Metrorrhagia associated with enterobiasis: a case report
Metrorrhagia associated with enterobiasis: a case report |
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Department of Obstetrics and Gynaecology, Diana, Princess of Wales Hospital, Grimsby
Northern Lincolnshire and Goole’s Hospitals NHS Trust, Scartho Road, Grimsby DN33 2BA, England
Key words: Metrorrhagia; Enterobius vermicularis
Abstract
Enterobius vermicularis is well known for producing perianal and ischioanal discharge and abscesses. However, this is the first case report where metrorrhagia is a presenting complaint in enterobiasis.
Case report
Mrs EW, a 20 year old regularly cycling multiparous Caucasian was admitted through the Accident and Emergency department with history of menorrhagia in the form of prolonged scanty vaginal bleeding for about 2 weeks. She lives with her partner with one child delivered at a normal vaginal delivery. She denied any urinary or gastrointestinal problems.
General and abdominal examination was unremarkable but vaginal examination showed scanty blood stained, mucousy, and foul smelly vaginal discharge. No heavy bleeding was revealed. The cervix was healthy and cervical os was closed. There were neither adnexal masses, tenderness nor reflex cervical excitation tenderness. High vaginal (HVS) and endocervical (ECS) swabs showed microscopic evidence of bacterial vaginosis and Chlamydia culture negative.
At a speculum examination, a threadworm was noted on the cervical os and was retrieved with a pair of fine forceps. This procedure was accompanied with minimal discomfort and no excessive vaginal bleeding ensued. She admitted to previous treatment for pinworm on questioning. She received 100mg of mebendazole orally and to be repeated after two weeks. She also received antibiotics in the form of augmentin and metronidazole for five days. A follow up appointment was made on two consecutive occasions but was not kept. The General Practitioner was informed of the diagnosis and the need for treatment of other members of her family.
Discussion
Enterobius vermicularis is recognised cause of endometritis and persistent vaginal
discharge1, pelvic inflammatory disease2 or pelvic abscess3. Bacteria cause most vulvovaginitis and symptomatic vaginal discharge, these usually being Gardnerella vaginalis in combination with various anaerobes. Protozoa (trichomonas vaginalis) causes 30% of all cases. Candida is a frequent cause in pregnancy and in people suffering from diabetes mellitus. In some women, oral contraceptives increase susceptibility to vaginal discharge. Other causes are shown table 1.
Metrorrhagia is a common symptom in young women usually due to dysfunctional uterine bleeding. Vaginal bleeding and metrorrhagia have never been reported in enterobiasis. The cause of bleeding might be due to erosion of superficial blood vessels in the endocervical canal.
Enterobium vermicularis infection is more common in the temperate regions of Western Europe and North America, (it being relatively rare in the tropics) and is found particularly in children. Examination of faecal samples of Caucasian children in the U.S.A. and Canada has shown prevalence of infestation of between 30% to 80%, with similar levels in Europe. Although these regions are the parasites strongholds, it may be found throughout the world, again often with high degrees of incidence. Interestingly non-Caucasians appear to be relatively resistant to infestation with this nematode. As a species, and contrary to popular belief, E. vermicularis is entirely restricted to man.
A pin worm (fig 1) is a small, round, white coloured worm 2-13mmm long that infests the area around the anus and other parts of the intestine. It typically affects children between the ages of 5-15 years old, but it may infest individuals at any age or socio-economic group. The knowledge of the life –cycle of pinworms is useful to understanding of treatment and prevention. Pin worn starts usually with the introduction of a microscopic egg into the mouth. The acid of the stomach softens the egg and it hatches in the small bowel. The worm travels to the appendix and large bowel. At night the female worms crawl out of the anus and leave eggs on the skin. The worms and the eggs cause itching and scratching, and the eggs are transferred to the fingers and fingernails. With eating or thumb sucking the eggs are re-introduced into the mouth and the cycle continues. Pinworms can also come from eggs that are airborne after shaking infested clothing and bed linen. Contact with toys and other handled objects can transfer eggs from one child’s hands to another’s. They can also hatch on the skin around the anus and then crawl back into the intestine to start another round of infection. Complications are much more common in the female than the male population. This stems from the fact that the female worm after depositing her eggs loses her way while trying to return to the colon. She enters the vagina instead, travelling up the uterus and fallopian tube 4. The mainstay of treatment is antiparasitic medication such as pyrantel pamoate, mebendazole or albendazole. The normal dose is a single dose of 100mg with mebendazole or 400mg of allendazole orally repeated after two weeks. As more than one household member is likely to be infested, treatment of the entire household is often recommended. General measures to control infestation involve male/female hygiene including washing of hands before meals and after use of the toilet, keeping fingernails short and clean, laundering all bed linen twice weekly, and cleaning toilet seats daily. Avoid scratching the infected area (area around the anus) as this contaminates the fingers and everything else that they subsequently touch. Keep hands and fingers away from the nose and mouth unless they are freshly washed. Carry out these measures while family members are treated with medication.
References
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