Right-sided scrotal ascariasis.

We report a case of 35-year-old male patient who presented with painful right side of scrotum and worm pouting out of the scrotum. The patient had undergone surgery for strangulated right inguinal hernia 2 years back. On exploration we found multiple adult Ascaris worms in the scrotum with right-sided hydrocele. All the worms were removed and eversion of sac was done.

INTRODUCTION

Ascariasis is the most common helminthic infection, with an estimated worldwide prevalence of 25% (0.8-1.22 billion people).[1] Usually asymptomatic, ascariasis is most prevalent in children of tropical and developing countries, where they are perpetuated by contamination of soil by human feces or use of untreated feces as fertilizer. Symptomatic ascariasis may manifest as growth retardation, pneumonitis, intestinal obstruction, or hepatobiliary and pancreatic injury. In developing countries, ascariasis may exist as a zoonotic infection in pigs, but little evidence has shown transmission of porcine ascariasis to humans.[2] Although intestinal ascariasis is a common disease, extra intestinal ascariasis is as extremely rare occurrence.

CASE REPORT

A 35-year-old male was referred to us from a peripheral hospital with chief complaints of sudden onset severe pain over right side of scrotum and fever since 2 days. He also gave history of worm coming out of root of scrotum since the same day. He had undergone surgery for right-sided strangulated inguinal hernia 2 years back. Resection and anastomosis was done through inguino scrotal incision. On examination patient was anxious, febrile and had tachycardia. Local examination revealed adult Ascaris worms (4–12 cm long, some with ventrally curved tail end) coming out of the root of scrotum [Figure 1]. Right side of scrotum was swollen, red and overlying skin was shiny. Local temperature was raised and it was tender to touch. Left scrotum was normal. Blood investigation revealed leucocytosis. Right side of scrotum was explored and all the worms present in the tunica vaginalis sac (containing hydrocele fluid) were taken out. Hydrocele fluid was clear. Testis was normal. Eversion of sac was done. Post operatively, deworming was done with albendazole. Patient was discharged on 7th postoperative day after uneventful recovery.

Figure 1

Worms pouting out of root of scrotum

DISCUSSION

Ascaris lumbricoides is a member of the Ascaris family causing the disease ascariasis. Infection begins with ingestion of embryonated eggs in faces contaminated soil or foodstuff. After ingestion, eggs hatch releasing larvae that penetrate intestinal wall and enter the portal circulation. Larvae migrate to pulmonary vascular beds and then to alveoli usually 1–2 weeks after ingestion. During this time, patient may develop pulmonary symptoms. Eggs are not shed in stools until 40 days after development of pulmonary symptom. After migrating out of the respiratory tract and being swallowed, the larvae mature, copulate and lay eggs in the intestine. Adult worms may live in gut for 24 months and cause intestinal symptoms like abdominal pain, intestinal obstruction and hepatobiliary and pancreatic complications.[3]

After an exhaustive search, we could not find any case of scrotal ascariasis reported in the literature. The pathogenesis of scrotal ascariasis can only be postulated. One possible mechanism is the migration of adult worm through the inguinal canal into the scrotum. Post operative adhesion of the bowel to the deep inguinal ring might have helped this migration. Another possible mechanism is that the larvae of ascariasis might have migrated to scrotal sac during surgery for strangulated hernia. Whether the hydrocele fluid provides a growing medium for maturation of larvae into adult worm remains questionable.

Other rare presentations of ascariasis include urinary ascariasis,[4] ascariasis through patent vitello intestinal duct,[5] ascariasis through chest drainage tube[6] and intraperitoneal ascariasis.[7]

CONCLUSION

Ascariasis infestation is a common condition affecting the gastrointestinal tract. However, scrotal involvement with ascariasis is an extremely rare occurrence and whether hydrocele fluid supports the growth of ascariasis larvae remains to be investigated.