ASCARIS LUMBRICOIDES PRESENTING AS AN OMENTAL MASS
GULZADEOZYALVACLI1, ABDULKADIRKUCUKBAYRAK2, ESENGULUZUNER3, EROLAYAZ4, MELTEMOZNUR5
1Abant Izzet Baysal Unıversity, Faculty of Medicine, Department of Pathology - 2Abant Izzet Baysal University, Faculty of Medicine, Department of Clinical Bacteriology and Infectious Diseases - 3Osmaniye State Hospital, Division of Pathology - 4Abant Izzet Baysal University, Faculty of Medicine, Department of Medical Parasitology - 5Namik Kemal University, Faculty of Medicine, Department of Medical Pathology, Bolu, Turkey
Introduction
Ascaris lumbricoides (AL) is the world’s most common helminth infection that generally affects children(1-3). In Turkey, it is more frequently seen in the Southeast/East region and Inner Anatolia, with prevalence rates varying between 0.25-96%(4,5).
The two main clinical forms of AL infection are pulmonary and intestinal ascariasis. The latter tends to show an asymptomatic course while the symptoms depend on the total number of helminths.
A mild intestinal infection presents with lack of appetite, weight loss, colicky abdominal pain and diarrhea. In adults, absorption of the nematode’s toxic and allergenic metabolites can lead to neuro- logical symptoms. Colics are particularly common in cases with epigastric involvement. A high num- ber of parasites can mechanically block the intestines, leading to intestinal obstruction(4). Diagnosis is made based on stool examination for eggs and parasites(6).
The adult form of AL can enter the biliary and pancreatic canals and migrate into the portal venous system or the abdominal cavity, affecting various localizations. Ectopic localizations of the AL infec- tion may present a diagnostic challenge and may lead to diffent type of morbidities(2,3,7). This report describes a rare case of ascariasis leading to the for- mation of a mass in the omentum.
Case report
A 35-year-old woman living in a city of Southeast Turkey underwent cesarean section at the 38th gestational week and delivered a healthy female infant. Past medical histories of her and her family were uneventful. She had no history of smoking or use of any other drugs. During surgery, two grey- white elastic-textured masses measuring 0.8 cm and 0.5 cm were noticed in the omental fat tissue and right paratubal area, respectively. The masses which grossly resembled endometriotic lesions were
Acta Medica Mediterranea, 2014, 30: 1393
ABSTRACT
Introduction: Ascaris lumbricoides (AL), is an intestinal parasite with various clinical presentations. It is common in underde- veloped rural areas both in Turkey and in the rest of the world. Ectopic localizations of AL are rare, and there only a few reported cases of omental localization.
Case: We present a rare case in which an omental and a paratubal mass were detected during cesarean section in an asympto- matic pregnant patient. The histopathological examination revealed a granulomatous reaction and AL eggs inside the masses.
Discussion: Infection with AL causes various intestinal complications like acute appendicitis, volvulus, invagination, intestinal perforation and granulomatous peritonitis.
Conclusion: It should be kept in mind that granulomatous lesions presenting as omental masses may be randomly detected in asymptomatic individuals and pregnant woman infected with AL.
Key words: Ascariasis, Omentum, Pregnancy.
Received May 18, 2014; AcceptedSeptember 02, 2014
excised. Microscopic examination showed a wide necrotic area surrounded by a mixed inflammatory cell infiltrate containing lymphocytes, eosinophils and multinucleated giant cells (granulomatous inflammation) (Figure 1, Figure 2).
Inside this necrotic area, multiple oval bipolar structures were remarkable (Figure 3). Since the size and morphological features of these oval structures were consistent with AL eggs (Figure 4) a diagnosis of omental ascariasis was made. There were no clini-
cal findings except weakness and mild abdominal pain. Following surgery, the patient did not come to the clinic to pick up the pathology report, and when contacted by telephone, she reported no symptoms in her history that could suggest ascariasis. As the patient declined further testing and treatment, no stool tests could be performed.
Discussion
Patients infected with AL are mainly asympto- matic. The parasite is usually transmitted by the fecal-oral route. After oral ingestion of eggs, there are three phases of the infection: pulmonary phase, intestinal phase and complications. Intestinal adult forms of AL can lead to complications like acute appendicitis, volvulus, invagination, intestinal perfo- ration and granulomatous peritonitis(8-10).
After causing intestinal perforation, the adult form passes to the peritoneum and is destroyed there.
However, as the eggs are resistant to destruction, their normal maturation may continue and they may cause granulomatous reactions in the tissues.
Perforation can occur along a suture line from a previous surgery, or when the adult form pro- ceeds to the appendix or Meckel’s diverticulum causing gangrene, although it can also sponta- neously close and self-limit without necessitating emergency surgery(2,3,10). In our case, the patient did not have any acute abdominal symptoms and there was no need for emergency surgery.
To the best of our knowledge, only 5 cases of omental ascariasis have been reported in the litera-
ture(2,11,12). One of these reports described a 25-year-
old woman with acute abdominal pain and abdomi- nal masses(12). During surgery, no perforation was detected in the gastrointestinal tract and the ovaries were normal(12). Examination of the omental masses excised at laparotomy showed an abscess formation
1394 Gulzade Ozyalvacli, Abdulkadir Kucukbayrak et Al
Figure 1: Necrosis, surrounded by granulomatous inflammation containing a fibrous band and multinuclea- ted giant cells (Hematoxylin-Eosin, x 40).
Figure 2: Necrosis, surrounded by granulomatous inflammation containing a fibrous band; oval eggs of Ascaris lumbricoides inside the necrosis (Hematoxylin- Eosin, x 40).
Figure 3: Inside the necrosis, oval eggs of Ascaris lum- bricoides (Hematoxylin-Eosin, x 400).
Figure 4: Oval eggs of Ascaris lumbricoides (Hematoxylin-Eosin, x 400).
containing necrosis and the adult female roundworm in the centre of necrosis. Histopathological examina- tion demonstrated AL eggs at the centre of the necro- sis, surrounded by lymphocyte and eosinophil infil- tration, giant cells and fibrosis. In our case, masses were detected in the omental fat tissue and paratubal area during cesarean section, with histopathological examination revealing similar findings. This case is unique since masses in this localization were found in an asymptomatic patient.
In conclusion, ectopic localization of AL is rare but possible. It must be kept in mind that omental masses caused by AL may be incidentally detected in asymptomatic infected individuals.
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Correspoding author GULZADEOZYALVACLı,
Department of Pathology, Abant Izzet Baysal University Faculty of Medicine
14280 Bolu (Turkey)
Ascaris Lumbricoides presenting as an omental mass 1395
