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An Unusual Case of Abdominal Pain CLINICAL VIGNETTE An unusual case of abdominal pain S Vaughan MD DTMH1,3, M Sadler MD1, S Jayakumar MD1,3, B Missaghi MD DTMH1,3, W Chan MD MSc DTMH2,4, DL Church MD PhD1,2,3,4 CASE Presentation A 50-year-old man presented to the emergency department (ED) with vomitting and epigastric pain 1 h after eating raw, wild salmon, which he had purchased from a major chain grocery store. He experienced immediate onset of profuse emesis and upper abdominal pain with no diarrhea. The epigastric pain was severe (described as 8 of 10) and persisted for 2 h. On presentation to the ED 6 h after eating the fish, he had a fever of 39°C and continued to experience severe abdominal pain, which local- ized to the left upper quadrant. On examination, the patient had abdominal tenderness, which was worse over the left upper quadrant and epigastrium. Hematological tests revealed a hemoglobin level of 167 g/L, a platelet count of 96×109/L and an elevated white blood cell count of 11.4×109/L, with predominant neutrophilia but no eosino- philia. His chest x-ray was unremarkable, and stool culture for ova and parasites was negative. An abdominal x-ray revealed an abnormal con- tour of air surrounding the gastric mucosa, suggesting extensive lobular thickening. A subsequent computed tomography scan revealed uniform thickening of the ruggae in the fundus and body of the stomach, sug- Figure 1) Endoscopy demonstrating acute gastritis and worms adherent to gestive of acute gastritis or neoplasia. He underwent esophagogastroduo- the mucosa denoscopy (EGD), at which time a diagnosis was made. DIAGNOSIS reported in the United States, and an even lower incidence in Gastric anisakiasis Canada (6-9). At endoscopy, punctate ulcerations were observed throughout the There are several reasons for the increasing incidence of anisakiasis stomach and, on closer inspection, a 1 cm to 2 cm worm at the centre worldwide. All major oceans and seas contain marine life that is of each ulcer (Figure 1). Two of the worms were removed and sent to infected with anisakids (1). More regulatory control over marine fish- the microbiology laboratory for identification. ing and marine mammals has increased the available host populations Gross initial examination of the worms under a stereomicroscope for anisakid worms; while at the same time, individuals worldwide are revealed small, white larval nematodes 20 mm × 0.5 mm. Some key consuming more raw or lightly-cooked fish and squid. Pseudoterranova morphological features of anisakid worms were identified, including: occurs more frequently in the United States and Canada because fine striations of the cuticle; the presence of a boring tooth ventral to Pseudoterranova decipiens is mainly found in Atlantic or Pacific cod, the mouth; and the presence of an excretory pore between the ven- Pacific halibut and red snapper (5). trolateral lips (1,2). Histopathological examination of transverse sec- To our knowledge, this is the first case of anisakiasis acquired tions revealed the absence of lateral alae and distinctive Y-shaped from raw ‘wild salmon’ purchased from a Canadian supermarket. Our lateral chords, confirming the identification of an anisakid worm patient had a classic presentation for this condition. After eating (2,3). The narrow base of these chords, as well as the shape and colour infected fish, patients typically present within 6 h with severe vomit- of the worm, suggested the specimen was Anisakis. ing and occasionally diarrhea, followed by profuse abdominal pain, as Anisakiasis is caused by the accidental ingestion of larval nema- occurred in the present case. EGD and surgical removal of the todes belonging to the family Anisakidae. Humans become infected Anisakis worms is the treatment of choice (1). Endoscopic extrac- by eating raw seafood in dishes such as sushi, sashimi, ceviche, lomi- tion should be urgently performed when gastric anisakiasis is sus- lomi, or other undercooked fish and squid dishes. Although a skilled pected because delayed worm removal may result in the larvae sushi chef will recognize the distinctive ‘watch coil’ appearance of embedding into the submucosa. Although only a small number of worms the larval worms (approximately 1 cm to 2 cm) in raw fish, individ- were surgically removed, the patient experienced significant improve- uals preparing their own sushi may not, and