Epididymitis from Enterobius Vermicularis: Case Report

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Med. J., 72: 1001, 1979. 9. Wees, S. J.: Testicular sarcoidosis. South. Med. J., 74: 255, 1981. 10. Amenta, P. S., Gonick, P. and Katz, S. M.: Sarcoidosis of testis and epididymis. Urology, 17: 616, 1981. 11. Seaworth, J. F., Davis, S. J. and Donovan, W. N.: Aggressive

delberg: Alfred Hu.thig Verlag, p. 18, 1965. 20. Roos, N., Bick, U., Vassallo, P., Diederich, S., Muller-Miny, H. Auffermann, W., Erlemann, R. and Peters, P. E.: Thorakale Sarkoidose. Radiologe, 30: 581, 1990. 21. Singer, E. P., Hensler, N. M. and Flynn, P. F.: Sarcoidosis: an

diagnostic approach indicated in testicular sarcoidosis. Urology, 21: 396, 1983. McWilliams, W. A., Abramowitz, L. and Tiamson, E. M.: Epididymal sarcoidosis: case report and review. J. Urol., 130: 1201, 1983. Haas, G. P., Badalament, R., Wonnell, D. M. and Miles, B. J.: Testicular sarcoidosis: case report and review of the literature. J. Urol., 135: 1254, 1986. Turk, C. 0., Schacht, M. and Ross, L.: Diagnosis and management of testicular sarcoidosis. J. Urol., 135: 380, 1986. Hackney, R. L., Jackson, A. G. and Worrell, R. G.: Sarcoidosis of report. J. Natl. Med. Ass., 78: 63, 1986. Parr, M. J. A. and Williams, M. V.: Sarcoidosis mimicking metastatic testicular tumour. Brit. J. Rad., 61: 516, 1988. Singer, A. J., Gavrell, G. J., Leidich, R. B. and Quinn, A. D.: Genitourinary involvement of systemic sarcoidosis confined to testicle. Urology, 35: 442, 1990. Barth, J. and Gross, W. L.: Sarkoidose aus der Sicht des Internisten. Med. Welt., 41: 37, 1990. Jorgensen, G.: Untersuchungen zur Genetik der Sarkoidose. Hei-

analysis of forty-five cases in a large military hospital. Amer. J. Med., 26: 364, 1959. Ricker, W. and Clark, M.: Sarcoidosis: a clinico-pathologic review of 300 cases including 22 autopsies. Amer. J. Clin. Path., 19: 725, 1949. Nickerson, D. A.: Boeck's sarcoid: a report of six cases in which autopsies were made. Arch. Path., 24: 19, 1937. Blacher, E. J. and Maynard, J. F.: Seminoma and sarcoidosis: an unusual association. Urology, 26: 288, 1985. Droz, J. P., Ruffie, P., Piot, G., Ghosn, M., Caillaud, J.-M., Elias, D., Perrin, J.-L. and Levasseur, P.: Sarcoidosis and testicular germ cell tumor. Case report. Scand. rtJrol.-Nephrol., 24: 171, 1990. Gefter, W. B., Glick, J. H., Epstein, D. M. and Miller, W. T.: Sarcoidosis: a cause of intrathoracic lymphadenopathy after treatment of testicular carcinoma. AJR, 139: 820, 1982. Colebunders, R.: Sarcoidosis after testicular carcinoma treatment. AJR, 140: 831, 1983. Sieber, P. R. and Duggan, F. E.: Sarcoidosis and testicular tumors. Urology, 31: 140, 1988.

12. 13. 14. 15. 16. 17. 18. 19.

22. 23. 24. 25.

the fesfis:acase

26. 27. 28.

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Vol. 147, 1114-1116, April 1992

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EPIDIDYMITIS FROM ENTEROBIUS VERMICULARIS: CASE REPORT G. KOLLIAS, M. KYRIAKOPOULOS

AND

G. TINIAKOS

From the Department of Urology, N.I.M. T.S. Hospital, Athens, Greece

ABSTRACT

A rare case of epididymitis caused by Enterobius vermicularis, a pinworm, is reported. A 52-yearold man underwent resection of the right epididymis and histological examination confirmed the diagnosis of pinworm infection by discovering parts of the body of the oxyurid in various sections. KEY

WORDS: epididymis, epididymitis, Enterobius, parasitic diseases, pinworms

Enterobius vermicularis is distributed worldwide and is the most common cause of helminthic infection. Man is the only host for the parasite. The most common symptom and sign is pruritus of the perianal area, particularly at night. Insomnia, restlessness, enuresis and irritability are also common symptoms especially in children. Anorexia, abdominal pain, nausea and vomiting have also been attributed to this infection. The diagnosis depends upon finding adult worms in the stool on the perianal skin. Worms also migrate, although unusually, into the vagina, uterus, fallopian tubes and so forth. We present a rare case of epididymitis due to E. vermicularis. CASE REPORT

