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Case ReportJ Korean Soc Radiol 2020;81(4):1013-1018https://doi.org/10.3348/jksr.2020.81.4.1013pISSN 1738-2637 / eISSN 2288-2928

Ascariasis Presenting as Hematoma in the Sigmoid Mesocolon: A Case Report구불창자간막 혈종으로 발현한 회충증: 증례 보고

Ji-Eun Kim, MD1 , Kyung Eun Bae, MD1* , Hyun-Jung Kim, MD2 , Byung-Noe Bae, MD3 , Ji Hae Lee, MD1 , Mi-Jin Kang, MD1 , Ji-Young Kim, MD1 , Jae Hyung Kim, MD1 Departments of 1Radiology, 2Pathology, 3Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea

Ascariasis is an intestinal disease caused by Ascaris lumbricoides. Most patients with ascariasis are asymptomatic; however, the presence of many larvae in the bowel can cause gastrointesti-nal complications, such as intestinal obstruction, obstructive jaundice, cholangitis, cholecysti-tis, and pancreatitis. Herein, we report a case of ascariasis presenting as hematoma and active bleeding in the sigmoid mesocolon of a 74-year-old man on computed tomography (CT). Sig-moid colon perforation was also detected on follow-up CT. Laparoscopic low anterior resection was performed; there was a large hematoma in the sigmoid mesocolon. Roundworms were microscopically identified in the mesenteric adipose tissue. The clinical and CT findings of this unusual presentation of ascariasis revealed serial complications during parasite migration from the intestinal lumen to the peritoneal cavity.

Index terms Ascariasis; Hematoma; Sigmoid Mesocolon; Bowel Perforation

INTRODUCTION

Ascaris lumbricoides (A. lumbricoides) is a soil transmitted nematode and one of the most common parasites in the world. Infection is acquired via fecal-oral transmission through ingestion of food, water, or soil contaminated with embryonated eggs and can manifest intestinal illness known as ascariasis. When ingested, the eggs hatch in the stomach and duodenum and release the larvae, which then penetrate the intestinal wall and enter the portal circulation (1). Among the various complications of ascariasis, computed tomography (CT) findings of hematoma with active bleeding in the sigmoid mesocolon are rarely reported. In this report, we describe a case of ascariasis manifest-ing with serial complication including colonic perforation and hematoma in the sig-moid mesocolon.

Received September 19, 2019Revised October 15, 2019Accepted October 20, 2019

*Corresponding author Kyung Eun Bae, MDDepartment of Radiology, Inje University Sanggye Paik Hospital, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea.

Tel 82-2-950-1184Fax 82-2-950-1220E-mail S2671@paik.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribu-tion Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduc-tion in any medium, provided the original work is properly cited.

ORCID iDsJi-Eun Kim https:// orcid.org/0000-0002-6358-1266 Kyung Eun Bae https:// orcid.org/0000-0002-2140-6160Hyun-Jung Kim https:// orcid.org/0000-0002-6617-4578Byung-Noe Bae https:// orcid.org/0000-0002-5542-5626Ji Hae Lee https:// orcid.org/0000-0002-4884-5876Mi-Jin Kang https:// orcid.org/0000-0001-8510-3268Ji-Young Kim https:// orcid.org/0000-0003-0588-0505Jae Hyung Kim https:// orcid.org/0000-0002-1195-4657

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Ascariasis Presenting as Hematoma in the Sigmoid Mesocolon

CASE REPORT

A 74-year-old man visited our hospital with a complaint of abdominal pain that had ap-peared one day before. He had no past history of medication, previous abdominal surgery or trauma, or overseas travel; however, he often had freshwater fish soup. On physical examina-tion, he complained of tenderness and mild rebound tenderness in the lower abdomen. The laboratory examination revealed a hemoglobin level of 11.3 g/dL. White blood cell and eosin-ophil counts were within the normal limits. An initial contrast-enhanced CT scan of the ab-domen and pelvis revealed an approximately 11.1 cm × 7.5 cm × 7.4 cm sized non-enhanc-ing high-attenuated mass-like lesion in the sigmoid mesocolon with extravasation of contrast media within the lesion and perilesional fat infiltration (Fig. 1A). The possibility of hemato-ma in the sigmoid mesocolon was suggested, and exophytic subepithelial tumor of the sig-moid colon with hemorrhage was considered as a differential diagnosis. Sigmoidoscopy was

Fig. 1. Ascariasis presenting as hematoma in the sigmoid mesocolon in a 74-year-old man with a complaint of abdominal pain.A. Initial contrast-enhanced CT images reveal a non-enhancing high-attenuation mass-like lesion, measur-ing approximately 11.1 cm × 7.5 cm × 7.4 cm, at the mesenteric border of the sigmoid colon (64 HU in all phases) with an extraluminal extravasation of contrast media (arrowheads) in the mass-like lesion and per-ilesional fat infiltration (arrows; mucosal layer of the sigmoid colon).B. Sigmoidoscopy shows diffuse edematous wall thickening of the sigmoid colon. Linear ulceration (arrow) is noted 25–28 cm from the anal verge. Further, a smooth well-defined mass-like intraluminal protrusion (arrowhead), measuring approximately 3 cm, is noted 15 cm from the anal verge, suggesting an extrinsic mass, with redness of the mucosa overlying it.CT = computed tomography, HU = Hounsfield units

