A 5-year old boy is presented by his parents to Pediatric Surgery Emergency of the Hospital Escuela Universitario (HEU) in Tegucigalpa, Honduras; with a 8-day history of pain in his right testicle, with sudden onset, continuous, intense enough to prevent him from wandering around, denying trauma backgrounds, followed by an increase of the volume with same amount of time; vomiting preceded by nausea, 3-day vomiting evolution with 4 daily episodes of alimentary content; concomitantly, 4-day history of high fever, without a timetable predominance, attenuated with acetaminophen.
Physical examination of genitals showed an augmentation in size of the right testicle in comparison with the left one, inflammatory changes, tenderness, positive Prehn sign, bilateral cremasteric reflex present.
Blood count showed leukocytosis with eosinophilia (Table 1). Sonogram reported a testicle of 1.8x1.0x1.1 cm, volume of 1.07 mL, with alteration on its axis and hypoecogenic areas with irregular appearance, no sign of abstraction of discharge to color Doppler, nor power Doppler; showed diffuse enlargement of the epididymis, edema and inflammatory changes on the scrotal bag; no hydrocele nor pyocele. Left testicle with normal size and form.
The treatment was a right simple orchiectomy, finding necrosis of the testicle and pyocele. The biopsy showed a reddish-purple aspect and soft consistency testicle, followed by the spermatic cord, with macroscopic outbreaks of necrosis and softening zones.
Histologic studies revealed the presence of a worm inside the testicular artery (Figure 1), surrounded by granulomatous inflammation with abundant eosinophils, testicular parenchyma showed wide discharges of hemorrhagic necrosis, eggs were not identified. Medical discharge was given 24 hours later with successful progress.
Patient presented to the Pediatric Surgical Emergency department 10 days after his last admission with a 7-day history of not having bowel movements, treated with 2 enemas without stimulating defecation; also 5-day evolution abdominal pain, located in the epigastrium, irradiated to the right iliac fossa, intense, attenuated with ibuprofen, 4-day history of fever, subjectively high, predominant at night. 3-day vomiting history with 4 daily episodes of dietary content.
During physical examination, abdomen was bloated with no umbilical scar deviation, to auscultation bowel sounds were absent, to percussion timpanums was confirmed, abdominal girth was 53 cm with tenderness and pain were located at the lower right quadrant, Blumberg and Rovsing signs were positive, no visceromegaly nor abdominal masses were found. Complete blood count presented increased WBC with eosinophilia (Table 1).
A laparoscopic appendicectomy was performed finding inflammatory changes in cecal appendix with small pinpoint marks in terminal ileum, caecum and appendix. The cecal appendix biopsy reported secondary eosinophilical appendicitis infection by A. costaricensis, secondary vascular occlusion and coagulative necrosis subsequently. Cecal appendix showed similar changes to the testicle, with worm in the arteriolar lumen, A. costaricensis eggs were found in capillaries, stroma and cecal appendix wall.