57 | Isolated delirium as a presenting sign of abdominal sepsis: a case of acute perforated diverticulitis in an elderly patient

C. Rispoli¹, V. Notarangelo² | ¹AORN Cardarelli, Napoli; ²Cava de' Tirreni (SA).

Introduction. With increasing life expectancy, emergency department visits among elderly patients are rising, requiring greater awareness of atypical presentations. Delirium may be the sole manifestation of severe, time-dependent conditions, with high risk of diagnostic delay in the absence of focal signs.

Case presentation. A 79-year-old woman with arterial hypertension presented with acute confusion and fever (38.7°C), without other symptoms. She was previously independent and in good health until the day prior to admission.

Material and Materials and Methods. Vital signs were stable (BP 170/80 mmHg, HR 95 bpm, SpO₂ 95%, GCS 15), and physical examination, including abdominal and neurological assessment, was unremarkable. Laboratory tests showed normal WBC (8.29×10³/µL), mildly elevated procalcitonin (0.3 ng/mL), and high C-reactive protein (100 mg/L). Chest X-ray, abdominal ultrasound, and brain CT were negative. Bladder catheterization showed clear urine, reducing suspicion of urinary infection. Persistent fever and delirium despite negative first-line tests prompted further investigation.

Results. Contrast-enhanced CT revealed sigmoid diverticulitis with contained perforation. The patient was admitted to emergency surgery and treated conservatively with intravenous fluids and antibiotics (metronidazole and ciprofloxacin). She was discharged after one week in fair condition, with planned follow-up.

Conclusions. Delirium may be the sole sign of severe intra-abdominal pathology in elderly patients, even without pain or focal findings. Biomarker discrepancies may complicate diagnosis, highlighting their limitations in the geriatric population. Such atypical presentations are increasingly frequent and require heightened clinical awareness. Delirium should be considered a red flag, prompting a proactive approach with early advanced imaging to avoid delays and improve outcomes.