appendicitis and enterobiasis in children · appendicitis and enterobiasis in children a...

APPENDICITIS AND ENTEROBIASIS IN CHILDREN

A HISTOLOGICAL STUDY OF 691 APPENDICES

BY

F. DURAN-JORDA*From the Department of Pathology, Booth Hall Children's Hospital, Manchester

(RECEIVED FOR PUBLICATION DECEMBER 17, 1956)

When the mucous membranes of the gastro-intestinal organs are fixed by a formol-vapourmethod the surface of these structures appears tobe covered by a 'cellular layer' (considered byorthodox histologists to be formed by a debris ofcells, mucus and food remnants). This upperstructure can be followed from the corneal layer ofthe stratified tissue of the oesophageal cardia to itsending in the similar layer of the anal skin. It doesnot stain by any of the mucin stains, it leaves ashafter micro-incineration, it contains a large sequenceof nuclei and in some places gives the impressionthat it contains capillaries (Duran-Jorda, 1946). Itwas to study its morphological changes inappendicitis that a systematic study was made ofappendices removed in this hospital during aperiod of 21 months, in all a total of 691 appendi-cular organs.

During this histological study Enterobius vermicu-laris was so frequently found in the sections that itwas decided to pay it special attention with thepurpose of establishing the role, if any, of theparasite in the aetiology of appendicitis.

MethodThe appendix, after removal, was carefully opened and

pinned on to the corked lid of a small jar containingundiluted formalin to a depth of 2 cm., and in order toavoid splashing the specimen during transportation to thelaboratory, filter paper of the diameter of the jar was leftfloating in the formalin. After the specimen had beenexposed to the fixative for three or four days the jar wasopened and the appendix, still attached to the lid, wasleft for two to three hours in contact with the atmospherefor the surface to dry. It was then cut lengthways,trimmed and immersed in formol-saline. The usualtechnique of paraffin embedding was then followed,sectioning at 5St and staining with haematoxylin andeosin.

* Dr. Duran-Jorda died on March 30, 1957.

Microscopic Findings

When the appendicular lumen containing alarge number of parasites is studied under thedissecting microscope (Fig. 1) it can be seen thatmost of the Enterobius vermicularis appear coveredwith some material, but others, especially the youngforms, can be seen buried in the organ itself.Microscopically, the appendices fixed by formol-vapour show a layer of cells of varying thickness,forming the uppermost layer of the mucous mem-brane, monocellular in normal areas and multi-cellular in acute appendicitis. It is within this layerthat Enterobius vermicularis is generally found, eithersingly or with other worms forming groups of threeor four side by side (Fig. 2), or resting not only onthe mucous membrane (Fig. 3) but also on somedisplaced glands.For the most part Enterobius vermicularis found

buried is in an early stage of development; it is moredifficult to find in the sections an adult worm com-pletely covered by the upper layer because thecontinuity of the semisquamous epithelial layer isgenerally broken during the worm's pre-mortemcontractions.

Enterobius vermicularis is able to establish itselfin the whole of the appendicular organ; it canoccupy the space of the mucous membrane (Fig. 4);burrow underneath it (Fig. 5); parasitize the middleof a lymphoid follicle (Fig. 6); or it can invade theperitoneal appendicular layer forming a cyst(Fig. 7). In one of our cases the Enterobius wasaccompanied by the remnant of the carapace of acrustacean (Cyclops, fam. Copepoda) often found inthe drinking water of this city (Fig. 8). We werequite sure that this finding was a genuine one becausethe cructacean remnants were surrounded bydiapedesic cells from the organ.The different tissues of the appendix showed no

undue cellular reaction towards the Enterobius, as if208

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F i. 1.

FIG. 1.-Fresh appendix showing lumen with extensive parasitosis.X 17.

FIG. 2.-Appendix fixed by formol-vapour showing three Enterobius.Haematoxylin and eosin. x 150.

FIG. 3.-Appendix fixed by formol-vapour showing larger magnifica-tion of a field with two layers of Enterobius, some in contact withdisplaced glands. Notice the cellular structure of the covering layer.

Haematoxylin and eosin. x 200.

F i;. 3.

Iw -4. 2.

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FiC;. 4.

