OXYURIS VERMICULARIS APPENDICITIS THE INCIDENCE OF OXYURIS VERMICULARIS IN A SERIES OF

1,016 CASES OF APPENDICITIS

WILLIAM VERNON WAX, M.D. AND NORMAN SCOTT COOPER, M.D.

CATSKILL, NEW YORK

I

N a series of I ,o 16 operative cases of appendicitis at the MemoriaI HospitaI of Greene County, (441 of which were

the authors’) from August, 1933, to May, 1940, there were eight cases of oxyuris vermicuIaris infestation of the appendix.

There are many synonyms for oxyuris VermicuIaris, nameIy : ascaris vermicularis, enterobius VermicuIaris, seat worm, thread- worm, pin-worm, aIso caIIed awI-tai1, maw- worm and maggot. It is a smaI1 whitish round worm which in man infests the Iarge intestine and very often the appendix. It is reported that they have been found as high as the cecum and have even been seen in the stomach and mouth. They apparentIy are incapabIe of muItipIying in situ; for deveIopment, the ova must be swaIIowed. Many believe that the oxyuris pIays no etioIogica1 r&Ie and that its occurrence in the acuteIy inffammed appendix is mereIy accidenta1. Invasion of the oxyuris into the mucosa of the appendix has been shown to be responsibIe for a considerabIe number of cases of appendicitis (seventeen in a series of 129, by CeciI and BuIkIey).2,4 This is an unusuaIIy high figure for as shown in our series we found only eight cases in the I ,o I 6 studied. AI1 removed appendices in this series were histopathoIogicaIIy examined. The oxyuris is, however, aIso found in apparentIy normal appendices, in the submucosa as we11 as in the lumen. Often little or no inflammatory reaction is found about the oxyuris; but whiIe it may be impossibIe to demonstrate the point at which the organisms penetrate the mucosa, they are supposed to produce character- istically shaIIow hemorrhagic uIcers in the mucosa. (Figs. I and 2.) These might be the starting point of an acute inflammatory

ATHENS, NEW YORK

process not unlike that described by Asch0ff.j Dean Lewis” states that “Oxyuris must be mentioned in a consideration of the etioIogy of appendicitis in chiIdren. They are occasionaIIy encountered in the aduIt.” This is apparent in our series aIthough 40 per cent of our cases were aduIts. It wouId seem that the younger the individual, the more severe the cIinica1 as we11 as the micropathoIogica1 findings are when the appendix is infested with oxyuris. Parasites are not nearIy so common in the suppurative and gangrenous forms of appendicitis as in the nonsuppurative type. In onIy one case was the appendix infested with oxyuris classified as a subacute appendicitis by the pathoIogist. AI1 others were cIassified as “chronic.” (TabIe I.)

AI1 the cases in the series of I ,o I 6 studied were operated upon primariIy for appen- dicitis, except for two cases. One was a prophyIactic appendectomy (Case #4409) performed during the course of a hysterec- tomy; oxyuris vermicuIaris was found in the appendix on histopathoIogica1 examina- tion. In the second case (#3612), this patient was operated upon for a right ruptured ectopic pregnancy by the authors on September 3, 1939. Because of her precarious condition at that time it was deemed advisable not to remove the ap- pendix, since there was no evidence of any gross pathoIogica1 findings in the appendix. She made an uneventfu1 recovery. Six months Iater, on February 27, 1940, she deveIoped typica symptoms of appendici- tis. The histopathoIogica1 report on the removed appendix showed infestation with enterobius VermicuIaris. There was no previous history of pin-worms. As already mentioned, during the previous operation

89

90 American Journal of Surgery Wax, Cooper-Appendicitis APRIL, ,941

of the right saIpingo-oophorectomy for the micularis infestation subsequentIy caused ruptured tubal pregnancy, there was no objective as we11 as subjective findings of evidence of worm infestation in the ap- appendicitis.

FIG. I. Section of appendix Case No. 4598. Show- ing characteristically shahow hemorrhagic ulcers in mucosa. Cross section of osyuris vermicuIaris in lumen of appendix. X ro3.

pendix when examined during the course of this operation. It, therefore, may be con- cIuded from this, that if worms were present at an earIier date, they had not previousIy created symptoms or signs of

FIG. 2. Section of appendix Case No. 4598. Showing cross section of oxyuris vermicuIaris in Iumen under higher magnification. Note ceIIuIar infiltration in this area and inflamma- tory reaction with disruption of mucosal continuity. X 480.

From the cases Iisted the incidence is greater in children and evidentIy excites more violent reactions in children than in

TABLE I

Case No., InitiaI

Date of Operation

I. B.A.#45g8... 6/rr/4o

2. A. N. #3g86. r r/29/39

3. W. F. #28j’5..

3129139 4. A. S. #3657..

913139 5. S.W.#1162...

r 2/7/37 6. M. B. #rrgr...

ro/26/34 7. H. F. #44og.

4124140 8. A. A. #3612. .

z/29/40

Age, Sex

5 yrs. FemaIe 10 yrs. Female I I yrs. MaIe II yrs. Male j yrs. FemaIe 23 yrs. FemaIe 34 yrs. FemaIe 26 yrs. Female

l--

I 1

1

I

lighest Preoper

ative Tem-

Peraturl

1050

lOI

99.E0

101.IO

100.8”

99.2O

99. I0

99. I0

e

!

