Enterobius
Vermicularis or Pinworm or Threadworm is usually an asymptomatic inhabitant
of the intestine, however when they do cause symptoms there can be
a spectrum of gastrointestinal complaints. The primary symptom is
of itching in the perianal area. Surgical intervention is rarely needed
to manage complications from the infestation like perforation, appendicitis
or bowel gangrene. Present case is of a 16-year-old male patient who
presented to us with an unusual manifestation of Enterrobius Vermicularis.
Introduction
The Nematode, pinworm or threadworm or Enterobius Vermicularis is
a common human parasite. It resides in the appendix, caecum and asending
colon in the humans. It causes the primary symptoms of itching in
the perianal area. Although pinworms are usually asymptomatic inhabitants
of the intestine, when they do cause symptoms there can be a spectrum
of complaints including diarrhoea, enterocolitis, ulceration and perforation
of the bowel.
The worm or its eggs may occasionally be seen in unusual sites. Granulomas
caused by the parasite have been reported in genitourinary tract,
peritoneum, ovaries, liver, lung and CSF.
The possibility of an Enterobius Vermicularis infestation should be
considered in a case of unexplained enterocolitis and bowel gangrene.
Case Report
Present case is a 16-year-old male patient who presented to us in
the emergency department with a history of pain in the abdomen, vomiting
and distension of the abdomen of 5 days duration. On enquiry, the
patient had not passed stools or flatus for 2 days before presenting
to us. The patient did not give any history of undergoing any surgery
or similar complaints in the past. On examination the patient was
having an increased pulse rate, the abdomen was distended without
any tenderness. The WBC counts were within normal limits except for
eosinophilia. A provisional diagnosis of intestinal obstruction was
made on the basis of clinical findings and an X-ray showing multiple
air fluid levels of jejunal obstruction.
 |
| Fig.
1 : Histopathology under high power (40 X) shows granulomatous
reaction with multinucleated giant cells with phagocytosed ova
of Enterobius vermicularis in sections of the gangrenous jejunum. |
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After close observation
and repeated assessments a decision was taken to explore the abdomen
as the patient had developed tachycardia, abdominal tenderness and
increased WBC counts. On explorative laparotomy, approximately half
a meter length of distal jejunum was found gangrenous along with mesenteric
lymphadenopathy. Resection anastomosis of the gangrenous segment was
done and mesenteric nodes were sampled. The specimen was sent for
histopathology.
The histopathology (Fig. 1) showed congested and ulcerated mucosa
on gross examination. Microscopic examination revealed inflammatory
infiltrate comprising eosinophils and polymorphs in transmural and
perivascular
locations. The mucosa also showed aggregates of ova of Enterobius
Vermicularis with granulomatous reaction and multinucleated giant
cells engulfing the ova. Based on these findings the histopathology
was reported as gangrene of the jejunum secondary to Enterobius Vermicularis
infestation, a rare cause of gangrene of the small bowel.
The patient’s post-operative course was unremarkable and the
patient was started on Tab Albendazole 400 mg single dose for three
times at weekly intervals subsequent to which the patient was asymptomatic
and his WBC counts returned to normal.
Discussion
The Nematode, pinworm or threadworm or Enterobius Vermicularis is
a common human parasite. It is primarily a disease of the children.
It resides in the caecum, asending colon and ileum in the humans.
The primary symptom, itching of the perianal area is produced when
a gravid female worm migrates to the anal area and inserts her tail
pin into the mucosa for deposition of eggs. Although pinworms are
usually asymptomatic inhabitants of the intestine, when they do cause
symptoms there can be a spectrum of gastrointestinal complaints. Diarrhoea
can occur during acute infection because of inflammation of the bowel
wall. Enterobius vermicularis is known to cause eosinophilic enterocolitis.1-3;
Ileal and colonic ulcerations4 and perforations.5 Pinworm
infestation is a recognized but very rare cause of appendicitis.6,7
In the present case jejunal enterocolitis due to Enterobius Vermicularis
infestation, which is rarely found in jejunum, is seen associated
with jejunal gangrene, showing granulomatous reaction with multinucleate
giant cells and phagocytosed ova of Enterobius vermicularis, which
is a rare complication of Enterobius vermicularis infestation.
The worm or its eggs may occasionally be seen in unusual sites. Granulomas
caused by the parasite have been reported in genitourinary tract,
peritoneum, perianal area, ovaries, liver, lung, and CSF. Ectopic
worms and/or eggs in granulomas have been described on the peritoneum
of the small and large intestine,8 which could be due to active penetration
of intestinal wall.9 A case of ectopic pinworm infestation
in inguinal hernia has also been described.10
Infestation is diagnosed using an adhesive tape test. A strip of adhesive
tape can be applied sticky side down to the uncleaned perianal area
in the morning prior to defaecation or bathing in order to capture
characteristic eggs. The adhesive side of the tape is then placed
onto a glass slide, and the slide is examined for eggs. Patient will
also manifest with eosinophilia in his differential WBC count. Our
case also showed eosinophilia in the differential count.
Most of the cases get resolved when treated with anti helminths like
Mebendazole or Albendazole being given orally three times three weeks
apart. However when the pathology is irreversible surgical intervention
may be called for and will include the procedures of closure of perforation
or appendicectomy or resection anastomosis for severe enterocolitis
causing bowel gangrene. In the present case resection of the jejunal
gangrene with anastomosis was done followed by antihelminthic therapy
to which the patient responded.
Acknowledgement
We would like to thank Dr. GB Daver, Head of the Department, Department
of General Surgery and Dean, Grant Medical College and JJ Group of
Hospitals, Mumbai for his kind permission in writing this manuscript.
References
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the ileum secondary to Enterobius vermicularis report of a rare case.
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6. Budd JS, Armstrong C. Role of Enterobius vermicularis in the aetiology
of appendicitis. Br J Surg 1987; 74 (8) : 748-9.
7. Williams DJ, Dixon MF. Sex, Enterobius vermicularis and the appendix.
Br J Surg 1988; 75 (12) : 1225-6.
8. Sinniah B, Leopairut J, Neafie RC, Connor DH, Voge M. Enterobiasis
: a histopathological study of 259 patients. Ann Trop Med Parasitol
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9. Chandrasoma PT, Mendis KN. Enterobius vermicularis in ectopic sites.
Am J Trop Med Hyg 1977; 20 : 644-9.
10. Tornieporth NG, Disko R, Brandis A, Barautzki D. Ectopic enterobiasis
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UNDERSTANDING
"DIASTOLIC" HEART FAILURE
As the elderly population expands, there will be marked increases
in the number of persons with heart failure. Epidemiologic studies
have established that 40 per cent to 50 per cent of patients
with heart failure have a normal ejection fraction (³ 50
per cent) without primary valve disease, a clinical syndrome
that is commonly referred to as "diastolic" heart
failure.
Patients with diastolic heart failure tend to be older than
those with systolic heart failure; more of them are female,
more have hypertension, and fewer have recognized coronary artery
disease.
Forty per cent of patients with diastolic heart failure meet
the echocardiographic criteria for left ventricular hypertrophy.
Given the complexity of heart failure, the paucity of studies
in actual patients with diastolic heart failure, and the potential
for heterogeneity in this condition, we must be cautious in
making assumptions regarding its pathophysiology.
N Eng J Med 2004; 350 : 1930-31. |
*Associate Professor and
Unit Head; **Lecturer; ***Resident, Department of General Surgery,
Grant Medical College and JJ Group of Hospitals, Mumbai 400 008.
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