Ascariasis is a helminthic infection of humans caused by Ascaris lumbricoides. Pediatric patients infected with Ascaris can develop multiple complications including appendicitis, gastrointestinal bleeding, hepatobiliary disease like cholangitis or obstructive jaundice, intussusception, and bowel obstruction among others. Ascaris is a rare cause of intestinal perforation even in endemic areas. METHODS A 2-year-old female Ethiopian toddler who was presented with a complaint of non-bilious, non-projectile vomiting of 06 days duration, about two-three episodes per day. Associated with this she had had progressive abdominal distension, intermittent abdominal cramps and loss of appetite. On examination, she was acutely sick looking. She had signs of dehydration. Subsequently, she was resuscitated, broad spectrum antibiotic started and operated. Finally, the child was discharged improved after 7 days of hospital stay. The clinical presentation of ascariasis can vary from asymptomatic child to one with severe disease requiring surgical intervention like our patient. Severity of disease depends on the worm burden; heavy worm infestation produces a wide range of acute abdominal complications such as intestinal obstruction, intussusception, cholangiohepatitis, pancreatitis, and acute appendicitis. Intestinal ascariasis rarely causes volvulus and intestinal gangrene, perforation and peritonitis. CONCLUSIONS Ascariasis must be considered in the differential diagnosis in patients presented with peritonitis especially those living or from temperate and tropical countries with a history of passage of worms. Ileum perforation is possible in patients with ascariasis due to pressing directly into the bowel wall, inflammatory reaction, or volvulus and intestinal wall necrosis.