International Journal of Gerontology 4 (2010) 199e201

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International Journal of Gerontology

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Case Report Endoscopic Diagnosis of Infection That Caused Anemia in an Elderly Personq

Yang-che Kuo 1,2, Chen-Wang Chang 1,2, Chih-Jen Chen 1,2, Tsang-En Wang 1,2, Wen-Hsiung Chang 1,2* Shou-Chuan Shih 1,2

1 Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan, 2 Division of Gastroenterology, Mackay Memorial Hospital, Taipei, Taiwan. article info summary

Article history: is a common intestinal in the world. Patients with a light hookworm Received 30 January 2010 infection are usually asymptomatic, but a moderate or heavy hookworm burden can result in fatigue, Accepted 13 March 2010 recurrent abdominal pain, and iron-deficiency anemia. We presented a case of 61-year-old man com- plained of general malaise and melena for 6 months due to hookworm infection. There is no eosinophilia, and the stool exam only revealed positive of occult blood, without ova or parasite identified. Upper Keywords: endoscopy revealed several squirming red worms in duodenum. Hookworm () hookworm infection, infection is diagnosed and eradiated by mebendazole successfully. His anemia is corrected after treat- Ancylostoma duodenale, endoscopy ment. Hence, hookworm infection should be noted in eldler patients with long term anemia in Taiwan. It is also important to check carefully in the duodenum at routine upper gastrointestinal endoscopy. Copyright Ó 2010, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.

1. Introduction corrected after successful eradication of the parasite infection by mebendazole. Hookworm infection is one of the most common intestinal infection in the world. There are about 740 million infected people in global prevalence, especially underdeveloped 2. Case Report countries in the tropics and subtropics. Most infected individuals are asymptomatic. A heavy worm burden, a prolonged duration of A 61-year-old male farmer complained of general malaise and infection, and an inadequate iron intake may result in iron defi- melena for 6 months. IDA had been diagnosed elsewhere on one ciency anemia (IDA) and hypoproteinemia in heavy infection. The occasion 3 years ago, although a definite etiology had not been most common species are Ancylostoma duodenale and Necator identified. The endoscopy had shown a small ulcer in the gastric americanus. Hookworm infection can be diagnosed by the detec- antrum but a normal duodenum 3 months ago. He was treated tion of eggs in feces, and several case reports presented the finding with a proton pump inhibitor, but the melena persisted. During in panendoscopy, colonscopy, and capsule endoscopy. Because of this time of admission, the physical examination was unremark- hygiene improvement in Taiwan in recent decades, there are only able except for mild external hemorrhoids, but there was no some case reports of hookworm infection. However, we should evidence of bleeding. The laboratory data were entirely normal keep the disease in mind because of increasing cross-border except for a hemoglobin of 6.5 g/dL (13.6e17.5 g/dL) and a mean female marriage immigrants and foreign workers in Taiwan. We corpuscular volume of 65 fL (88.3e98.0 fL). Stool examination was report a case of hookworm (Aduodenale) infection with general positive for occult blood, but no ova or parasites were identified. malaise owing to prolonged IDA for 6 months. Anemia was The endoscopy this time showed several squirming red worms swimming in the duodenal bulb to the third portion of duodenum (Fig. 1). Hookworm (Aduodenale) infection (Figs. 2 and 3) was diagnosed histologically from a specimen obtained endoscopi- q cally, but repeat stool examination was still negative. Mebenda- All contributing authors declare no conflict of interest. zole was started immediately, along with iron replacement, * Correspondence to: Wen-Hsiung Chang, No. 92, Section 2, Zhongshan North Road, Zhongshan District, Taipei City 10449, Taiwan. resulting in a significant improvement in the hemoglobin to E-mail address: [email protected] (W.-H. Chang). 10.1 g/dL 3 months later.

1873-9598/$ e see front matter Copyright Ó 2010, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.ijge.2010.11.008 200 Y.-c. Kuo et al.

Fig. 3. Histologic features of the worms identified them as Ancylostoma duodenale (original magnification, 100Â).

