Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (10): 663-664 663 INTRODUCTION In developing countries, where a great part of the population lives in low hygienic conditions and lack of basic sanitation facilities, there is an increased incidence of parasitosis. Consequently, the complications of these pathologies are more frequent and represent important medical, social and economic problems for these nations. 1 The parasitic worms usually reside in the intestine; however, due to the tendency to migrate, they can move to any part of the human body. Occasionally, they can perforate the intestinal tract and give rise to intense granulomatous inflammatory reaction which mimics tuberculosis. 2 This report describes the clinical and diagnostic approach of an atypical case of pseudotumorous form of Ascaris. CASE REPORT A 35-year-old lady, who had a previous history of passage of worms in the stools, developed on and off dull lower abdominal pain in the right lower part of the abdomen. The pain increased in intensity and became continuous. Later on, she developed amenorrhoea. On consultation with the gynaecology department, her laboratory findings were found to be within normal limits. An abdominal ultrasound revealed an abdominal mass, containing Ascaris, probably arising from the uterine wall. The CT scan showed a well-defined lobulated tubular mass with thick enhancing walls adjacent to the caecum (Figure 1). Concomitant ultrasound showed live Ascaris within the mass. An ill-defined complex mass with thin internal septations was also seen in the left adnexal region. At laparotomy, the findings were a hard tubular abdominal mass adherent to the anterior abdominal wall and adjacent loop of jejunum. Despite adherence to the gut, no communication was noted. The findings were suggestive of a mass. Tuberculosis was also suspected as cheesy material oozed out of the mass while separating it from the gut. The left ovary was found to have a haemorrhagic cyst. The uterus and other ovary were found to be normal. Cut section of the mass revealed a long central tunnel with a live Ascaris lumbricoides (Figure 2 and 3). The biopsy report showed acute on chronic granulomatous inflammation and the worm was found to be female. Postoperative recovery was smooth. The patient was discharged on antihelminthics and followed in the outpatient department. DISCUSSION Adult worms usually cause no symptoms related to intestinal tract if there load is low. However, as they can migrate, even a single worm can cause serious complications. The worms may enter into viscera any of the gastrointestinal system or find their way into the peritoneal cavity. Involvement of unexpected sites such as the kidney or even pleural cavity by this parasite can lead to life-threatening complications. Tuberculosis can lead to a similar granulomatous reaction and therefore must be considered in the differential diagnosis. Usually, intestinal ulcerations provide a passage for this worm to pass into the abdominal cavity. Occasionally, the worm may itself perforate the intestine. Then, the female worm lays eggs which produce an intense granulomatous inflammation, after which the worm dies leading to a large abscess. It can even lead to severe granulomatous peritonitis. 3 This is often fatal since there is secondary bacterial infection. After its death, the worm can go to any place it could visit during life. ABSTRACT A 35-year-old woman presented with lower abdominal pain and amenorrhoea. CT showed a thick walled lobulated mass with Ascaris adjacent to caecum along with the presence of a left ovarian mass. The peroperative findings were a tubular mass with central tunneling containing an Ascaris lumbricoides. Left ovary showed a haemorrhagic cyst. Biopsy of the mass showed acute on chronic granulomatous inflammation and the worm was found to be female. This was a rare case of Ascaris lumbricoides presenting as a pseudotumorous mass. Key words: Ascaris. Pseudotumor. Abdomen. Chronic granuloma. Department of Surgery, Ward No. 3, Jinnah Postgraduate Medical Centre, Karachi. Correspondence: Dr. Iram Bokhari, 62/II B, Street 5, Off Khayaban-e-Momin, Phase V, DHA, Karachi. E-mail:i_bokhari@hotmail.com Received October 23, 2008; accepted June 08, 2009. A Case of Pseudotumorous Form of Ascaris Iram Bokhari, Nawaid Farooque Khan, Qurrat-ul-Ain Tahir, Nasir Ali and Asadullah Khan CASE REPORT