brazjinfectdis2019;23(6):471–473
w w w . e l s e v i e r . c o m / l o c a t e / b j i d
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
Letter
to
the
editor
Ancylostoma
duodenale
as
a
cause
of
upper
gastrointestinal
bleeding:
a
case
report
Deareditor,
Hookworm infection in humans is usually caused by the helminth nematodes Necator americanus and Ancylostoma duodenale.1–3Itisfoundinapproximately25%oftheworld
pop-ulation,especiallyinpoortropicalandsubtropicalareas.1–3In
Peru,aprevalenceof14% isreported,themajorityofcases areinMadredeDios,Amazonas, Loreto,andCusco.1
Simi-larfigureshavebeenreportedinColombiaandBolivia.1–3The
infectionisacquiredbydirectcontactoftheskinwith con-taminatedsoilandfecal-oralroute.3
Themajority ofinfectedpatients remain asymptomatic andirondeficiencyanemiaduetochroniclossesthroughthe digestivetractisthemaincomplication.4Bothspeciesadhere
tothemucosaofthesmallintestine,absorbblood,cause ero-sions,ulcers,andfavorbloodlossbysecretionofanticoagulant substancesandenzymes.Theamountofbloodlosscausedby hookwormsinanadultisabout0.05to0.3mlforAncylostoma duodenale and 0.01to 0.04mlfor Necator americanus.4–6 The
resultinganemiacanbemild,moderateorsevere,depending ontheparasiticload(numberofeggseliminatedpergramof feces).3However,manifestgastrointestinalbleedingisrare.4
Herein,wepresentthecaseofa91-year-oldmalefarmer, fromAmazonas,withnorelevantmedicalorfamilyhistory. Hereportstwoweeksofastheniaandshortnessofbreathat moderateefforts.Onedaybeforehisadmissionhepresented hematemesis,dizzinessandsyncope.Onphysical examina-tionthepatient’svitalsignswereunstablewithtachycardia and hypotension,he was pale, withno adenopathies, had rhythmicheartsoundswithamultifocalsystolicmurmur,soft abdomen,depressiblewithoutvisceromegaly,with disorienta-tionintimeandspace.
Laboratorytests revealed hemoglobinof1.9g/dL, hema-tocrit 8%, leukocytes 3.5×103/uL (eosinophils 10%) and
platelets232×103/uL,urea63andcreatinine2,completeliver
andcoagulationprofilewithinnormalranges,rapidtestfor HIV and ELISA for HTLV-1 negative. The upper endoscopy showedmultiplecylindricalwormsofapprox.20mminbulb andsecondduodenalportionadheredtothemucosa(Fig.1).
Fecalexaminationbyrapidsedimentation ofLumbreras showed hookworm eggs and few adult parasites (Fig. 2).
Colonoscopywasperformedwheredeadparasiteswerefound withoutneoplasticlesions.
ThepatientwastreatedwithAlbendazole400mgq24hfor threedays,mebendazole100mgq24hforfivedaysand multi-plebloodtransfusions.Thepatientevolvedfavorablyandtwo weeksthereaftertheparasitologicalexaminationinfeceswas negative.
Thesehookwormsliveinthesmallintestine,layeggsthat areeliminatedinthefeceswhich,underoptimalconditions, matureandproducelarvaethatwhenincontactwiththeskin, penetrateitandarecarriedthroughthebloodvesselstothe heartandthentothelungs.Theypenetrateintothealveoli, ascendthebronchialtreetothepharynx,andareswallowed. Thelarvaereachthesmallintestine,completingitscyclein theintestine.4–7
The diagnosis is based on the identification of eggs in feces ofpatients withhypochromicmicrocytic anemia and eosinophilia.4–6 However, sometimes there is no increased
totaleosinophilcount,asinthiscase.Althoughtheeggsofthe twospeciescannotbedifferentiatedbybasiclightmicroscopy, theadultwormsdohavedifferences:theancylostomaislarger andthestructureofitsmouthopeninghastwopairsofteethor hooksofequalsize,andthenecatorapairofcuttingplates.3–6
Theclinicalpresentationvariesdependingonthephaseof the parasiteandtheintensity oftheinfection,beingfound from cutaneous, respiratory, non-specific digestive findings suchasnausea,vomitinganddiarrheatofailuretothrivein thecaseofchildrenduetomalabsorptionandmalnutrition.2,8
InPeru,onlytwocasesofgastrointestinalbleedinghave beenreportedasaformofpresentationofthisinfection:in a27-dayoldpatientwithsevereanemiaandmelena9andin
a34-year-old malepatientfrom thejunglewithlow diges-tive hemorrhage. Both cases were also diagnosed through endoscopicevaluation.10Thisisthefirstcaseofuncinariasis
reportedinthecountryofanolderadultpatientwithclinical manifestationofuppergastrointestinalbleedingwithsevere anemiaandendoscopicdemonstrationoftheadultworm.
