Journal of Infection and Public Health (2016) 9, 519—522

SHORT COMMUNICATION

Co-infection with Enterobius

vermicularis and Taenia saginata
mimicking acute appendicitis
Kasra H. Saravi a, Mahdi Fakhar b,∗, Javad Nematian a,
Maryam Ghasemi c

a Department of Pathobiology, School of Medicine, Islamic Azad University, Tehran,

Iran
b Molecular and Cell Biology Research Center, Department of Parasitology, School of

Medicine, Mazandaran University of Medical Sciences, Sari, Iran

c Immunogenetics Research Center, Department of Pathology, School of Medicine,

Mazandaran University of Medical Sciences, Sari, Iran

Received 1 September 2015 ; received in revised form 4 November 2015; accepted 11 November 2015

KEYWORDS Summary In this report, we describe an unusual case of verminous appendicitis due
Verminous to Enterobius vermicularis and Taenia saginata in a 29-year-old woman from Iran.
appendicitis; The histopathological examinations and parasitological descriptions of both worms
Enterobius found in the appendix lumen are discussed. The removed appendix exhibited the
vermicularis; macroscopic and microscopic features of acute appendicitis. Antihelminthic therapy
Taenia saginata was initiated with single doses of praziquantel for the taeniasis and mebendazole
for the enterobiasis, and the patient was discharged.
© 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier
Limited. All rights reserved.

Introduction verminous appendicitis remains common [1]. Sev-

In tropical countries in which intestinal para-
sitic infections are quite common, such as Iran,
∗ Corresponding author at: Molecular and Cell Biology Research
Center, Department of Parasitology, School of Medicine,
Mazandaran University of Medical Sciences, Farah Abad, Sari
481751665, Iran. Tel.: +98 1133543248; fax: +98 1133543248.
E-mail address: mahdif53@yahoo.com (M. Fakhar).
eral parasitic infections involving the appendix
have been reported as the etiologies of appendici-
tis in humans. Among these infections, helminthes
(verminuos) infections caused by Enterobius ver-
micularis, Taenia sp., Ascaris sp., Schistosoma
sp., and Trichuris trichiura are most frequently
reported [2—8].
Human enterobiasis caused by Enterobius ver-
micularis (E. vermicularis) infection is usually

http://dx.doi.org/10.1016/j.jiph.2015.11.013
1876-0341/© 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Limited. All rights reserved.

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 520 K.H. Saravi et al.

asymptomatic. The most common symptom is pruri-
tus in the perianal region, but infestation may also
present with ileocolitis, urinary tract infection, vul-
vovaginitis and appendicitis [9]. The presence of
pinworms in the appendix has been demonstrated
to mimicking appendicitis and/or appendiceal colic
[10], but there is frequently no histological evi-
dence of acute inflammation [9,11—13]. However,
E. vermicularis is the most common worm found in
the appendix, particularly in children and/or ado-
lescents. Moreover, in our pervious study in the
Mazandaran Province of northern Iran, verminous
appendicitis was found to be more prevalent in the
age group below 10 years old [14]. Additionally,
the mean prevalence of E. vermicularis infection
in the province has been reported to be approx-
imately 4% [15]. Human taeniasis (due to Taenia
saginata and Taenia solium) is a zoonotic tapeworm
infection that is characterized by the presence of
the adult form of the helminth in the human small
intestine. Infection frequently occurs in individuals
who eat poorly cooked and or unfrozen beef or pork
containing the cysticerci.
Case report
In July 2012, a 29-year-old woman from the Mazan-
daran Province (53◦ 6 E, 36◦ 23 N), which is south of
the Caspian Sea in northern Iran and has subtropical
climate conditions, was referred to our emergency
department due to acute abdominal pain in her
right lower quadrant (RLQ) with a one-day his-
tory of colic pain, anorexia, vomiting and nausea.
A physical examination revealed right iliac fossa
tenderness and a mild fever. A laboratory exami-
nation revealed an elevated white blood cell (WBC)
count of 10,600/␮L with marked neutrophilia (67%
neutrophils). No marked eosinophilia was observed
(2% eosinophils). The removed appendix exhibited
the macroscopic and microscopic features of acute
appendicitis. Microscopic slides revealed mucosal
ulceration and luminal exudates accompanied by an
elongated and flattened segment of the helminth.
A large number of round eggs with remarkable
embryophores (an appearance of thick radial stri-
ations) were within the parasite uteri (known as
gravid proglottids) and also freely floating in the
lumina (Fig. 1). These characteristics confirmed
that the helminth belonged to the genus Taenia sp.
However, the eggs of both Taenia spp. are mor-
phologically identical, but based on the history
of the patient, which included no consumption of
pork, the species was putatively identified as T.
saginata. The patient was from the Mazandaran
Province in which taeniasis caused by T. saginata is
endemic, and the prevalence of the taeniasis in this
province is estimated to be approximately 1—2%
[16]. In contrast, because Iran is a Muslim country,
no pork is eaten; accordingly, all human taeniasis
occurs following the consumption of undercooked
beef. Human infections with T. saginata have been
observed in various regions of the country, par-
ticularly the Mazandaran Province in northern Iran
where our patient lived.
Moreover, many transverse cross-section of E.
vermicularis pinworms displaying the characteris-
tic cuticular ridge (known as an alae) on both sides
were identified (Fig. 2). Antihelminthic therapy was
initiated with single doses of praziquantel for the
taeniasis and mebendazole for the enterobiasis,
and the patient was discharged.
Discussion
There is only one report of taeniasis/enterobiasis
co-infection, which occurred in a 12-year-old boy