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FIG. 4.-Appendix fixed by formol-vapour. Enterobius vermicularisburied in the area topographically belonging to the mucous

membrane.FIG. 5.-Appendix fixed by formol-vapour. Enterobius vermicularisburied under the mucous membrane. Notice the keratinous edgesand channel built by the appendicular cells. Haematoxylin and

eosin. x 200.FIG. 6.-Appendix fixed by formol-vapour. Enterobius buried in themiddle of a lymphatic nodule. Notice the continuity of the semi-

squamous epithelial layer. Haematoxylin and eosin. x 80.FIG. 7.-Appendix fixed by formol vapour. Cyst in the peritonealappendicular layer with an Enterobius vermicularis. Haematoxylin

and eosin. X116. FIG. 7.



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the organ and the parasite had been able to establisha perfect symbiotic relationship.A careful study of Enterobius vermicularis shows in

its head a double fin-like formation called alae(Fig. 9) from which two very well developedkeratinous structures run parallel to the sides of itsbody. These keratinous structures are serrated(Fig. 10) and when the worm is cut transversallyshow two very sharp edges similar to a double-edged dagger. The strength of these keratinousstructures is demonstrated by the canal built aroundthem by the appendicular cells that house them(Fig. 5). When a fully developed Enterobius vermi-cularis filled with ova is seen buried in the superficiallayer it produces an imprint of its irregularities onthe top surface of the mucous membrane whichshows a perfect replica of the shape of the edge ofthe worm (Fig. 11). The Enterobius also appears tomoult (Fig. 12), leaving behind an extra keratinouscover before beginning its long journey to the anus.Thus it appears that the appendix suffers mechan-

ical damage on two occasions: when the larva leavesthe ovum and burrows into the appendicular semi-squamous epithelial layer in search of a place todevelop to adult stage in comfort, and again whenthe individual parasite has reached full maturation,freeing itself and emigrating, full of ova, to the anus.It seems that during these two migratory stages theorgan is in great danger of infection from theintestinal flora in its lumen.

Frequency of Infestation in ChildrenThe assessment of parasitosis in the appendices

was studied on a histological basis and, therefore,our figures are smaller than those of other authorswho have studied the presence of ova or parasitesin the appendicular lumen by scraping its surface(Schenken and Moss, 1942).Of the 691 appendices (400 in boys, 291 in girls),

52 showed positive findings (7 5%); in the 400appendices of the boys, 19 (4 7 %) were positive andin the 291 appendices of the girls 33 (11-3%) werepositive. These figures demonstrate that appendicitisoccurred more frequently in boys than in girls(1 -3 to 1), but that enterobiasis was found to havea more than double frequency in girls than in boys(l I OO% to 4 7% respectively).

It was after these results that we decided to carryout a survey of the frequency of infestation in

FIG. 8.-Appendix fixed by formol-vapour. Serial section of theappendix from Fig. 7 showing remnants of the skeleton (carapace)of a crustacean (Cyclops, fam. Copepoda) often found in drinking

water. Haematoxylin and eosin. x 150.FIG. 9.-A female Enterobius vermicularis in fresh preparation showing

its alae and keratinous body sides. X 100.

FIG. 8.

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ARCHIVES OF DISEASE IN CHILDHOOD

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FIG. 10.-A female Enterobius vermicularis in fresh preparationshowing the serrated aspect of the edge of its body. x 230.

FIG. 11.-Appendix fixed by formol-vapour. Detail of the lowerpart of an Enterobius vermicularis showing the imprint of its edge inthe large cellular structure surrounding it. Haematoxvlin and

eosin. x 200.

FIG. 12 -Appendix fixed by formol-vapour. Detail of the upper part of the Enterobius vermicularis of Fig. 11 showing the moultingof an extra keratinous cover. Notice the cellular aspect of the semi-squamous epithelial layer. Haematoxylin and eosin. X 300.

