Pinworm in the Appendix: An Unusual Cause of Appendiceal Inflammation; A Case Report

Pinworm in the Appendix: An Unusual Cause of Appendiceal Inflammation; A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Pinworm in the Appendix: An Unusual Cause of Appendiceal Inflammation; A Case Report Mohammad Nabeel Aamir Syed, Muhammad Taha Arshad Shaikh, Fabeha Hilal Makhdoomi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6623733/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Jan, 2026 Read the published version in SN Comprehensive Clinical Medicine → Version 1 posted 4 You are reading this latest preprint version Abstract Purpose Enterobius Vermicularis , usually causing perianal pruritus in children, can rarely become the cause of acute appendicitis. It is imperative to discuss this unique manifestation of this parasitic infestation. Methods The Medline database was extensively searched for literature covering the different aspects of this clinical manifestation to discuss alongside the unusual case presentation. Results Enterobius Vermicularis is a nematode endemic to various parts of the developing world with a significantly rising prevalence. Colonizing humans as a primary host, the parasite usually causes perianal pruritus. In rare instances, however, after successful migration and obstruction of the appendiceal lumen, acute appendicitis may ensue. Acute appendicitis, diagnosed via clinical presentation and radiologic investigation, warrants surgical intervention. Conclusion Parasitic manifestation may be visible perioperatively or become evident upon histopathology. Anti-helminthic therapy commencement should not be delayed to effectively reduce transmission risk and inevitably cure the condition. Enterobius Vermicularis Pinworm Helminth Acute Appendicitis Figures Figure 1 Figure 2 Introduction Among emergency abdominal surgical procedures, acute appendicitis emerges as one of the most frequent causes, afflicting approximately 7.6% of the population worldwide [ 1 ]. An affliction of the younger population, acute appendicitis occurs due to the inflammation and possible infection of the vermiform appendix, a tubular structure present at the convergence of the taenia coli at the base of the cecum [ 2 ]. The constellation of symptoms occurs when the inside passage of the appendix is blocked, resulting in edema and inflammation. The diagnosis is largely based on the patient’s history, clinical examination, and laboratory evaluation. Confirmation through abdominal imaging may be achieved as well. The classic presentation outlines vague periumbilical pain with migration to the right lower quadrant of the abdomen and low-grade fever, as well as accompanying nausea, intermittent vomiting, and anorexia [ 3 ]. A wide spectrum of inciting factors has been cited as causes of acute appendicitis, ranging from the rarest of neuroendocrine tumors and serrated adenomas to low-grade mucinous neoplasm, hyperplastic lymph nodes and polyps, and intestinal parasites [ 4 ]. Laparoscopic appendectomy still holds fort as the most common intervention. Enterobius Vermicularis (E. vermicularis ) is a globally prevalent parasite most frequently affecting the pediatric population [ 5 ]. E. Vermicularis , also known as pinworm, is a globally common nematode infection, usually transmitted between humans via the feco-oral route. The initial infestation remains asymptomatic while the eggs are being laid which leads to worm migration towards the anal margin causing nocturnal perianal pruritus [ 6 ]. Hence, appendicitis due to this nematode presents as a peculiar case indeed and one that is described in this report. Case Presentation A 11-year-old girl, without a significant medical or surgical history, presented to the emergency department with the acute onset of right iliac fossa pain, which she elaborated to be constant, sharp, and non-radiating with associated mild fever, anorexia, nausea, and one episode of vomiting. Examination revealed a soft abdomen with tenderness in the right iliac fossa, along with a positive rebound sign. Urinalysis showed no infectious etiology for her condition. Laboratory investigations showed a hemoglobin level of 11 g/dL and a white cell count of 12.5×10 9 with marked neutrophilia. Coagulation profile and renal function tests were well within normal values. Subsequently, abdominal and pelvic ultrasonography was ordered. Pelvic ultrasonography showed normal pelvic anatomy and ovaries with no free fluid, however, abdominal ultrasonography revealed an edematous pelvic appendix with significant wall thickening, suggestive of acute appendicitis. Upon performing a reevaluation, abdominal tenderness remained persistent despite adequate hydration and analgesia; consequently, an open appendectomy under general anesthesia was performed. Intraoperatively, a hyperemic and severely edematous appendix was visualized and subsequently excised. The appendiceal tip was especially swollen, giving an impression of luminal collection, as illustrated in Fig. 1 . Upon dissecting