Printed in the USA. All rights reserved0736-4679/$–see front matter
doi:10.1016/j.jemermed.2007.11.044
ClinicalCommunications: Pediatrics
APPENDICITIS: A RARE CAUSE
Muhammad Waseem, MD* and Shruti Simha, MD†
*Department of Emergency Medicine and †Department of Pediatrics, Lincoln Medical & Mental Health Center, Bronx, New YorkReprint Address: Muhammad Waseem, MD, Department of Emergency Medicine, Lincoln Medical & Mental Health Center,
e Keywords—appendicitis; helminthic infection; abdomi-nal pain
CASE REPORT
A previously healthy 16-year-old boy presented with a2-day history of abdominal pain, mainly in the rightlower quadrant. His pain was colicky without any radi-ation, relieved by bowel movements, and aggravated bymovement. The pain score was 6/10. He also had feverand three episodes of non-bloody diarrhea on the day ofpresentation. He had no symptoms of nausea, vomiting,or anorexia. There were no sick contacts and no historyof uncooked food consumption. His travel history in-cluded a visit to Puerto Rico approximately 6 monthsprior. The past medical history was unremarkable.
RECEIVED: 11 January 2007; FINAL SUBMISSION RECEIVED:
CCEPTED: 2 November 2007
e9
On arrival, he was alert and appeared uncomfortable.His vital signs were as follows: temperature 38.1°C(100.7°F), heart rate 109 beats/min, respiratory rate 18breaths/min, and blood pressure 118/66 mm Hg. Physicalexamination revealed tenderness in the right iliac fossabut no rebound tenderness or guarding. There were noperitoneal signs. The rectal examination showed mildtenderness but no blood or mucus. There was no perianalerythema. The chest was clear with equal breath soundsbilaterally. The remainder of the physical examinationwas unremarkable. Laboratory evaluation included acomplete blood count, which showed white blood cells15,000/mm3 with 66% neutrophils, 11% lymphocytes,nd 3% eosinophils. The urinalysis was negative.
Based on the findings of the physical examination, alinical diagnosis of appendicitis was made without obtain-ng any imaging studies. The patient was taken to theperating room for laparoscopic appendectomy. During theaparoscopic surgery the appendix was found to be normal,ut multiple mobile helminthes were noted in the lumen ofhe appendix (Figure 1). The cytopathology report of theelminthes identified them as Enterobius vermicularis. Theatient was treated with mebendazole and recovered com-letely from abdominal symptoms. He was discharged on therd post-operative day. He was well at 2 weeks follow-up visit.
DISCUSSION
Acute appendicitis is the most common surgical cause ofabdominal pain in children (1). The appendix is the most
ril 2007;
14 Ap
e10 M. Waseem and S. Simha
commonly resected and examined intra-abdominal organ(2). Acute appendicitis is most frequently due to coinci-dence of obstruction, reduced blood supply, ischemic dam-age of the mucosa, and bacterial infection. The organismsthat colonize the bowel can cause appendicitis, but parasiticinfections may also account for a small percentage of cases
Figure 1. Operative image of appendix showing enterobius.
of appendicitis. Fecoliths have been widely implicated in
the etiology of acute appendicitis, and parasites have beenrecovered from these fecoliths (3).
The role of parasitic infection in the etiology of ap-pendiceal disease has been known for many years (4,5).In a recent study, the parasites were most frequently seenin histologically normal appendices, and were rarely
associated with the histological changes of acute appen-
1
1
1
1
1
1
1
1
1
1
2
2
A Rare Cause of Appendicitis e11
dicitis (6). The presence of these parasites in the appen-dix can give the symptoms of acute appendicitis (7).These parasites may invade the wall of the appendix,with resultant inflammatory reactions (8). Many cases ofactive penetration of the intestinal wall have been re-ported (9). Review of the histopathological findings inappendices removed for acute appendicitis has confirmeda link with parasitic infestation (10).
Enterobius vermicularis is the most common nema-tode parasite of humans in the developed world, and isthe most prevalent nematode in the United States (11). Itis known to cause symptoms simulating appendicitis.There are many case reports of appendicitis caused byinfestation of enterobius (12–16). The occurrence of E.vermicularis infestation with acute appendicitis variesfrom 0.2% to 3.8% worldwide (17,18). There is a higherreported incidence of granulomas in the appendix in thepresence of pinworms in the appendix (19). Enterobiushas been found during colonoscopy (20).