Larvae can penetrate skin and enter bloodstream, then reach heart Fig. 1. Endoscopy showed red worms swimming in the duodenum. and enter lung capillaries and alveola spaces about 10 days from hatch. Patients coughed up larvae and swallowed them into the gastrointestinal tract, where the larvae molt twice and develop to 3. Discussion the adult stage. Then each female hookworm can produce thou- sands of eggs daily and repeat the life cycle. We presented a case of an elderly male with long-term IDA Repeated exposure to third-stage larvae of N americanus or A fi history, with an incidental nding of hookworm infection during duodenale results in a local pruritic, erythematous, papular rash fi panendoscopy. Hookworm is rst described by an Italian physician, known as “ground itch”.6 The most hookworm-related disease in 1 Dubini, in 1838, after an autopsy on a woman in Milan. It is esti- human is IDA, which occurred when the adult parasites cause mated that approximately 740 million people had hookworm intestinal blood loss.7 The mechanism of blood loss is not only infection in the world, and the disease mainly occurs in resource- mechanically through mucosa injury by worm suck but also 2 poor communities in the developing world. The chemically. The adult hookworms can release anticlotting agents A duodenale and N americanus are widespread among humans. A (one of these, a novel factor VIIa/tissue factor inhibitor).8 Albonico duodenale is more geographically restricted, whereas N americanus et al.9 mentioned that infection with A duodenale causes greater is the most common hookworm worldwide. Hookworm is trans- blood loss than infection with N americanus, and the degree of IDA mitted through contact with contaminated soil, especially fecal induced by hookworms depends on the species. There is also contamination is much more common than the penetration of the a direct correlation between the quantitative egg counts and the 3 skin. The infection rate ranged from 50% to 90% in Taiwan before reduction in hemoglobin, serum ferritin, and protoporphyrin levels. 4 1950. Then it decreased to less than 1% after general sanitation and Otherwise, esosinophilia can be found in laboratory finding, and 5 medicine improving. peumonitis accompanied by pulmonary hookworm infection is Human acquired hookworm from the third-stage infective reported in rare cases. larvae, which hatched and developed in soil from egg in feces. The definite diagnosis is usually made by repeated examination of patient’s feces for finding the eggs. In our case, we could not find ova at the initial fecal examination, and the IDA did not improve despite treatment of proton pump inhibitor. Because of positive occult blood in stool, we repeated the endoscopic examination, by which the hookworms were found in the duodenum. By picking them up directly with biopsy forceps, the type of hookworm could be confirmed as A duodenale. The specific treatment of choice for elimination of hookworms from the intestines is a benzimidazole , either albendazole (400 mg once) or mebendazole (100 mg orally twice a day for 3 days or 500 mg once).10 In northern Taiwan, between 1999 and 2000, the fecal samples from foreign workers were positive for parasite infection for about 10%.11 In China, age accounts for 27% of the variation in the intensity of hookworm infection, with the highest intensity among middle- aged persons, or even those over the age of 60 years.12 Such infection patterns present implications for the world’s expanding elderly populations. The usual method of hookworm infection is through the skin; this is commonly caused by walking barefoot through areas contaminated with fecal matter, like the elderly Fig. 2. Histologic features of the worms identified them as Ancylostoma duodenale farmer. This parasite should always be considered as a cause of IDA, (original magnification, 20Â). especially in elderly patients who have the history of walking Endoscopic Diagnosis of Hookworm Infection 201 barefoot in soil. Fecal examination and endoscopy are suggested for 5. Parasite Control Association of R.O.C. Working Report of Parasite Prevention in anemia study, and it is especially important to check duodenum Primary School Children in Taiwan. Taiwan: Department of Health, Taiwan Provincial Government; 1992 [In Chinese]24e25. carefully during endoscopy. Furthermore, our case suggests that 6. Hotez PJ, Brooker S, Bethony JM, et al. Hookworm infection. N Engl J Med mebendazole is an effective antiworm medication for removal of 2004;351:799e807. e hookworm, and taking more care of the sanitation surrounding the 7. Hotez PJ, Pritchard DI. Hookworm infection. Sci Am 1995;272:68 74. 8. Del Valle A, Jones BF, Harrison LM, et al. Isolation and molecular cloning of elderly patients might reduce the infection. a secreted hookworm platelet inhibitor from adult Ancylostoma caninum. Mol Biochem Parasitol 2003;129:167e177. 9. Albonico M, Stoltzfus RJ, Savioli L, et al. Epidemiological evidence for a differ- References ential effect of hookworm species, Ancylostoma duodenale or Necator ameri- canus, on iron status of children. Int J Epidemiol 1998;27:530e537. 1. Dock G, Bass CC. Hookworm disease. St Louis: C. V. Mosby Company; 1910. 10. Drugs for parasitic infections. Available at: http://www.medicalletter.com/ 20e63. freedocs/parasitic.pdf [Date accessed: 26 July 2004]. 2. de Silva NR, Brooker S, Hotez PJ, et al. Soil-transmitted helminth infections: 11. Fan PC, Chung WC, Chen ER. Current status of imported parasitic infection updating the global picture. Trends Parasitol 2003;19:547e551. among foreign workers in northern Taiwan (1999-2000). Kaohsiung J Med Sci 3. Owen RL. Parasitic diseases. In: Sleisenger MH, Fordtran JS, editors. Gastroin- 2001;17:503e508. testinal Disease. Philadelphia: Saunders; 1993. p. 1211e1212. 12. Bethony J, Chen JZ, Lin SX, et al. Emerging patterns of hookworm infection: 4. Shieh SC. Hookworm disease and the prevalence in Taiwan. Med J 1958;1:1e3 influence of aging on the intensity of Necator infection in Hainan Province, [In Chinese]. People’s Republic of China. Clin Infect Dis 2002;35:1336e1344.