Volume 5, Issue 4 , Pages 165-166, December 2010
Ascariasis into the middle ear: Report of two cases from Iran
Article Outline
Abstract
Ascaris lumbricoides is found in various parts of the world, mainly in poor sanitation conditions and in developing countries with very crowded areas. Although the prevalence of ascariasis has decreased in Iran due to improved hygiene situation and the use of pesticides in farms, we recently encountered a rare case complication in which the worm was found exiting the middle ear.
Keywords: Ascaris lumbricoides, Ectopic, Middle ear
1. Introduction
Ascaris lumbricoides is a common parasite in various parts of the world, especially among the lower socioeconomic groups. Although the ascariasis infestation had decreased [1], but there are still reports of eye, ear, bile duct, pancreas, liver, lung and kidney infestation [2], [3].
2. Case reports
2.1. Case 1
A 17-year-old female from rural area of Kermanshah province (western Iran) presented with pale complexion, weakness, loss of appetite, purulent otorrhea, hearing loss, fretfulness and pain on the mastoid bone. The socioeconomic status of her family was too poor. Routine antibiotic therapy and painkillers for suspected otitis media did not reduce the patient's systems. Her family had tried a traditional method to relieve ear pain including placing mashed onion onto the ear and leaving it overnight. The next morning, the patient's mother observed two round worms on her pillow and one coming out of the external auditory meatus and brought them to physician. The tympanic membrane was examined and a rupture was evident. The worms, 12–14
cm in length, 2–3mm in diameter and pink in coloration, were sent for microscopic examination (Fig. 1). Microscopic cross-section of the worms established the genus and species of the worms as adult A. lumbricoides. The patient and her family received anthelminthic therapy and the patient finally recovered from ascariasis in two weeks duration.
Fig. 1.
Ascaris lumbricoides recovered from the patient's ear. B. Cross-sections of the cuticle, hypodermis, lateral cord, muscle cells, intestines and uterus are all evident (Hematoxyline staining, 250).
2.2. Case 2
A 4-year old male child lives in Kermanshah in the western of Iran and had weakness, screaming in sleep due to pain of right ear, stream purulent, ottorrhea, low hearing, loss of appetite, malnutrition and fretfulness. It looked to have mental retardation, disability related motor function and speech. The place where he lived had low sanitation and sociocultural levels. The doctor ordered for stool exam in a parasitological laboratory. He observed WBC, yeast and blastocystis hominis in the fecal exam. According to traditional remedy he to put some visceral chicken on the ear overnight and the next morning about twenty worms came out from his right ear of size 6–7cm by 2–3mm and dark cream color (Fig. 1). Based on the preparation of cross-section of cuticle, hypodermis, muscle cells and other organs an adult ascaris was detected (Fig. 1).
3. Discussion
In ectopic ascariasis, the parasite is found outside the intestines as the worms migrate from the intestines to other organs. This has been reported in different parts of body such as bile, pancreatic ducts [4], [5], lungs [6], liver and kidneys [7]. They may be naturally expelled or may crawl out of mouth. They may also enter the nasal cavity via nasopharynx and exit through the naris. Although, lacrimal duct may also be infested by immature worms [8]. There was also a report from Zaire about a male adult A. lumbricoides worm in the lacrimal duct that attempted to enter the eye [9]. Likewise, a worm in oropharynx may enter eustachian tube and penetrate into the middle ear through tympanic membrane and into the external auditory meatus [10].
Two cases of ascaris in the middle ear have been reported from India [11].
The worms that were exiting from the middle ear were adult and seemed to be inhabitants of the intestines. Because the worms exited from the right ear after the topical application of mashed onion on the ear in the case 1 and visceral chicken the case 2. It seems likely that the onion juice and the visceral chicken could have stimulated the worms to move and perforate the tympanic membrane.
In rural areas where helminthic infestations are very common, a stool examination could help physician to rule out uncommon complications of highly prevalent diseases. Patients should be warned about old-fashioned home remedies which could result in extra complications in the patients. Primary care physician should also change the course of therapy or refer their patients to the proper specialists if their empirical therapies fail. More work is needed upon failure in treatment before the patient or her family attempt non-standard treatment modalities.
References
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- Ascariasis –its complication, unusual presentations and surgical approaches. South Med. J. 1997;70:176–178
- . Periampullary carcinoma following billiary ascariasis a case report. Indian J. Cancer. 1997;34:136–138
- . Ascaridiase cardiac. Rev. Golana Med. 1972;18:215–226
- Ectopic ascariasis: report of a case with adult worms in the kidney. Am. J. Trop. Med. Hyg. 1977;26:568–569
- . Ascaris in the lacrimal duct. Trans. R Soc. Trop. Med. Hyg. 1971;65:540
- . An ascaris in the lacrimal duct. Apropose of a case in Zaire. Sante. 1996;6:258–259
- . Ascaris lumbricoides from the right ear. Indian Pediatr. 1969;6:92–93
- . Abnormal migration of ascaris into middle ear. Indian Pediatr. 1998;65:147–148
PII: S1871-4048(09)00055-0
doi:10.1016/j.pedex.2009.09.002
© 2009 Elsevier Ireland Ltd. All rights reserved.
Volume 5, Issue 4 , Pages 165-166, December 2010
