Case Report

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American Journal of Emergency Medicine

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Hookworm infestation as unexpected cause of recurrent pancreatitis

Abstract

Parasite infestation is still associated with significant morbidity and mortality. Hookworm infestation is a very rare cause of pancreatitis. This parasitic infestation might be asymptomatic. Acute pancreatitis as a result of the hookworms migrating into the ampulla of Vater with chronic inflammation was a very rare complication. We report a case of hookworm infestation that was associated with significant complication of recurrent pancreatitis. The patient was treated with mebendazole. He was asymptomatic and had gained weight at the 3-month follow-up. Our case demonstrates that pancreatitis secondary to hookworm infection can occur and may resolve after anthelmintic treatment.

An 86-year-old man who had recently been treated for iron deficiency anemia presented to our emergency department (ED) because of general weakness, edema, dyspnea, diarrhea, abdominal pain, and dyspepsia for 5 days. He had no history of diabetes mellitus, hypertension, alcohol consumption, or malignancy. He did not have headaches, Nasal discharge, productive cough, sore throat, chest pain, dysuria, or trauma. He was initially diagnosed and treated for recurrent pancreatitis and iron deficiency anemia at a local clinic for 6 months prior to his ED presentation.

On physical examination, he appeared malnourished. His blood pressure was 110/80 mm Hg, with a heart rate of 112 beats/min and a respiratory rate of 30 breaths/min. He was afebrile. The physical examination was otherwise unremarkable, except for pale conjunc- tiva, Abdominal distention, and tenderness more marked over the umbilicus with no guarding or rebound tenderness. Bowel sounds were decreased. A complete blood cell count showed the following: leukocyte count, 6900/mm³; segmented neutrophils, 90%; no eosin- ophil, anemia with a hemoglobin level of 4.0 g/dL; hematocrit, 15.6%; and platelet, 110 000/uL. Other laboratory studies included the following: glucose, 96 mg/dL; serum urea nitrogen, 50 mg/dL; serum creatinine, 1.6 mg/dL; sodium, 148 mEq/L; potassium, 2.5 mEq/L; glutamic oxaloacetic transaminase (GOT), 265 U/L; albumin, 3.4 g/dL; total bilirubin, 1.1 mg/dL; C-reactive protein, 2.73 mg/L; lipase, 988 U/L; and prothrombin time with an international normalized ratio of 1.89. Stool examination was positive for occult blood and ova. His chest x-ray showed a right lower lung infiltration and pleural effusion. He was transfused with 6 U Packed red blood cells. With a working diagnosis of recurrent pancreatitis, an Endoscopic retrograde cholangiopancreatography was performed on the day of admission with extraction of multiple worms (Fig.). Endoscopic retrograde cholangiopancreatography examination showed erythema and edema of the ampulla of Vater and Duodenal ulceration with duodenitis. The worms were identified as Ancylostoma duodenale. Based on these findings, oral mebendazole 100 mg twice a day for 3 days was prescribed. Iron supplements were used to treat iron deficiency anemia. After initiation of the therapy, the patient showed signs of improvement

and recovered uneventfully after 7 days treatment. He was asymptomatic with recovery of appetite and weight, and no further abdominal pain occurred and no stool ova was found at subsequent outpatient visits.

Abdominal pain is the most common chief concern of patients in ED [1]. Pancreatitis should be considered in all patients with unexplained abdominal pain. The patient presented with multiple episodes of pancreatitis and anemia for which the etiology was initially unknown. Parasitic agents are rarely identified in ED. The persistent and worsening of abdominal pain and anemia was related to hookworm infestation. Longstanding hookworm infection may result in malabsorption in affected individual. The major consequence of heavy hookworm infestation is iron deficiency anemia and hypoproteinemia. It may lead to iron deficiency anemia that results from chronic blood loss [2]. Mature worms of A duodenale develop in the duodenum and jejunum, bite into mucosa, and suck blood at a rate of 0.25 mL/d per worm, causing a variable degree of anemia. Hookworms in the intestine can cause abdominal pain, nausea, and diarrhea [3]. It commonly causes small intestinal infections, but pancreatitis induced by A duodenale is an unusual diagnosis. The pancreatitis occurred secondary to chronic inflammation involving the ampulla of Vater.

Most infected individuals are asymptomatic. Hookworm infection is

a treatable condition and results in Complete recovery. The protein losses associated with heavy hookworm infection can result in hypoproteinemia and anasarca. Loss of plasma protein results from malabsorption and increased intestinal permeability secondary to inflammation. Because large infestation is associated with high morbidity, it is critical to screen by examining stools under a microscope for the presence of worm larvae or eggs. Endoscopic retrograde

Fig. Image from endoscopic retrograde cholangiopancreatography shows A duodenale

hookworms attached to the duodenum (arrows).

0735-6757/(C) 2014

cholangiopancreatography may be used for direct diagnosis [4]. Hookworm infestation is acquired by contacting soil contaminated with human feces and ingesting larvae crawling on contaminated fresh vegetables. It should be suspected in patients with a history of exposure on poor sanitation and hygiene and immigrants from endemic areas.

Our case demonstrates that pancreatitis secondary to hookworm infection can occur and may resolve after anthelmintic treatment. Hookworm infection should be considered in malnourished patients with clinical signs and symptoms of abdominal pain, diarrhea with occult bleeding, and anemia.

Li-Ming Tseng, MD

Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan

Cheuk-Kay Sun, MD

Department of Gastroenterology Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan

Tzong-Luen Wang MD, PhD

Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan

Aming Chor-Ming Lin MS, MD

Emergency Department Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan Department of Intensive Care Unit

Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan School of Medicine, Fu-Jen Catholic University

New Taipei City, Taiwan E-mail addresses: [email protected]

[email protected]

http://dx.doi.org/10.1016/j.ajem.2014.03.046

References

1. Graff IV Louis G, Robinson Dave. Abdominal pain and emergency department evaluation. Emerg Med Clin North Am 2001;19(1):123-36.
2. Stoltzfus RJ, Dreyfuss ML, Chwaya HM. Hookworm control as a strategy to prevent iron deficiency. Nutr Rev Jun 1997;55(6):223-32.
3. Varghese Thomas, Harish K, Tony J, Sunilkumar R, Ramachandran TM, Anitha PM. Colitis due to Ancylostoma duodenale. Indian J Gastroenterol 2006;25:210-1.
4. Osman M, Bach Lausten S, El-Sefi T, Boghdadi I, Rashed M-Y, Lindkaer Jensen SM. Biliary parasites. Dig Surg 1998;15:287-96.