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Sharp lower abdominal pain and calcified abdominal mass.

A male with a history of heart transplantation 10 years before for cardiomyopathy on chronic immunosuppression presented to the emergency department with persistent diffuse lower abdominal pain and urinary frequency. His medical history was notable for chronic renal insufficiency, ventricular septal defect status post closure 20 years before, gastroesophageal reflux disease, and hyperlipidemia. Chronicmedications included tacrolimus, CellCept, Nexium, Pravachol, prenisone, allopurinol, magnesium, and Xanax. He reported that the day before, he developed sudden onset of severe sharp lower abdominal pain that lasted for 30 minutes, which then transitioned to persistent dull bilateral lower abdominal pain, worse in the right lower quadrant. He also had diarrhea but no nausea, vomiting, fever, or chills. Vital signswere stable with blood pressure of 152/105, heart rate of 84, respiratory rate of 18, and temperature of 97.6-F. Physical examination confirmed tenderness to palpation in both lower quadrants of the abdomen but no evidence of peritonitis, and no palpable abdominal masses. White blood cell count was 5.5 (neutrophils, 83.4%; lymphocytes, 5.9%), hemoglobin was 13.5 g/dL, hematocritwas 39.9%, platelet count was 124,000, blood urea nitrogen was 34,was creatininewas 1.8.Urinalysis finding was normal. Abdominal ultrasonography confirmed a tubular structure and adjacent heterogeneous mass in the lower abdomen concerning for possible appendicitis with perforation and abscess. Abdominal computed tomographic (CT) scan (Fig. 1) showed a 4.5-cm round structure of predominantly soft tissue attenuation in the pelvis. This structure had a thin eggshell calcified perimeter, was near the appendix, and was superior to the bladder. There was no evidence of appendicitis. What Is the Diagnosis?