A

B

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Fig. 1. Ascariasis presenting as hematoma in the sigmoid mesocolon in a 74-year-old man with a complaint of abdominal pain.C. Follow-up contrast-enhanced CT images after 10 days reveal pneumoperitoneum (arrows) and hemoperi-toneum (63 HU, asterisk). Perforation on the mesenteric side of the sigmoid colon (arrowhead) abutting the mass with extraluminal air is noted. Extraluminal air is noted both inside and outside the mass (open arrows).D. Gross findings and microscopic sections of the segmentally resected large intestine. Grossly, the segmen-tally resected large intestine (upper panel, not fixed) shows a diffusely edematous mucosa, with a geo-graphic ulcer (arrowhead) and luminal perforation (arrow). The mesenteric side of the fixed bowel (lower panel) reveals dark brownish discoloration, with a hematoma (circle). E. The sections show a deeply penetrating ulcer (arrow), with submucosal and mesenteric (circle) hemato-mas (H&E stain, × 10). The purple box reveals a hematoma (zone 1) surrounded by inflamed granulation tis-sues (zone 2), neighboring the PM layer (zone 3) (H&E stain, × 40).CT = computed tomography, F = mesenteric fat, H&E = hematoxylin and eosin, HU = Hounsfield units, M = mucosa, PM = proper muscle, SM = submucosa

C

D

EM

SM

PM

F

Zone 1

Zone 2

Zone 3

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Ascariasis Presenting as Hematoma in the Sigmoid Mesocolon

performed to find the bleeding focus and to discriminate the possibility of a tumor and re-vealed diffuse edematous wall thickening of the sigmoid colon. Linear ulceration was noted at a distance of 25–28 cm from the anal verge; additionally, a smooth well-defined mass-like intraluminal protrusion approximately 3 cm in size with redness of the overlying mucosa was noted at a distance of 15 cm from anal verge, suggesting an extrinsic mass (Fig. 1B). The linear ulceration was biopsied, and the results showed chronic colitis with focal erosion and regenerative hyperplasia. The patient was undergoing conservative care. From the next day, the patient had intermittent hematochezia for 2 days. Ten days after the day of admission, the patient complained of severe acute abdominal pain. Immediate follow-up CT was per-formed to exclude the surgical abdomen. It revealed pneumoperitoneum with perforation of the mesenteric side of sigmoid colonic wall abutting the presumed hematoma (Fig. 1C). Emergent laparoscopic evaluation was performed and revealed a deep penetrating perfora-tion site in the sigmoid colon attached to a huge hematoma with an old blood clot in the mesenteric fat. Laparoscopic low anterior resection was done. The gross finding of segmen-tally resected large intestine revealed diffusely edematous mucosa with geographic ulcer and luminal perforation. The mesenteric side of the fixed bowel showed dark brown dis-coloration along with the hematoma (Fig. 1D). Microscopic sections revealed a deeply pen-etrating ulcer with submucosal and mesenteric hematomas (Fig. 1E). The cut surface of the intestinal lumen disclosed a huge mesenteric hematoma. A whitish material was identi-fied in the mesocolonic hematoma. On microscopy, a round worm was identified in mesen-teric fat tissue. The round worm had thick cuticle and internal organs and was most likely A.

Fig. 1. A 74-year-old man with a complaint of abdominal pain.F. The cut surface of the intestinal lumen shows a huge mesenteric hematoma (H; red dotted line). A whitish dot-like material (red arrow) is identified in the mesenteric hematoma. A roundworm is identified (white ar-row) in the mesenteric adipose tissue (H&E stain, × 10). The roundworm has a thick cuticle (blue arrow) and internal organs and is most likely Ascaris lumbricoides (H&E stain, × 40).F = mesenteric fat, H&E = hematoxylin and eosin, M = mucosa, PM = proper muscle, SM = submucosa

F

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lumbricoides (Fig. 1F).

DISCUSSION

A. lumbricoides causes the intestinal disease known as ascariasis. A. lumbricoides infesta-tion is common in tropical and subtropical areas, especially in areas with poor sanitation. In-fection occurs when embryonated eggs are ingested from contaminated food or water. Most people infected with A. lumbricoides have no symptoms due to plasticity of the intestine that allows accumulation of many worms. However, depending on the worm burden, infection can manifest various symptoms, ranging from minimal gastrointestinal complaints to severe abdominal pathology (1). There are several known abdominal complications of ascariasis, such as intestinal obstruction, biliary disease, pancreatitis, appendicitis, and primary perito-nitis (2). On the other hand, ascariasis manifesting as bowel perforation and gastrointestinal bleeding is uncommon. There are few reported cases of ascariasis that manifest gastrointes-tinal intraluminal bleeding; this is mostly seen in pediatric patients (3-6), and worms are un-commonly found in the mesentery or mesocolon. Jeong et al. (7) reported a case of omental involvement of Paragonimus westermani with conglomerated calcifications in pelvic cavity. Kim et al. (8) reported a case of anisakiasis involving a lymph node in mesocolon. Kim et al. (9) reported that Fasciola hepatica was found in abscesses formed in the mesocolon. Howev-er, to our knowledge, there is no reported case of hematoma in sigmoid mesocolon as ascari-asis.

