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Int J Surg Case RepInt J Surg Case RepInternational Journal of Surgery Case Reports2210-2612Elsevier S2210-2612(19)30524-310.1016/j.ijscr.2019.09.025ArticleEnterobius vermicularis causing acute appendicitis, a case report with literature review Hammood Zuhair D. aSalih Abdulwahid M. bMohammed Shvan H. cdKakamad Fahmi H. jeremygutierrez@example.org⁎salih Karzan M. aOmar Diyar A. cfHassan Marwan N. cSidiq Shadi H. cMustafa Mohammed Q. cgHabibullah Imad J. aUsf Drood C. cAl obaidi Anmar E. ca Sulaimani Teaching Hospital, Sulaimani, Kurdistan, Iraqb Faculty of Medical Sciences, School of Medicine, Department Surgery, University of Sulaimani, Sulaimani, Kurdistan, Iraqc Kscien Organization, Hamdi Str., Azadi Mall, Sulaimani, Kurdistan, Iraqd Chara Laboratory, Shahedan Street, Kalar, Kurdistan, Iraqe Faculty of Medical Sciences, School of Medicine, Department Cardiothoracic and Vascular Surgery, University of Sulaimani, Sulaimani, Kurdistan, Iraqf Erbil Polytechnic University, Shaqlawa Technical Institute, Erbil, Kurdistan, Iraqg Medical Analysis Department, Science Faculty, Ishik university, Erbil, Kurdistan, Iraq⁎ Corresponding author at: Doctor City, Building 11, Apartment 50, Zip code: 0064, Sulaimani, Iraq. jeremygutierrez@example.org 9 2019 2019 25 9 2019 63 153 156 11 9 2019 17 9 2019 © 2019 The Author(s)2019This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).Highlights
• 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.

Keywords
AcuteAbdomenTendernessInfestationParasite
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1 Introduction
Acute appendicitis (AA) represents one of the commonest causes for emergency operations worldwide with a cumulative lifetime incidence rate of 9.0%, accounting to a significant portion of intraabdominal conditions. During the 20th century, the disease was mostly reported within the western countries, however a rise in its incidence has been noted within newly industrialized countries in 21st century [1]. In the United States only, annually more than 70,000 children are diagnosed with appendicitis during hospital admission [2]. Over the age of 40 years, appendicitis may have more morbid causes, like caecal cancer among other colorectal pathology, though neoplasm is uncommon but should not be ignored in this age group [3]. Parasitic infestation represents one of the controversial etiologies for acute appendicitis and their relation has been in debate [4]. However Enterobius vermicularis remains one of the commonest parasitic infestation worldwide, with an estimate of 209 million affected people and often it is referred to as threadworm or pinworm [5]. Although perianal pruritus is the most common manifestation of Enterobius vermicularis (pinworms), pinworms have been reported to be found in different multiple locations, including the vermiform appendix. Regarding appendiceal helminthes, recent literature concentrate mainly on the pathological changes that caused by the presence of intraluminal parasites [6]. In this paper we present an adult patient with acute appendicitis caused by Enterobius vermicularis and go over the literature briefly. The case has been reported in line with SCARE guideline [7].

1.1 Patient information
A 23-year-old housewife patient presented to Emergency Department with a right lower abdominal pain for the past 8 h with concomitant anorexia, nausea and vomiting twice. Other than having a mild fever, the patient had normal vital signs.

1.2 Clinical findings
Clinical examination revealed right iliac fossa (RIF) tenderness upon palpation and rebound tenderness upon release. Other signs like Rovsing and pointing signs were positive as well.

1.3 Diagnostic assessment
Complete blood count revealed mild leukocytosis (12,000 m/mm3) while other routine investigations like urinalysis, blood urea and serum creatinine were not remarkable. Abdominal and pelvic ultrasound reported no unusual findings and pregnancy was excluded through blood test. The patient was diagnosed as a case of suspected acute appendicitis (S.A.A.).

1.4 Therapeutic intervention
The condition was explained to the patient and informed consent was taken for surgery. During hospital stay she received 1 unit of normal saline (500 cc) and then was taken into the operation theatre. Pre-operative prophylactic antibiotic given (single dose of Ceftriaxone vial 1 g). The patient was anesthetized with General Anesthesia (GA) and intubated. Delivery of the vermiform appendix done through right grid iron incision. Intra operatively an inflamed appendix obstructed by Enterobius vermicularis was noted (Fig. 1, Fig. 2). An eventful classical appendicectomy done. Terminal ileum and right ovary checked and both were normal.Fig. 1 Intraoperative picture showing Enterobius vermicularis through the wall of the appendix.

Fig. 1Fig. 2 Appendix after resection with the word seen inside the lumen.

Fig. 2

1.5 Follow-up and outcomes
The patient recovered without any complications and was transferred to the surgical ward for observation. Within 8 h, she passed flatus and started oral feeding. After 24 h, she was sent home in a good heath condition and scheduled to visit after 8 days, where she was healthy and the would stiches removed.

