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Pogorelić Z, Babić V, Bašković M, Ercegović V, Mrklić I. Management and Incidence of Enterobius vermicularis Infestation in Appendectomy Specimens: A Cross-Sectional Study of 6359 Appendectomies. J Clin Med 2024; 13:3198. [PMID: 38892909 PMCID: PMC11172809 DOI: 10.3390/jcm13113198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/13/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Background: The role of Enterobius vermicularis infestation in the context of appendicitis is largely overlooked, but Enterobius vermicularis is considered an unexpected and significant appendicectomy finding. The aim of this study was to investigate the frequency of Enterobius vermicularis findings in appendectomies and to evaluate the clinical and histopathologic features of patients with Enterobius vermicularis-associated acute appendicitis and those with appendiceal Enterobius vermicularis infestation. Methods: The medical records of all children who underwent an appendectomy in two large pediatric centers in Croatia between 1 January 2009 and 1 January 2024 were retrospectively reviewed. Of 6359 appendectomies, 61 (0.96%) children were diagnosed with Enterobius vermicularis on histopathology and included in further analysis. The groups were compared with regard to demographic characteristics, laboratory values, clinical features and histopathological findings. Results: The incidence of enterobiasis fluctuated slightly in the individual study years, but was constant overall. The median age of all patients was 11 years (IQR 8.5, 13), with females predominating (60.7%). Acute appendicitis was observed in 34% of the appendiceal species. The patients with Enterobius vermicularis infestation, without appendicitis, were younger (9 years (IQR 8, 13) vs. 12 years (IQR 10, 15); p = 0.020), had longer duration of symptoms (36 h (IQR, 12, 48) vs. 24 h (IQR, 12, 36); p = 0.034), lower body temperature (37 °C (IQR 36.8, 37.4) vs. 37.6 °C (IQR, 37, 38.6) p = 0.012), lower Appendicitis Inflammation Response (AIR) score (3 (IQR 2, 5) vs. 7 (IQR 5, 9.5) p < 0.001), lower incidence of rebound tenderness (57.1% vs. 20%; p = 0.003) and less frequent vomiting (12.5% vs. 47.6%; p = 0.004) compared to the patients with Enterobius vermicularis-associated acute appendicitis. Acute inflammatory markers in the laboratory showed significantly higher values in the group of patients with acute appendicitis: C-reactive protein (p = 0.009), White blood cells (p = 0.001) and neutrophils (p < 0.001). Eosinophilia was not found in any of the groups, although eosinophil counts were significantly higher in children who had Enterobius vermicularis infestation than in those with Enterobius vermicularis-related appendicitis (2.5% (IQR 0.9, 4.3) vs. 1.8% (IQR 0.7, 2.1); p = 0.040). Conclusions: Pediatric surgeons should consider Enterobius vermicularis infestation as a differential diagnosis when removing a vermiform appendix. Younger age, longer duration of symptoms, lower body temperature, lower AIR score, lower diameter of the appendix and normal laboratory inflammatory markers could predict Enterobius vermicularis infection in children presenting with right iliac fossa pain and avoid unnecessary appendectomy.
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Affiliation(s)
- Zenon Pogorelić
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Vlade Babić
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
| | - Marko Bašković
- Department of Pediatric Surgery, Children’s Hospital Zagreb, 10000 Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Vladimir Ercegović
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
| | - Ivana Mrklić
- Department of Pathology, Forensic Medicine and Cytology, University Hospital of Split, 21000 Split, Croatia
- Department of Pathology, School of Medicine, University of Split, 21000 Split, Croatia
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Chhetri S, Al Mamari AH, Al Awfi MM, Al Khaldi NHN, Abed NM, Pandak N, Khamis F, Balushi ZA, Alalawi RMK, Al Lawati S, Ba'Omar M, Shukaili N, Al-Abri S. Enterobius vermicularis Related Acute Appendicitis: A Case Report and Review of the Literature. Infect Dis Rep 2023; 15:417-424. [PMID: 37489396 PMCID: PMC10366835 DOI: 10.3390/idr15040042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/02/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
While the debate on the association between Enterobius vermicularis (E. vermicularis) and acute appendicitis has not been settled, a few case reports of this very rare encounter are beginning to come to light. E. vermicularis is one of the most common parasitic infections around the world, and acute appendicitis, on the other hand, is also a commonly encountered condition in general surgery. However, the association between these two conditions remains controversial. Here we present a case report of a young woman with appendicitis associated with E. vermicularis.
