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The endoscopic diagnosis of colonic enterobiasis
copy. Lancet 1977;1:371. 5. Fishman EK, Goldman SM. Pneumoscrotum after colonoscopy. Urology 1981;18:171-2. 6. Ecker MD, Goldstein M, Hoexter B, Hyman RA, Naidich JB, Stein HL. Benign pneumoperitoneum after fiheroptic colonoscopy. Gastroenterology 1977;73:226-30. 7. Hedbert S. Quoted by Wherry DC, Zehner H. Colonoscopyfiberoptic endoscopic approach to the colon and polypectomy. Med Ann Distr Colombia 1974;43:189-92. 8. Telmos AJ, Mittal VK. Splenic rupture following colonoscopy. JAMA 1977;237:2718. 9. Ellis WR, Harrison JM, Williams RS. Rupture of spleen at colonoscopy. Br Med J 1979;1:307-8. 10. Reynolds FS, Moss LK, Majeski JA, Lamar Jr, C. Splenic rupture following colonoscopy. Gastrointest Endosc 1986; 32:307-8. 11. Castelli M. Splenic rupture: an unusual late complication of colonoscopy. Can Med Assoc J 1986;134:916-7. 12. Tuso P, McElligott, Marignani P. Splenic rupture at colonos-
copy. J Clin Gastroenterol 1987;9:559-62. 13. Doctor NM, Monteleone F, Zarmakoupis C, Khalife M. Splenic injury as a complication of colonoscopy and polypectomy: report of a case and review of the literature. Dis Col Rectum 1987; 30:967-8. 14. Levine E, Wetzel LH. Splenic trauma during colonoscopy. AJR 1987;149:939-40. 15. Taylor FC, Frankl HD, Riemer KD. Late presentation of splenic trauma after routine colonoscopy. Am J Gastroenterol 1989;84:442-3. 16. Smith LE, Nivatvongs S. Complications in colonoscopy. Dis Col Rectum 1975;18:214-20. 17. Sheldon GF, Croom RD, Meyer AA. The spleen. In: Sabiston DC Jr, ed. Textbook of surgery. 13th ed. Philadelphia: WB Saunders, 1986:1208-9. 18. Federle MP. The acute abdomen: computed tomography. Radiographies 1985;5:307-22. 19. Federle MP, Griffiths B, Minagi H, et al. Splenic trauma: evaluation with CT. Radiology 1987;162:69-71.
The endoscopic diagnosis of colonic enterobiasis
Computed tomography of the head revealed several small areas of decreased attenuation bilaterally and somewhat prominent ventricles. On the 10th day of hospitalization, after aspirin therapy was initiated, the patient passed two blood-streaked stools. On anoscopy, the anorectal junction was markedly erythematous and friable. Because a 1.5-cm sessile polyp was noted on flexible left sided colonoscopy, a full colonoscopic examination was performed. Multiple thread-like undulating 1cm worms were seen in the cecum (Fig. 1), and others throughout the colon to the level of the sigmoid (Fig. 2). A biopsy forceps was used to remove an intact worm for study under the dissecting microscope. An adult female E. vermicularis, engorged with numerous asymmetric ovoid eggs, was seen (Fig. 3). The patient received a l-g dose of pyrantel pamoate, and a second dose 2 weeks later, without recurrent symptoms.
Steven P. Goldenberg, MD Pierluigi Marignani, MD
Enterobiasis is prevalent throughout the world and is the most common helminthic infection in the United States, with an estimated 42 million people harboring this intestinal roundworm.! Although infestation is usually asymptomatic, pruritus ani and restless sleep are often present, due to a local skin reaction resulting from the nocturnal migration and egg laying by female pinworms. 2 The diagnosis of Enterobius uermicularis infestation is made by examination of the anal region for the characteristic ova, segments of the adult worms, or even intact worms. 3 Although undoubtedly frequently observed, the finding of pinworm infestation on colonoscopy has never been reported. Since in a few cases, such as ours, the endoscopic observation may have clinical significance, we describe a patient with rectal bleeding and intense pruritus ani, who, on colonoscopic examination, was found to have enterobiasis.
CASE REPORT A 49-year-old male resident of a shelter for the homeless presented to Griffin Hospital with right-sided hemiparesis and slurred speech. He had a long history of hypertension and constipation, as well as pruritus ani, especially during the summer months. He had undergone appendectomy 22 years before at another institution. Medications included atenolol and verapamil. Physical examination was remarkable for right-sided hemiparesis and perianal erythema. From the Department of Medicine, Division of Gastroenterology, The Griffin Hospital, Yale University School of Medicine, Derby, Connecticut. Reprint requests: Pierluigi Marignani, MD, The Griffin Hospital, 130 Division Street, Derby, Connecticut 06418. VOLUME 36, NO.3, 1990
DISCUSSION
E. uermicularis is a small, white, thread-like nematode measuring approximately 5 mm for the male and up to 13 mm for the female. The life cycle begins with ingestion or inhalation of viable ova that hatch within the small intestine, mature, and mate. Gravid females attach themselves to the mucosa of the distal ileum, appendix, cecum, or ascending colon, and then migrate to the perianal skin, where they release an average of 11,000 eggs,4 and die. The ova mature within 6 hours and remain infective for approximately 2 weeks. Diagnosis is usually made by the identification of ova obtained from pressing transparent adhesive tape against the perianal area. There have been many reports of pinworm infestation first noted at the time of surgery, most often associated with the appendix,5-? although ectopic enterobiasis has also been described. 8- 10 To our knowledge, although undoubtedly observed on colonoscopic examination, pinworm infestation diagnosed in this manner has never been 309
reported. Small white threads on the colonic mucosa should be observed for evidence of the sinuous movement suggesting pinworm infestation. Treatment consists of a single 100-mg oral dose of mebendazole, or pyrantel pamoate, 11 mg/kg, either of which results in eradication in about 90% of cases. A second dose 2 weeks later is usually recommended. Although a tape test may be useful in assessing response to therapy, pruritus ani generally disappears with treatment and reappears with reinfection. l l Some experts suggest that all other household members be treated, even though there is no evidence that this measure significantly reduces reinfection.
REFERENCES 1. Warren KS. Helminthic disease endemic in the United States. Am J Trop Med Hyg 1974;23:723-30. 2. Brady FJ, Wright WHo Studies on oxyuriasis. The symptoma· tology of oxyuriasis as based on physical examination and case histories on 200 patients. Am J Med Sci 1939;198:367-72. 3. Jones JE. Pinworms. A F P 1988;38:159-64. . 4. Reardon L. Studies on oxyuriasis. The number of eggs produced by the pinworm, Enterobius uermicularis, and its bearing on infection. Public Health Rep 1938;53:978-84. 5. Mogensen K, Pahle E, Kowalski K. Enterobius uermicularis and acute appendicitis. Acta Chir Scand 1985;151:705-7. 6. Budd JS, Armstrong C. Role of Enterobius uermicularis in the aetiology of appendicitis. Br J Surg 1987;74:748-9. 7. Williams DJ, Dixon MF. Sex. Enterobius uemicularis and the appendix. Br J Surg 1988;75:1225-6. 8. Symmers WS. Pathology of Oxyuriasis with special reference to granulomas due to the presence of Oxyuris uermicularis and its ova in the tissues. Arch Pathol 1950;50:475-516. 9. Knuth KR, Fraiz J, Fisch JA, Draper TW. Pinworm infestation of the genital tract. A F P 1988;38:127-30. 10. Daly JJ, Baker GF. Pinworm granuloma of the liver. Am J Trop Med Hyg 1984;33:62-4. 11. Weller TH, Sorenson CWo Enterobiasis. Its incidence and symptomatology in a group of 505 children. N Engl J Med 1941;224:143-6.
Figure 1. A small white thread-like pinworm (arrow), adjacent to two peas, is noted in the cecum. Figure 2. Close-up endoscopic view of a pinworm lying on the sigmoid mucosa. Figure 3. Under the dissecting microscope a female pinworm, containing the characteristic ovoid eggs (arrow), is easily identified.
310
GASTROINTESTINAL ENDOSCOPY
copy. J Clin Gastroenterol 1987;9:559-62. 13. Doctor NM, Monteleone F, Zarmakoupis C, Khalife M. Splenic injury as a complication of colonoscopy and polypectomy: report of a case and review of the literature. Dis Col Rectum 1987; 30:967-8. 14. Levine E, Wetzel LH. Splenic trauma during colonoscopy. AJR 1987;149:939-40. 15. Taylor FC, Frankl HD, Riemer KD. Late presentation of splenic trauma after routine colonoscopy. Am J Gastroenterol 1989;84:442-3. 16. Smith LE, Nivatvongs S. Complications in colonoscopy. Dis Col Rectum 1975;18:214-20. 17. Sheldon GF, Croom RD, Meyer AA. The spleen. In: Sabiston DC Jr, ed. Textbook of surgery. 13th ed. Philadelphia: WB Saunders, 1986:1208-9. 18. Federle MP. The acute abdomen: computed tomography. Radiographies 1985;5:307-22. 19. Federle MP, Griffiths B, Minagi H, et al. Splenic trauma: evaluation with CT. Radiology 1987;162:69-71.
The endoscopic diagnosis of colonic enterobiasis
Computed tomography of the head revealed several small areas of decreased attenuation bilaterally and somewhat prominent ventricles. On the 10th day of hospitalization, after aspirin therapy was initiated, the patient passed two blood-streaked stools. On anoscopy, the anorectal junction was markedly erythematous and friable. Because a 1.5-cm sessile polyp was noted on flexible left sided colonoscopy, a full colonoscopic examination was performed. Multiple thread-like undulating 1cm worms were seen in the cecum (Fig. 1), and others throughout the colon to the level of the sigmoid (Fig. 2). A biopsy forceps was used to remove an intact worm for study under the dissecting microscope. An adult female E. vermicularis, engorged with numerous asymmetric ovoid eggs, was seen (Fig. 3). The patient received a l-g dose of pyrantel pamoate, and a second dose 2 weeks later, without recurrent symptoms.
Steven P. Goldenberg, MD Pierluigi Marignani, MD
Enterobiasis is prevalent throughout the world and is the most common helminthic infection in the United States, with an estimated 42 million people harboring this intestinal roundworm.! Although infestation is usually asymptomatic, pruritus ani and restless sleep are often present, due to a local skin reaction resulting from the nocturnal migration and egg laying by female pinworms. 2 The diagnosis of Enterobius uermicularis infestation is made by examination of the anal region for the characteristic ova, segments of the adult worms, or even intact worms. 3 Although undoubtedly frequently observed, the finding of pinworm infestation on colonoscopy has never been reported. Since in a few cases, such as ours, the endoscopic observation may have clinical significance, we describe a patient with rectal bleeding and intense pruritus ani, who, on colonoscopic examination, was found to have enterobiasis.
CASE REPORT A 49-year-old male resident of a shelter for the homeless presented to Griffin Hospital with right-sided hemiparesis and slurred speech. He had a long history of hypertension and constipation, as well as pruritus ani, especially during the summer months. He had undergone appendectomy 22 years before at another institution. Medications included atenolol and verapamil. Physical examination was remarkable for right-sided hemiparesis and perianal erythema. From the Department of Medicine, Division of Gastroenterology, The Griffin Hospital, Yale University School of Medicine, Derby, Connecticut. Reprint requests: Pierluigi Marignani, MD, The Griffin Hospital, 130 Division Street, Derby, Connecticut 06418. VOLUME 36, NO.3, 1990
DISCUSSION
E. uermicularis is a small, white, thread-like nematode measuring approximately 5 mm for the male and up to 13 mm for the female. The life cycle begins with ingestion or inhalation of viable ova that hatch within the small intestine, mature, and mate. Gravid females attach themselves to the mucosa of the distal ileum, appendix, cecum, or ascending colon, and then migrate to the perianal skin, where they release an average of 11,000 eggs,4 and die. The ova mature within 6 hours and remain infective for approximately 2 weeks. Diagnosis is usually made by the identification of ova obtained from pressing transparent adhesive tape against the perianal area. There have been many reports of pinworm infestation first noted at the time of surgery, most often associated with the appendix,5-? although ectopic enterobiasis has also been described. 8- 10 To our knowledge, although undoubtedly observed on colonoscopic examination, pinworm infestation diagnosed in this manner has never been 309
reported. Small white threads on the colonic mucosa should be observed for evidence of the sinuous movement suggesting pinworm infestation. Treatment consists of a single 100-mg oral dose of mebendazole, or pyrantel pamoate, 11 mg/kg, either of which results in eradication in about 90% of cases. A second dose 2 weeks later is usually recommended. Although a tape test may be useful in assessing response to therapy, pruritus ani generally disappears with treatment and reappears with reinfection. l l Some experts suggest that all other household members be treated, even though there is no evidence that this measure significantly reduces reinfection.
REFERENCES 1. Warren KS. Helminthic disease endemic in the United States. Am J Trop Med Hyg 1974;23:723-30. 2. Brady FJ, Wright WHo Studies on oxyuriasis. The symptoma· tology of oxyuriasis as based on physical examination and case histories on 200 patients. Am J Med Sci 1939;198:367-72. 3. Jones JE. Pinworms. A F P 1988;38:159-64. . 4. Reardon L. Studies on oxyuriasis. The number of eggs produced by the pinworm, Enterobius uermicularis, and its bearing on infection. Public Health Rep 1938;53:978-84. 5. Mogensen K, Pahle E, Kowalski K. Enterobius uermicularis and acute appendicitis. Acta Chir Scand 1985;151:705-7. 6. Budd JS, Armstrong C. Role of Enterobius uermicularis in the aetiology of appendicitis. Br J Surg 1987;74:748-9. 7. Williams DJ, Dixon MF. Sex. Enterobius uemicularis and the appendix. Br J Surg 1988;75:1225-6. 8. Symmers WS. Pathology of Oxyuriasis with special reference to granulomas due to the presence of Oxyuris uermicularis and its ova in the tissues. Arch Pathol 1950;50:475-516. 9. Knuth KR, Fraiz J, Fisch JA, Draper TW. Pinworm infestation of the genital tract. A F P 1988;38:127-30. 10. Daly JJ, Baker GF. Pinworm granuloma of the liver. Am J Trop Med Hyg 1984;33:62-4. 11. Weller TH, Sorenson CWo Enterobiasis. Its incidence and symptomatology in a group of 505 children. N Engl J Med 1941;224:143-6.
Figure 1. A small white thread-like pinworm (arrow), adjacent to two peas, is noted in the cecum. Figure 2. Close-up endoscopic view of a pinworm lying on the sigmoid mucosa. Figure 3. Under the dissecting microscope a female pinworm, containing the characteristic ovoid eggs (arrow), is easily identified.
310
GASTROINTESTINAL ENDOSCOPY