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Case profile: Calcified parasite in retroperitoneum
CASE PROFILE:
CALCIFIED
FIGURE 1. (A) Plainjlm of abd omen showing relationship of calci$cation to renal pelvis.
214
PARASITE IN RETROPERITONEUM
string-like calci$cation
UROLOGY
in left renal area. (B) Pyelogram
/ FEBRUARY1976
/ VOLUMEVII,
showing
NUMBER2
Urologic consultation was sought after string-like calcifications in the area of the left kidney were noted on a plain film of the abdomen, obtained because of nonurologic complaints (Fig. 1A). The patient was a thirty-two-year-old male, recent emigre from Pakistan. As a child he washed in community baths and recalls worms crawling under the skin of his legs. About two years prior to this study, an abdominal x-ray examination was said to have revealed these string-like calcifications. Since the patient was asymptomatic, no further workup was recommended nor therapy administered. During this admission an intravenous pyelogram revealed normal renal outlines and collecting systems. The calcified lesions were noted to be adjacent to the posterior medial aspect of the left kidney (Fig. 1B). A diagnosis of calcified retroperitoneal worm was made. The patient was asymptomatic, therefore no therapy was recommended. Comment This is an example of calcification of a dead Dracunculus Medinensis (Guinea worm) in the retroperitoneum. The geographic distribution of the Guinea worm includes the Nile Valley; Central, Northwest, and West Africa; Middle East; Afghanistan; Pakistan; India; and Southeast U.S.S.R. After ingestion of the cyclops from contaminated water, duodenal enzymes digest the wall
UROLOGY
/ FEBRUARY
1976 / VOLUME
VII, NUMBER 2
of the cyclops, releasing the larvae. These larvae migrate through the intestinal wall to the retroperitoneal tissues, where they mature to adult worms in eight to twelve months. The gravid female migrates to the skin, causing a severe allergic reaction with a cutaneous blister. On contact with water the blister bursts, releasing the worm and many cyclops. The cyclops are then ingested, thus reestablishing the life cycle. Radiographically, calcification of the dead worm is commonly seen in inhabitants of the endemic areas. Clinically, penetration to the skin by the adult worm is usually accompanied by fever, malaise, confusion, local edema, dyspnea, vomiting, and other gastrointestinal symptoms. Chronic infestation of joints may occasionally result in crippling synovitis and arthritis. Guinea worm epididymitis has been reported. Treatment of the symptomatic patient consists of surgical excision of the adult worm, and a therapeutic course of either diethylcarbamazine citrate (Hetrazan) or niridazole (Ambilhar). Prognosis is usually good, and the main preventive measure is to keep infected persons from bathing in water used for drinking. R. S. Warner, M.D. S. Kallet, M.D. R. Rowan, M.D. M. Reddy, M.D. Cabrini Health Care Center and New York University Medical Center New York, New York
215
CALCIFIED
FIGURE 1. (A) Plainjlm of abd omen showing relationship of calci$cation to renal pelvis.
214
PARASITE IN RETROPERITONEUM
string-like calci$cation
UROLOGY
in left renal area. (B) Pyelogram
/ FEBRUARY1976
/ VOLUMEVII,
showing
NUMBER2
Urologic consultation was sought after string-like calcifications in the area of the left kidney were noted on a plain film of the abdomen, obtained because of nonurologic complaints (Fig. 1A). The patient was a thirty-two-year-old male, recent emigre from Pakistan. As a child he washed in community baths and recalls worms crawling under the skin of his legs. About two years prior to this study, an abdominal x-ray examination was said to have revealed these string-like calcifications. Since the patient was asymptomatic, no further workup was recommended nor therapy administered. During this admission an intravenous pyelogram revealed normal renal outlines and collecting systems. The calcified lesions were noted to be adjacent to the posterior medial aspect of the left kidney (Fig. 1B). A diagnosis of calcified retroperitoneal worm was made. The patient was asymptomatic, therefore no therapy was recommended. Comment This is an example of calcification of a dead Dracunculus Medinensis (Guinea worm) in the retroperitoneum. The geographic distribution of the Guinea worm includes the Nile Valley; Central, Northwest, and West Africa; Middle East; Afghanistan; Pakistan; India; and Southeast U.S.S.R. After ingestion of the cyclops from contaminated water, duodenal enzymes digest the wall
UROLOGY
/ FEBRUARY
1976 / VOLUME
VII, NUMBER 2
of the cyclops, releasing the larvae. These larvae migrate through the intestinal wall to the retroperitoneal tissues, where they mature to adult worms in eight to twelve months. The gravid female migrates to the skin, causing a severe allergic reaction with a cutaneous blister. On contact with water the blister bursts, releasing the worm and many cyclops. The cyclops are then ingested, thus reestablishing the life cycle. Radiographically, calcification of the dead worm is commonly seen in inhabitants of the endemic areas. Clinically, penetration to the skin by the adult worm is usually accompanied by fever, malaise, confusion, local edema, dyspnea, vomiting, and other gastrointestinal symptoms. Chronic infestation of joints may occasionally result in crippling synovitis and arthritis. Guinea worm epididymitis has been reported. Treatment of the symptomatic patient consists of surgical excision of the adult worm, and a therapeutic course of either diethylcarbamazine citrate (Hetrazan) or niridazole (Ambilhar). Prognosis is usually good, and the main preventive measure is to keep infected persons from bathing in water used for drinking. R. S. Warner, M.D. S. Kallet, M.D. R. Rowan, M.D. M. Reddy, M.D. Cabrini Health Care Center and New York University Medical Center New York, New York
215