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Affiliation(s)
- Shabnam Chhetri
- Department of Infectious Diseases, The Royal Hospital, Muscat, PC 111, Oman
| | | | | | | | - Nibras Mejbel Abed
- Department of Colorectal Surgery, The Royal Hospital, Muscat, PC 111, Oman
| | - Nenad Pandak
- Department of Infectious Diseases, The Royal Hospital, Muscat, PC 111, Oman
| | - Faryal Khamis
- Department of Infectious Diseases, The Royal Hospital, Muscat, PC 111, Oman
| | | | | | - Sultan Al Lawati
- Department of Infectious Diseases, The Royal Hospital, Muscat, PC 111, Oman
| | - Muna Ba'Omar
- Department of Infectious Diseases, The Royal Hospital, Muscat, PC 111, Oman
| | - Nasser Shukaili
- Department of Infectious Diseases, The Royal Hospital, Muscat, PC 111, Oman
| | - Seif Al-Abri
- Department of Infectious Diseases, The Royal Hospital, Muscat, PC 111, Oman
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An Evaluation of the Efficacy of Systemic Immune-Inflammation Index in Predicting Enterobius-Associated Appendicitis Preoperatively. Cureus 2023; 15:e36733. [PMID: 36992816 PMCID: PMC10041780 DOI: 10.7759/cureus.36733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
Objective Our study aimed to retrospectively evaluate Enterobius-associated appendicitis cases and compare them with acute appendicitis cases in terms of parameters such as the neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP)-to-lymphocyte ratio (CLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII). We primarily aimed to evaluate the utility of SII in the differential diagnosis of Enterobius-associated appendicitis. Methods The appendectomy specimens of pediatric patients who were operated on for acute appendicitis between June 2016 and August 2022 were retrospectively evaluated. Enterobius-associated appendicitis cases were included for analysis. All patients were evaluated regarding age, gender, blood count, surgery, and pathology reports. Pathology reports were evaluated for the presence of histological signs of acute appendicitis. The patients were classified into an Enterobius-associated appendicitis group and a regular acute appendicitis group. CRP, white blood cell (WBC), red cell distribution width (RDW), neutrophils, lymphocytes, NLR, monocytes, eosinophils, platelet (PLT), PLR, CLR, and SII values were compared between the two groups. Results Eleven cases of Enterobius-associated appendicitis were identified out of 430 total cases (2.55%) examined. The mean age of the group with acute appendicitis was 12.83 ±3.16 years, while the mean age of the group with Enterobius-associated appendicitis was 8.55 ±2.54 years. There was no statistically significant difference in terms of CRP, WBC, RDW, lymphocytes, neutrophils, NLR, monocytes, eosinophils, PLT, PLR, and CLR values between the two groups (p>0.05). However, when the SII values of the participants were analyzed, it was observed that the SII values of the participants in the regular appendicitis group were significantly higher than those of the participants in the Enterobius group (p<0.05). Among the 11 Enterobius-associated appendicitis patients, seven appendectomy specimens revealed no inflammation and were regarded as negative appendectomy (63.63%). Conclusion This is the first study to demonstrate the utility of preoperative SII evaluation in Enterobius-associated appendicitis. SII is a simple, easy-to-calculate indicator of Enterobius-associated appendicitis and aids in the preoperative differential diagnosis of acute appendicitis.
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Alshihmani SHA. Acute appendicitis due to infection with Enterobius vermicularis, A case report. Ann Med Surg (Lond) 2022; 80:104094. [PMID: 36045827 PMCID: PMC9422074 DOI: 10.1016/j.amsu.2022.104094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/24/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction & importance Enterobius vermicularis is the most common parasitic infection in developed countries of temperate and cool climates.The feco-oral route is the most common route of human infection. Due to obstruction of appendiceal lumen, the presence of parasites in the appendix may cause appendiceal colic or cause inflammation of the appendix. Case presentation A 17 years old male was referred to our Emergency Department with acute abdominal pain in his right lower quadrant. The physical and laboratory examination revealed right iliac fossa tenderness and leukocytosis with neutophilia. An open appendectomy was performed. The lumen of appendix was filled with pinworms and were moved out of the appendiceal lumen. Postoperatively, one oral dose of 100 mg of mebendazole was administered to our patient and his family members and was repeated after 14 days. Conclusion Infrequently the E. vermicularis can be found in appendectomy pathological specimens. Rarely, acute appendicitis caused by parasitic infections, especially in adults. So the clinical signs of intestinal parasite infection can be may mimic acute appendicitis. A careful evaluation of symptoms such as pruritus ani, or eosinophilia on laboratory examination, could prevent unnecessary appendectomies. Enterobius vermicularis is the most common parasitic infection in developed countries of temperate and cool climates. The presence of parasites in the appendix may cause appendiceal colic or cause inflammation of the appendix. Infrequently the E. vermicularis can be found in appendectomy pathological specimens. A careful evaluation of symptoms such as pruritus ani, or eosinophilia on laboratory examination, could prevent unnecessary appendectomies.
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Sarici B, Akbulut S, Ozcan M, Demyati K, Samdanci E. Unusual infectious agents detected in appendectomy specimens: A retrospective analysis of 42 cases. Turk J Surg 2020; 36:291-296. [PMID: 33778385 PMCID: PMC7963316 DOI: 10.47717/turkjsurg.2020.4713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/24/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the clinical and histopathological features of 42 patients with unusual infectious agents detected in their appendectomy specimens. MATERIAL AND METHODS Between January 1999 and November 2018, 2.754 patients underwent emergency or incidental appendectomy in our clinic, and their pathology reports were retrospectively reviewed. Unusual infectious agents or eosinophilic infiltration of the appendix were reported in the initial pathological examinations of 57 patients. The pathological slides of these patients were re-examined by histopathologists. The examinations revealed that 15 of these patients had no microscopic findings suggestive of parasitic infections. The remaining 42 patients with unusual appendiceal infectious agents were included into the study. RESULTS A total of 42 patients (25 females and 17 males) aged 18 to 75 years were included into this study. While 32 of these patients (76%) underwent emergency appendectomy with a presumed diagnosis of acute appendicitis (AAp), the remaining 10 patients underwent incidental appendectomy for various reasons. Twenty-two patients (52.4%) had histopathological changes consistent with AAp while 20 patients had no evidence of AAp. Histopathological examination revealed infection with Enterobius vermicularis in 38 of the patients, Taenia species in 2, and Ascaris lumbricoides and Actinomyces species in 1 patient each. A total of 24 patients were treated for infections with mebendazole (n = 20), albendazole (n =1), niclosamide (n = 2), and amoxicillin (n = 1). CONCLUSION Unusual infectious agents should be considered as factors potentially triggering AAp, especially in patients living in endemic areas. The appendiceal stump should be inspected for parasite residues.
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Affiliation(s)
- Baris Sarici
- Inonu University Faculty Of Medicine, Surgery, Malatya, Turkey
| | - Sami Akbulut
- Inonu University Faculty Of Medicine, Surgery, Malatya, Turkey
| | - Mehmet Ozcan
- Inonu University Faculty Of Medicine, Patholgoy, Malatya, Turkey
| | - Khaled Demyati
- An-najah National University, Suegery, Nablus, Palestinian Territories
| | - Emine Samdanci
- Inonu University Faculty Of Medicine, Patholgoy, Malatya, Turkey
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The neglected role of Enterobius vermicularis in appendicitis: A systematic review and meta-analysis. PLoS One 2020; 15:e0232143. [PMID: 32324817 PMCID: PMC7179856 DOI: 10.1371/journal.pone.0232143] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/07/2020] [Indexed: 01/13/2023] Open
Abstract
Although the main cause of appendicitis is unclear, infection with Enterobius vermicularis is suggested as a neglected risk factor. Since, there is no comprehensive analysis to estimate the prevalence of E. vermicularis in appendicitis; therefore, we conducted a global-scale systematic review and meta-analysis study to estimate the prevalence of E. vermicularis infection in appendicitis cases. PubMed, Scopus, Web of Science and Google Scholar databases were systematically searched for relevant studies published until 15 August 2019. Pooled prevalence of E. vermicularis infection was estimated using the random effects model. Data were classified based on the continents and countries. Moreover, subgroup analyses regarding the gender, the human development index (HDI), and income level of countries were also performed. Fifty-nine studies involving 103195 appendix tissue samples belonging to the individuals of appendicitis were included. The pooled prevalence of E. vermicularis infection was (4%, 95%CI, 2–6%), with the highest prevalence (8%, 95% CI: 0–36%) and lowest prevalence (2%, 95% CI: 1–4%) in Africa and Americas continents, respectively. With respect to countries, the lowest and highest prevalence rates were reported from Venezuela (<1%, 95% CI: 0–1%) and Nigeria (33%, 95% CI: 17–52%), respectively. Indeed, a higher prevalence was observed in females, as well as in countries with lower levels of income and HDI. Our findings indicate the relatively high burden of E. vermicularis infection in appendicitis cases. However, our findings suggest the great need for more epidemiological studies to depth understand overlaps between E. vermicularis infection and appendicitis in countries with lower HDI and income levels.
