Perforation of the appendix due to intestinal schistosomiasis at a tertiary hospital in North Central Nigeria

Samuel Ali Sani; Monday G Yilkudi

doi:10.4103/nnjcr.nnjcr_25_18

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CASE REPORT

Year : 2019 | Volume : 8 | Issue : 13 | Page : 38-39

Perforation of the appendix due to intestinal schistosomiasis at a tertiary hospital in North Central Nigeria

Samuel Ali Sani¹, Monday G Yilkudi²
¹ Department of Surgery, College of Health Sciences, University of Abuja, Abuja, Nigeria
² Department of Surgery, University of Abuja Teaching Hospital, Abuja, Nigeria

Date of Web Publication

19-Feb-2019

Correspondence Address:
Samuel Ali Sani
Department of Surgery, College of Health Sciences, University of Abuja, Abuja
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/nnjcr.nnjcr_25_18

Abstract

In Nigeria, schistosomiasis is endemic and intestinal form affects the various internal organs. However, perforation of the appendix secondary to intestinal schistosomiasis is few. We report the case of a 35-year-old male with perforation of the appendix due to infestation with Schistosoma mansoni, following histopathological examination of the appendix after a laparotomy.

Keywords: Exploratory laparotomy, intestinal schistosomiasis, perforated appendix, Schistosoma mansoni

How to cite this article:
Sani SA, Yilkudi MG. Perforation of the appendix due to intestinal schistosomiasis at a tertiary hospital in North Central Nigeria. N Niger J Clin Res 2019;8:38-9

How to cite this URL:
Sani SA, Yilkudi MG. Perforation of the appendix due to intestinal schistosomiasis at a tertiary hospital in North Central Nigeria. N Niger J Clin Res [serial online] 2019 [cited 2023 Sep 21];8:38-9. Available from: https://www.mdcan-uath.org/text.asp?2019/8/13/38/252582

Introduction

Schistosomiasis is a parasitic infestation of surgical importance. Intestinal schistosomiasis is well-documented in the literature; however, perforation of appendix is a less common sequelae.

Schistosomiasis is a water-borne trematode infestations and one of the most prevalent parasitic disease in the world.^[1] The disease is endemic in most parts of the world with the highest burden in Sub-Saharan Africa where it has huge economic and public health implications. Of the 1183 histologically examined appendices at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria, 27 (2.3%) were due to schistosomiasis of the appendix.^[2]

Here, we present an unusual case of perforated appendix secondary to intestinal schistosomiasis.

Case Report

A 35-year-old policeman admitted as an emergency in our institution, a teaching hospital in the Federal Capital Territory, Abuja, following a 6-day history of the colicky right iliac fossa pain. The pain started suddenly, initially involving the central abdomen, with radiation to the groin but became generalized 2 days before the presentation with abdominal swelling, constipation, and fever. There was a distinct history of anorexia but no associated nausea or vomiting. There was no urinary symptom. He was not a known diabetic or hypertensive and no drug allergies.

On examination, he was acutely ill-looking, afebrile, anicteric, and not pale but moderately dehydrated. He had tachycardia, with the pulse rate of 115 bpm and blood pressure of 100/80 mmHg. The abdomen was distended with generalized tenderness and absent bowel sound. The internal organs were not palpably enlarged.

A provisional diagnosis of acute abdomen secondary to perforated appendix was entertained. Urinalysis was normal; packed cell volume 48%; serum electrolyte, urea, and creatinine were normal, and chest X-ray revealed air under the diaphragm.

The patient was resuscitated and had an emergency exploratory laparotomy a few hours later with intraoperative findings of perforation at the tip of the appendix and about a liter of peritoneal fluid. An anterograde appendectomy was performed, and the peritoneal cavity lavaged with copious amount of warm saline solution. He was given intravenous fluid, antibiotic, and analgesics after the surgery among others.

Furthermore, the patient had an uneventful postoperative recovery and was discharged 10^th day after operation and recommended for a review 2 weeks later at the surgical outpatient department.

Histology showed acute on chronic granulomatous inflammation of the appendix. The wall of the appendix showed numerous calcified Schistosoma mansoni ova.

He subsequently had praziquantel as a single dose.

Discussion

Schistosomiasis of the appendix was first described by Turner in 1909^[3] and has been reported in endemic areas.

The most usual organisms are Schistosoma haematobium and S. mansoni. The actual role of infestation in the development of appendicitis is still a subject of much controversy. The egg of the parasite enters into stagnant water through excreta of infected persons. The egg hatch into a larval form known as miracidium, which infect aquatic snails. Human infestation occurs when cercariae are released from intermediate snail host and penetrate the skin during contact with water. The worms mature and mate in the liver, then finally migrate to specific venous systems. The disease is caused by the deposition of the parasite in tissues with consequent inflammatory reaction-associated with eosinophilia and fibrosis.

The characteristic pathological tissue response is believed to be a granulomatous inflammatory reaction to the Schistosoma ova, with the lesion predominantly in the submucosa and serosa. There is formation of epithelioid cell granulomas which ultimately undergo fibrosis. Intramuscular oviposition (submucosa) causes an obstructive type of appendicitis with a greater risk of perforation. Serosal involvement causes inflammation and the formation of adhesions.^[4],[5],[6]

It is noteworthy that five species of Schistosoma can infect humans. S. haematobium causes genitourinary disease (fibrosis, calcification, and obstruction of the urinary tract). S. mansoni, Schistosoma mekongi, Schistosoma japonicum and Schistosoma intercalatum are associated with chronic intestinal and hepatic fibrosis, as well as portal hypertension, splenomegaly, and hematemesis.

Schistosomiasis of the appendix is a well-recognized disease. Some reports have implicated S. haematobium, S. mansoni and S. japonicum species in having a preference for the appendix.^[7],[8],[9]

The mainstay of medical treatment is Praziquantel 40 mg/kg body weight for both urinary and gastrointestinal forms of the disease, administered as a single oral dose.^[10] Praziquantel, an acylated quinoline-pyrazine that is active against all schistosome species is now most widely used. The drug acts within 1 h of ingestion by paralyzing the worms and damaging the integument.^[11] This leads to loss of the worm's attachment to the endothelium of vessel wall. They are transported to the liver, and thus, destroyed by granulocytes, phagocytes, and cell-mediated immunity.

Conclusion

Improper sanitation, poor sewage disposal, lack of portable water, and walking barefooted as well as low socioeconomic status have all been implicated in the etio-pathogensis of the disease.

It is imperative for surgeons working in endemic areas to consider intestinal schistosomiasis as a cause of perforation of the appendix.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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