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A Hospital-Based Study of Intestinal Capillariasis in Thailand: Clinical Features, Potential Clues for Diagnosis, and Epidemiological Characteristics of 85 Patients

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A Hospital-Based Study of Intestinal Capillariasis in Thailand: Clinical Features, Potential Clues for Diagnosis, and Epidemiological Characteristics of 85 Patients Am. J. Trop. Med. Hyg., 98(1), 2018, pp. 27–31 doi:10.4269/ajtmh.17-0465 Copyright © 2018 by The American Society of Tropical Medicine and Hygiene A Hospital-Based Study of Intestinal Capillariasis in Thailand: Clinical Features, Potential Clues for Diagnosis, and Epidemiological Characteristics of 85 Patients Lakkhana Sadaow,1,2 Oranuch Sanpool,1,2 Pewpan M. Intapan,1,2* Wattana Sukeepaisarnjaroen,3 Thidarat K. Prasongdee,1,2 and Wanchai Maleewong1,2 1Department of Parasitology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 2Research and Diagnostic Center for Emerging Infectious Diseases, Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand; 3Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand Abstract. Intestinal capillariasis caused by Capillaria philippinensis,afish-borne nematode, is an important, emerging zoonotic helminthiasis. Cases may be fatal if suitable treatment is not administered in time. We reported a hospital-based study of 85 cases in Thailand, most of which were in the northeast. All patients had a history of eating raw or insufficiently cooked fresh water fish or prawns. The clinical manifestations are characterized by chronic diarrhea, borborygmi, ab- dominal pain, marked weight loss, muscle weakness, fatigue, dizziness, anorexia, and edema, as well as protein and electrolyte loss. Fecal examination revealed C. philippinensis in all patients. Although 16 of the total of 85 (18.8%) cases were initially found to be negative for C. philippinensis using fecal examination, further examination using an immuno- blotting technique found them to be positive for the IgG antibody against Trichinella spiralis larval antigen. One day after administration of 400 mg of albendazole, eggs and/or larvae and/or adult C. philippinensis were found in 16 fecal samples. After treatment with mebendazole (200 mg twice a day for 30 days) or albendazole (200 mg twice a day for 10 days), all 85 patients recovered. The potential clues for diagnosis are clinical manifestations, history of eating raw contaminated food, and positive serological test, and fecal examinations under professional. Administration of anthelminthic drugs stimulates the excretion of larvae, eggs, and/or adult worms and can be used as a supportive method for the diagnosis of intestinal capillariasis in areas where serological test is not available. INTRODUCTION hospital (male:female = 66:19; mean age ± SD [range] = 43 ± 15 [10–81] years). All of these patients had experienced Intestinal capillariasis caused by Capillaria philippinensis,a chronic diarrhea for more than 1 month and were found neg- fish-borne nematode, is an important, emerging zoonotic fi 1 ative for human immunode ciency virus. All patients were helminth that has become more prevalent in recent years. hospitalized, treated, and prospectively studied. Epidemio- Fish contract the parasite from water containing the feces of logical data, clinical diagnosis, and treatment data were col- infected birds or humans. Humans are infected by consuming lected and analyzed. Diagnoses were confirmed by eggs and/ fi small freshwater sh, either raw or partially cooked. The par- or larvae and/or adult C. philippinensis in the patients’ feces. asite can reproduce within an individual host, resulting in a The stool specimens were examined in the same hospital visit large number of worms in the small intestine. Consequently, if using both direct smear3 and formalin-ethyl acetate concen- the parasite burden increases to massive levels, it can cause tration methods.22 Although 16 of the 85 cases encoun- disease. This kind of infection was first recorded in the 2,3 tered since 2006 were initially found to be negative for Philippines. Subsequently, cases have been reported in C. philippinensis using the direct smear and formalin-ethyl the Philippines,4 Indonesia,5 the Lao People’s Democratic 6 7 8 9 10 11,12 acetate concentration methods, they were found positive Republic, Japan, Taiwan, India, Iran, and Egypt. when subjected to serological examination using an immu- Capillariasis has also been found to be carried from an outside 5,13,14 noblotting technique against Trichinella spiralis larval anti- source into Europe. In Thailand, the cases have been 23 15–21 gen. All patients received mebendazole at 200 mg twice per reported in at least 25 provinces. This report describes day for 30 consecutive days or albendazole at 200 mg twice the clinical and epidemiological characteristics of a new group per day for 10 consecutive days.7,24 This retrospective study of intestinal capillariasis