An 'appendiceal colic' caused by the Enterobius vermicularis.

To cite: Kaczynski J, Hilton J. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013202962 DESCRIPTION A 35-year-old woman presented with a 96-h history of constant right iliac fossa (RIF) pain on movement and coughing. The pain was associated with vomiting and anorexia, but there was no associated change in bowel habit, weight loss or dysuria. At presentation, she was menstruating and her medical history included asthma, but no previous abdominal pain or surgery. The patient was a smoker, but did not consume alcohol and had no family history of note. On admission, the patient had a temperature of 37.4°C but otherwise normal observations, and examination of the cardiovascular and respiratory system was normal. On palpation, the abdomen was soft with percussion tenderness in the RIF, but digital rectal examination was normal. Laboratory tests showed elevated white cell count of 14×10/L and C reactive protein of 223 mg/L. Her liver function tests, amylase and electrolytes were normal. Dip stick urine testing revealed a trace of blood, protein and white cell count but no nitrates, and urine β-human chorionic gonadotropin (β-HCG) was negative. A provisional diagnosis of an acute appendicitis was made, but due to the prolonged duration of presentation a pelvic ultrasound scan (US) was performed to exclude gynaecological pathology prior to surgery. US demonstrated normal ovaries, a retroverted uterus and no free fluid was seen. Therefore, the decision was made to perform a diagnostic laparoscopy. A general anaesthetic laparoscopy using a threeport technique was performed and the gallbladder, small bowel and colon were normal. In addition, there was no free abdominal fluid and the uterus and ovaries had normal appearance. The appendix was macroscopically normal. However, in view of the above history and raised inflammatory markers the decision to perform an appendicectomy was made. Two braided Vicryl suture endoloops (polyglactin 910, Ethicon Endoloop Ligature) were applied proximally to the base of the appendix and one endoloop distally. The appendix was divided between the proximal and distal endoloops and a live pinworm (Enterobius vermicularis) was visible (figure 1), which was immediately removed. The appendix was removed in a specimen bag, and further careful inspection revealed no other worms (figure 2). Histology revealed no inflammation or infestation in the appendix. The patient and family received a single dose of mebendazole 100 mg. The patient has made an uncomplicated recovery. Acute appendicitis is the most common abdominal pathology requiring an emergency operation. 2 It may present in any age group, but the peak incidence is in the early adolescents, in boys aged 10–14 years (27.6/10 000 population per year) and in girls aged 15–19 years (20.5/10 000 population per year). The reported individual lifetime risk of appendicectomy is 8.6% for men and 6.7% for women, respectively. Although numerous parasites have been implicated in the appendiceal infection, E vermicularis remains the most common parasite worldwide. This is of a particular importance to surgeons as free intraperitoneal contamination may have serious consequences including omentitis, pelvic peritoneal granuloma, salpingitis, chronic pelvic pain and pelvic inflammatory disease. 4 In addition, if untreated colitis and perianal abscess have been described. The histopathological appearances associated with the E vermicularis infestation may vary from lymphoid hyperplasia, chronic inflammatory infiltrate of eosinophils, acute phlegmonous appendicitis and even gangrenous appendicitis with Figure 1 Intraoperative view demonstrating Enterobius vermicularis at the base of the appendix stump.