the appendiceal tip and subsequently the entire length, it was revealed that the primary cause of the inflammation was luminal blockage by a nest of worms, as illustrated in Fig. 2 . As a consequence, anti-helminthic therapy consisting of albendazole 400 mg twice daily for one week was commenced for the patient and close contacts, leading to successful treatment and subsequent discharge in 24 hours. Upon follow-up appointment, she was generally doing well and had no complaints. Examination showed a well-healed and uninfected scar. The histopathology report revealed an inflamed appendix along with E. Vermicularis eggs within the appendiceal lumen. Discussion Enterobius Vermicularis is the most common helminthic infection globally, especially among school-aged children [ 5 , 6 ]. Reports from the World Health Organization indicate that roughly 200 million people worldwide are affected by enterobiasis, with prevalence in children ranging from 4–28%. A significant portion of over 30% of cases occur in children aged 5–10 years. A notable difference is also observed between different regions, with some studies indicating prevalence rates between 2.5–4.5% in Latin America, 18% in Norway, 18.5% in South Korea, and 2.9% in Ethiopia [ 5 ]. Although a decline in prevalence has been observed in Iran from 17.2–6.7%, due to better hygiene practices and public health measures, the overall prevalence remains high [ 7 ]. The life cycle of pinworm is completed exclusively in humans, taking around 4–8 weeks on average to reach completion. The transmission mainly occurs via the fecal-oral route; eggs are ingested and hatch in the small intestine, while the larvae mature in the colon. Gravid female pinworms migrate to deposit the eggs in the perianal region at night, causing perianal pruritus, and subsequently aiding in further transmission of the pinworm eggs. Pruritus serves as an important symptom to form the diagnosis through the adhesive tape test, allowing the visualization of the eggs and larvae [ 6 ]. Pinworm infestations can present with clinical findings ranging from remaining asymptomatic and rarely detectable in stool examination to symptomatic presentation of abdominal pain or genitourinary symptoms like vulvovaginitis due to aberrant migration of pinworms [ 6 ]. E. vermicularis can rarely cause appendiceal lumen obstructive appendicitis with an inflammatory response that closely mimics and is indistinguishable from acute appendicitis both clinically and histologically. The exact pathophysiology remains unclear; however, current studies support a dual pathogenesis model describing that inflammation may be caused either by mechanical obstruction or by eosinophilic immune-mediated hypersensitivity reaction [ 4 , 5 , 8 ]. Acute appendicitis remains one of the most common afflictions warranting emergency abdominal surgery in children and adolescents, with an estimated lifetime risk of approximately 7–8% worldwide [ 1 , 3 ]. The function of the appendix, once believed to be vestigial, is now recognized as an immunological organ based on its rich lymphoid tissue [ 2 , 9 ]. The anatomy of the appendix, with a narrow lumen and situated at the ileocecal junction, predisposes it to become obstructed relatively easily, making it the most common initiating event in the pathophysiology of appendicitis. As a consequence of the obstruction, an elevation in the intraluminal pressure occurs, compromising venous and lymphatic drainage and inevitably leading to further distension. This process ushers in ischemia and necrosis, increasing the likelihood of the appendiceal wall getting perforated [ 10 ]. Obstructions of the appendiceal lumen can occur due to many potential reasons, commonly including fecaliths, foreign bodies, lymphoid hyperplasia, or neoplasia. While parasitic infections are relatively rare, they do remain in the differentials, especially in the pediatric population and endemic regions [ 3 , 4 ]. A study conducted in Benghazi, Libya between August and December indicated the presence of 7.2% (i.e. 18 of 250) of E. vermicularis in pediatric appendectomy specimens [ 11 ], a relatively higher prevalence than Pakistan with 2.8% out of 2956 cases [ 12 ] and Turkey (1.8% of 1334 cases) [ 13 ]. In a cohort of pediatric patients undergoing appendiceal surgery from the UK, the prevalence of E. vermicularis was reported to be about 7%, however, the majority of the cases lacked histological evidence of acute inflammation [ 14 ]. In the case narrated above, the patient was suspected to have appendicitis based on the classical constellation of symptoms, i.e., right Iliac fossa pain, fever, nausea, and anorexia. Laboratory findings displayed evidence of infection with leukocytosis and neutrophilia. Ultrasonography, considered a first-line imaging modality, revealed a clear picture of a thickened, edematous appendix. Although the accuracy of ultrasound is operator-dependent, it is still considered a reliable modality for typical presentations. Nevertheless, in atypical cases, CT or MRI may