Figure 1 (A) Cross-section of Taenia saginata in the appendiceal lumen showing proglottid segment containing the
numerous eggs; the mucosa shows an acute inflammation. (B) Note the characteristic emberyphore (radial striation) of
Taenia eggs inside the proglottid. Hematoxylin and eosin stain (100× and 400× magnification for A and B, respectively).

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 Co-infection with Enterobius vermicularis and Taenia saginata
Figure 2 (A) Cross-sections of E. vermicularis in the appendiceal lumen. Note the characteristic pair of cuticular
ridge (cephalic alae). (B) Flattened asymmetrically on one side, ovoid eggs. Hematoxylin and eosin stain (100× and
400× magnification for A and B, respectively).
from Iran [17]. To the best of our knowledge,
this is the second report of the co-existence of
taeniasis and enterobiasis from Iran. Therefore,
it seems that this unusual condition is extremely
rare. Tapeworm infections due to T. saginata are
prevalent worldwide, and T. solium is more fre-
quent in non-Muslim countries. Because pork is
believed to be a non-Halal meat in Islam, Mus-
lims do not eat pork. Generally, eating undercooked
pork is the primary risk factor for acquiring taenia-
sis due to T. solium. The main clinical symptoms
of this infection are abdominal pain that occa-
sionally occurs with mild eosinophilia and fever.
The occurrence of the co-existence of enterobi-
asis and taeniasis in the appendix is extremely
unusual. However, recently in Turkey, Çallı et al.
[4] presented a case of appendicitis in which E.
vermicularis was only the worm detected in the
appendectomy material, but T. saginata eggs were
detected, and the adult worm was detected in
the stool of the patient. However, the association
of taeniasis and acute appendicitis is uncom-
mon.
In conclusion, the association between parasitic
infections of the appendix and acute appendicitis
has been widely investigated. However, the role of
the helminthes in appendicitis remains controver-
sial. In general, helminthes cause acute abdominal
pain by blocking the gut lumen. Moreover, this con-
dition can clinically mimic acute appendicitis. We
believe that in our patient, a luminal obstruction
of the appendix due to adult Taenia worms may
have caused the acute appendicitis. Radiological
and laboratory findings do not help in the diag-
nosis of acute appendicitis. In histopathological
examinations of the appendix, the finding of acute
inflammation of the appendix may not be defined.
For patients with normal pathological examina-
tions, screening for parasites should be performed,
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521
and anti-parasitic treatment should be initiated
after appendectomy.
Conflicts of interest
The authors declare that they have no conflicts of
interest.
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