Parasitosis is a public health problem in endemic countries with temperate climates. A variety in geography is noted[5
]. While often considered tropical, parasitic diseases are now seen more frequently in developed countries because of immigration and increased world travel. Intraluminal parasites within the resected appendix specimen is generally an incidental finding. The role of parasites in acute appendicitis is discussed [3
]. They mostly accompany a noninflamed appendix. In retrospective studies they constitute only a minor percentage of false acute appendicitis.
Gastrointestinal infection due to Enterobius vermicularis occurs worldwide and is considered to be the most common helminth infection. Although seen in all ages and socioeconomic levels, there is a distinct predilection for children and youngsters. Pinworms are usually asymptomatic inhabitants of the intestine. In children who exhibit intense pruritus in the perianal region, which may be associated with symptoms like loss of appetite, insomnia and restlessness, pinworm infection should be suspected. Diagnosis may be achieved by direct visualization of the adult worms or microscopic detection of eggs in a fecal flotation, but only a minority of patients have eggs in their stool. A night-time application of cellophane tape in the perianal area can serve as an easy way to manage the diagnosis. The parasite wanders widely inside the bowel including the appendix. Worldwide, the reported incidence of Enterobius infestation in patients with symptoms of appendicitis ranges from 0.2–41.8%[9
]. The association of Enterobius infestation and appendicitis was first described in 1899[10
]. Since then, there have been several studies describing this entity [9
The simple presence of E. vermicularis in the appendix can produce symptoms of acute appendicitis[9
]. E. vermicularis infestation of the appendix can produce clinical features of acute appendicitis, referred to as 'appendiceal colic', independent of histological acute inflammation. Instead, either no tissue reaction or a chronic inflammatory infiltrate of eosinophils is associated.
Taeniasis is a well-known worm infection, characterized by the presence of the helminth in the human intestine. Infection occurs frequently in individuals who eat undercooked beef or pork. Most cases of infection do not cause any symptoms, while others may produce abdominal pain, weight loss, digestive disturbances. Infection is generally recognized when the segments of the parasite appear in the stool or exit through the anus. The occurrence of Taenia spp. in the cecal appendix is so rare that the situation invites case reports[13
Parasites can definitely be associated with the evolution of classic appendicitis. In series, there exists a range of pathologic findings from nonspecific changes to frankly ruptured appendicitis[9
]. Observations show that their presence may indicate an luminal obstruction. Ova release from female parasites may be a feature of appendiceal obstruction, which consequently is followed by bacterial overgrowth and finally ending to acute appendicitis. The reversibility of the process may be questioned. One of the patints in our study, had a clinical history of a privious appendiceal pain, but no surgery was performed as he got well in observation.
An appendiceal colic caused by parasitic infestation can not be differenciated from the right lower quadrant pain of usual acute appendicitis. Clinical and laboratory findings of an infection are generally observed as the intestinal system is already involved by the parasites. In some cases a careful history may point to antecedent symptoms and a time course that are incompatible with typical appendicitis, but physical examination is generally not specific enough to differentiate between parasitic and ordinary appendiceal pain. Blood work for eosinophilia and a rapid examination of the stools by an experienced technician may serve some help. When suspected, these patients may benefit from clinical observation and re-evaluation before proceeding directly to emergency appendectomy. If such patients are not improving after a period of observation, further diagnostic studies are recommended. Radiologic procedures are strongly experience dependent, and these cases may easily be missed as seen in our study. The surgeon, handling a patient with a right lower quadrant pain, and a radiology suspecting an acute appenciditis, may face a noninflamed appendix in operation. The appendix hosting the parasites without an acute inflamation will put the surgeon in trouble, as excision of every appendix is questioned after the more common use of laparoscopy. Surgery should be planned with attension especially in children and youth age groups, travelars, and immigrants.
Appendectomy, open or laparoscopic, should proceed with caution if the appendix is observed not to be acutely inflamed. The surgeon must bare in mind the possibility of resident worms in the vermiform appendix. The application of laparoscopic appendectomy technique in patients with parasitic infestation requires some technical considerations[14
]. It may be troublesome to deal with worms released after the appendix has been divided, especially if the surgeon is not prepared for it.
It is imperative that patients receive antihelminthic treatment afterwords, because the appendectomy treats only a consequence but not the root of the disease. E. vermicularis infestation is treated with an oral dose of mebendazole, which is repeated in 1–2 weeks. Reinfection may be expected, because humans do not develop a protective immunity against pinworms. In cases of Taeniasis, spesific species identification is not required for treatment and patients are treated with a single dose of praziquantel.