Pediatric Intussusception Associated with Enterobius vermicularis
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n 11-month-old girl presented with intussusception, which was unable to be reduced by enema. She was taken to surgery and found to have ileocecal intussusception along with mesenteric lymphadenitis in the region. The intussusception was reduced, and although the appendix appeared normal, it was taken to avoid future confusion related to her incision site. Pathology demonstrated Enterobius vermicularis worms in the appendix (Figures 1 and 2). The patient recovered uneventfully and was discharged on pyrantel pamoate. Intussusception is the most common cause of pediatric bowel obstruction. It is believed that in most cases, a viral infection (frequently upper respiratory) leads to enlargement of intestinal lymphatic tissue, creating a lead-point, which causes “telescoping” of a proximal portion of bowel distally, producing the intussusception.1 In patients without peritonitis, reduction is first attempted with a pressurized enema. If this fails, surgery is indicated. Enterobius vermicularis, also known as the pinworm, is a parasitic nematode. There are an estimated 200 million human hosts worldwide, and ova have been found in fossilized stool from 7800 BC.2 Ingested eggs hatch in the small bowel Figure 2. Enterobius vermicularis containing multiple ova (20 magnification).
and the adult worms live in the cecum. After mating, females migrate out through the anus to deposit their eggs in the perianal region. Resultant pruritus stimulates scratching and anal-to-oral transmission. Treatment consists of mebendazole or other anti-helminthic agents.2,3 In this case, the patient did not have a recent viral infection or generalized lymphadenopathy. The highly localized inflamed lymph nodes in the region of the cecum suggest that her Enterobius infection caused her intussusception leadpoint. Although intussusception due to parasites is common in some animal species, intussusception due to pinworms is very rare in humans.4,5 Intussusception may arise at any type of lead-point, and cases such as this illustrate that it may occur even in the absence of the classic antecedent viral infection. n Bruce L. Tjaden, Jr., MD Kurt P. Schropp, MD Figure 1. Appendix containing Enterobius vermicularis worms seen in cross-section (2 magnification).
J Pediatr 2014;165:1272. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.08.006
1272
University of Kansas Medical Center Kansas City, Kansas
References available at www.jpeds.com
Vol. 165, No. 6 December 2014
References 1. Hackam DJ, Grikscheit TC, Wang KS, Newman KD, Ford HR. Pediatric surgery. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, et al., eds. Schwartz’s principles of surgery. 9th ed. New York, NY: McGraw-Hill; 2010. Chapter 39. 2. Enterobius Vermicularis - Parasites and Pestilence - Infectious Public Health Challenges Winter 2006. http://www.stanford.edu/class/ humbio103/ParaSites2006/Enterobius/Enterobius%20vermicularis.htm. Accessed June 8, 2014.
3. Brooks GF, Carroll KC, Butel JS, Morse SA, Mietzner TA. Medical parasitology. In: Brooks GF, Carroll KC, Butel JS, Morse SA, Mietzner TA, eds. Jawetz, Melnick, and Adelberg’s medical microbiology. 26th ed. New York, NY: McGraw-Hill; 2013. Chapter 46. 4. McDermott VG, Taylor T, Mackenzie S, Hendry GM. Pneumatic reduction of intussusception: clinical experience and factors affecting outcome. Clin Radiol 1994;49:30-4. 5. Debek W, Dzienis-Koronkiewicz E, Hermanowicz A, Nowowiejska B. Oxyuriasis-induced intestinal obstruction in a child—case report. Rocz Akad Med Bialymst 2003;48:115-7.
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n 11-month-old girl presented with intussusception, which was unable to be reduced by enema. She was taken to surgery and found to have ileocecal intussusception along with mesenteric lymphadenitis in the region. The intussusception was reduced, and although the appendix appeared normal, it was taken to avoid future confusion related to her incision site. Pathology demonstrated Enterobius vermicularis worms in the appendix (Figures 1 and 2). The patient recovered uneventfully and was discharged on pyrantel pamoate. Intussusception is the most common cause of pediatric bowel obstruction. It is believed that in most cases, a viral infection (frequently upper respiratory) leads to enlargement of intestinal lymphatic tissue, creating a lead-point, which causes “telescoping” of a proximal portion of bowel distally, producing the intussusception.1 In patients without peritonitis, reduction is first attempted with a pressurized enema. If this fails, surgery is indicated. Enterobius vermicularis, also known as the pinworm, is a parasitic nematode. There are an estimated 200 million human hosts worldwide, and ova have been found in fossilized stool from 7800 BC.2 Ingested eggs hatch in the small bowel Figure 2. Enterobius vermicularis containing multiple ova (20 magnification).
and the adult worms live in the cecum. After mating, females migrate out through the anus to deposit their eggs in the perianal region. Resultant pruritus stimulates scratching and anal-to-oral transmission. Treatment consists of mebendazole or other anti-helminthic agents.2,3 In this case, the patient did not have a recent viral infection or generalized lymphadenopathy. The highly localized inflamed lymph nodes in the region of the cecum suggest that her Enterobius infection caused her intussusception leadpoint. Although intussusception due to parasites is common in some animal species, intussusception due to pinworms is very rare in humans.4,5 Intussusception may arise at any type of lead-point, and cases such as this illustrate that it may occur even in the absence of the classic antecedent viral infection. n Bruce L. Tjaden, Jr., MD Kurt P. Schropp, MD Figure 1. Appendix containing Enterobius vermicularis worms seen in cross-section (2 magnification).
J Pediatr 2014;165:1272. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.08.006
1272
University of Kansas Medical Center Kansas City, Kansas
References available at www.jpeds.com
Vol. 165, No. 6 December 2014
References 1. Hackam DJ, Grikscheit TC, Wang KS, Newman KD, Ford HR. Pediatric surgery. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, et al., eds. Schwartz’s principles of surgery. 9th ed. New York, NY: McGraw-Hill; 2010. Chapter 39. 2. Enterobius Vermicularis - Parasites and Pestilence - Infectious Public Health Challenges Winter 2006. http://www.stanford.edu/class/ humbio103/ParaSites2006/Enterobius/Enterobius%20vermicularis.htm. Accessed June 8, 2014.
3. Brooks GF, Carroll KC, Butel JS, Morse SA, Mietzner TA. Medical parasitology. In: Brooks GF, Carroll KC, Butel JS, Morse SA, Mietzner TA, eds. Jawetz, Melnick, and Adelberg’s medical microbiology. 26th ed. New York, NY: McGraw-Hill; 2013. Chapter 46. 4. McDermott VG, Taylor T, Mackenzie S, Hendry GM. Pneumatic reduction of intussusception: clinical experience and factors affecting outcome. Clin Radiol 1994;49:30-4. 5. Debek W, Dzienis-Koronkiewicz E, Hermanowicz A, Nowowiejska B. Oxyuriasis-induced intestinal obstruction in a child—case report. Rocz Akad Med Bialymst 2003;48:115-7.
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