Most reports of gastrointestinal bleeding secondary to
AncylostomaduodenalecomefromendemicareaslikeChina, where Tan et al. reported a case of massive hemorrhage due to duodenal ancylostoma diagnosed by endoscopic
472
braz j infect dis.2019;23(6):471–473Fig.1–1a-1bMultiplecylindricalwormsofapproximately20mminbulbandsecondduodenalportion.
Fig.2–Stoolexaminationbyrapidsedimentationof Lumbrerasshowedhookwormeggsandfewadult parasites.
capsule.11 In addition, Wei et al. reported on 424 Chinese
patients with overt obscure gastrointestinal bleeding diag-nosed by endoscopy, colonoscopy, capsule endoscopy, or double-balloonenteroscopy,allofthemwithgoodresponse tomedicaltreatment.12
Therecommendedtreatmentissingleoraldoseof alben-dazole 400mg. However, failures havebeen reported, so it is recommended to administer 400mg of albendazole for three consecutive days or as a single 800mg dose.3 Our
patient persisted with positive stool tests, so he received a longer course with mebendazole for five more days and the expected clinical and laboratory response was achieved.
Inconclusion, infection withAncylostomaduodenale usu-allymanifestsclinicallyasirondeficiencyanemiaintropical areas,butpresentationasdigestive hemorrhageassociated withmassiveinfestationandisinfrequent.9,10
Itisimportanttoconsiderthispathologywithinthe dif-ferential diagnosis in cases of gastrointestinal bleeding of patientsfromendemicareas.Anti-helminththerapyisvery effectivewithrapidclinicalimprovementasobservedinour patient.9
Conflicts
of
Interest
Theauthorsdeclarenoconflictsofinterest.
r
e
f
e
r
e
n
c
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1.MINSAPerú.HelmintosIntestinalesenelPerú:análisisdela prevalencia(1981-2001).OficinadeEpidemiología.2003. 2.HotezPJ,BottazziME,Franco-ParedesC,etal.Theneglected
tropicaldiseasesofLatinAmericaandtheCaribbean:a reviewofdiseaseburdenanddistributionandaroadmapfor controlandelimination.PLoSNeglTropDis.2008;2:e300. 3.Calvopi ˜naM,FloresJ,GuamanI,etal.Anemiacrónicagrave
porAncylostomaduodenaleenEcuador.Diagnósticopor duodenoscopia.RevChilenaInfectol.2017;34(5):499–501. 4.ChenJM,ZhangXM,WangLJ,etal.Overtgastrointestinal
bleedingbecauseofhookworminfection.AsianPacJTrop Med.2012:331–2.
5.RocheM,LayrisseM.Thenatureandcausesof ¨hookworm anemia¨.AmJTropMedHyg.1966;15(6):1029.
6.BarakatM,IbrahimN,NasrA.InVivoEndoscopicImagingof AncylostomiasisInducedGastrointestinalBleeding:Clinical andBiologicalProfiles.AmJTropMedHyg.2012;87(4):701–5. 7.Fonseca-AizpuruEM,García-PineyE,Nu ˜no-MateoFJ,etal.
Varónconanemiaferropénicaseveraporuncinariasis.An MedInterna(Madrid).2006;23(9).
8.RestrepoJP,AlvarezJC,Ortíz-RiveraCJ.Anemiasevera secundariaauncinariasenunHospitaldenivelIII.Revista GastrohnupA ˜no.2017;Volumen19Numero2Suplemento2 (mayo-junio):e4–8.
9.ValdiviesoP,CetraroD,AnguloD.Hemorragiadigestivaen neonatoconuncinarias,HospitalNacionalSanBartolomé. Reportedecaso.RevGastroenterolPeru.2017;37(1):82–6. 10.NairGV,CazorlaE,ChoqueH,etal.Infecciónmasivapor
Ancylostomaduodenalecomocausadehemorragia
intestinalyanemiasevera.RevGastroenterolPeru.2016;36(1): 90–2.
11.TanX,ChengM,ZhangJ,etal.Hookworminfectioncaused acuteintestinalbleedingdiagnosedbycapsule:acasereport andliteraturereview.KoreanJParasitol.2017;55(4):417–20. 12.WeiK,YanQ,TangB,etal.Hookworminfection:aneglected
causeofovertobscuregastrointestinalbleeding.KoreanJ Parasitol.2017;55(4):391–8.
brazj infect dis.2019;23(6):471–473
473
AndreaCarlinRonquillo a,∗,LidiaBenitesPuellesa, LuisPampaEspinozaa,VíctorAguilarSáncheza,b,
JoséLuisPintoValdiviaa,b
aServiceofGastroenterologyCayetanoHerediaHospital,Lima,Peru bSchoolofMedicine-CayetanoHerediaUniversity,Lima,Peru
Correspondingauthor.
E-mailaddress:[email protected](A.C.Ronquillo).
Availableonline14October2019 1413-8670/
©2019SociedadeBrasileiradeInfectologia.Publishedby ElsevierEspa ˜na,S.L.U.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
