Presentation
5-year-old male with a recent history of immigration to the United States who presents to the emergency department with right lower quadrant pain. The pain is worsening and associated with nausea, diarrhea, and vomiting. No history of fevers, weight loss, rectal bleeding or melena. Acute appendicitis is suspected and an abdominal ultrasound is performed.
Patient Data
In the right lower quadrant of the abdomen, within the bowel loops, there is a mobile, hypoechoic, tubular structure with echogenic walls and central linear echogenicity. These sonographic findings and patient's history are most consistent with a parasitic infection, likely ascariasis, which is an infection of the small intestine caused by Ascaris lumbricoides, a species of roundworm.
The appendix is fully visualized with no presence of appendicolith, no free fluid, no tenderness on compression, no wall hyperemia, and no wall thickening.
Thank you Dr. Antoine Hamedi-Sangsari, MD and Dr. Gaurav Saigal, MD from the University of Miami Health System and the Jackson Memorial Hospital for your contribution and support in writing this case.
Case Discussion
Acute abdominal pain is a common reason for emergency department visits in the pediatric world 1. The differential diagnosis for right lower quadrant abdominal pain in children includes various etiologies, such as appendicitis, gastroenteritis, urinary tract infection, constipation, intussusception, and parasitic infections 1. In this case, the ultrasound image findings were most consistent with a parasitic infection, likely ascariasis which was later confirmed via stool studies. Ascariasis is an infection of the small intestine caused by Ascaris lumbricoides, a species of roundworm 2,3. The mobile, hypoechoic, tubular structure seen on ultrasound corresponds to the presence of the worms within the bowel loops and are classic ultrasound findings 3.
Ascariasis is commonly found in areas with poor sanitation and transmission occurs through ingestion of food or water contaminated with the parasite's eggs 2. Given the patient's history, it is likely that he was exposed to the parasite in his country of origin 4. The symptoms of ascariasis, including abdominal pain, nausea, diarrhea, and vomiting, are a result of the worm burden in the small intestine 2-4.
In this case, the initial suspicion of acute appendicitis was ruled out based on the ultrasound findings, which were more consistent with ascariasis or other parasitic infection. This case highlights the importance of considering parasitic infections in young patients with abdominal pain, particularly in those with a history of travel or immigration and with signs and symptoms of appendicitis.
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