications, the patient was kept NPO and was administered one unit of FFP to support recovery. Specific dosages of IV fluids, antibiotics, and paracetamol were administered; however, exact quantities are not detailed in the provided documentation. Postoperative care involved several days in the PICU, followed by continued monitoring and management in the pediatric ward. The patient was managed conservatively with NPO, IV fluids, and analgesics. However, given the severity of the condition, characterized by colonic obstruction and peritonitis, surgical intervention became necessary. Following surgery, the therapeutic approach prioritized recovery, involving the administration of IV antibiotics and analgesics to control infection and alleviate pain, alongside the gradual reintroduction of oral intake as tolerated.

Follow-up and outcomes

The patient showed gradual improvement during the hospital stay. He was discharged in good general condition after 10 days of hospitalization specific follow-up diagnostic tests or results are mentioned in the file. The patient adhered to the prescribed interventions, including IV fluids, antibiotics, and analgesics. Tolerability was assessed through clinical observation, noting a protracted recovery course with poor oral intake and episodes of vomiting.

DISCUSSION

Acknowledging the effect of mechanical obstruction on inducing appendicitis by mass, food, fecalith, or seeds, the bacterial overgrowth within the substance of the impacted seed in the lumen^[1] is a significant point to look after, especially when finding out that acute appendicitis is associated with elevated Campylobacter jejuni levels.^[10] Despite poor basic food hygiene being the main source of contamination, this bacterium is recognized as one of the four leading global causes of diarrheal diseases and is the most common bacterial agent responsible for gastroenteritis in humans. Nonetheless, bacterial overgrowth caused by blockage of the appendix lumen is thought to be a key factor in triggering appendicitis.^[11] Despite recent studies have suggested a mixed bacterial infiltrate in the inflamed appendices, the exact microbial structure remains unknown on top of the fact that many bacterial species were identified to be the causative etiology of appendicitis.^[11] A study analyzing archived cases of acute appendicitis detected Campylobacter jejuni DNA using molecular methods, suggesting a current or recent infection. However, further research is necessary to determine whether the presence of C. jejuni DNA directly indicates that C. jejuni enteritis is involved in the onset of appendicitis.^[12]

It has been reported that pumpkin seeds may trigger anaphylaxis in children who tolerate pumpkin pulp, possibly due to similarities in amino acid sequences within storage proteins. This cross-reactivity between various nuts and edible seeds suggests a potential allergic mechanism. Consequently, it raises concerns about whether pumpkin seeds could act as an inflammatory trigger in the development of appendicitis.^[12]

it is suggested that consuming unshelled pumpkin seeds under poor hygienic conditions may contribute to both mechanical obstruction and bacterial retention in the appendix, potentially leading to inflammation. This may occur either through physical blockage or as a secondary complication from Campylobacter jejuni enteritis, which has an incubation period ranging from 1 to 7 days. Clinically, symptoms often include abdominal cramps and fever, with possible nausea, vomiting, and diarrhea.

Seed bezoars are caused by indigestible vegetable or fruit seeds causing constipation and pain. Furthermore, 62.7% of children admitted to the ED complained of constipation. Suspicion of acute appendicitis should be concerned in children who have ambiguous right lower quadrant or hypogastric pain as 5 of 83 children diagnosed with seed bezoars and had been admitted to the hospital with an initial working diagnosis of appendicitis.^[5] In addition, a negative culture result of the child’s blood sample cannot rule out Campylobacter-related bacteremia, since it is a self-limiting infection in healthy individuals. These facts are supported by a study that concluded: classical detection techniques which are applied within hospital laboratories are not optimal for the effective detection of Campylobacter bacteria, and the application of more sensitive molecular detection techniques is needed.^[13]

Based on the case details from the file, here is a possible draft for the “patient perspective” section:

Patient perspective

The patient, being a 4-year-old child, was unable to provide a direct account of their experience; however, the family shared their observations and perspective on the care received. They expressed relief and gratitude for the prompt and effective medical intervention that addressed the child’s severe abdominal symptoms.^[14] Despite the initial fear and distress caused by the child’s condition and the need for surgical management, the family appreciated the clear communication from the medical team, which helped them understand the diagnosis and treatment plan. The parents noted the challenging postoperative period, marked by their child’s poor tolerance of oral intake and persistent vomiting, which caused concern. Nonetheless, they were reassured by the gradual improvement observed and were ultimately satisfied with the comprehensive care provided, leading to their child’s discharge in good health.^[15]

CONCLUSIONS

Consuming raw pumpkin seeds that may contain harmful bacteria can elevate the risk of developing foodborne illnesses.^[16] In children, such bacterial overgrowth—combined with the seeds’ potential to cause mechanical blockage (known as phytobezoars)—could contribute to gastrointestinal issues such as constipation, ulcers, or damaging the intestinal mucosa, including possible obstruction of the appendix.^[17] Although the role of pumpkin seeds in triggering appendicitis remains uncertain, further research is needed to explore this hypothesis, especially when compared to the more widely accepted explanation involving bacterial overgrowth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This research is supported by the ongoing research funding program [ORF-2025-631], King saud University, Riyadh, Saudi Arabia.

Conflicts of interest

There are no conflicts of interest.