A 52-year-old white man was hospitalized with a swollen right epididymis. Family history was free of any similar findings. He reported no previous serious or chronic diseases, or previous surgical procedure except for the usual childhood diseases. The patient was a sailor by profession and was obliged to stay at various ports of the world, such as in Indochina, Egypt and Thailand. Six years before hospitalization, while he was in South America, the patient reported that he was voiding pinworms in the urine, for which he had taken prescribed medication. At examination the right epididymis was swollen and in places it was of firm consistency. The patient was afebrile and Accepted for publication August 12, 1991.

he was taking antibiotics (tetracycline) for 1 month because of the epididymitis. However, the symptoms were unchanged. There was constant tenderness in the right inguinal region. Routine laboratory studies showed mild eosinophilia, which was considered unimportant at that time. The urine culture was negative and an excretory urogram was free of any abnormalities. With the patient under spinal anesthesia the right epididymis was resected. During the operation inflammatory tissue was noted to cover the area between the skin of the scrotum, the testicular coats and the epididymis. Macroscopically, the epididymis was diffusely inflamed and it was removed completely. Convalescence was uneventful. Histological examination of the excised epididymis showed foci of inflammatory granulomatous tissue in some areas consisting mainly of leukocytes, lymphocytes and histiocytes. The centers of these granulomatous foci appeared to be necrotic and included 1 or several male pinworms on transverse section (diameter 250 to 350 µ., see figure). DISCUSSION

E. vermicularis is a pinworm that measures approximately 8 to 13 mm., is found in all climates and causes an intestinal infection in humans, who are the only hosts of the pinworm. The gravid female and male worms live with the heads attached to the mucosa of the cecum, appendix and adjacent areas of the bowel. The life span is 30 to 45 days. Many infected patients

EPIDIDYMITIS FROM ENTEROBIUS VERMICULARIS

A, 5 transverse sections of 1 or more male pinworms in foci of inflammatory granulomatous tissue. H & E, reduced from xlOO. B, transverse sections of several male pinworms surrounded by inflammatory cells (bottom). Details from epididymis are seen at top. H & E, reduced from X40. C, transverse section of 1 pinworm at higher magnification shows details of structure, and of surrounding inflammatory granulomatous and necrotic area. H & E, reduced from Xl60.

are asymptomatic. The most common complaint is pruritus ani, which is most troublesome at night and is related to the migration of the gravid female worms and deposition of their eggs. Pruritus ani can also be caused by hemorrhoids, anal inflammatory lesions, anal fissures and so forth but the differential diagnosis is relatively easy. Other minor complaints include insomnia, irritability and enuresis. Vaginal discharge has been reported and, rarely, chronic granulomatous salpingitis, endometritis, pyelitis or urethritis results from the presence of ectopic adult pinworms. In our patient the migration of the pinworms in the urogenital system caused epididymitis. The manner in which the pinworm reached the epididymis is unknown to us. However, our patient had undergone a barium enema 10 months before epididymectomy and no pathology was found. De Ruiter et al found worms that had penetrated the mucosa

and were buried completely in the wall of the intestine. Our explanation agrees with the hypothesis of Chandrasoma and Mendis that the pinworm has the ability for further penetration and theoretically it can be found at ectopic sites after active penetration of the intestinal wall. Treatment consists of oral medication except for a few patients who require surgical intervention. Two highly satisfactory drugs are available. Pyran tel pamoate given in a single oral dose of 10 mg./kg. (maximum 1.0 gm.) is probably the drug of choice and can be given again after 2 and 4 weeks. Alternatively, a single 100 mg. oral dose of mebendazole can be used. Pyrvinium pamoate is equally effective but less convenient and it is given orally as a single dose of 5 mg./kg. (maximum 0.25 gm.) in liquid form. The dose is repeated after 2 and 4 weeks. The prognosis is good. Eradication of the worms is relatively easy but reinfection is frequent. Pyrantel pamoate was prescribed for our patient at the afore-

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CORBELLA AND ASSOCIATES

mentioned dosage. The treatment was begun after epididymectomy and diagnosis of the disease. At 8 months after epididymectomy and 7 months after pharmacological treatment there were no symptoms and no signs of recurrence. REFERENCES BIJLMER, J .: An exceptional case of oxyuriasis of the intestinal wall. J. Parasitol., 32: 359, 1946. CHANDRASOMA, P. T. AND MENDIS, K. N.: Enterobius vermicularis in ectopic sites. Amer. J. Trop. Med. Hyg., 26: 644, 1977. DE RUITER, H., RIJPSTRA, A. C. AND SWELLENGREBEL, N. H.: Ectopic

Enterobious vermicularis. Variations in its pattern. Trop. Geogr. Med., 14: 375, 1962. FAUST, E. C.: Human Helminthology, A Manual for Physicians, Sanitarians, and Medical Zoologists, 3rd ed. Philadelphia: Lea & Febiger, p. 548, 1949. FINGERLAND, A. AND MARSALEK, J.: Parasitic granuloma of inguinal canal caused by Oxyuris. Casop. Lek. Cesk., 80: 532, 1941. SUSMAN, M. P.: Threadworms in the periotoneal cavity. J. Coll. Surg. Australasia, 2: 273, 1929. SYMMERS, W. ST. C.: Pathology of oxyuriasis, with special reference to granulomas due to the presence of Oxyuris vermicularis (Enterobius vermicularis) and its ova in the tissues. Arch. Path., 50: 475, 1950.

