Download A”pin”dicitis

A”pin”dicitis: A Case of Adult
Appendicitis in the Setting of
Enterobius vermicularis.
LT Isaac Ilaoa DO (Associate)
LCDR Catherine Berjohn MD, MPH (Associate)
LCDR Nehkonti Adams MD (Associate)
CAPT Mary Bavaro MD (Fellow)
Department of Internal Medicine and Infectious Diseases
Naval Medical Center, San Diego, CA
Case
• 24 year old female presented with 36 hours of abdominal pain.
• Described pain as:
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–
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Sharp/stabbing
Initially mid abdomen, but migrated to right lower quadrant
Unrelieved by Ibuprofen
Exacerbated by movement
• Associated symptoms:
– Nausea, with non-bloody emesis
– Non-bloody diarrhea
– Fever to 100.9 F
• Review of systems: otherwise negative
PMH
• Past medical history surgical history
– Depression
– Generalized Anxiety
• Past surgical history
– Dilation and Curettage
– Laparoscopy for left ovarian cyst (age 13)
• Social history
– Married, with 3 children
– Denied Tobacco, Alcohol, or Illicit drug use
Physical Exam
• Vital signs:
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•
Temperature: 97.5 degrees Fahrenheit
Blood pressure: 99/52 mmHg (consistent with baseline)
Heart Rate: 89 beats per minute
Respiratory rate: 18 respirations per minute
Oxygen saturation: 98% on room air
Physical:
– Abdomen:
• Soft, with bowel sounds present
• Localized tenderness to right lower quadrant
• Positive rebound tenderness
• Positive guarding
Labs/Rads
• Complete blood cell count
– Absolute Eosinophil count of 770 per microliter
• (normal less than 500)
– White blood cells: 9,400 per microliter
• Normal metabolic panel
• Urinalysis: within normal limits
• Computerized Tomography of the abdomen and pelvis:
– “borderline dilated appendix with surrounding inflammatory
changes. An acute appendix is not excluded”.
Enterobius vermicularis:
“The Pinworm”
• Epidemiology:
– Humans only known host
– Predominance in…
• Children (ages 5-9 years)
• Closed-crowded living spaces
– One of the most common human parasites
• Prevalence estimated to be approximately 40 million in
the United States
Enterobius vermicularis
Clinical Manifestations
• Most common symptom is perianal itching
– Aka pruritus ani
• Up to 1/3 can be asymptomatic
• Other reported associations
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Appendicitis
Mesenteric Abscess
Enterocolitis
Vulvovaginitis
Salpingitis, oophoritis
Diagnosis
Discussion
• The role of E. vermicularis in appendicitis?
– E. vermicularis detected in 0.6 – 13 % of resected
appendices.
- Appendicitis versus “Appendiceal Colic”
E.
vermicularis
Inflammation
No
Inflammation
Present
23
40
Absent
1,085
719
Total
1,108
759
Adapted from: Table 1. Histological features of appendices
E.
vermicularis
Inflammation
No
Inflammation
Present
76
68
Absent
3,309
1,595
Total
3,385
1,663
Adapted from: Table 2. Pathology distribution of E. vermicularis
Conclusion
• Despite the high prevalence of E. vermicularis
this case highlights an interesting and
uncommon presentation of this infection.
• Although there is a known relationship
between pinworm infections and appendicitis,
appendiceal colic was the most likely etiology
in this case.
References
• Akbulut S, et al; Unusual histopathological findings in appendectomy
specimens: A retrospective analysis and literature review. World J
Gastroenterol 2011 Apr21;17(15):1961-70.
• Arca MJ, et al; Clinical manifestations of appendiceal pinworms in children:
an institutional experience and a review of the literature. Pediatr Surg Int
2004 May; 20(5):372-5
• Centers for Disease Control and Prevention. Enterobiasis (Enteroblus
vermicularis) www.dpd.cdc.gov/DPDx/HTML/Enterobiasis.htm (Accessed
on Sep 25, 2014). no abstract available
• Dahlstrom J.E., et al; Enterobius vermicularis: A possible cause of
symptoms resembling appendicitis. Aust. N.Z. J. Surg. (1994) 64, 692-694,
1994 May 24
• Invisible Tape. Officeworks. 2008-2014.
[http://officeworks.com.au/shop/officeworks/office-supplies/tape-anddispensers/invisible-tape]
• Isik B, et al; Appendiceal Enterobius vermicularis
infestation in adults. Int Surg 2007 Jul-Aug; 92(4):221-5
• Lamps LW. Infectious causes of Appendicitis. Infect Dis
Clin N Am 24 (2010) 995-1018.
doi:10.1016/j.idc.2010.07.012
• Life cycle of Enterobius vermicularis. Centers for
Disease Control and Prevention. 2013 Jan 10.
[http://www.dpd.cdc.gov/dpdx]
• Ramezan M, et al; Relationship between Enterobius
vermicularis and the incidence of acute appendicitis.
Dept of Community and Preventive Medicine, ISMSU
Isfahan, Iran. Vol 38 No.1 January 2007
Thank You
• Any Questions?