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A Case of Chronic Diarrhea Secondary to Capillaria

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A Case of Chronic Diarrhea Secondary to Capillaria CASE REPORTChronic DiarrheaHeart from Failure Capillaria and Short philippinensis Stature in a 43 year-old in Mindoro male Table 1. AInitial Case Laboratory of Chronic Results Diarrhea Secondary to Capillaria philippinensis in OccidentalCBC Mindoro: PossiblyBlood chem. a Newly-DescribedUrinalysis Endemic Area?ABG Reference Result Reference Result Color straw pH 7.408 Value Value WBC 5-10 Mary Ondinee4.5 U. RBSManalo,1 Virgilio3.9-6.1 P. Bañez6.32 and VicenteTransp Y. Belizario,Clear Jr.3,4 pCO2 49.1 RBC 4-6 HGBA1C 4.27-6.07 6.4 Sp Gravity 1.010 pO2 70 HGB 120-150 90 BUN 2.6-6.4 5.0 pH 8.0 HCO3 31.3 HCT 0.38-0.481Department of Medicine,0.27 CollegeCREA of Medicine an53-115d Philippine General123 Hospital, UniversitySugar of the PhilippinesNEG ManilaO2 sat 93.6 MCV2Section of 80-100Gastroenterology, FL Department of AMedicine,LB College of34-50 Medicine and32 Philippine GeneralProtein Hospital, UniversityNEG of the PFihilippinesO2 Manila21% MCH 27-31 PG 3NationalTAG Institutes of Health,0.34-1.7 University0.82 of the PhilippinesRBC Manila 0-1 Temp 36.9 MCHC 320-360 G/L 4Department of Parasitology,HDL College0.91-1.56 of Public Health,0.67 University of theWBC Philippines Manila0-2 RDW 11.5-15.5% LDL 1.1-3.8 4.21 Cast PBS PLT 200-400 Inc TOTAL CHOL 4.2-5.2 5.25 Epith cell Rare Slight poikilocytosis, RETIC 0.005-0.015 AST 15-37 95 Bacteria Occ’l acanthocytes, ovalocytes, SEG 50-70% 48 ALT 30-65 91 Mucus th CaseRare slight toxic granulation, LYMPH 20-44% 50 Alk po4 184A 41-year-oldCrystals male from theRare town ofslight Alacaak, anisocytosis Sta. Cruz, MONO 2-9% 2 NA 140-148 Occidental136.9 MindoroAm urates presented with a one-year history of EO 0-4% 0 K 3.6-5.2 3.35 BASO 0-2% 0 CL 100-108 colicky86 abdominal pain and watery diarrhea. Multiple BLAST 0% 0 CA++ 2.12-2.52 consults2.37 were done in their region that revealed P “unremarkable2.27 fecalyses”. He was given various antibiotics MG++ 0.74-1 but0.83 this did not resolve his symptoms. Six months prior to admission, four men in their barangay died from chronic diarrhea and this prompted the fatpatient pad. toCardiac seek consultenzymes in were Manila. not consistentHe was admittedwith an acutein a Table 2. Thyroid Function Tests coronaryprivate hospital event (Table for work3), however,-up where intravenous fecalysis (IV) again heparin was Reference Value Result (overlapping“unremarkable”, with abdominaloral warfarin) CT wasthat stillrevealed given tono cover masses, for Free T4 (0.8-2.0) 0.02 ng/dL theand presencecolonoscopy of awith possible biopsy L Vthat thrombus revealed asmild demonstrated nonspecific TSH (0.4-6.0) 24.75 Uiu/ml colitis. During this time, the patient had lost more than a Introduction by rheologic stasis on cardiac ultrasound. Medications werethird shiftedof his weightto IV diuretics and developed and inotropes; bipedal oral edema. digoxin Patient was Intestinal capillariasis or capillariasis philippinensis is started.was repeatedly IV antibiotics readmitted were butgiven no fordefinite possible diagnosis pulmonary was caused by a small nematode known as Capillaria infection.established. The He patient was never later onfebrile. showed improvement, and was philippinensis. Symptoms of this illness are diarrhea, eventuallyThe patient weaned had off afrom history ventilatory of pulmonary support, tuberculosis extubated, borborygmi, and abdominal pain. This helminthic infection treated for only a week. He was fond of eating dogs and was virtually unknown until 1963 when Chitwood reported kilawin. He knew the four people who died in their locality. the first case, a schoolteacher from Bacarra, Ilocos Norte. He Table 3. Cardiac Enzymes He admitted to having been in a drinking binge with at least had a history of intractable diarrhea for 3 weeks with ascites, one of them and ateReference kilawin Range during (mmoL) their binges.Result He worked emaciation and cachexia and later died at the Philippine asQualitative a farmer, as a fisherman, and as a tricyclePOSITIVE driver. He General Hospital in Manila.1,2 Troponin I would catch fish in Pagbahan River, but would sometimes In the 1960s, a capillariasis outbreak occurred in CK-MB 0-6.0 1.14 buy from the local market. No other family member Tagudin, Ilocos Sur where almost a hundred died.3 Another CK-TOTAL 21-232 543 presented with diarrhea. He had no history of travel. epidemic was recorded in Southern Leyte in the Philippines The patient presented at the Emergency Room of the in the early 1980s.4 In the recent past, this parasite was also Philippine General Hospital severely emaciated, unable to isolated in Compostela Valley Province2 and Zamboanga del ambulate and with palpatory BP (Figure 1). He weighed 42 Norte in Western