Acute appendicitis is generally a clinical diagnosis. Inthe presence of strong clinical suspicion, based on his-tory and physical findings, further studies generally arenot needed for confirmation. In most reported cases,therefore, the diagnosis of parasitic condition is madeonly after surgery (21).
Patients with parasite-associated appendicitis shouldreceive anti-helminthic treatment because appendectomyeliminates the complication but not the cause of intesti-nal disease. Pyrantel pamoate is the drug of choice forEnterobius vermicularis infestation. Other alternativesare albendazole and mebendazole.
CONCLUSION
Parasitic infestation, especially enterobius, is an uncom-mon cause of acute appendicitis in children in the UnitedStates. Emergency physicians and surgeons should beaware of parasitic causes of appendicitis, especially inimmigrant patients. Early diagnosis and treatment mayprevent life-threatening complications such as perfora-
tion and peritonitis.
REFERENCES
1. Leung AK. Acute abdominal pain in children. Am Fam Physician2003;67:2321–6.
2. Lamps LW. Appendicitis and infections of the appendix. SeminDiagn Pathol 2004;21:86–97.
3. Feng CS. Parasites in faecaliths. J Clin Pathol 1988;41:232–3.4. Sidky HA, Maksoud MA, Aziz HA, Saleh A. Acute appendicitis as
a complication of helminthic infection among some Egyptian pa-tients. J Egypt Soc Parasitol 1981;11:469–73.
5. Berry LR, Burrows RB. Appendicitis with cestodes: report of acase. AMA Arch Pathol 1955;59:587–93.
6. Sah SP, Bhadani PP. Enterobius vermicularis causing symptomsof appendicitis in Nepal. Trop Doct 2006;36:160–2.
7. Wiebe BM. Appendicitis and Enterobius vermicularis. Scand JGastroenterol 1991;26:336–8.
8. Mogensen K, Pahle E, Kowalski K. Enterobius vermicularis andacute appendicitis. Acta Chir Scand 1985;151:705–7.
9. Chandrasoma PT, Mendis KN. Enterobius vermicularis in ectopicsites. Am J Trop Med Hyg 1977;26:644–9.
0. Ojo OS, Udeh SC, Odesanmi WO. Review of the histopathologicalfindings in appendices removed for acute appendicitis in Nigerians.J R Coll Surg Edinb 1991;36:245–8.
1. Walshe T, Kavanagh DO, Bennani F, Eustace PW. The escapedworm. J Am Coll Surg 2006;203:579.
2. Yildirim S, Nursal TZ, Tarim A, Kayaselcuk F, Noyan T. A rarecause of acute appendicitis: parasitic infection. Scand J Infect Dis2005;37:757–9.
3. Bhaskaran CS, Devi ES, Rao KV. Enterobius vermicularis andvermiform appendix. J Indian Med Assoc 1975;64:334–6.
4. Vinuela A, Fernandez-Rojo F, Martinez-Merino A. Oxyuris gran-ulomas of pelvic peritoneum and appendicular wall. Histopathol-ogy 1979;3:69–77.
5. Abramson DJ. Acute appendicitis and a Meckel’s diverticulumwith Enterobius vermicularis. First reported case. Am Surg 1966;32:343–6.
6. Arca MJ, Gates RL, Groner JI, Hammond S, Caniano DA. Clinicalmanifestations of appendiceal pinworms in children: an institu-tional experience and a review of the literature. Pediatr Surg Int2004;20:372–5.
7. Dahlstrom JE, MacArthur EB. Enterobius vermicularis: a possiblecause of symptoms resembling appendicitis. Aust N Z J Surg1994;64:692–4.
8. Budd JS, Armstrong C. Role of Enterobius vermicularis in theaetiology of appendicitis. Br J Surg 1987;74:748–9.
9. Sterba J, Vlcek M. Appendiceal enterobiasis—its incidence and rela-tionships to appendicitis. Folia Parasitol (Praha) 1984;31:311–8.
0. Brown MD. Images in clinical medicine. Enterobius vermicularis.N Engl J Med 2006;354:e12.
1. Nadler S, Cappell MS, Bhatt B, Matano S, Kure K. Appendicealinfection by Entamoeba histolytica and Strongyloides stercora-lis presenting like acute appendicitis. Dig Dis Sci 1990;35:
