Enterobiasis: a histopathological study of 259 patients

Utility and diagnostic value of postmortem microbiology associated with histology for forensic purposes

Nowadays, the diagnostic value of postmortem microbiological investigations is still a debated topic, but postmortem microbiology (PMM) remains a discipline with great forensic potential. To evaluate the usefulness and diagnostic-forensic value of postmortem microbiological cultures, it has been conducted a study on cadaveric material sampled during autopsy aiming to identify the correct cause of death. The study analyzed 45 cadavers subjected to judicial autopsy, divided into two groups based on the presence or absence of external or internal macroscopic autopsy signs suggesting infectious pathology. In the same cases, both the microbiological and conventional histological investigations have been simultaneously carried out. From the investigations, mono-bacterial, mono-fungal, mixed and negative cultures were observed. In mono-species microbiological growth, the histological epicrisis confirmed an infectious cause of death due to the presence of signs of acute infection with an aggressive infectious agent. In cases where growth was mixed, it was possible to distinguish between simple postmortal contamination and perimortem colonization. Finally, in some cases where the microbiology was negative, this has been essential in highlighting signs of a vital reaction to viral or parasitic infection. The joint and integrated evaluation of the laboratory results made it possible to correctly understand even those peculiar situations in which the PMM results alone would not have been significant. These methods, when combined, constitute an optimal forensic approach for the identification of the real cause of death and thus reduce the number of unsolved cases.

Infections Are a Very Dangerous Affair: Enterobiasis and Death

BACKGROUND

Enterobiasis or oxyuriasis from Enterobius vermicularis is an infection usually localized in the large bowel and cecum. Generally, the symptoms are characterized by anal itching, and intestinal or nervous disorders. Rarely, it is responsible for death.

METHODS

A forensic autopsy of a 52-year-old white male inmate who died 5 days after hospitalization was performed. Histological and toxicological analyses were also performed.

RESULTS

The death occurred by localization of Enterobius vermicularis in the duodenum and in the proximal ileum, with intestinal haemorrhage, inflammation, and peritonitis documented by histological examination.

CONCLUSION

This is a common infectious disease, and can rarely occur with a fatal outcome, even in advanced populations. The lack of knowledge related to the rarity of death from enterobiasis disease can determine a dangerous concern.

Hypothesis: Multiple sclerosis is caused by three-hits, strictly in order, in genetically susceptible persons

Multiple Sclerosis is a chronic, progressive and debilitating neurological disease which, despite extensive study for over 100 years, remains of enigmatic aetiology. Drawn from the epidemiological evidence, there exists a consensus that there are environmental (possibly infectious) factors that contribute to disease pathogenesis that have not yet been fully elucidated. Here we propose a three-tiered hypothesis: 1) a clinic-epidemiological model of multiple sclerosis as a rare late complication of two sequential infections (with the temporal sequence of infections being important); 2) a proposal that the first event is helminthic infection with Enterobius Vermicularis, and the second is Epstein Barr Virus infection; and 3) a proposal for a testable biological mechanism, involving T-Cell exhaustion for Epstein-Barr Virus protein LMP2A. We believe that this model satisfies some of the as-yet unexplained features of multiple sclerosis epidemiology, is consistent with the clinical and neuropathological features of the disease and is potentially testable by experiment. This model may be generalizable to other autoimmune diseases.

Perianal nodule due to Enterobius vermicularis: Cytomorphological spectrum on fine needle aspiration cytology with a review of literature

Enterobius vermicularis (EV), an intestinal nematode, causes lesions at ectopic sites also. Although lesions are fully curable with antihelminthic drugs, patients may require surgical intervention in clinically unsuspected cases to arrive at correct diagnosis and appropriate treatment. Accurate diagnosis of these lesions on fine needle aspiration cytology (FNAC) has an advantage of avoiding unwanted surgery. To the best of our literature search, there are few case reports of EV diagnosed on cytology, but none of them describes the various stages of development of eggs and hatching of larvae. Dealing cytopathologist should be cognizant of them as parasite can be present in any of these forms/stages. Recently, we came across an interesting case of young boy who presented with perineal nodule and on FNAC from the lesion showed EV larvae and its eggs in various stages of hatching and development. The patient responded to antihelminthic treatment (AHT). Morphological clues with a review of cytological literature are discussed.

Prevalence of Parasitic Infections in Surgically Removed Appendices: Parasitological and Histopathological Studies

Intestinal parasites may cause symptoms similar to acute appendicitis. Moreover, the diagnosis of parasitic infections is only done by post-operative histopathological examination of the appendices. Therefore, our aims are to assess the prevalence of intestinal parasitic infections among patients who were be appendectomized at Tanta Hospitals, Egypt and to investigate the possible association between these parasitic infections and appendicitis. To achieve these objectives, we performed a cross-sectional study including 65 patients chosen randomly who had undergone appendectomy over a period of one year from Oct 2015 to Oct 2016. Demographic data were retrieved. Complete blood picture was done. Moreover, appendiceal faecolith were examined macroscopically then by direct smear examination, formol-ether concentration technique, modified Ziehl-Nelseen stain and rapid immunochromatographic test. Histopathological examination of resected appendices was done. We found that parasitic infections were detected in 24.6 % of examined cases. Most of parasitic infections were prevalent in patients belonging to the school age group. Different parasitic infections were detected in the faecolith specimens. Moreover, Enterobious vermicularis adult female and Schistosoma mansoni granuloma were detected in histopathological sections. Also, a spectrum of pathological changes in the appendices was found ranging from lymphoid hyperplasia to acute inflammation with peritonitis. In conclusion, intestinal parasites may cause clinical picture similar to that of acute appendicitis. Therefore, careful attention to clinical history, stool examination and high eosinophilia may aid diagnosis and avoid unnecessary appendectomy. Moreover, the presence of different parasitic stages in the narrow lumen of the appendix may have a role in the development of appendicitis and this needs further studies.

Granulomas in the gastrointestinal tract: deciphering the Pandora's box

Granulomas are organised collection of activated histiocytes induced by a persistent antigen stimulus. A wide variety of antigens encountered by the gastrointestinal tract are of this nature and hence the resulting granulomatous inflammation represents a tissue reaction pattern. The potential causes can be broadly classified as infections or non-infectious immune reactions. There is also a group where a cause is never identified. Granulomas may be of varying morphological appearance, most commonly epithelioid, foreign body type, suppurative and necrotizing. This may provide a clue as to the aetiology; however, in most cases, the cause requires further inquiry. Pathologists may need to cut deeper levels to look for foreign material and apply special stains to look for microorganisms. Pathologists also need to be certain that the process is a true granuloma and not a mimic. The site of occurrence in the gastrointestinal tract and the clinical setting is often paramount in establishing the aetiology. For instance, infections are more likely the cause in developing countries or when there is immunosuppression. Similarly, granulomas in the stomach are usually due to Crohn's disease; however, it is only rarely the cause of granulomas isolated to the appendix.

Parasitic infestation in pediatric and adolescent appendicitis: a local experience

OBJECTIVE

The relationship between parasites and pediatric appendicitis is a highly debatable issue. This study aims to investigate the role of parasitic infestation in the etiology of acute pediatric appendicitis.

METHODS

A retrospective study including 1600 pediatric and adolescent patients who had undergone surgical therapy for a diagnosis of acute appendicitis over a period of ten years from Jan 2001 to Dec 2010. Demographic data were retrieved including the patient's age, sex, clinical data, clinical presentations, laboratory investigations, operative data and pathological findings to identify the presence and type of parasites. Patients were divided into two groups according to the presence or absence of parasites in the appendix lumen. In group I (n: 88), parasitic infestation was observed, whereas in group II (n: 1502), no parasitic infestation was present.

RESULTS

Parasites were present in 5.5% (88 patients), and of those 88 parasitic infestations, 45 (51.1%) were Enterobaisis, 8 (9.1%) were Schistosomiasis, 23 (26.1%) were Ascariasis, 7 (8%) Trichuriasis, and 5 (5.7%) were Teania Saginata. The percentage of patients with suppurative, gangrenous or perforated appendicitis was similar in both groups with no statistical significance, irrespective of the presence or absence of parasitic infestation.

CONCLUSION

The low prevalence of parasites among the appendectomy specimens did not support the notion that parasites were a major cause of appendicitis in pediatric patients.

Eosinophilic acute appendicitis caused by Strongyloides stercoralis and Enterobius vermicularis in an HIV-positive patient

A 29 year old female HIV-positive patient presented in emergency with acute right lower quadrant abdominal pain, fever, tenderness and positive Blumberg sign. Laboratorial tests revealed eosinophilia, anaemia and leukocytosis. She underwent exploratory laparotomy followed by appendectomy. The pathological analysis of the appendix revealed acute appendicitis, accentuated eosinophilia and infestation by Strongyloides stercoralis and Enterobius vermicularis. She did well after surgery and adequate treatment. To the authors' knowledge, this is the first case of eosinophilic acute appendicitis caused by these two parasitic worms reported in the medical literature.

Fatal case of ectopic enterobiasis: Enterobius vermicularis in the kidneys

Enterobius vermicularis is one of the most common intestinal parasites found in humans. They commonly infest the terminal ileum and large intestine, and are usually considered an innocuous parasite that can be easily eradicated with proper treatment. However, extraintestinal migration of worms, although very rare, may lead to severe health disorders or even death. This article, reports the first fatal case of ectopic enterobiasis known to the authors, which developed in an adult patient with E. vermicularis infection, causing perforation of the large intestine and generalized bacterial peritonitis. Despite emergency laparotomy, the patient died from septic shock on the day after surgery. During pathological examination, worms were found not only in the large intestine, but also in the renal parenchyma; worm eggs were found deposited in the lungs as well.

Persistent scrotal pain and suspected orchido-epididymitis of a young boy during pinworm (Enterobius vermicularis) infection in the bowel

AIM

Pinworm (Enterobius vermicularis) is the most common parasite among mankind. Ectopic pinworm infections in number of organs are broadly reported. The aim of this report is to review the pinworm infection in the scrotum on the basis of our case.

METHODS AND RESULTS

Our patient is a young boy with persistent pain in the scrotums together with abdominal symptoms. He underwent several urgent operations. Pinworm was finally found in appendix vermiformis. We hypothesize that concurrent unresponsive orchido-epididymitis was caused by pinworm as well. Eradication happened finally with pyvrinembonate.

CONCLUSION

Pinworm is a parasite that lives usually in the bowel. Many ectopic locations, like scrotum, are known. Orchido-epididymitis by pinworm has to be kept in mind when treating boys with persistent scrotal pain.

Infectious causes of appendicitis

The pathologic spectrum of the inflamed appendix encompasses a wide range of infectious entities, some with specific histologic findings, and others with nonspecific findings that may require an extensive diagnostic evaluation. The appendix is exclusively involved in some of these disorders, and in others may be involved through extension from other areas of the gastrointestinal tract. This review discusses the pathologic features of bacterial, viral, fungal, and parasitic infections affecting the appendix, including adenovirus; cytomegalovirus; Yersinia, Actinomyces, Mycobacterium, or Histoplasma species; Enterobius vermicularis; schistosomiasis; and Strongyloides stercoralis. Pertinent ancillary diagnostic techniques and the clinical context and significance of the various infections are also discussed.

Enterobius vermicularis infection with tuboovarian abscess and peritonitis occurring during pregnancy

BACKGROUND

Extraintestinal Enterobius vermicularis infections are rare but may occasionally affect the female genital tract. Although mostly asymptomatic or causing minor clinical problems, they may lead to severe infectious complications.

METHODS

Case report and review of the pertinent English language literature.

RESULTS

A 31-year-old, 30-week-pregnant female was admitted with a clinical suspicion of appendicitis. At surgery, the appendix appeared normal, but generalized peritonitis of unclear origin was present. Eggs of Enterobius vermicularis were found upon microbiological and pathological examination. Because of persisting infectious disease, the patient underwent an elective caesarean section, and at that time the diagnosis of a right tuboovarian abscess was made, and salpingo-oophorectomy was performed. The pathology report confirmed the diagnosis of an E. vermicularis salpingo-oophoritis.

CONCLUSION

This case was extraordinary because of a combination of tuboovarian abscess and generalized peritonitis with E. vermicularis infection occurring during late pregnancy. Ectopic enterobiasis should be considered in the differential diagnosis of pelvic infections of gynecological origin.

Enterobiasis in ectopic locations mimicking tumor-like lesions

Both the clinical and the histopathological diagnostic difficulties of oxyuriasis in unusual sites and their importance from a clinical point of view are pointed out. The authors report two ectoptic cases of enterobiasis observed in Northern Italy, one located in a fallopian tube of a 57-year-old woman and the other in a perianal subcutaneous tissue of a 59-year-old man, mimicking tumor-like lesions. The authors take advantage of the occasion to focus the attention of the medical world on this subject, lamenting the scarce importance given to this parasitosis in university courses of medical schools and in medical textbooks as it is incorrectly considered “out-of-fashion.”

[Enterobiasis of the female pelvi-genital tract: a report of three cases]

Ectopic localization of oxyuriasis is rare and frequently does not cause clinical problems. It has been reported in the vagina, endometrium, fallopian tube, peritoneal surface and ovary; In these localizations it often causes pseudo-tumoral granulomas. The aim of our study was to describe etiopathogenic and clinical criteria of this rare pathology. We report one case of endometrial enterobiasis which developed in a 28-year-old women and two cases of tubo-ovarian pseudotumoral abscesses containing the ova of enterobius which appeared as a latero-uterin mass in women aged 28 and 38 years. Enterobius vermicularis may cause tubo-ovarian abscess formation with necrotizing epitheloid granulomas mimicking tumors. Antihelminth therapies are successful.

Appendicitis and infections of the appendix

The pathologic spectrum of the acutely inflamed appendix encompasses a wide range of infectious and noninfectious entities. The appendix suffers alone in some of these disorders, and in others may be involved through extension from other areas of the gastrointestinal tract. Although the appendix is the most commonly resected and examined intraabdominal organ, the pathogenesis and etiology of acute nonspecific appendicitis (the most common diagnosis made in this organ) remains enigmatic. This review encompasses the pathology, pathogenesis, and bacteriology of acute appendicitis, as well as controversial issues such as the diagnosis of chronic appendicitis and the significance of a morphologically unremarkable appendectomy specimen in the clinical context of appendicitis. In addition, the pathologic features, pertinent diagnostic techniques, and clinical significance of several specific bacterial, viral, fungal, and parasitic infections affecting the appendix are presented, including adenovirus, cytomegalovirus, Yersinia species, actinomycosis, Mycobacteria species, histoplasmosis, pinworms, schistosomiasis, and Strongyloides stercoralis.

Clinical manifestations of appendiceal pinworms in children: an institutional experience and a review of the literature

The association of Enterobius vermicularis infestation with acute appendicitis varies from 0.2-41.8% worldwide. Our purpose was to determine the significance of Enterobius-associated appendicitis by retrospective review of appendectomies performed during a 5-year period at a major children's hospital. The Surgical Pathology database at Children's Hospital, Columbus, Ohio, was reviewed for appendiceal specimens found to have Enterobius infestation. Corresponding patient charts were evaluated for age, gender, presenting symptoms, laboratory data, operative findings, and clinical course. Of the 1,549 appendectomies performed from January 1998 through January 2003, 21 specimens (1.4%) were found to contain Enterobius vermicularis. Fifteen of the appendectomies were performed for symptoms of acute appendicitis; the remaining six were incidental appendectomies in conjunction with other operations. The mean age was 8.9 years. Ten patients were male; 11 were female. Of the 15 symptomatic children, nine presented with fever >99.0 degrees F, and 11 had a WBC count >10,000. Intra-operative appearance of the appendix ranged from normal to perforation. Pathologic evaluation showed neutrophil or eosinophil infiltration in 15 of the 21 specimens. Enterobius infestation is an uncommon cause of acute appendicitis in children in the United States. It may be associated with acute appendicitis, "chronic appendicitis," ruptured appendicitis, or with no significant clinical symptoms.

Pelvic pain caused by intraperitoneal Enterobius vermicularis (threadworm) ova with an associated systemic autoimmune reaction

AIM

The aim of this paper, based on a case study was two-fold; firstly to review the sites and gynecologic complications of ectopic Enterobius vermicularis and secondly study the autoimmune accompaniments of parasitic infestations.

METHODS

A case of intraperitoneal ectopic Enterobius vermicularis, with accompanying autoimmune signs and symptoms, is presented and its response to surgical and medical treatment described. A medical literature search was carried out into the subject of ectopic Enterobius vermicularis, particularly from the gynecologic perspective along with a study of autoimmune activation associated with parasitic infestation.

RESULTS

Pelvic pain was found to be caused by chronic inflammation from ectopic Enterobius vermicularis. This was treated both surgically and medically, with the surgical treatment proving to be inadequate but with a good response to immune modification. In the literature ectopic Enterobius vermicularis was found to be treatable surgically.

CONCLUSION

Ectopic Enterobius vermicularis was found to create symptomatic inflammatory lesions that could be treated surgically and an associated autoimmune response treatable by immune modification.

Perineal nodule due to enterobiasis: an aspiration cytologic diagnosis

Subcutaneous swelling due to Enterobious vermicularis infection is rare. Their presence in perineal subcutaneous tissue is unusual and a clinical curiosity. A case of subcutaneous nodule in the perineum due to E. vermicularis infection diagnosed on fine-needle aspiration is described. Tissue reaction was granulomatous with neutrophils and eosinophils. Lack of familiarity with the morphology of parasites or its eggs, degeneration, and inadequate sampling may make the diagnosis difficult. This case report provides the morphologic clues to cytopathologists toward rendering a diagnosis and alerts them to the possibility of parasitic infection in unusual locations.

Fatal infection with human pinworm, Enterobius vermicularis, in a captive chimpanzee

A fatal infection with human pinworms, Enterobius vermicularis, was found in a 26-year-old chimpanzee kept in a zoo. Grossly, the animal was highly emaciated, and had severe enteritis with cecal multifocal nodules and severe cholelithiasis. Histopathologically, a large number of human pinworms were observed in the nodular lesions in the cecum and intestinal wall. These migrating worms were surrounded by an inflammatory cell infiltration which lacked eosinophils. There were areas of multifocal hyperemia and/or hemorrhages in various organs including the entire gastrointestinal tract. Pinworms were also observed in the portal venule and parenchyma of the liver. A light infection with Strongyloides cf. stercoralis was also observed.

[Granulomatous nodule with Enterobius vermicularis in epiploon simulating metastasis of ovarian cancer]

The authors describe a case of peritoneal enterobiasis presenting as necrotizing granuloma, in a adolescent with tumor of the ovarian endodermic sinus. The diagnosis was established through biopsy of peritoneal nodule, during laparotomy for staging system of ovarian cancer. Granulomatous nodules due to parasites could simulate metastasis, and cause confusion in the staging system for cancer.

Chemotherapy of enterobiasis (oxyuriasis)

Enterobius vermicularis (syn. Oxyurus vermicularis), also known as pinworm or seatworm, is the causative agent of human enterobiasis (oxyuriasis). The disease is more prevalent in temperate regions and is facilitated by factors such as overcrowding in schools and family groupings, as well as inadequate personal and community hygiene. Although the infection is more likely to occur in lower socioeconomic groups, enterobiasis has been reported to affect virtually every level of the general population and especially children. In the great majority of cases, enterobiasis is asymptomatic. One common symptom is intense pruritus ani that in some patients can lead to insomnia, restlessness and irritability. Scratching may cause skin irritation, and in more serious cases, eczematous dermatitis, haemorrhage or secondary bacterial infections. Ectopic migration of E. vermicularis often results in pinworm infestation of the female genital tract often causing granulomas of the uterus, ovary and the fallopian tubes and pelvic peritoneum. Anthelmintic therapies for enterobiasis are successful and include mebendazole, albendazole and pyrantel pamoate. Mass medication of affected groups reduced symptoms rapidly, progressively and in a cost-effective way.