A. lumbricoides has no sucker, only soft lips, so the pathogenesis of bleeding with mesen-teric hematoma and perforation is thought to result from mechanical trauma due to its at-tachment to the intestinal lining, mucosal chemical irritation by its secretions, and massive migration of the parasite through the intestinal wall (1, 10). The present case showed mesen-teric hematoma and colonic perforation, which are sequential complications as the larvae migrated.

Clinically common causes of mesocolic or mesenteric hematoma are spontaneous bleed-ing or trauma, but if serial complications such as gastrointestinal bleeding and perforation are noted, parasite infection should be considered as the differential diagnosis with the help of the relevant clinical information, including the patient's travel and food intake histories.

Diagnosis of ascariasis is generally based on the presence of adult worms or eggs in the stool samples; however, in case of complications an imaging modality such as CT is neces-sary. Ascariasis can be successfully treated with anthelmintic therapy, as long as there are no potentially fatal complications, such as bowel perforation.

Knowledge of ascariasis manifesting mesocolic hematoma and its CT imaging features will help radiologists and clinicians to make prompt diagnosis and appropriate therapeutic and management, and to avoid further surgical complication.

Author ContributionsConceptualization, B.K.E.; data curation, B.K.E., K.H., B.B.; investigation, all authors; methodology,

K.J., B.K.E.; project administration, B.K.E., K.H.; resources, all authors; supervision, B.K.E.; visualiza-tion, B.K.E., K.H., B.B.; writing—original draft, K.J.; and writing—review & editing, B.K.E.

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Conflicts of InterestThe authors have no potential conflicts of interest to disclose.

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2. Villamizar E, Méndez M, Bonilla E, Varon H, De Onatra S. Ascaris lumbricoides infestation as a cause of in-testinal obstruction in children: experience with 87 cases. J Pediatr Surg 1996;31:201-4; discussion 204-205

3. Huang SC, Shieh CS. Ascariasis presenting as massive gastrointestinal bleeding. Pediatr Surg Int 1996;400-401

4. Sangkhathat S, Patrapinyokul S, Wudhisuthimethawee P, Chedphaopan J, Mitamun W. Massive gastroin-testinal bleeding in infants with ascariasis. J Pediatr Surg 2003;38:1696-1698

5. Pitanga Lukashok H, Robles-Jara C, Robles-Medranda C. Multiple intestinal erosions as a result of hemor-rhage due to parasites: case reports and review of the literature. Diagn Ther Endosc 2011;2011:340869

6. Stephen DD, Siow SL. Acute lower gastrointestinal haemorrhage secondary to small bowel ascariasis. Ma-lays J Med Sci 2012;19:92-95

7. Jeong WK, Kim Y, Kim YS, Park DW, Park CK, Baek HK, et al. Heterotopic paragonimiasis in the omentum. J Comput Assist Tomogr 2002;26:1019-1021

8. Kim HJ, Park C, Cho SY. A case of extragastrointestinal anisakiasis involving a mesocolic lymph node. Kore-an J Parasitol 1997;35:63-66

9. Kim AJ, Choi CH, Choi SK, Shin YW, Park YK, Kim L, et al. Ectopic human Fasciola hepatica infection by an adult worm in the mesocolon. Korean J Parasitol 2015;53:725-730

10. Sharma BC, Bhasin DK, Bhatti HS, Das G, Singh K. Gastrointestinal bleeding due to worm infestation, with negative upper gastrointestinal endoscopy findings: impact of enteroscopy. Endoscopy 2000;32:314-316

구불창자간막 혈종으로 발현한 회충증: 증례 보고

김지은1 · 배경은1* · 김현정2 · 배병노3 · 이지혜1 · 강미진1 · 김지영1 · 김재형1

회충증은 Ascaris lumbricoides에 의하여 유발되는 장 질환이다. 대부분의 회충증 환자는

무증상이지만 장내 유충이 많은 경우에는 장 폐색, 폐쇄성 황달, 담관염, 담낭염, 췌장염과 같

은 합병증이 생길 수 있다. 저자들은 컴퓨터단층촬영(이하 CT)에서 구불창자간막에 혈종과

활동성 출혈이 발생하여 회충증으로 진단된 74세 남자의 사례를 경험하였다. 이후에 환자가

시행한 CT에서는 이와 더불어 구불창자의 천공 발생이 확인되었다. 복강경을 통한 저위전방

절제술이 시행되었고 구불창자간막에 큰 혈종이 있었으며 장간막 지방 조직에서 현미경적

으로 회충이 확인되었다. 이러한 회충증의 드문 임상적, 영상의학적 소견은 기생충이 장관의

내강 안에서 복강 내로 이동하는 과정에서 발생한 순차적인 합병증들을 보여준다.

인제대학교 상계백병원 1영상의학과, 2병리학과, 3외과