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Hammood ZD, Salih AM, Mohammed SH, Kakamad FH, Salih KM, Omar DA, Hassan MN, Sidiq SH, Mustafa MQ, Habibullah IJ, Usf DC, Al Obaidi AE. Enterobius vermicularis causing acute appendicitis, a case report with literature review. Int J Surg Case Rep 2019; 63:153-156. [PMID: 31586892 PMCID: PMC6796714 DOI: 10.1016/j.ijscr.2019.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/17/2019] [Indexed: 12/29/2022] Open
Abstract
Enterobius vermicularis is one of the commonest parasitic infestations worldwide. Its association with acute appendicitis remains controversial. It is very rarely encountered during appendectomy. In this report, a case of acute appendicitis caused by Enterobius vermicularis has been presented.
Introduction Enterobius vermicularis is one of the commonest parasitic infestations worldwide but its association with acute appendicitis remains controversial. It is very rarely encountered during appendectomy. The aim of this paper is to report a case of acute appendicitis caused by Enterobius vermicularis. A 23-year-old housewife presented with a right lower abdominal pain for the past 8 h. Clinical examination revealed right iliac fossa tenderness upon palpation and rebound tenderness upon release. The patient was diagnosed as a case of suspected acute appendicitis. The patient was anesthetized and intubated. Delivery of the vermiform appendix done through right grid iron incision. Intra operatively an inflamed appendix obstructed by Enterobius vermicularis was noted. Conclusion Enterobius vermicularis can habit the appendix and induce the signs and symptoms of A.A with or without actual histopathological acute appendicitis. The treatment of choice is surgical resection of the appendix.
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Affiliation(s)
| | - Abdulwahid M Salih
- Faculty of Medical Sciences, School of Medicine, Department Surgery, University of Sulaimani, Sulaimani, Kurdistan, Iraq
| | - Shvan H Mohammed
- Kscien Organization, Hamdi Str., Azadi Mall, Sulaimani, Kurdistan, Iraq; Chara Laboratory, Shahedan Street, Kalar, Kurdistan, Iraq
| | - Fahmi H Kakamad
- Kscien Organization, Hamdi Str., Azadi Mall, Sulaimani, Kurdistan, Iraq; Faculty of Medical Sciences, School of Medicine, Department Cardiothoracic and Vascular Surgery, University of Sulaimani, Sulaimani, Kurdistan, Iraq.
| | | | - Diyar A Omar
- Kscien Organization, Hamdi Str., Azadi Mall, Sulaimani, Kurdistan, Iraq; Erbil Polytechnic University, Shaqlawa Technical Institute, Erbil, Kurdistan, Iraq
| | - Marwan N Hassan
- Kscien Organization, Hamdi Str., Azadi Mall, Sulaimani, Kurdistan, Iraq
| | - Shadi H Sidiq
- Kscien Organization, Hamdi Str., Azadi Mall, Sulaimani, Kurdistan, Iraq
| | - Mohammed Q Mustafa
- Kscien Organization, Hamdi Str., Azadi Mall, Sulaimani, Kurdistan, Iraq; Medical Analysis Department, Science Faculty, Ishik university, Erbil, Kurdistan, Iraq
| | | | - Drood C Usf
- Kscien Organization, Hamdi Str., Azadi Mall, Sulaimani, Kurdistan, Iraq
| | - Anmar E Al Obaidi
- Kscien Organization, Hamdi Str., Azadi Mall, Sulaimani, Kurdistan, Iraq
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Sosin M, Kent JR, Chahine AA. Enterobius vermicularis Appendiceal Colic. J Laparoendosc Adv Surg Tech A 2019; 29:717-719. [PMID: 30720386 DOI: 10.1089/lap.2018.0693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Enterobius vermicularis associated appendiceal colic and acute appendicitis are rarely encountered in the United States. The 9-year-old patient described in this case presented with right lower quadrant abdominal pain, nausea, and vomiting consistent with acute appendicitis and was brought to the operating room for an appendectomy. Intraoperatively a pinworm, E. vermicularis, was visualized and the presumptive diagnosis of acute appendicitis was revised to E. vermicularis associated appendiceal colic. Retrospective review of the preoperative imaging demonstrates the first reported ultrasonographic image of pinworm inhabitance within the appendiceal lumen. The patient was treated postoperatively with a course of albendazole and recovered appropriately. This article reviews the geographic epidemiology, pathophysiology, surgical, and medical treatment recommendations in the management of E. vermicularis diseases of the appendix. Through dissemination of this ultrasonographic imaging, the authors hope to inform other providers about E. vermicularis associated appendiceal colic and reduce the incidence of avoidable surgeries.
