Last update:
19-Sep-2000

Arch Hellen Med, 16(6), November-December 1999, 607-608

SHORT COMMUNICATION

Two cases of ascariasis with different presenting symptoms

Ν. YILMAZ,¹ A. UZUNKOY,² O.F. AKINCI,² A. COSKUN,² Z. EREN^3
1Department of Internal Medicine,
²Department of Surgery, Harran University Faculty of Medicine, Ϋanliurfa,
³Altunizade Dialysis Centre, University of Baϊkent, Istanbul, Turkey

Key words: Ascariasis, Common hepatic duct, Esophagus

Ascaris lumbricoides is a nematode which entrenches in the small intestine in human beings giving rise to a variety of medical problems. Transmission typically occurs via fecally contaminated soil. After the eggs are swallowed the larvae hatch in the intestine, invade the mucosa and migrate via the circulation to the small intestine where they develop into adult worms. Clinical disease arises from pulmonary hypersensitivity and intestinal complications.^1,2 Ascaris lumbricoides infestation is common in the region of Ϋanliurfa in Turkey. Most patients seek medical help following oral or rectal expulsion of the worm but some complain only of stomach ache or dyspepsia.

CASE REPORT

Case 1

A 35-year-old female patient, previously completely healthy, presented complaining of eructation. There were no clinical findings except for eructation 8 or 10 times per second at the physical examination. On routine laboratory investigation the only pathological findings was eosinophilia (15%). Radiographic examination of the chest and abdomen was normal. Endoscopic examination was suggested which the patient did not accept. The barium swallow study showed a single tubular filling defect in the long axis of the esophagus (fig. 1). Following the diagnosis of parasitosis she was treated with mebendazol 100 mg/day and sisaprid 30 mg/day. The symptoms disappeared and a total of five worms were passed in the stool after a three day treatment.

Case 2

A 40-year-old male presented with a one week history of pain in the right hypochondrium. On physical examination slight jaundice was detected and there was tenderness on palpation in the right hypochondrium. The pathological laboratory findings are summarised in table 1. Ultrasonography revealed typical echogenic tubular filling defects along the long axis of the common bile duct, sometimes exhibiting slow movements and containing a central sonolucent line (fig. 2). As the patient’s condition did not require urgent intervention, he was given mebendazole 100 mg day for three days. The nematode disappeared spontaneously from the common bile duct one week later at which time the jaundice regressed and the laboratory findings became normal by (tabl. 1).

COMMENT

Ascaris lumbricoides is the largest intestinal nematode parasite of humans.^1,2 During the lung phase of larval migration patients may develop an irritating non productive cough and burning substernal discomfort which is aggravated by coughing or deep inspiration. In established infestations, the adult worms in the small intestine usually cause no symptoms, but in heavy infections, they can cause pain and small bowel obstruction. Sometimes migration of an adult worm up the esophagus can provoke coughing and oral expulsion of the worm. Unusual symptoms such as eructation must be regarded as suspicious for ascariasis in endemic regions.

Aberrant ascaris infections may be the cause of serious complications.^1,2 A large worm can enter and occlude the biliary tree, causing biliary colic, cholecystitis, cholangitis, pancreatitis and hepatic abscesses. In highly endemic areas, intestinal and biliary ascariasis may rival acute appendicitis and gallstones in frequency as a cause of surgical acute abdomen.^1–4 Ultrasonography permits early diagnosis and prompt treatment.⁵ The management of biliary parasitosis begins with conservative measures, including analgesics and antihelminthic therapy. In refractory cases or in patients with acute cholangitis, endoscopic biliary drainage and extraction of the worms may be necessary. In some cases open surgery may be necessary.^3,4,6 Improvement in sanitation plays a crucial role in the control of these parasitic diseases.^1,2

REFERENCES

1. ROSSI MA, BISSON FW. Fatal case of multiple liver abscesses caused by adult A. lumbricoides. Am J Trop Med Hyg 1983, 32:523–525
2. FAUCI AS ET AL. Harrison’s Principles of Internal Medicine. McGraw Hill, 1998:1208–1210
3. VALGAEREN G ET AL. Endoscopic treatment of biliary ascariasis. Acta Clin Belg 1996, 51:97–100
4. SANDOUK F ET AL. Pancreatic biliary ascariasis: experience of 300 cases. Am J Gastroenterol 1997, 92:2264–2267
5. LARRUBIA JR ET AL. The role of sonography in the early diagnosis of biliopancreatic ascariasis infestation. J Clin Gastroenterol 1996, 22: 48–50
6. LEUNG JW, YU AS. Hepatolithiasis and biliary parasites. Baillieres Clin Gastroenterol 1997, 11:681–706