patients (85 cases) from a hospital- was approved by the Khon Kaen University Ethics Committee based study in Thailand, and potential clues for diagnosis are for Human Research (HE 581335). discussed. The information presented here could possibly be useful for clinicians who care for patients residing in endemic areas. Infection could be avoided by expanding focus on RESULTS health communication by responsible units. The public health Over the study period, 85 patients were found to have in- control strategy is still important to break possible morbidity testinal capillariasis. Stool examinations found eggs and/or and mortality due to this helminthic disease in this area. larvae and/or adults of C. philippinensis (Figure 1). All of whom had a history of eating raw or insufficiently cooked freshwa- MATERIALS AND METHODS ter fish or prawns. The provinces from which these cases emerged are shown in Figure 2. Eighty-three of the cases were Between 2000 and 2014, 85 cases of intestinal capillariasis found in the northeastern region. Macroscopic fecal charac- ’ have been diagnosed at Khon Kaen University s Srinagarind teristics, signs, and symptoms are presented in Tables 1–3 and Figures 3 and 4. Infected individuals had mainly experi- * Address Correspondence to Pewpan M. Intapan, Department of enced chronic diarrhea, borborygmi, abdominal pain, and Parasitology, Faculty of Medicine, Khon Kaen University, Khon Kaen abdominal bloating. Intestinal pseudo-obstruction was found 40002, Thailand. E-mail: [email protected] in three cases (3.5%) after treatment. Macroscopic fecal 27 28 SADAOW AND OTHERS FIGURE 2. Map of Thailand showing provinces in which intestinal capillariasis has been discovered. The figures in parentheses indicate the number of cases. total protein, and albumin, as well as malabsorption of fat were discovered. Fecal examination revealed C. philippinensis in 69 of the 85 patients (81.2%) before treatment with helminthic drugs. Since 2006, some cases (N = 16) have been diagnosed as suspected intestinal capillariasis and referred from community and provincial hospitals to the Srinagarind Hospital, the uni- versity hospital at Khon Kaen University. In these cases, all stool samples were previously found to be negative for C. philippinensis using the direct smear method. Then, the patients had been investigated using several other diagnostic methods (i.e., routine laboratory tests, liver function tests, thyroid function tests, antihuman immunodeficiency virus tests, long gastrointestinal studies, tests for tumor makers for differential gastrointestinal cancer, etc.). All patients pre- sented with the following clinical symptoms: chronic diarrhea, abnormal defecation, nighttime diarrhea, abdominal gurgling for more than 1 month, abdominal pain and bloating, weight loss, and hypoalbuminemia. The patients were prone to eating raw or insufficiently cooked scaled freshwater fish. Repeated FIGURE 1. The representative morphology of Capillaria philip- pinensis in fecal specimens. (A) Adult male and female of C. philip- pinensis indicating stichocyte (Sc), salient vulva (Vu), uterus (UT), larvae (Lv) and eggs (Eg) in the UT (Bar = 100 μm). (B) Adult male TABLE 1 C. philippinensis spicule (Sp), extended spicule (Ss), and Sc and Macroscopic fecal characteristic of 85 intestinal capillariasis patients* (C) magnification of the posterior end of C. philippinensis adult male from (B, rectangular area) (Bar = 100 μm). (D and E) Adult female of C. Characters philippinensis (Bar = 50 μm), (D) indicating Sc, salient Vu, and Eg in the Chronic diarrhea (> 1 month) 85 (100%) UT. (E) Adult female of C. philippinensis whole body indicating Sc, Abnormal defecation 85 (100%) salient Vu, and Lv. (F) The larva and Eg of C. philippinensis recovered Night time diarrhea 85 (100%) from fresh feces of a patient, the Eg (the upper right figure) are peanut Gross blood 1 (1.2%) shaped, flattened bipolar plugs sized about 40 μm long and 20 μm Gross Mucous 5 (5.9%) wide (Bar = 20 μm). Foul smell 48 (56.5%) Food debris in stool 61 (71.8%) * Out of 85 cases, Capillaria phillipinensis eggs were found in 39 cases; C. phillipinensis and Opisthorchis viverrini eggs were found in 22 cases; C. phillipinensis eggs and Strongyloides characteristics took the form of chronic diarrhea with night stercoralis larvae were found in 11 cases; C. phillipinensis eggs, O. viverrini eggs, and S. time defecation. Clinical signs, such as weight loss, muscle stercoralis larvae were found in five cases; C. phillipinensis and Echinostome eggs were found in two cases; C. phillipinensis eggs, Echinostome eggs, and S. stercoralis larvae were found in weakness, fatigue, dizziness, anorexia, and edema, were two cases; C. phillipinensis, O. viverrini, and minute intestinal flukes eggs were found in one frequently present. Laboratory parameters are presented in case; C. phillipinensis eggs, S. stercoralis larvae, and hook worm eggs were
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