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Vol. 147, 1116-1117, April 1992

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FLUCONAZOLE TREATMENT IN TORULOPSIS GLABRATA UPPER URINARY TRACT INFECTION CAUSING URETERAL OBSTRUCTION XAVIER CORBELLA, JORDI CARRATALA, MANUEL CASTELLS

AND

BEGONA BERLANGA

From the Departments of Infectious Disease, Urology and Neurology, Bellvitge Hospital, University of Barcelona, Barcelona, Spain

ABSTRACT

We report a case of Torulopsis glabrata upper urinary tract infection causing ureter al obstruction. The infection was successfully treated with fluconazole, a new triazole derivative, combined with ureteral catheterization. KEY WORDS: urinary tract infections, urinary catheterization, fluconazole, candida

Development of ureteral obstruction associated with Torulopsis infections of the upper urinary tract is an uncommon but serious and difficult to treat infectious complication. 1 • 2 It usually occurs in diabetic or immunocompromised patients. We report a case of ureteral obstruction complicating Torulopsis glabrata upper urinary tract infection treated successfully with fluconazole and ureteral catheterization. CASE REPORT

A 59-year-old diabetic woman was hospitalized because of a 4-day history of fever and severe left flank pain. A month before hospitalization idiopathic transverse myelitis causing spastic paraparesis with an incontinent bladder was diagnosed. Since then, the patient has had an indwelling bladder catheter and she has been taking 15 mg. prednisone daily. At hospitalization temperature was 40C. Laboratory findings revealed normal renal parameters. Admission blood cultures were negative. Urine culture yielded Escherichia coli. Therapy with intravenous ceftriaxone (1 gm. per day) was initiated. After 3 days of antibiotic therapy the patient was still febrile. Therefore, cultures of urine and blood were repeated. The intravenous catheter was removed and cultured. The urine and catheter tip cultures were negative. Blood cultures yielded T. glabrata. Ceftriaxone therapy was discontinued and intravenous fluconazole at 200 mg. daily was initiated. After 4 days on fluconazole therapy the fever persisted. Ultrasound examination showed dilatation of the left collecting system with no images of lithiasis. Excretory urography (IVP) revealed a functional delay of the left kidney with ureteropyelocaliceal ectasia up to the L5 level within 2 hours, with a 0. 7 X 1 cm. radiolucent filling defect (see figure). The right collecting system was normal. A 4F ureteral catheter passed cystoscopically for drainage obtained purulent urine. Later, the Accepted for publication September 27, 1991.

patient passed apparent tissue fragments per urethram. The urine culture from the ureteral catheter and fungal debris yielded T. glabrata. Two days after catheterization the patient became apyretic and the urine cultures were negative. After 10 days retrograde pyelography demonstrated no filling defects and return to normal of the left collecting system. The ureteral catheter was then removed. Two weeks later an IVP was normal and the patient was discharged from the hospital. She continued on 200 mg. oral fluconazole daily for 1 month. There was no recurrence at 6 months. DISCUSSION

Fungal obstructions of the upper urinary tract must be considered in the differential diagnosis of ureteropelvic obstruction in a susceptible patient, especially when a radiolucent filling defect is visualized on an IVP. Urine and fungal debris should be sent specifically for fungal culture, since most fungi will not grow on routine bacterial culture media. 1• 2 The recommended treatment consists of local irrigation with amphotericin B, associated with systemic administration when fungemia is present. In all cases adjunctive surgical procedures, including ureteral catheterization, percutaneous extraction of the fungal mass or a conventional operation, are needed. 3- 5 To date amphotericin B has been the gold standard of systemic antifungal therapy. However, the necessity of intravenous administration and the additional nephrotoxicity have limited its use and have stimulated a search for new agents. 6 Ketoconazole has become the most important imidazole antifungal agent but the search for improved antifungal azole agents with less toxicity and better distribution into body fluids has continued. 6• 7 Fluconazole is a new triazole derivative that differs from ketoconazole in that the imidazole ring is replaced with a triazole ring that increases the polarity of the molecule resulting in enhanced absorption, decreased protein binding and renal rather than hepatic elimination. 8 Fluconazole has the