Received Date: August 05, 2017; Accepted Date: August 22, 2017; Published Date: August 29, 2017
Citation: Malallah H, Al-Onaizi T, Shuaib A, Alsharaf K, Behbehani A (2017) Schistosomiasis as a Cause of Acute Appendicitis in Non-Endemic Areas. Trop Med Surg 5: 216. doi:10.4172/2329-9088.1000216
Copyright: © 2017 Malallah H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Schistosomiasis is one of the most widespread parasitic diseases in the world. There are about 200 million people infected worldwide, 85% of whom are concentrated south of the Sahara in Africa. Appendicular schistosomiasis was first reported by Turner in 1909. It remains rare in non-endemic areas. The reported incidence rate of appendicular schistosomiasis in non-endemic areas is 0.001% and is due to traveling and labor migration. We report a case of a 29-year-old Egyptian gentleman who presented with a clinical picture of acute appendicitis and underwent a laparoscopic appendectomy. He was diagnosed histologically and post-operatively with a schistosomiasis of the appendix. The pathogenesis of appendicular schistosomiasis could be through two pathogenic pathways: granulomatous or obstructive. Treatment with appendectomy and anti-helminthic therapy are adequate to limit further extensive disease or chronic complications.
Appendicular schistosomiasis; Schistosomiasis; Acute appendicitis
Schistosomiasis, also known as bilharzia, bilharziosis, and snail fever, is a waterborne trematode, and is one of the most widespread parasitic diseases in the world [1,2]. It occurs in well-defined, endemic areas . There are about 200 million people infected worldwide, 85% of whom are concentrated south of the Sahara in Africa . Appendicular schistosomiasis was first reported by Turner in 1909 . The most common organisms are Schistosoma haematobium and S. mansoni . Schistosomiasis causing and presenting as acute appendicitis is reported in up to 6.3% of cases, which represents 28.6% of chronic appendicitis in endemic areas .
A 29-year-old Egyptian gentleman presented to our Emergency Department with diffuse lower abdominal pain, nausea, and vomiting over duration of five days. He reported normal bowel habits and there was no fever. There was no history of previous abdominal surgical procedures. On examination, the patient was afebrile, conscious, and oriented. There was rebound tenderness and guarding in the lower abdomen, more so in the right iliac fossa area. Laboratory investigation showed an elevated white blood cell count. The patient was admitted to the surgical ward as a case of acute appendicitis and underwent an open appendectomy. The post-operative period was unremarkable. He tolerated a normal diet on the second post-operative day and was discharged from the hospital on the third post-operative day.
Microscopic examination of paraffin embedded 4 μm thick section of the appendix stained with hematoxylin and eosin (H&E) revealed transmural suppurative and granulomatous inflammatory infiltration consisting mainly of neutrophils, eosinophils, lymphocytes, and plasma cells (Figure 1). Non-necrotizing granulomas with histiocytes, eosinophils, and multinucleated Langerhans giant cells were seen surrounding the bilharziasis ova (Figure 2).
The diagnosis of appendicular schistosomiasis was purely a histopathological diagnosis [4,6]. There was no evidence in the patient’s history or clinical examination of acute appendicitis which might indicate schistosomiasis of the appendix. There were no pathognomonic clinical or operative findings [4,6].
The pathogenesis of appendicular schistosomiasis could be caused through two pathogenic pathways: granulomatous or obstructive [6,7]. In the first, there would be an immunological granulomatous reaction to the parasitic infestation, leading to tissue destruction and acute appendicitis [6,7]. In the second, there would be long-standing inflammation and calcified ova in the wall of the appendix, which would lead to extensive fibrosis. Extensive fibrosis can lead to appendix lumen obstruction and, subsequently, bacterial infection [6,7]. In the present case, the microscopic findings were consistent with granulomatous pathogenesis .
The incidence of appendicular schistosomiasis is uncommon even in endemic areas . It is reported by Duvie that the incidence rate is 6.2% in Nigeria . Another study reported an incidence rate of schistosomiasis of the appendix in a non-endemic area of 0.001% . The incidence rate of appendicular schistosomiasis in non-endemic areas is because of traveling and labor migration, which is significant because the foreign labor participation rate in Kuwait is 88.6% in the governmental and private sectors [2,6,10].
While the incidence rate is low, schistosomiasis could present and cause acute appendicitis in non-endemic areas. The diagnosis of appendicular schistosomiasis is purely histological. Treatment with appendectomy and anti-helminthic therapy are adequate to limit further extensive disease or chronic complications.
The authors declare no conflicts of interest.