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• W48367274 abstract "A 13-year-old girl was referred for her fourth episode of severe, right lower quadrant (RLQ) abdominal pain of two days duration. Three similar episodes had occurred in the preceding 18 months. Each episode lasted for 2–3 days, and was characterized by intermittent severe attacks of “stabbing” pain lasting 15 minutes per attack and recurring throughout the day and the night. She was nauseated with these episodes but had no associated fever, vomiting, diarrhea or dysuria. Her menses were regular and unrelated to her abdominal pain. She was entirely well between episodes. Examination during each previous episode by the pediatric surgery service had revealed RLQ tenderness without rebound or peritoneal signs. Plain films of the abdomen, and ultrasound of the abdomen and pelvis were normal with each episode. On examination during her fourth episode, her abdomen was soft with mild tenderness to palpation over the RLQ, without rebound, guarding or peritoneal signs. Rectal examination revealed no perianal disease and was hemoccult negative. Her examination was otherwise unremarkable. Family history was significant for migraine headaches, but was negative for acid peptic disease and inflammatory bowel disease. The patient had not consumed well water and had no pets. She had traveled to Puerto Rico three years earlier to visit family, but she had no recent travel history. Laboratory evaluation included a normal complete blood cell count and differential, chemistry profile, amylase, sedimentation rate and urinalysis. An upper gastrointestinal series with small bowel follow through was obtained which was diagnostic (Fig. 1A-B). FIG. 1Figure 1: ContinuedWhat is your diagnosis? A. Crohn's disease B. Acute appendicitis C. Abdominal migraine D. Ascaris infection E. Endometriosis Answer: (D) Ascaris infection Stool culture for O & P was positive for the adult eggs of Ascaris lumbricoides. The patient was treated with mebendazole 100 mg orally twice a day for 3 days after which she passed a large worm >30 cm in length. She was asymptomatic after passage of the worm with no further episodes of abdominal pain. Comment: Ascariasis is a helminthic infection of global distribution with more than 1.4 billion persons infected worldwide. The majority of infections occur in the developing countries of Asia and Latin America. Of the four million individuals infected in the United States, a large percentage are immigrants from developing countries or have a history of travel to one of these countries as our patient did. Ascaris infection is acquired by ingestion of the embryated eggs. Intestinal ascariasis is usually discovered incidentally. In our patient, the worm in the terminal ileum was causing a partial obstruction or appendicial irritation which resulted in intermittent appendicitis-like symptoms. Acute appendicitis and perforation have been reported as a complication of worms entering the appendix. Most Ascaris infections are not associated with clinical disease, which is usually restricted to subjects with a heavy worm load. Ascaris-induced intestinal obstruction is a frequent problem in children in developing countries with heavy worm loads and can be complicated by intussusception, perforation or gangrene of the bowel. The larvae, which migrate through the lungs during the maturation process, can cause pneumonia. Hepatobiliary and pancreatic ascariasis are less common in children, but can present with biliary colic, cholecystitis, cholangitis, pancreatitis or hepatic abscess. Mebendazole, pyrantel pamoate and albendazole are drugs of choice. With many institutions shifting to stool antigen screening (for Giardia and Cryptosporidium) instead of direct examination of the stool for ova and parasites, this parasite may be missed. Although Crohn's disease frequently presents with right lower quadrant pain, the sporadic nature of our patient's pain and her normal growth and laboratory studies made this diagnosis less likely. Despite her family history, the absence of vomiting and photophobia made a migraine variant unlikely. Endometriosis is also unlikely with no relation of her pain to her menstrual cycle. Although Ascaris infection can result in acute appendiceal obstruction, the recurrent nature of our patient's pain over 18 months made acute appendicitis, due to a fecalith or other cause, unlikely." @default.
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• W48367274 doi "https://doi.org/10.1097/00005176-200005000-00017" @default.
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