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APPENDICITIS AND ENTEROBIASIS IN CHILDRENCases ENTEROBIASIS IN (

213CHILDREN

31%

B

5 - 11

300 Cases164 Boys. 40 pos. - 24%136 Girls. 41 pos. - 30%

* infestation

30%

11 - 16

SUMMARY OF 300 CASES

81 pos. = 27%

FIG. 13.-Scotch tape illuminated by a mercury vapour source of lightshowing the primary fluorescence of an ovum of Enterobius vermi-

cularis. Wood's filter. X 200.

children. Two hundred patients already in the wardswere examined by the Scotch tape method (Hall,1937) and later a further 100 cases were examined.Each slide was investigated using a projectingmicroscope against a screen of 8 in. diameter whichgave us the opportunity of studying the whole ofthe tape adhered to the glass slide without unduefatigue. With a mercury vapour lamp as the sourceof illumination we found that the ova of Enterobiusvermicularis showed a primary fluorescence whichwas confirmed by filtering the light with a Wood'sfilter, a phenomenon which eased the detection ofthe ova (Fig. 13). Studying the source of fluores-cence in the ova by spectroscopy, it appears that itcontains a chromatogen with a maximum of lightabsorption in the region of the violet band.The results of the 300 examinations were as

follows: boys 164, parasitized 40 (24%); girls 136,parasitized 41 (30%) (Fig. 14). In order to obtaina better understanding of the frequency of infestationin children, we divided them into three age groups:from 0 to 5 years, from 5 to 11 years and from11 to 16 years, and these results are also shown inFig. 14. It can be seen that during the critical schoolyears from 5 to 11 the girls showed an increased

Cases

250

225

200

175

150

125

100

75

50

25

0 .

Cases450

400

350

300

250

200

150

100

so

0

FIG. 14.

ENTEROBIASIS IN APPENDICITIS

0% 0%

f

6%

B

G1

16%

400 Boys, 19 pos. = 5%291 Girls. 33 pos. = 11%

infestation

4%

B

0 - 5 S 11

SUMMARY OF 691 CASES

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n10-5

.I I _55-1 1

Age Groups

FIG. 15.

G

11 - 16

52 pos. = 7

11-16

100

90

80

70

60

50

40 B G

30

20

to

00 - 5

Cases200

175

150

125

100

75

I I I I I



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ARCHIVES OF DISEASE IN CHILDHOOD

percentage of 45% as against 31 % in the boys,thereby pointing to the danger held by the lavatoryseat for the girls in the primary school. The totalincidence of Enterobiasis in the 300 cases was27%.

If the appendicectomized children are nowdivided into school age groups a more realistic viewcan be obtained (Fig. 15). No parasitosis of theappendix was found in boys and girls under 5, butin the 5-11-years group we found 237 boys with14 positives (5-9%) and 170 girls with 27 positives(15-9%). These results correspond with the higherrate of infestation in girls, although the incidence ofappendicitis is greater in boys.

PathologyThe full length of the appendices was examined

microscopically, the pathology being studied accord-ing to any abnormal change, irrespective of extensionof area. Our classifications were as follows:

Normal Appendix. The semisquamous epitheliallayer would be seen formed only by 'one cell' thick-ness. Normal glandular morphology and nohyperaemia or cellular infiltration in any layer of theorgan.

Early Appendicitis. In this condition there wasseen a multicellular thickness epithelial layer withdiapedesic cells and red blood corpuscles. Themucous membrane and other layers would some-times show patches of interglandular hyperaemia orsmall haemorrhagic areas also.

Acute Appendicitis. A large cellular infiltrationof the semisquamous epithelial layer was seen withgranulocytes and red blood corpuscles, some areasof clotted plasma, congested or haemorrhagicmucous membrane infiltrated by granulocytes, withthe other layers of the organ showing the sameinfiltration.

Appendicular Abscess. No semisquamous epi-thelial layer was present but the mucous membranewas destroyed with substitution by a large accumula-tion of granulocytes occupying part of the appendi-cular lumen, all other layers of the organ being verycongested and infiltrated by granulocytes.

Chronic Appendicitis. The covering layer wasmonocellular or non-existent with patches of clottedplasma forming small ulcers in the areas where themucous membrane had disappeared; atrophiedmucous membrane formed by one layer of glandularcells; large areas of lymphocytes.

Using the above classifications no normal

Cases20

18

16

14

12

10

8

6

4

2

0

ENTEROBIASIS IN APPENDICITIS - 52 CasesHISTOLOGICAL CLASSIFICATION

G

B

B G

N L |

0 - 5 5 - IIAge Groups

FIG. 16.

early acute abcess

I 0

B G B G B G B G

n *inna11 - 16

appendices were found in the 52 cases with entero-biasis; 14 were classified as early appendicitis; 30 asacute appendicitis and eight as showing appendicularabscesses. The division of these results into agegroups and sexes is shown in Fig. 16.

