presence of enterobins (oxyuris) vermicularis in the ovary

PRESENCE OF ENTEROBIUS (OXYURIS) VERMICULARIS IN THE OVARY*

A. J. GILL, M.D., AND ALICE L. SMITH, M.D.

Department of Pathology of the Soulhxoestem Medical School of the University of Texas, Dallas, 'Texas

Infestation by Enterobius vermicularis is worldwide in distribution, but is generally regarded as a relatively unimportant disease of chief concern as a cause of pruritus ani in children. There have been a few reports of observation of this parasite or its ova in tissues, however. Ova and parasites have been observed in the wall of the appendix or intestine by Ruffer4 and others, and in perianal abscess1 and ischioanal abscess.3 Granulomatous lesions in the appendix caused by Enterobius have been mentioned by several authors, including Schen-ken and Burns.6 Gordon2 observed these worms in the wall of the appendix on several occasions, but did not see a reaction that would indicate actual penetration of the wall during life. He described a few superficial mucosal lesions, however, which he felt might be attributed to the presence of the worms. Involvement of the fallopian tube has also been noted by several observers. These and other reported studies suggest that the tissues may react to the presence of this parasite or its ova, although there might be doubt as to whether the parasite is important as a -primary invader of tissues.

In 1950, Symmers6 published a comprehensive review of the pathology of enterobiasis (oxyuriasis) and added 3 new cases in which this parasite was observed in lesions outside the intestine. He noted that one of the important sites of lesions where the changes are undoubtedly caused by the parasites or ova of Enterobius is the pelvic peritoneum of the female. Two of his 3 cases were of this type.

I t is known that this parasite migrates from the lower intestine to the perianal and perineal skin; and there are several reports of observation of the worms in the lower female genital tract and of mature worms in the lumens of fallopian tubes.

In Symmer's extensive review, 16 cases of enterobiasis of the pelvic peritoneum were listed prior to his own 2 additional cases. All these were in females, and it is the present consensus that the lesions were a consequence of direct migration of the worm from perianal skin by way of the internal genitalia to the peritoneal cavity.

We have had an opportunity to observe 2 cases of granulomatous lesions of the ovary caused by the presence of this parasite or its ova. In view of the relative rarity of definite lesions of this character and because we are not aware of any previous finding of such a lesion in or on the ovary, we wish to record these cases.

* Received for publication, April 24, 1952.

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880 GILL AND SMITH

REPORT OF CASES

Case 1

A woman 37 years of age was admitted in early gestation because of edema and severe hypertension (blood pressure 212/136). Material presented to the laboratory consisted of uterus, with contained fetus and placenta, right tube and ovary and appendix. None of the tissues was unusual with the exception of the ovarj', which measured 4 by 2 by 1 cm. Near one end of the ovary, just beneath the serosa, was a small well-circumscribed nodule measuring approximately 0.5 cm. in diameter. The structure had a thin, but definite, tough wall. The central portion was soft and yellowish.

Microscopic examination of the ovarian nodule disclosed a well-defined capsule. Most of the capsule was made up of coarse, hyalinized, collagenous bundles in which scattered inflammatory cells appeared. The inflammatory cells were rather irregularly disposed with dense accumulations in part of the wall, whereas in other areas almost no inflammation was present. The majority of the cells were lymphocytes and plasma cells, but many typical eosinophils were also observed. Part of the inner portion of the capsule was lined by a fairly thick layer of epithelioid cells with numerous scattered eosinophils. The remaining central bulk of the nodule was composed of necrotic granular debris, some of which resembled caseous necrosis and in some of which shadowy outlines of original cells of the area remained, giving the impression of coagulative necrosis. Numerous ova of Enterobius vermicu-laris were scattered in the necrotic area (Figs. 1 and 2). No part of a mature worm was present. No parasites or ova were seen upon gross or microscopic examination of the appendix.

Case 2

The patient, a woman 29 years old, gave no history of observation of worms or any symptom suggestive of pinworm infestation. In the course of an elective operation the right ovary presented a firm, raised mass, which was removed with the attached tube for study. The specimen was received in the laboratory already fixed in formalin. The ovary measured 4.5 by 3 by 1.5 cm. in greatest diameters. Protruding above the free convex surface was a polypoid mass measuring 1.2 by 0.6 by 0.8 cm., which appeared to have a somewhat narrow stalk of ovarian tissue. The main bulk of the mass was grayish yellow, of uniform soft texture, and circumscribed by a thin tough membrane. Several small follicular cysts were present in the ovarian stroma. Sections of the principal lesion were quite similar to those of the first case. The capsule was composed of dense collagenous fibers with scattered inflammatory cells, especially in the outer portions of the capsule. The inflammatory exudate consisted of lymphocytesy.many eosinophils and in several places groups of lymphocytes disposed as

•lymphoid follicles. A few cells of epithelioid type were present in the inner part of the capsule: The main central portion of the lesion stained pink and was made up of granular, necrotic debris, which upon close inspection showed shadowy outlines of the original architecture and degenerated remains of inflammatory cells. In the midportion there were many Enterobius eggs and degenerated but still recognizable sections of one or more worms (Fig.3).

COMMENT

There have been rare reports of finding the common intestinal parasite Enterobius vermicularis and its ova in sites other than the bowel. It is now well recognized

FIG. 1 (upper). Case 1. Low-power view showing ovarian tissue, wall and central necrotic area with scattered ova. X 35.

FIG. 2 (middle). Case 1. Ova in necrotic central area. X 325. FIG. 3 (lower). Case 2. Degenerated section of worm and ova lying in the necrotic center

of the lesion. X 130. . •


F I G S . 1-3

SSI


882 GILL AND SMITH

that a definite morphologic pattern may result from the presence of this parasite or its ova when found in tissues outside the normal habitat.

The lesions present in each of the cases are similar to those described as occurring on pelvic peritoneum by others, and we do not feel that there is any essential difference except for the location. The mechanism of involvement of the ovary in the first case, in which the lesion was superficial, does not seem different from that in which the small granulomas develop on pelvic peritoneal surfaces elsewhere. The first case may be somewhat different, howevei', because the lesion is seen to lie beneath the surface of the ovary. We think it is possible that the worm may have gained access to the tissues beneath the surface by some opening such as might have been provided by the rupture of a graafian follicle.

SUMMARY

Two cases are reported in which the ovary was the site of a granulomatous lesion caused by Enterobius vermicularis.

The lesions were incidental findings and did not produce any symptoms. The parasite probably reached the abdominal cavity by direct migration from the perineum through the internal genitalia.

R E F E R E N C E S

1. F I T Z W I L M A M S , D . C. L . : Fistula-in-ano, caused bv the ova of Oxyuris vermicularis. . Proc. Roy. Soc. Med., 27:932-934, 1934..

2. GORDON, if.: Appcndical oxyuriasis and appendicitis. Arch. Path. , 16: 177-194, 1933. 3. MARSHALL, G. R., AND WOOD, Q. L . : Ischioanal abscess caused by Oxyuris vermicularis.

Northwest Med., 37: 180-182, 1938. 4. R U F F E R , M. A.: Note on the lesions produced by Oxyuris vermicularis. Bri t . M. J. , 1:

208-209, 1901. 5. SCHENKEN, J . R., AND B U R N S , E. L . : The Gastro-Intestinal Tract . In: Pathology by

W. A. D . Anderson. St. Louis: C. V. Mosby Co., 1948, p. 845. 6. SYMMERS, W. S T . C : Pathology of oxyuriasis. Arch. Path. , 50: 475-516, 1950.


presence of enterobins (oxyuris) vermicularis in the ovary

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