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| DISPATCHES |
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| Year : 2022 | Volume
: 12
| Issue : 2 | Page : 126-129 |
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Rare presentations of ocular enterobiasis – Case reports
Sayani Bose1, Tanusree Mondal2, Sudip Kumar Das3, Aitihya Chakraborty1, Subhoroop Ghosh4, Netai Pramanik1, Tapashi Ghosh4, Ardhendu Maji4
1 Department of Tropical Medicine, Calcutta, Kolkata, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
2 Department of Community Medicine, Calcutta Medical College, Kolkata, West Bengal, India
3 Department of ENT, IPGMER and SSKM Hospitals, Kolkata, West Bengal, India
4 Department of Microbiology, Calcutta, Kolkata, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| Date of Submission | 14-Apr-2021 |
| Date of Acceptance | 24-May-2021 |
| Date of Web Publication | 24-Nov-2022 |
Correspondence Address:
Aitihya Chakraborty
Department of Microbiology, School of Tropical Medicine, 88, College Street, Kolkata - 700 073, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/tp.tp_27_21
 Abstract | | |
Enterobius vermicularis, also known as pinworm or threadworm, is a large intestinal nematode which has a high prevalence among children and peripubertal age in our country. Transmission usually occurs by autoinfection like finger contamination of the embryonated eggs deposited by the gravid female worm on the perianal and perineal region. Globally, only a few reports are there regarding the isolation of the parasite from extra-intestinal sites. These are two rare case reports of ocular enterobiasis. The first case was a middle-aged female and the second one was a 14-year-old girl, both of whom were referred from other tertiary care hospitals to Calcutta School of Tropical Medicine and who presented with discharge of live motile worms from their eyes (conjunctiva). In both the cases, identification was done by saline wet mount and direct microscopy of a gravid female worm. Plano-convex embryonated eggs were also observed. The oval embryonated eggs, plano-convex in shape, and the gravid female, with its cervical alae near the anterior end and straight thin pointed tail, were identified under the microscope. Although E. vermicularis is a very common large intestinal parasitic infestation of children and adolescents, it can also rarely be isolated from unusual sites, which should be taken into account for effective diagnosis and treatment.
Keywords: Autoinfection, Enterobius vermicularis, extraintestinal infection
How to cite this article:
Bose S, Mondal T, Das SK, Chakraborty A, Ghosh S, Pramanik N, Ghosh T, Maji A. Rare presentations of ocular enterobiasis – Case reports. Trop Parasitol 2022;12:126-9 |
| Introduction | |  |
These are two rare case reports of ocular enterobiasis. The first case was a 14-year-old girl and the second one was a middle-aged female, both of whom were referred from other tertiary care hospitals to Calcutta School of Tropical Medicine and who presented with discharge of live motile worms from their eyes (conjunctiva).
Very few instances of such presentations have been reported globally and in India. In recent literature, cases were reported from Chicago, USA,[1] Assam, India,[2] Nepal,[3] Madras, India,[4] and West Bengal, India.[5]
| Patient Information | | |
Case 1
A 14-year-old girl presented to a tertiary care hospital with redness, irritation, itching, watering from her left eye and reported discharge of worm-like structures form her left eye and left nostril. The worms were traveling from the medial canthus of the eye toward the lateral side and finally crawling out of the eye [Figure 1]. A total of 14/15 such worms were discharged over a period of 1 week as per words of the patient. She also had a history of perianal pruritus with nocturnal aggravation. | Figure 1: Enterobius vermicularis: Adult worm crawling out from the lateral side of eye
Click here to view |
Case 2
A 35-year-old woman presented to a tertiary care hospital with complaints of irritation, foreign body sensation, and watering from her left eye and crawling out of worm-like structures from the same eye. The patient had no history of perianal pruritus.
| Clinical Findings | | |
- Case 1: Ocular examinations were normal and visual acuity was 6/6
- Case 2: Patient presented with redness of eyes. Ocular examination of the patient was within normal limits.
| Diagnostic Assessment | | |
Identification
In both the cases, white-tan-colored worms, 5–10 mm in length, were collected in saline and submitted for identification to the Helminthology Laboratory of School of Tropical Medicine.
