Rodolfo Valentino Syndrome: Perforated Duodenal Ulcer Mimicking Appendicitis

Case Presentation: 80-year-old patient with history of lung cancer on immune checkpoint inhibitor therapy presented with acute right lower abdominal pain, elevated inflammatory markers and mild lactic acidosis. The patient had rebound pain in the right lower quadrant and right flank. CT showed free air below the liver (Figure 1). During laparotomy a perforated duodenal ulcer was found. The omentum had wrapped itself to the perforation, which was sealed. There were inflammatory adhesions globally to anterior abdominal wall, pus in the infrahepatic space and right paracolic gutter and ecrotic omentum adjacent to abscess cavity.

Valentino´s syndrome is a rare condition caused by irritation of the peritoneum due to fluid from a perforated ulcer migrating into the paracolic sulcus (1, 2). This situation may mimic acute appendicitis or other differential diagnoses of right lower quadrant pain such as ureteral colic, diverticulitis, diverticulum rupture, ovarian torsion, ruptured ectopic pregnancy, perforated cholecystitis, pancreatitis, and pelvic inflammatory disease (1-3).

Rodolfo Pietro Filiberto Raffaello Gugliemi di Valentina d`Antonguolla), a famous Italian-American actor who starred in several well-known silent films of the 1920s (1, 2). Known in Hollywood as the “Latin Lover”, he died in 1926 at the age of 31 from septic complications (peritonitis and pleuritis) of an undiagnosed perforated peptic ulcer. This ulcer simulated appendicular abdominal pain and was treated surgically with an appendectomy, the final diagnosis being made at autopsy (1, 2).

References:

1. Kara Carmo F, Santorcuato Cubillos F, Maldonado Schoijet I. Valentino’s Syndrome: from History to Images. A Case-based Literature Review. Acta Gastroenterol Latinoam. 2023;53(2):188-192. https://doi.org/10.52787/agl.v53i2.313

2. Noussios G, Galanis N, Konstantinidis S, Mirelis C, Chatzis I, Katsourakis A. Valentino’s syndrome (with retroperitoneal ulcer perforation): A rare clinical-anatomical entity. Am J Case Rep [Internet]. 2020;21:e922647. http://dx.doi.org/10.12659/AJCR.922647

3. Wijegoonewardene SI, Stein J, Cooke D, Tien A. Valentino’s syndrome a perforated peptic ulcer mimicking acute appendicitis. BMJ Case Rep 2012;2012(jun28 1):bcr0320126015-bcr0320126015. http://dx.doi.org/10.1136/bcr.03.2012.6015

An 80-year-old on immune checkpoint therapy hits the ED with RLQ pain, rebound, and free air on CT—appendicitis, right? Laparotomy says no: perforated duodenal ulcer sealed by omentum. Classic Valentino’s syndrome, where fluid migration fools even seasoned clinicians.

This mimic persists as a pitfall, echoing Rudolph Valentino's fatal 1926 misdiagnosis. Today, with imaging at our fingertips, spotting atypical peritoneal sources saves lives and avoids unnecessary procedures.

When perforations play hide-and-seek, be ready.