DiscussionThe problem of enterobiasis and its relationship

to appendicitis is a very old one (Garrod and Fair-bank, 1907). Some authors, finding the Enterobiusburrowed in the structures of the appendix, believedthat the parasite moved into them as a result of apost-operative phenomenon (Gordon, 1933), but noconsideration was given to the need of having an'untouched' appendix fixed with a technique thatshows the whole structure of the organ, togetherwith the material deposited or already existent in itslumen. Only then could it be realized that theinvasion of the organ was a genuine one and notthe result of faulty histological technique.We believe that Enterobius vermicularis seeks

cover and protection against the digestive juices andperistalsis in the appendicular structures and usesits alae to plough a burrow. Our view is supportedby the fact that other Enterobius infesting somemammals, especially the one found in the hare(Oxyuris ambigua), take shelter in the intestinal wall(Penso, 1932). Other helminths which parasitize thegastro-intestinal mucosae of herbivora (cow, sheep,horse) also penetrate them. Therefore, the mechan-ism of human parasitosis described explains thedanger to which the appendix is subjected duringthe double migratory life of Enterobius vermiculariswhich breaks the defences of the mucous membranesand twice opens them to infection, and it is possiblethat these migratory phases are manifested by

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APPENDICITIS AND ENTEROBIASIS IN CHILDREN 215

abdominal pains or by a complete appendicularsyndrome.Apart from this the histological picture of Entero-

bius vermicularis buried in the organ appears to befree of any cellular inflammatory changes as if,during its development in situ, it has established aperfect symbiosis.The penetration into the intestinal wall may also

explain the difficulty experienced in actually reachingthe parasite with the use of anthelmintics which actlocally in immediate contact with the Enterobius(Dowsett and Brown, 1953).Our histological and morphological findings

warrant greater consideration of the role played byEnterobius vermicularis in appendicitis than hitherto.In this study no normal appendix was found to beparasitized by Enterobius vermicularis. However,the study on the incidence of enterobiasis on the onehand and the frequency of appendicitis with itsparadoxical results on the other, leaves the problemof the relationship between Enterobius and appendi-citis still unsolved.

SummaryThe preparation with formol-vapour fixation of

691 appendices demonstrated the relationship ofEnterobius vermicularis with the different appendi-cular structures. A double migratory phase in thelife cycle of Enterobius vermicularis is postulated-from the lumen into the organ in the larval stage,

and from the organ into the lumen when thenematode has reached full maturation after passingthrough the stage of moulting.The incidence of enterobiasis in 300 in-patient

children has been analysed, dividing the results intothree age groups. Parasitosis was present most oftenin girls of primary school age. These figures werecompared with the incidence of enterobiasis inappendicitis in similar age groups. As the ova ofEnterobius vermicularis show a primary fluorescencethe use of a mercury vapour lamp as a source oflight can be used with advantage for their detection.

This study would not have been possible without theenthusiasm of the surgical staff of this hospital, especiallyMr. A. Forman, Mr. K. H. Smith, Mr. E. J. Petersonand Mr. V. Kritzinger; the collaboration of physiciansfor permitting the use of their patients; and the nursingstaff for the collection of swabs, and especially Sister M.Foster in theatre for preparing the appendices afterremoval.Thanks are also due to Mr. J. D. Joseph, A.R.I.C.,

F.C.S., Chief Chemist, Manchester Waterworks, for theidentification of the crustacean; to my staff for thenumerous sections and photographs, and to the HospitalBoard of Management for a grant from the EndowmentFund towards expenses.

REFERENCESDowsett, L. M. and Brown, A. E. (1953). Lancet, 1, 1070.Duran-Jorda, F. (1946). Brit. J. Suirg., 33, 346.Garrod, A. E. and Fairbank, H. A. T. (1907). Lancet, 2, 772.Gordon, H. (1933). Arch. Path. (Chicago), 16, 177.Hall, M. C. (1937). Amer. J trop. Med., 17, 445.Penso, G. (1932). Ann. Parasit. num. comp., 10, 271.Schenken, J. R. and Moss, E. S. (1942). Amer. J. clin. Path., 12, 509.

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appendicitis and enterobiasis in children · appendicitis and enterobiasis in children a...

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