Mindanao.5 kilograms (BMI=16), with bronchovesicular breath sounds, FigureWe 1. presentElectrocardiogram a case of uponchronic admission diarrhea secondary to normal cardiac rate and regular rhythm, scaphoid abdomen multiple enteric pathogens, including Capillaria philippinensis which was normoactive, grade 2 bipedal non-pitting edema, in Occidental Mindoro, a possible newly-described endemic transferred to the intensive care unit (ICU) for ventilatory and unremarkable digital rectal exam. Neurologic findings area. support and closer monitoring. On bedside cardiac ultrasound, were normal. He was hydrated and started on inotropes. there was a finding of eccentric left ventricular hypertrophy, Initial investigations revealed the following: severe global_______________ hypokinesia with depressed overall systolic function hypoalbuminemia (2g/L) with no proteinuria, hemoglobin with concomitant spontaneous echo contrast on left ventricular 9 Corresponding author: Mary Ondinee U. Manalo, MD 142g/L, wbc 7.4 x 10 /L (neut 0.64 lymph 0.32 eos 0.013), and (DepartmentLV) cavity of suggestive Medicine of rheologic stasis, the ejection fraction low electrolytes (sodium, potassium, calcium, magnesium, wasPhilippine 25%, General with Hospital moderate mitral regurgitation, moderate and phosphorus). He had normal creatinine, bilirubins, and aorticUniversity regurgitation of the Philippines with Manila aortic sclerosis, severe tricuspid liver enzymes. His ECG had low voltage complexes. His Taft Avenue, Ermita, Manila 1000 Philippines regurgitation with mild pulmonary hypertension, pulmonary initial stool examination showed abundant white blood Telephone: +632 8062209 / 0923 6503548 Figure 2. Chest radiograph on admission regurgitation,Email: [email protected] and minimal pericardial effusion or pericardial cells, without any RBC, fat globules, ova, or parasites. Fecal VOL. 4643 NO.N0. 4 3 2009 2012 ACTAACTA MEDICAMEDICA PHILIPPINAPHILIPPINA 1381 Chronic Diarrhea from Capillaria philippinensis in MindoroCASE REPORT occult blood was likewiseHeart negative.Failure Investigations and Short for Stature rhabditiform in a 43larvae. year-old First line treatmentmale for strongyloidiasis pulmonary tuberculosis including a chest film and sputum is Ivermectin but this was not available in the Philippines. AFB wereKaterina normal. T. L eyritanaNo enteric1, Ma. pathogen Czarlota was M. isolated Acelajado-Valdenor on Second1, lineAmado drug O is. albendazoleTandoc III2 400and mg Agnes bid x D. 5 daysMejia every1 2 initial stool culture. Stool was sent to the College of Public weeks x 2 cycles and this was started on the patient the Health for FECT1Department which revealed of Medicine, no College parasites. of Medicine A 2D and-echo Philippine same General day. Hospital, Since University the patient of the had Philippines been treated Manila multiple times 2 was requested to rule out a cardiogenicDepartment of cause Pathology, for Collegethe shock of Medicine, for University amoebiasis, of the Philippinesdiloxanide Manila furoate, a luminal agent, was and it revealed a small pericardial effusion with an ejection added on top of metronidazole. fraction of 33%. The next stool sample had suspected Capillaria philippinensis ova, which were atypical because they did not possess bipolar plugs. Another stool sample was sent the following day and the diagnosis of capillariasis was Presentation of the case requireestablished regular when laxative it revealed use. There typical was Capillariaalso a report ova of with two This is a case of a 43-year-old male presenting with short morebipolar syncopal plugs (Figure episodes. 2). TheHe waspatient brought was thento another treated doctor with stature and heart failure. The patient was admitted at the inthe a followinprivate ghospital drugs: wherealbendazole the assessment 400 mg bid was x 10still days a “heart then medicine ward of the Philippine General Hospital (PGH) problem”.repeated after The 2 weekspatient (this was covered again for prescribed both C. philippinensis unrecalled for dyspnea. This paper will investigate several issues: medicationsand S. stercoralis and); againmetronidazole was lost 500 to mgfollow-up. tabs q6 xThis 14 days;time, differentiating congenital from acquired hypothyroidism, however,diloxanide symptoms furoate 500 were mg tabpersistent. tid x 14 Hedays; later fluconazole consulted 200 at the relationship between hypothyroidism and the anothermg cap xlocal 10 days;hospital, and where quadruple he was anti admitted-Koch’s. andBy thismanaged time, cardiomyopathies, and the therapeutic options in patients asthe a chroniccase of anemiadiarrhea and of bronchialthe patient asthma. was attributed He was discharged to: 1.) TB with cardiomyopathy secondary to hypothyroidism. slightlycolitis, 2.) improved C. philippinensis after four, 3.)days, S. stercoralis,only
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