Enterobius vermicularis associated appendiceal colic and acute appendicitis are rarely encountered in the United States. The 9-year-old patient described in this case presented with right lower quadrant abdominal pain, nausea, and vomiting consistent with acute appendicitis and was brought to the operating room for an appendectomy. Intraoperatively a pinworm, E. vermicularis, was visualized and the presumptive diagnosis of acute appendicitis was revised to E. vermicularis associated appendiceal colic. Retrospective review of the preoperative imaging demonstrates the first reported ultrasonographic image of pinworm inhabitance within the appendiceal lumen. The patient was treated postoperatively with a course of albendazole and recovered appropriately. This article reviews the geographic epidemiology, pathophysiology, surgical, and medical treatment recommendations in the management of E. vermicularis diseases of the appendix. Through dissemination of this ultrasonographic imaging, the authors hope to inform other providers about E. vermicularis associated appendiceal colic and reduce the incidence of avoidable surgeries.