2 Discussion
Enterobius vermicularis is known by many names (seatworm, pinworm, oxyuriasis, threadworm) and first description of human infestation nearly dates back 10,000 years. However, it was Fabrius in 1634 who first described involvement of the worm in appendicitis. Once E. vermicularis reaches maturity, it stays and reproduces in terminal ileum, caecum, appendix and ascending colon. The lifecycle of the male worm ends after fertilization and dies, while the female must migrate to the anal canal to lay eggs [8]. The lifespan of Enterobius vermicularis (pinworm) is between 2 and 5 weeks(panidis). Despite that the relationship between E. vermicularis and pathogenesis of appendicitis had been studied for many years, the influence of the parasite to induce inflammation is still unclear. Although E. vermicularis(pinworm) may have a role in causing appendiceal disconfort or appendiceal chronic inflammation due to obstruction, the majority of cases have no acute inflammation [8]. The belief that Enterobius infestation can cause diseases like acute appendicitis, chronic appendicitis and ruptured appendicitis is shared by others [6], and even more morbid complications like gangrenous appendicitis and perforation resulting in peritonitis [9]. None the less, there have been reports of completely asymptomatic patients [6]. The "appendiceal syndrome" represents clinical symptoms without acute inflammation and is also referred to as appendiceal colic, where the patient has an intermittent chronic pain in right lower quadrant and pelvic region, and appendiceal obstruction presents a reasonable hypothesis for the condition [9]. Once the worm is detected in theatre, the patient should be treated for systemic infestation in case there are subclinical infestation elsewhere. The diagnosis of AA is mostly clinical and proper history, physical examination and a raised inflammatory parameter help with the diagnosis [10]. To this day, the gold standard treatment for AA is appendectomy, and interval appendectomy nowadays is not uncommon [11]. Non-Operative Management (NOM) of AA has been proposed by several randomized controlled trails 2–8 and meta-analyses 7,9–15 and see it as viable option along with the century standing practice of surgical resection [12]. Appendectomy in these patients are merely a treatment for a complication, but the root cause is still there. Pyrantel pamoate is the drug of choice for Enterobius vermicularis treatment. It is an agent that blocks neuromuscular depolarization making the worm undergo spastic paralysis through continuous nicotinic activation, ultimately the worm detaches from the host and consequently will be expelled through defecation [13]. Table 1 reviews the most important reports regarding acute appendicitis and Enterobius vermicularis.Table 1 The most prominent reports describing acute appendicitis with Enterobius vermicularis.

Table 1Authors/references	No. of cases positive for E. V/year of publication	Country of report	Gender distribution/ mean age	Inflamed appendix	
Akkapulu [14]	9/2015	Turkey	7 females, 2 males/ 31	One case	
Balci [15]	1/2018	Turkey	Female/ 35 years	One case	
Budd [16]	38/1987	UK	Not found	14 cases	
Chilkar [17]	1/2016	India	Male/ 8 years	Suppuration	
Cruz [18]	1/2012	Brazil	Female/29 years	One case	
Dahlstroam [19]	63/1994	Australia	--/22.8 years	23 cases	
Dunphy [20]	1/2017	UK	Female/10 years	None	
Efared [21]	1/2017	Morocco	Male/ 21 years	One case	
Efraimidou [22]	1/2008	Greece	Female/ 15 years	None	
Eleftherios [8]	7/2012	Greece	4 females, 3 males/25 years	None	
Fleming [23]	13/2015	Ireland	--/11.4 years	4 cases	
Habashi [24]	1/2019	Canada	Male/ 9 years	One case	
Hamdona [25]	30/2013	Palestine	17 male/ 13 female/---	23 cases	
Harris [26]	22/1925	USA	19 females 3 males/ 23 years	---	
Lala [27]	109/2014	New Zealand	--/11.6 years	27 cases	
Vleeschouwers [28]	1/2013	Belgium	Female/ 17 years	None	
Madhukar [9]	1/2014	India	Female/ 18 years	one	
Maki [29]	16/2012	USA	--/9.5 years	Two cases	
Panidis [5]	1/2011	Greece	Female/52 years	None	
Ramezani [30]	144/	Iran	82 female, 62 male/20.4 years	76 cases	
Risio [31]	1/2016	Iran	Female/23	One case	
Sah [32]	9/ 2006	Nepal	--/15 years	3 cases	
Upadhyaya [33]	6/ 2015	Nepal	---/--	None	


In composite, 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.

Sources of funding
No source to be stated.

Ethical approval
Approval has been taken from Kscien centre.

Consent
Consent has been taken from the patient and the family of the patient.

Author contribution
Zuhair D. Hammood and Abdulwahid M. Salih: Surgeon performed the operation and follow up.

Shvan H. Mohammed, Fahmi H. Kakamad, and Karzan M. salih: Writing the manuscript and follow up.

Diyar A. Omar, Marwan N. Hassan, Shadi H. Sidiq, Mohammed Q. Mustafa, Imad J. Habibullah, and Drood C. Usf: literature review, final approval of the manuscript.

Registration of research studies
Not applicable

Guarantor
Fahmi Hussein kakamad.

Provenance and peer review
Not commissioned, externally peer-reviewed.

Declaration of Competing Interest
There is no conflict to be declared.
==== Refs
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