Total White Count

-r F

1

‘er Cent of

PoIy- morpho. iucIears

21,400 86

15,200 50

I 6,400 34

I 6,000 82

17,800 76

I 6,800 80

8,700 49

-

T-

;F

-

‘er Cent, of HistopathoIogicaI Diagnosis,

Eosin- Bender Laboratory, Dr. John J. CIemmer ophiles

0 Subacute appendicitis infestation with en- terobius vermicularis

I Chronic appendicitis infested with entero- bius vermicularis

0 Chronic appendicitis oxyuris vermicularis in appendix

I Chronic appendicitis with enterobius vermi- cuIaris

2 Chronic appendicitis oxyuris vermicuIaris in appendix

0 Chronic appendicitis oxyuris vermicularis present in the lumen

Chronic appendicitis infestation of appendix with enterobius vermicuIaris

0 Chronic appendicitis infestation with enter- obius vermicularis

appendicitis; but there is definite evidence aduIts. (TabIe I.) Oxyuris Iodged in the to show that appendicitis did occur and appendix of chiIdren (and Iess frequentIy in worms were found in the removed ap- aduIts) produces a typica clinica picture pendix, indicating that the oxyuris ver- of appendicitis. There is pain, vomiting,

NEW SERIES VOL. LII. No. 1 Wax, Cooper-Appendicitis American Journal of Surgery 9’

eIevation of temperature, IocaI tenderness, increased rigidity and Ieukocytosis. Eosino- phiha is not a constant finding as shown by our records, and if present, is not very marked. The writers know of no method by which it can be differentiated unIess one cares to reIy entirely on the increase of the eosinophiles in the differentia1 blood count. The most conservative pIan to foIlow is to advise operation when typical signs present themselves, rather than depend entirely upon the eosinophiha aIone, even when oxyuris vermicuIaris infestation is remotely suspected.

A. BattagIia and H. de Fiore’ found that appendicitis is caused by oxyuris with a frequence of z per cent. Our figures in the series of I o I 6 cases reviewed show .007 per cent. Battaglio’s and de Fiore’s findings agree in that it is more frequent in children than in adults. They state that two patients out of the six of their group of eleven suffering from oxyuris appendicitis compIained of symptoms of oxyuriasis- occasional dizziness with unconsciousness. In a review of our series there was no his- tory of dizziness or unconsciousness.

The microscopic study of the removed appendix was performed in onIy three of the six cases in the series reported by Battaglia and de Fi0re.l In our total of the eight cases charted, al1 the I ,OI 6 ap- pendices were microscopicaIly examined. (Table I.) The appendix was the site of chronic inflammation and typical oxyuris lesions. The hemogram in the three cases quoted by Battaglia and de Fiore showed an eosinophiIia of 4, 5 and 8 per cent, respectively. As shown in our table, our eosinophilia findings were much Iower; the highest in case #I 162 was onIy 2 per cent. There was no mortaIity in the cases of oxyuris appendicitis. In only one case was there a history of inffammatory reaction with itching of the ana region prior to operation (Case #I 191). The other cases gave no history of previous IocaI ana irrita- tion or infestation with pin-worms which is so generaIIy accepted as characteristic.

CONCLUSIONS

I. In a series of I ,016 cases operated upon for appendicitis the incidence of oxyuris vermicuIaris infestation of the appendix was .007 per cent. This is con- siderabIy lower than figures quoted in previous literature.

2. EosinophiIia as a diagnostic differen- tia1 point cannot be relied upon definiteIy.

3. Oxyuris vermicuIaris may be present in the appendix without creating symptoms of signs of appendicitis.

4. In the cases reviewed the exciting cause of the inflammatory reaction in the appendix was the oxyuris vermicularis, except in two cases, in which the worms were present without creating visibIe path- oIogica1 hndings.

5. In spite of eosinophilia being present, when objective and subjective signs of appendicitis are present, operation should be advised.

6. Infestation of the appendix with oxyuris in chiIdren usua1Iy creates more vioIent clinica as well as pathoIogica1 reactions.

7. The oxyuris is rarely if ever found in suppurative and gangrenous forms of appendicitis.

8. LocaI symptoms such as itching and inffammatory reaction of the anus is not necessarily present and was reported in the preoperative history of only one case in the series studied.

REFERENCES

I. B.~TTAGLIA, A. and DE FIORE, H. Prensa med. urgent., 24: 1349. 1937.

2. CECIL, R. L. and BULKLEY, K. A critica study of oxyuris and trichocephalus appendicitis. Am. J. Med. SC., 143: 793, 1912.

3. ORTON, S. T. Oxyuris vermicularis in the vermiform appendix. Med. Surg. Rep., Boston City Hosp., ~01. 15, 1905.

4. CECIL, R. L. and BULKLEY, K. On the lesions pro- duced in the appendix by oxyuris vermicularis and trichocephaIus Trichiura. J. Exper. Med., 15: 225,

1912.

5. ASCHOFF. Die Wurmfortsatzentziindung. Jena, 1908.

6. LEWIS, DEAN. Text Book of Medicine-Cecil, R. I_. P. 716. PhiIadeIphia, 1929. W. B. Saunders Co.