may, inadvertently, ment of his symptoms, and no additional larvae were identified on become infected after ingestion of the larval nematodes. repeat EGD. Anisakiasis is caused by members of the genera Anisakis and Patients should be warned to not eat raw fish prepared at home Pseudoterranova. Anisakis can be distinguished from Pseudoterranova by because it can contain not only Anisakis, but also Gnathostoma spin- the presence of butterfly shaped lateral chords, >100 intestinal cells igerum, Gnathostoma hispidum, Diphyllobothrium pacificum and and an intestinal cecum (4). Anisakis simplex causes most human infec- Diphyllobothrium latum (1). Enteric bacterial infections that may also tions, but other Anisakidae can rarely be involved (2,5). Anisakiasis occur after eating raw fish include cholera (Vibrio cholerae) or Escherichia is a rare condition in North America, with approximately 60 cases coli. However, if patients persist in eating raw fish and preparing their 1Departments of Medicine and Pathology; 2Department of Laboratory Medicine, Alberta Health Services, 3University of Calgary, 4Calgary Laboratory Services, Calgary, Alberta Correspondence: Dr Stephen Vaughan, University of Calgary, South Health Campus, Calgary, Alberta T3M 1M4. Telephone 403-956-2401, fax 403-956-2995, e-mail stephen-vaughan@albertahealthservices.ca This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (http:// creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact support@pulsus.com Can J Infect Dis Med Microbiol Vol 26 No 6 November/December 2015 297 Vaughan et al own sushi, they should be instructed to freeze the fish for seven days at A detailed recent food and beverage history should be recorded for –20°C or at a lower temperature for a shorter period of time (<–20°C for patients presenting to the ED with rapid onset of acute abdominal pain four days). Sushi that is prepared in Canadian restaurants and supermar- to diagnose this condition. Endoscopy and worm removal is urgently kets is very unlikely to contain any parasitic infections because it is required to treat this condition, and to prevent long-term complica- likely either flash frozen to –35°C for 15 h or frozen for a prolonged tions. Prevention relies on the adequate cooking of fish and seafood, period of time, as outlined above. Provincial legislation across Canada or the proper storage of these foods by freezing. varies; however, in Alberta, regulations require mandatory freezing unless raw fish is either farm fed or tuna (10). DISCLOSURES: The authors have no financial relationships or conflicts Increasing reports of acute anisakiasis will likely occur in the next few of interest to declare. decades given the growing consumption of sushi and sashimi worldwide. REFERENCES 1. Hochberg NS, Hamer DH. Anisakidosis: Perils of the deep. 7. Kowalewska-Grochowska K, Quinn J, Perry I, Sherbaniuk R. A case Clin Infect Dis 2010;51:806-12. of anisakiasis – Alberta. Canada Diseases Weekly Report 2. Sakanari JA, McKerrow JH. Anisakiasis. Clin Microbiol Rev 1989;15:221-3. 1989;2:278-84. 8. Anisakiasis becoming problem in United States. 3. Hsiu JG, Gamsey AJ, Ives CE, D’Amato NA, Hiller AN. Gastric J Am Vet Med Assoc 1990;196:1218. anisakiasis: Report of a case with clinical, endoscopic, and 9. Pufall EL, Jones-Bitton A, McEwen SA, et al. Prevalence of histological findings. Am J Gastroenterol 1986;81:1185-7. zoonotic Anisakid nematodes in Inuit-harvested fish and mammals 4. Oshima T. Anisakis and anisakiasis in Japan and adjacent areas. from the eastern Canadian Arctic. Foodborne Pathog Dis Prog Med Parsitol Jpn 1972;4:305-93. 2012;9:1002-9. 5. Audicana MT, Kennedy MW. Anisakis simplex: From obscure 10. Alberta Health Services. Guidelines for the Preparation of Sushi infectious worm to inducer of immune hypersensitivity. Products. <www.albertahealthservices.ca/EnvironmentalHealth/ Clin Microbiol Rev 2008;21:360-79, Table of contents. wf-eh-guidelines-for-sushi-prep.pdf> (Accessed January 23, 2015). 6. Kliks MM. Human anisakiasis: An update. JAMA 1986;255:2605. 298 Can J Infect Dis Med Microbiol Vol 26 No 6 November/December 2015 M EDIATORSof INFLAMMATION The Scientific Gastroenterology Journal of Research and Practice Diabetes Research Disease Markers World Journal Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of International Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com
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