effectively be employed, with MRI being preferable in children due to less exposure to ionization radiation [ 10 ]. Diagnostic accuracy may be enhanced with the utilization of the Alvarado clinical scoring system, which assists in establishing an assessment scheme by integrating parameters like symptoms, signs, and laboratory findings that aid in the decision-making process [ 15 ]. Surgical intervention remains the mainstay of treatment, with the laparoscopic approach being preferred as it facilitates a faster recovery and minimizes complications [ 15 ]. However, in this case, due to clinical urgency, an open appendectomy was performed. Intraoperative findings included a hyperemic and distensible appendix with a visible worm infestation. Although Enterobius vermicularis can cause appendiceal inflammation, it often fails to impart histological findings of acute appendicitis in the majority of cases, as many appendices appear grossly normal intraoperatively, leading to underdiagnosis if the histopathology is omitted [ 16 ]. A cohort study of the pediatric population found that only 25% of the E. Vermicularis -positive appendices displayed true inflammation despite presenting with classical symptoms of appendicitis [ 16 ]. This presentation, also described as pseudo-appendicitis, may result in unnecessary surgery and a delay in anti-helminthic treatment, which can potentially increase recurrence and household transmission risk. Therefore, the ultimate diagnosis is made via histopathology that identifies an E. Vermicularis egg or adult worm within the appendiceal lumen, as illustrated in the case here. Postoperatively, Albendazole 400mg was prescribed twice for one week. Albendazole is both effective and ovicidal against nematodes and appropriate in children over two years of age and weighing > 10kg. A dosage of 200 mg is appropriate for children less than two years old or weighing under 10 kg [ 17 ]. Alternatives include Mebendazole (100 -200mg as a single dose, repeated on days 14 and 28) and Pyrantel Embonate (10 mg/kg for children over 7 months). Ivermectin may be reserved for extraintestinal or resistant cases [ 17 ]. Though non-operative management of uncomplicated appendicitis using antibiotics alone is gaining attention, it requires careful patient selection due to a high risk of recurrence. In complicated cases such as perforation or abscess, initial conservative management with intravenous antibiotics followed by interval appendectomy may be appropriate [ 3 , 10 ]. This case underscores the importance of considering parasitic etiologies such as E. Vermicularis in pediatric appendicitis, particularly in endemic areas. It also reinforces the value of routine histopathological examination of appendectomy specimens, which can uncover rare but clinically significant causes. Early diagnosis, appropriate surgical treatment, and timely anti-helminthic therapy are critical for optimal outcomes. Conclusion Parasitic infestation by Enterobius Vermicularis has a high global prevalence. Mostly causing perianal pruritus in the pediatric population, aberrant migration may also cause acute appendicitis through obstruction of the appendiceal lumen. Surgical intervention, the mainstay of treatment in acute appendicitis, may allow visualization of the nematodes; however, histopathology remains the most accurate tool to confirm their presence. Anti-helminthic therapy should not be delayed and commenced during the hospital stay. Declarations 1. Funding: None to disclose. 2. Conflicts of interest/Competing interests: None to disclose. 3. Ethics approval: Not applicable for case reports. 4. Consent to participate: Written informed consent was obtained from the patient involved and is reproducible upon demand. 5. Written Consent for publication: Written informed consent was obtained from the patient involved and is reproducible upon demand. 6. Availability of data and material: Not applicable. 7. Code availability: Not applicable. 8. Authors' contributions: N.A. wrote the main manuscript, T.A. curated the figures, and F.M. edited the manuscript. All the authors reviewed the manuscript References Walter K. Acute Appendicitis. JAMA. 2021 Dec 14;326(22):2339. doi: 10.1001/jama.2021.20410. PMID: 34905029. Deshmukh S, Verde F, Johnson PT, Fishman EK, Macura KJ. Anatomical variants and pathologies of the vermix. Emerg Radiol. 2014 Oct;21(5):543-52. doi: 10.1007/s10140-014-1206-4. Epub 2014 Feb 26. PMID: 24570122; PMCID: PMC4324638 Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015 Sep 26;386(10000):1278-1287. doi: 10.1016/S0140-6736(15)00275-5. Erratum in: Lancet. 2017 Oct 14;390(10104):1736. doi: 10.1016/S0140-6736(17)31502-7. PMID: 26460662. Harman Kamali G, Ulusoy C, Nikolovski A, Eğin S, Kamalı S. Uncommon causes of acute appendicitis: Retrospective analysis of 6785 histopathological findings in a tertiary center. Ulus Travma Acil Cerrahi Derg. 2022 Dec;28(12):1708-1715. doi: 10.14744/tjtes.2022.84937. PMID: 36453793; PMCID: PMC10198309. Lashaki EK, Mizani A, Hosseini SA, Habibi B, Taherkhani K, Javadi A, Taremiha A, Dodangeh S. Global prevalence of enterobiasis in young children over the past 20 years: a systematic review and meta-analysis. Osong Public Health Res Perspect. 2023 Dec;14(6):441-450. doi: 10.24171/j.phrp.2023.0204. Epub 2023 Dec 28. PMID: 38204424; PMCID: PMC10788413. Rawla P, Sharma S. Enterobius Vermicularis. 2023 Aug 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 30725659. Moosazadeh M, Abedi G, Afshari M, Mahdavi SA, Farshidi F, Kheradmand E. Prevalence of Enterobius vermicularis among Children in Iran: A Systematic Review and Meta-analysis. Osong Public Health Res Perspect. 2017 Apr;8(2):108-115. doi: 10.24171/j.phrp.2017.8.2.02. Epub 2017 Apr 30. PMID: 28540154; PMCID: PMC5441434. Pogorelić, Z.; Babić, V.; Bašković, M.; Ercegović, V.; Mrklić, I. Management and Incidence of Enterobius vermicularis Infestation in Appendectomy Specimens: A CrossSectional Study of 6359 Appendectomies. J. Clin. Med. 2024, 13, 3198. https://doi.org/10.3390/jcm13113198 Penny SM. Imaging the Vermiform Appendix. Radiol Technol. 2018 Jul;89(6):571- 590. PMID: 30420527. Lotfollahzadeh S, Lopez RA, Deppen JG. Appendicitis. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493193/ Younis EZ. Prevalence of Enterobius vermicularis among Appendicitis Children Using Histopathology Technique in Benghazi, Libya. Ann Clin Med Res. 2021; 2(5): 1041. Ahmed MU, Bilal M, Anis K, Khan AM, Fatima K, Ahmed I, Khatri AM, Shafiq-urRehman. The Frequency of Enterobius Vermicularis Infections in Patients Diagnosed With Acute Appendicitis in Pakistan. Glob J Health Sci. 2015 Feb 24;7(5):196-201. doi: 10.5539/gjhs.v7n5p196. PMID: 26156929; PMCID: PMC4803892. Gerçel G, Anadolulu Aİ, Kocaman OH, Yol C. Enterobius vermicularis: A cause or an incidental finding in pediatric appendicitis?. Turkish J Ped Surg 2024;38(1):7- 12. doi: 10.62114/JTAPS.2024.18. Fleming CA, Kearney DE, Moriarty P, Redmond HP, Andrews EJ. An evaluation of the relationship between Enterobius vermicularis infestation and acute appendicitis in a paediatric population--A retrospective cohort study. Int J Surg. 2015 Jun;18:154-8. doi: 10.1016/j.ijsu.2015.02.012. Epub 2015 Mar 11. PMID: 25771103 A. Petroianu Diagnosis of acute appendicitis Int. J. Surg.(2012) Lala S, Upadhyay V. Enterobius vermicularis and its role in paediatric appendicitis: protection or predisposition? ANZ J Surg. 2016 Sep;86(9):717-9. doi: 10.1111/ans.13464. Epub 2016 Mar 16. PMID: 26990375. Wendt S, Trawinski H, Schubert S, Rodloff AC, Mössner J, Lübbert C. The Diagnosis and Treatment of Pinworm Infection. Dtsch Arztebl Int. 2019 Mar 29;116(13):213-219. doi: 10.3238/arztebl.2019.0213. PMID: 31064642; PMCID: PMC6522669 Additional Declarations No competing interests reported. Supplementary Files CAREchecklistEnglish2013.pdf Cite Share Download PDF Status: Published Journal Publication published 24 Jan, 2026 Read the published version in SN Comprehensive Clinical Medicine → Version 1 posted Editorial decision: Revision requested 28 May, 2025 Editor assigned by journal 26 May, 2025 Submission checks completed at journal 26 May, 2025 First submitted to journal 08 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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An affliction of the younger population, acute appendicitis occurs due to the inflammation and possible infection of the vermiform appendix, a tubular structure present at the convergence of the taenia coli at the base of the cecum [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The constellation of symptoms occurs when the inside passage of the appendix is blocked, resulting in edema and inflammation.\u003c/p\u003e \u003cp\u003eThe diagnosis is largely based on the patient\u0026rsquo;s history, clinical examination, and laboratory evaluation. Confirmation through abdominal imaging may be achieved as well. The classic presentation outlines vague periumbilical pain with migration to the right lower quadrant of the abdomen and low-grade fever, as well as accompanying nausea, intermittent vomiting, and anorexia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A wide spectrum of inciting factors has been cited as causes of acute appendicitis, ranging from the rarest of neuroendocrine tumors and serrated adenomas to low-grade mucinous neoplasm, hyperplastic lymph nodes and polyps, and intestinal parasites [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Laparoscopic appendectomy still holds fort as the most common intervention.\u003c/p\u003e \u003cp\u003e \u003cem\u003eEnterobius Vermicularis (E. vermicularis\u003c/em\u003e) is a globally prevalent parasite most frequently affecting the pediatric population [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. \u003cem\u003eE. Vermicularis\u003c/em\u003e, also known as pinworm, is a globally common nematode infection, usually transmitted between humans via the feco-oral route. The initial infestation remains asymptomatic while the eggs are being laid which leads to worm migration towards the anal margin causing nocturnal perianal pruritus [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Hence, appendicitis due to this nematode presents as a peculiar case indeed and one that is described in this report.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 11-year-old girl, without a significant medical or surgical history, presented to the emergency department with the acute onset of right iliac fossa pain, which she elaborated to be constant, sharp, and non-radiating with associated mild fever, anorexia, nausea, and one episode of vomiting. Examination revealed a soft abdomen with tenderness in the right iliac fossa, along with a positive rebound sign. Urinalysis showed no infectious etiology for her condition. Laboratory investigations showed a hemoglobin level of 11 g/dL and a white cell count of 12.5\u0026times;10\u003csup\u003e9\u003c/sup\u003e with marked neutrophilia. Coagulation profile and renal function tests were well within normal values.\u003c/p\u003e \u003cp\u003eSubsequently, abdominal and pelvic ultrasonography was ordered. Pelvic ultrasonography showed normal pelvic anatomy and ovaries with no free fluid, however, abdominal ultrasonography revealed an edematous pelvic appendix with significant wall thickening, suggestive of acute appendicitis. Upon performing a reevaluation, abdominal tenderness remained persistent despite adequate hydration and analgesia; consequently, an open appendectomy under general anesthesia was performed. Intraoperatively, a hyperemic and severely edematous appendix was visualized and subsequently excised. The appendiceal tip was especially swollen, giving an impression of luminal collection, \u003cem\u003eas illustrated in\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Upon dissecting the appendiceal tip and subsequently the entire length, it was revealed that the primary cause of the inflammation was luminal blockage by a nest of worms, \u003cem\u003eas illustrated in\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAs a consequence, anti-helminthic therapy consisting of albendazole 400 mg twice daily for one week was commenced for the patient and close contacts, leading to successful treatment and subsequent discharge in 24 hours. Upon follow-up appointment, she was generally doing well and had no complaints. Examination showed a well-healed and uninfected scar. The histopathology report revealed an inflamed appendix along with \u003cem\u003eE. Vermicularis\u003c/em\u003e eggs within the appendiceal lumen.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cem\u003eEnterobius Vermicularis\u003c/em\u003e is the most common helminthic infection globally, especially among school-aged children [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Reports from the World Health Organization indicate that roughly 200\u0026nbsp;million people worldwide are affected by enterobiasis, with prevalence in children ranging from 4\u0026ndash;28%. A significant portion of over 30% of cases occur in children aged 5\u0026ndash;10 years. A notable difference is also observed between different regions, with some studies indicating prevalence rates between 2.5\u0026ndash;4.5% in Latin America, 18% in Norway, 18.5% in South Korea, and 2.9% in Ethiopia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although a decline in prevalence has been observed in Iran from 17.2\u0026ndash;6.7%, due to better hygiene practices and public health measures, the overall prevalence remains high [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe life cycle of pinworm is completed exclusively in humans, taking around 4\u0026ndash;8 weeks on average to reach completion. The transmission mainly occurs via the fecal-oral route; eggs are ingested and hatch in the small intestine, while the larvae mature in the colon. Gravid female pinworms migrate to deposit the eggs in the perianal region at night, causing perianal pruritus, and subsequently aiding in further transmission of the pinworm eggs. Pruritus serves as an important symptom to form the diagnosis through the adhesive tape test, allowing the visualization of the eggs and larvae [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Pinworm infestations can present with clinical findings ranging from remaining asymptomatic and rarely detectable in stool examination to symptomatic presentation of abdominal pain or genitourinary symptoms like vulvovaginitis due to aberrant migration of pinworms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eE. vermicularis\u003c/em\u003e can rarely cause appendiceal lumen obstructive appendicitis with an inflammatory response that closely mimics and is indistinguishable from acute appendicitis both clinically and histologically. The exact pathophysiology remains unclear; however, current studies support a dual pathogenesis model describing that inflammation may be caused either by mechanical obstruction or by eosinophilic immune-mediated hypersensitivity reaction [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAcute appendicitis remains one of the most common afflictions warranting emergency abdominal surgery in children and adolescents, with an estimated lifetime risk of approximately 7\u0026ndash;8% worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The function of the appendix, once believed to be vestigial, is now recognized as an immunological organ based on its rich lymphoid tissue [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The anatomy of the appendix, with a narrow lumen and situated at the ileocecal junction, predisposes it to become obstructed relatively easily, making it the most common initiating event in the pathophysiology of appendicitis. As a consequence of the obstruction, an elevation in the intraluminal pressure occurs, compromising venous and lymphatic drainage and inevitably leading to further distension. This process ushers in ischemia and necrosis, increasing the likelihood of the appendiceal wall getting perforated [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eObstructions of the appendiceal lumen can occur due to many potential reasons, commonly including fecaliths, foreign bodies, lymphoid hyperplasia, or neoplasia. While parasitic infections are relatively rare, they do remain in the differentials, especially in the pediatric population and endemic regions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A study conducted in Benghazi, Libya between August and December indicated the presence of 7.2% (i.e. 18 of 250) of \u003cem\u003eE. vermicularis\u003c/em\u003e in pediatric appendectomy specimens [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], a relatively higher prevalence than Pakistan with 2.8% out of 2956 cases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and Turkey (1.8% of 1334 cases) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In a cohort of pediatric patients undergoing appendiceal surgery from the UK, the prevalence of \u003cem\u003eE. vermicularis\u003c/em\u003e was reported to be about 7%, however, the majority of the cases lacked histological evidence of acute inflammation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the case narrated above, the patient was suspected to have appendicitis based on the classical constellation of symptoms, i.e., right Iliac fossa pain, fever, nausea, and anorexia. Laboratory findings displayed evidence of infection with leukocytosis and neutrophilia. Ultrasonography, considered a first-line imaging modality, revealed a clear picture of a thickened, edematous appendix. Although the accuracy of ultrasound is operator-dependent, it is still considered a reliable modality for typical presentations. Nevertheless, in atypical cases, CT or MRI may effectively be employed, with MRI being preferable in children due to less exposure to ionization radiation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDiagnostic accuracy may be enhanced with the utilization of the Alvarado clinical scoring system, which assists in establishing an assessment scheme by integrating parameters like symptoms, signs, and laboratory findings that aid in the decision-making process [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Surgical intervention remains the mainstay of treatment, with the laparoscopic approach being preferred as it facilitates a faster recovery and minimizes complications [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, in this case, due to clinical urgency, an open appendectomy was performed.\u003c/p\u003e \u003cp\u003eIntraoperative findings included a hyperemic and distensible appendix with a visible worm infestation. Although \u003cem\u003eEnterobius vermicularis\u003c/em\u003e can cause appendiceal inflammation, it often fails to impart histological findings of acute appendicitis in the majority of cases, as many appendices appear grossly normal intraoperatively, leading to underdiagnosis if the histopathology is omitted [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A cohort study of the pediatric population found that only 25% of the \u003cem\u003eE. Vermicularis\u003c/em\u003e-positive appendices displayed true inflammation despite presenting with classical symptoms of appendicitis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This presentation, also described as pseudo-appendicitis, may result in unnecessary surgery and a delay in anti-helminthic treatment, which can potentially increase recurrence and household transmission risk. Therefore, the ultimate diagnosis is made via histopathology that identifies an \u003cem\u003eE. Vermicularis\u003c/em\u003e egg or adult worm within the appendiceal lumen, as illustrated in the case here.\u003c/p\u003e \u003cp\u003ePostoperatively, Albendazole 400mg was prescribed twice for one week. Albendazole is both effective and ovicidal against nematodes and appropriate in children over two years of age and weighing\u0026thinsp;\u0026gt;\u0026thinsp;10kg. A dosage of 200 mg is appropriate for children less than two years old or weighing under 10 kg [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Alternatives include Mebendazole (100 -200mg as a single dose, repeated on days 14 and 28) and Pyrantel Embonate (10 mg/kg for children over 7 months). Ivermectin may be reserved for extraintestinal or resistant cases [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThough non-operative management of uncomplicated appendicitis using antibiotics alone is gaining attention, it requires careful patient selection due to a high risk of recurrence. In complicated cases such as perforation or abscess, initial conservative management with intravenous antibiotics followed by interval appendectomy may be appropriate [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis case underscores the importance of considering parasitic etiologies such as \u003cem\u003eE. Vermicularis\u003c/em\u003e in pediatric appendicitis, particularly in endemic areas. It also reinforces the value of routine histopathological examination of appendectomy specimens, which can uncover rare but clinically significant causes. Early diagnosis, appropriate surgical treatment, and timely anti-helminthic therapy are critical for optimal outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eParasitic infestation by \u003cem\u003eEnterobius Vermicularis\u003c/em\u003e has a high global prevalence. Mostly causing perianal pruritus in the pediatric population, aberrant migration may also cause acute appendicitis through obstruction of the appendiceal lumen. Surgical intervention, the mainstay of treatment in acute appendicitis, may allow visualization of the nematodes; however, histopathology remains the most accurate tool to confirm their presence. Anti-helminthic therapy should not be delayed and commenced during the hospital stay.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e1. Funding:\u0026nbsp;\u003c/strong\u003eNone to disclose.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;2. Conflicts of interest/Competing interests:\u0026nbsp;\u003c/strong\u003eNone to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Ethics approval:\u0026nbsp;\u003c/strong\u003eNot applicable for case reports.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;4. Consent to participate:\u0026nbsp;\u003c/strong\u003eWritten\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003einformed consent was obtained from the patient involved and is reproducible upon demand.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;5. Written Consent for publication:\u0026nbsp;\u003c/strong\u003eWritten\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003einformed consent was obtained from the patient involved and is reproducible upon demand.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Availability of data and material:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;7. Code availability:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;8. Authors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eN.A. wrote the main manuscript, T.A. curated the figures, and F.M. edited the manuscript. All the authors reviewed the manuscript\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWalter K. Acute Appendicitis. JAMA. 2021 Dec 14;326(22):2339. doi: 10.1001/jama.2021.20410. PMID: 34905029.\u003c/li\u003e\n\u003cli\u003eDeshmukh S, Verde F, Johnson PT, Fishman EK, Macura KJ. Anatomical variants and pathologies of the vermix. Emerg Radiol. 2014 Oct;21(5):543-52. doi: 10.1007/s10140-014-1206-4. Epub 2014 Feb 26. PMID: 24570122; PMCID: PMC4324638\u003c/li\u003e\n\u003cli\u003eBhangu A, S\u0026oslash;reide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015 Sep 26;386(10000):1278-1287. doi: 10.1016/S0140-6736(15)00275-5. Erratum in: Lancet. 2017 Oct 14;390(10104):1736. doi: 10.1016/S0140-6736(17)31502-7. PMID: 26460662.\u003c/li\u003e\n\u003cli\u003eHarman Kamali G, Ulusoy C, Nikolovski A, Eğin S, Kamalı S. Uncommon causes of acute appendicitis: Retrospective analysis of 6785 histopathological findings in a tertiary center. Ulus Travma Acil Cerrahi Derg. 2022 Dec;28(12):1708-1715. doi: 10.14744/tjtes.2022.84937. PMID: 36453793; PMCID: PMC10198309.\u003c/li\u003e\n\u003cli\u003eLashaki EK, Mizani A, Hosseini SA, Habibi B, Taherkhani K, Javadi A, Taremiha A, Dodangeh S. Global prevalence of enterobiasis in young children over the past 20 years: a systematic review and meta-analysis. Osong Public Health Res Perspect. 2023 Dec;14(6):441-450. doi: 10.24171/j.phrp.2023.0204. Epub 2023 Dec 28. PMID: 38204424; PMCID: PMC10788413.\u003c/li\u003e\n\u003cli\u003eRawla P, Sharma S. Enterobius Vermicularis. 2023 Aug 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan\u0026ndash;. PMID: 30725659.\u003c/li\u003e\n\u003cli\u003eMoosazadeh M, Abedi G, Afshari M, Mahdavi SA, Farshidi F, Kheradmand E. Prevalence of Enterobius vermicularis among Children in Iran: A Systematic Review and Meta-analysis. Osong Public Health Res Perspect. 2017 Apr;8(2):108-115. doi: 10.24171/j.phrp.2017.8.2.02. Epub 2017 Apr 30. PMID: 28540154; PMCID: PMC5441434. \u003c/li\u003e\n\u003cli\u003ePogorelić, Z.; Babić, V.; Ba\u0026scaron;ković, M.; Ercegović, V.; Mrklić, I. Management and Incidence of Enterobius vermicularis Infestation in Appendectomy Specimens: A CrossSectional Study of 6359 Appendectomies. J. Clin. Med. 2024, 13, 3198. https://doi.org/10.3390/jcm13113198 \u003c/li\u003e\n\u003cli\u003ePenny SM. Imaging the Vermiform Appendix. Radiol Technol. 2018 Jul;89(6):571- 590. PMID: 30420527.\u003c/li\u003e\n\u003cli\u003eLotfollahzadeh S, Lopez RA, Deppen JG. Appendicitis. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493193/\u003c/li\u003e\n\u003cli\u003eYounis EZ. Prevalence of Enterobius vermicularis among Appendicitis Children Using Histopathology Technique in Benghazi, Libya. Ann Clin Med Res. 2021; 2(5): 1041.\u003c/li\u003e\n\u003cli\u003eAhmed MU, Bilal M, Anis K, Khan AM, Fatima K, Ahmed I, Khatri AM, Shafiq-urRehman. The Frequency of Enterobius Vermicularis Infections in Patients Diagnosed With Acute Appendicitis in Pakistan. Glob J Health Sci. 2015 Feb 24;7(5):196-201. doi: 10.5539/gjhs.v7n5p196. PMID: 26156929; PMCID: PMC4803892. \u003c/li\u003e\n\u003cli\u003eGer\u0026ccedil;el G, Anadolulu Aİ, Kocaman OH, Yol C. Enterobius vermicularis: A cause or an incidental finding in pediatric appendicitis?. Turkish J Ped Surg 2024;38(1):7- 12. doi: 10.62114/JTAPS.2024.18.\u003c/li\u003e\n\u003cli\u003eFleming CA, Kearney DE, Moriarty P, Redmond HP, Andrews EJ. An evaluation of the relationship between Enterobius vermicularis infestation and acute appendicitis in a paediatric population--A retrospective cohort study. Int J Surg. 2015 Jun;18:154-8. doi: 10.1016/j.ijsu.2015.02.012. Epub 2015 Mar 11. PMID: 25771103\u003c/li\u003e\n\u003cli\u003eA. Petroianu Diagnosis of acute appendicitis Int. J. Surg.(2012) \u003c/li\u003e\n\u003cli\u003eLala S, Upadhyay V. Enterobius vermicularis and its role in paediatric appendicitis: protection or predisposition? ANZ J Surg. 2016 Sep;86(9):717-9. doi: 10.1111/ans.13464. Epub 2016 Mar 16. PMID: 26990375.\u003c/li\u003e\n\u003cli\u003eWendt S, Trawinski H, Schubert S, Rodloff AC, M\u0026ouml;ssner J, L\u0026uuml;bbert C. The Diagnosis and Treatment of Pinworm Infection. Dtsch Arztebl Int. 2019 Mar 29;116(13):213-219. doi: 10.3238/arztebl.2019.0213. PMID: 31064642; PMCID: PMC6522669\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Enterobius Vermicularis, Pinworm, Helminth, Acute Appendicitis","lastPublishedDoi":"10.21203/rs.3.rs-6623733/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6623733/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003e \u003cem\u003eEnterobius Vermicularis\u003c/em\u003e, usually causing perianal pruritus in children, can rarely become the cause of acute appendicitis. It is imperative to discuss this unique manifestation of this parasitic infestation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe Medline database was extensively searched for literature covering the different aspects of this clinical manifestation to discuss alongside the unusual case presentation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e \u003cem\u003eEnterobius Vermicularis\u003c/em\u003e is a nematode endemic to various parts of the developing world with a significantly rising prevalence. Colonizing humans as a primary host, the parasite usually causes perianal pruritus. In rare instances, however, after successful migration and obstruction of the appendiceal lumen, acute appendicitis may ensue. Acute appendicitis, diagnosed via clinical presentation and radiologic investigation, warrants surgical intervention.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eParasitic manifestation may be visible perioperatively or become evident upon histopathology. Anti-helminthic therapy commencement should not be delayed to effectively reduce transmission risk and inevitably cure the condition.\u003c/p\u003e","manuscriptTitle":"Pinworm in the Appendix: An Unusual Cause of Appendiceal Inflammation; A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 05:46:17","doi":"10.21203/rs.3.rs-6623733/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-28T07:56:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-26T09:53:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-26T07:52:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2025-05-08T22:40:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"02c741c2-ee4d-4a3b-8ced-ff8c4a601e0d","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:07:13+00:00","versionOfRecord":{"articleIdentity":"rs-6623733","link":"https://doi.org/10.1007/s42399-026-02264-4","journal":{"identity":"sn-comprehensive-clinical-medicine","isVorOnly":false,"title":"SN Comprehensive Clinical Medicine"},"publishedOn":"2026-01-24 15:57:19","publishedOnDateReadable":"January 24th, 2026"},"versionCreatedAt":"2025-06-23 05:46:17","video":"","vorDoi":"10.1007/s42399-026-02264-4","vorDoiUrl":"https://doi.org/10.1007/s42399-026-02264-4","workflowStages":[]},"version":"v1","identity":"rs-6623733","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6623733","identity":"rs-6623733","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}