Clinical Case 083: Itchy britches

Hi readers – another case-based quiz for you all.

In case you had not noticed – it is Paeds month here at Broome Docs.  So, apologies to all you adult docs out there.

This case falls into the category of Boring EM. {check it out if you like common, everyday ED pearls}

A 17 month old girl is brought into the ED at 2 in the morning.   Her mother has spent the last few nights trying to get her settled – but she keeps waking up crying and irritable.  She is scratching her perineum in her sleep and mum is concerned that she might be developing a UTI. Mum has been changing her nappy regularly – and she says it all looks normal to her.

She is otherwidse well, growing and developing normally.  No history of UTI.

On examination – her abdomen is soft.  Urinalysis is normal – maybe a few red cells – but expected on the history.

More is missed by not looking than by not knowing” as spoken by Dr Thomas McCrae, [protege of Osler].

So, always examine the perineum of children.  This is often overlooked – but as you will find – many diseases manifest themselves in this area – and it can often be the clue in Paeds that clinches an otherwise perplexing cluster of symptoms into a diagnosis.

So I had a quick look.  Her vulva was a bit inflammed.  And then I saw the problem.  Diagnosis confirmed!

Q1.  What did I see?

Q2.  What is the treatment?

Q3.  What are the possible [albeit rare] complications of this disease?

Be a Broome Docs Quiz legend and get your answers in first. C




  1. Common things are common, so my guess is pinworm/threadworm infection. The worms migrate out of the anus at night hence the increased itching and potentially normal nappy appearance to mum. Treatment is with single dose anti-worm eg albendazole – and a good idea to treat the whole family. Scrub the kids fingernails and wash all the clothes / bedlinen / towels and vacuum carpet to prevent reinfection. Complications? I suppose if it was severe enough it could lead to anaemia or nutritional defiencies. I believe there is a risk of GI infection eg vaginitis endometritis.

    Am I anywhere close? 🙂

    I’ve seen a few girls with itchy perineums and it often seems to come in early primary school age when they are picking their nose and then scratching themselves and transmitting bacterial vulvitis from resp tract or GIT eg e. coli or strep. Sometimes see a purulent sort of discharge but sometimes not so often swab to help with diagnoses (not sure if this is necessary. Would be interested in others views). Have never come back with thrush even though mum’s always ask about it. My impression is that thrush does not really occur much in pre-pubertal girls. Of course dermatoses can occur as well, particularly if history of atopy and exposure eg sitting around in wet bathers or playing in grass.

    Look forward to the other comments and the “solution”!

  2. Nice diagnosis Dr Wilson. Love the “treat the whole clan: – very GP thinking Doc.

    Yes, pin (or thread) worms. Creatures of the night who come out to play when the lights are down. Classic GP diagnosis – we used to put sticking tape in the jocks to catch them in the act. Does anybody still do this?

    Enterobius vermicularis – it is a human pathogen, lives its whole life in the GIT of us! So do not blame the dog in this case.
    Here is a fact sheet from the CDC:

    On rare occasions they can invade either vertically into the genital tract, or through the intestinal wall. Check out these case reports:;jsessionid=12DFFDCB363454E2EF4EE4E06867E459.d01t03?deniedAccessCustomisedMessage=&userIsAuthenticated=false

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