Saline wet mount and direct microscopy of the worms were done. Microscopic examination of a representative worm revealed gravid female E. vermicularis was identified by the following features – first, a cervical alae [Figure 2]a which is a wing-like expansion at the anterior end of the worm; second, posterior end of the esophagus dilated to form a double-bulbed esophagus [Figure 2]b; third, thin tapering pin-like posterior end [Figure 2]c; and lastly, the gravid female worm, full of embryonated eggs [Figure 3]. | Figure 2: (a) Enterobius vermicularis (unstained wet mount): Cervical alae. (b) Enterobius vermicularis (unstained wet mount): Double-bulb oesophagus. (c) Enterobius vermicularis (unstained wet mount): Posterior end, tail tip
Click here to view |
 | Figure 3: Enterobius vermicularis: Release of ova from gravid female worm
Click here to view |
Stool examination done in case of both the patients revealed no findings in the second case but revealed eggs of E. vermicularis which were identified by plano-convex shapes (flattened on one side and convex on the other side) and nonbile stained (saline mount of the eggs was colorless) [Figure 4].
| Follow-Up and Outcomes | | |
Patients were suggested to maintain healthy and hygienic habits, to use eye drops for some time till the conjunctival irritation persist. Testing and treatment also were advised for household contacts.
No further complains or abnormalities were recorded on the follow-up visits in both the cases.
| Discussion | | |
Humans are the only host of large-intestinal nematode E. vermicularis, and embryonated eggs are the infective form. The prevalence is maximum among school-going children and young adults, though no age is barred. Transmission usually occurs by finger contamination of the embryonated eggs due to poor hand hygiene. Once the eggs are ingested, they reach the cecum where the larva hatches out from the eggs and develops into adults. Adult worms mature within a month and fertilization takes place following which the male worms die and the gravid female worms migrate to the large intestine to lay eggs on the perianal skin. The most common symptom is perianal pruritus which is aggravated at night due to nocturnal migration of the female worms to lay eggs on the perianal skin. The adult female worms can also migrate to invade the female genital tract leading to vulvovaginitis, chronic salpingitis, and pelvic granuloma. Rarely, other sites such as urinary tract, peritoneal cavity, appendix, lungs, and rarely liver may also be invaded. Ocular migration of the adult female worms through finger contamination may explain the presentations in the cases above.
In the existing medical literature, rare cases of ocular Enterobiasis with similar presentations have been reported globally and in India. A 14-year-old girl from Chicago, Illinois, had presented with discharge of worms from the conjunctiva of eye and also from her nares.[1] A 15-year-old girl from Assam, India, complained of worms crawling out of her eye.[2] A 3-year-old girl in Nepal presented with E. vermicularis in the anterior chamber of her eye.[3] An 11-year-old girl in Madras, India, presented with discharge of worms from both eyes.[4] A 2½-year-old boy from West Bengal, India, presented with worms in the conjunctival sac of his eye [Table 1].[5]
Take away lessons
Although E. vermicularis is a common intestinal parasitic infestation in children, identified by examination of stool or perianal region by scotch tape method, it can also rarely be encountered from unusual sites such as the ocular region as seen by us within a span of 1 year.
| Patient Perspective | | |
Both cases were referred from tertiary care hospitals – IPGMER and SSKM hospitals and Regional Institute of Ophthalmology, respectively. The patients were under OPD care and under systematic treatment of the respective hospitals. The patient perspective was satisfactory as the treatment management followed.
Informed consent
Informed consent was taken from both patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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.
Acknowledgments
We hereby extend my acknowledgement and express my heartfelt gratitude to my teachers who have helped me in shaping up this entire study. (1) Prof.(Dr) Tapashi Ghosh, Unit In-Charge, Helminthology Unit, Department of Microbiology, School of Tropical Medicine, Kolkata. (2) Dr. Netai Pramanik, Unit In-Charge, Unit 4, Department of Tropical Medicine, School of Tropical Medicine, Kolkata. (3) Dept. of ENT, IPGMER and SSKM Hospitals, Kolkata. (4) Regional Institute of Ophthalmology.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Babady NE, Awender E, Geller R, et al. Enterobius vermicularis in a 14-year-old girl's eye. Journal of Clinical Microbiology 2011; 49:4369-70. doi: 10.1128/jcm.05475-11.  |
| 2. | Dutta LP, Kalita SN. Enterobius vermicularis in the human conjunctival sac. Indian J Ophthalmol 1976;24:34-6. [ PUBMED] [Full text] |
| 3. | Bajracharya K, Bhari A, Rai S, Pandey S. Enterobius vermicularis in anterior chamber of eye. Asian Journal of Medical Sciences 2019;10:90-2. |
| 4. | Menaka C. Enterobius vermicularis or pinworm or thread worm in eye - A rare case report. University Journal of Surgery and Surgical Specialties 2019;5. |
| 5. | Mallick SK, Sengupta R, Banerjee AK. Unusual presentation of Enterobius vermicularis in conjunctival sac. Trop Doct 2015; 45:247-9. doi: 10.1177/0049475514562494. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1]
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