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Affiliation(s)
- Michael Sosin
- Department of Surgery, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Johnathan R Kent
- Department of Surgery, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - A Alfred Chahine
- Division of Pediatric Surgery, Children's National Health System, Washington, District of Columbia
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Parasitic Appendicitis: A Novel Laparoscopic Approach for the Prevention of Peritoneal Contamination. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2018; 2018:3238061. [PMID: 29977414 PMCID: PMC5994267 DOI: 10.1155/2018/3238061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/05/2018] [Accepted: 04/30/2018] [Indexed: 11/17/2022]
Abstract
Background/Aim Although rare, parasitic infection can cause acute appendicitis and result in contamination of the peritonea during appendectomy. The goal of this study was to summarize our experiences with parasitic appendicitis and describe a novel laparoscopic technique to prevent contamination. Method All patients diagnosed with acute appendicitis who underwent appendectomy between January 2016 and January 2017 were included in the study. All appendectomies were performed using the standard three-port laparoscopic method, and a video recording was made of each procedure. Following separation of the mesoappendix, a single endoloop was placed in the base of the appendix, and the appendix was then transected 3-4 mm above the clamp with the aid of a thermal cauterizing/sealing device. The appendix was extracted from the 10 mm trocar hole below the umbilicus and placed inside a bag prepared from a glove. After pathological confirmation of parasitic appendicitis, medical records were retrospectively analyzed in each case for whether peritoneal contamination had occurred or not. Results Out of 97 appendectomies, parasitic infection was observed in 4 cases, as confirmed by pathological examination. In two of these patients, E. vermicularis was detected, while the other two were infected with Balantidium coli. Intraoperative contamination did not occur in any of the cases, and retrospective review of the video recordings indicated no peritoneal contamination. Conclusion As a result of the coagulation and sealing effects of thermal devices, airtight seals were created on the residual appendiceal stumps, and consequently, no contamination was observed in any of the cases.
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Efared B, Atsame-Ebang G, Soumana BM, Tahiri L, Hammas N, El Fatemi H, Chbani L. Acute suppurative appendicitis associated with Enterobius vermicularis: an incidental finding or a causative agent? A case report. BMC Res Notes 2017; 10:494. [PMID: 28985767 PMCID: PMC5639576 DOI: 10.1186/s13104-017-2822-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 09/30/2017] [Indexed: 11/10/2022] Open
Abstract
Background Histological acute appendicitis patterns associated with Enterobius vermicularis is an extremely rare finding. The exact role of this parasite in acute appendicitis is controversial as usually resected specimens show no evidence of histological inflammation. Case presentation We present herein a case of a 21-year-old male Arabic patient who presented with clinical syndrome of acute appendicitis. Emergency appendectomy was performed and the histopathological examination of the resected specimen showed the presence of E. vermicularis as well as intense acute inflammatory patterns such as mucosal ulceration and suppurative necrosis. The post-operative course was uneventful and the patient was discharged with appropriate anti-helmintic drug prescription. Conclusion Acute appendicitis due to E. vermicularis is a very rare occurrence. The histopathological analysis of resected specimens should pay special attention to search for this parasite for adequate post-operative treatment of patients.
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Affiliation(s)
- Boubacar Efared
- Department of Pathology, Hassan II University Hospital, Fès, Morocco.
| | | | | | - Layla Tahiri
- Department of Pathology, Hassan II University Hospital, Fès, Morocco
| | - Nawal Hammas
- Department of Pathology, Hassan II University Hospital, Fès, Morocco.,Faculty of Medicine and Pharmacology, Sidi Mohamed Ben Abdellah University, Fès, Morocco
| | - Hinde El Fatemi
- Department of Pathology, Hassan II University Hospital, Fès, Morocco.,Faculty of Medicine and Pharmacology, Sidi Mohamed Ben Abdellah University, Fès, Morocco
| | - Laila Chbani
- Department of Pathology, Hassan II University Hospital, Fès, Morocco.,Faculty of Medicine and Pharmacology, Sidi Mohamed Ben Abdellah University, Fès, Morocco
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