|Year : 2014 | Volume
| Issue : 5 | Page : 631-633
Gastroscopic diagnosis of ankylostoma duodenale infestation as a cause of iron-deficiency anemia
Sunita Bamanikar1, Arvind Bamanikar2, Vinay Sawlani1, Dakshayani Pandit3
1 Department of Pathology, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
2 Department of Medicine, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
3 Department of Microbiology, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||10-Sep-2014|
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Source of Support: None, Conflict of Interest: None
Hookworm is one of the most common nematode causing intestinal infestation in the world. Patients with a mild hookworm load are usually asymptomatic, but a moderate or heavy hookworm burden can result in fatigue, recurrent abdominal pain and iron-deficiency anemia. We present here an unusual case of a 35-year-old man with iron deficiency anemia in whom adult hookworm were visualized and recovered on gastroscopy. There was no eosinophilia, and stool examination was negative for occult blood, and parasite ova/cysts. Upper gastroscopy revealed several squirming red worms in the stomach. Ancylostoma duodenale infection was confirmed by histopathological examination and eradicated by albendazole successfully. His anemia was corrected after treatment.
Keywords: Gastroscopy, hookworm, iron-deficiency anemia
|How to cite this article:|
Bamanikar S, Bamanikar A, Sawlani V, Pandit D. Gastroscopic diagnosis of ankylostoma duodenale infestation as a cause of iron-deficiency anemia. Med J DY Patil Univ 2014;7:631-3
|How to cite this URL:|
Bamanikar S, Bamanikar A, Sawlani V, Pandit D. Gastroscopic diagnosis of ankylostoma duodenale infestation as a cause of iron-deficiency anemia. Med J DY Patil Univ [serial online] 2014 [cited 2022 Sep 25];7:631-3. Available from: https://www.mjdrdypu.org/text.asp?2014/7/5/631/140454
| Introduction|| |
Hookworms are an important soil-transmitted helminthes for humans around the world. About 740 million people are estimated to be infected by hookworms.  Two species namely Ancylostoma duodenale (A. duodenale) and Necator americanus (N. americanus) are responsible for human infection. Infected individuals suffer from chronic blood loss, vomiting, abdominal pain, iron-deficiency anemia, and other anemia-associated symptoms and signs. Hookworm infestation is usually diagnosed by characteristic non-bile stained oval eggs on stool microscopy and eosinophilia on blood examination.  Most infected individuals are asymptomatic. A heavy worm burden, prolonged duration of infection and an inadequate iron intake may result in iron deficiency anemia (IDA) and hypoproteinemia.  We report here a case of hookworm (A. duodenale) infection with general malaise owing to prolonged IDA for over six months.
| Case Report|| |
A 35-year-old male presented with left-sided chest pain and pain in epigastric region since 15 days. Abdominal pain was more after food intake associated with burning sensation in epigastrium which also progressed to burning pain in retrosternal region. He had history of nausea not associated with vomiting. There was no history of fever, vomiting or bowel upsets. Patient was a chronic alcoholic and tobacco chewer since 15 years. Abdominal ultrasonography did not reveal any abnormality. Laboratory investigations revealed iron-deficiency anemia with microcytic hypochromic erythrocytes [RBC: 3.60 × 10 6 /μL, hemoglobin: 4.6 g/dl, hematocrit: 17.5%, mean corpuscular volume (MCV): 69.2% (normal 79-95 fl), mean corpuscular hemoglobin (MCH) 20.5 pg (normal 27-33 pg), and MCHC 25.1 g/dL (normal 32-36 g/dL). Platelet count, 175 × 10 3 /μL (normal 130-400 × 10 3 /μL)]. Hemoglobin electrophoresis was not done. Serum Fe was 9 μg/dL (normal 37-145 mg/dL), total iron-binding capacity 318 mg/dL (normal 228-428 mg/dL) and serum ferritin 10 ng/mL (normal 10-130 ng/mL). The differential count showed neutrophils 60%, lymphocytes 31%, monocytes 05% and eosinophils 4%. Bone marrow aspiration-showed erythroid hyperplasia with micronormoblasts, and iron stores were 1+. Other biochemistry examinations, including electrolytes, liver and renal functions were within normal limits. Stool routine examination showed presence of occult blood but no parasitic eggs were detected microscopically. Under the impression of peptic ulcer disease with chronic blood loss, upper gastroscopy was performed.
Endoscopic examination revealed several live and motile worms less than 1 cm in length [Figure 1]. The gastric mucosa was erythematous. Two live worms were individually easily lifted off the mucosa with the standard biopsy forceps. They were removed through the biopsy channel, placed in saline, and sent for histopathologic examination (HPE). The worm was likely to be a male in view of the absence of convoluted ovaries on HPE. The presence of buccal capsule on HPE of the worm is suggestive of A. duodenale [Figure 2] and [Figure 3]. Gastric antral biopsies obtained at the time of the gastroscopy showed changes of chronic superficial gastritis. Repeated stool routine examination failed to show evidence of A. duodenale eggs.
|Figure 1: Gastroscopic view showing hookworms (arrows) on the gastric mucosal surface|
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|Figure 2: Longitudinal section of Ancylostoma duodenale showing (ES) muscular esophagus and (OC) oral cavity (H and E, ×100)|
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|Figure 3: Transverse section of Ancylostoma duodenale showing (MU) musculature, (ED) excretory ducts and (IN) intestine (H and E, ×400).|
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| Discussion|| |
A. duodenale is one of the most common parasites in the world.  It is a common cause of occult gastrointestinal bleeding and anemia.  Adult A. duodenale are 0.8-1.5 cm long, white, cylindrical worms.
The teeth of the adult worm allow it to grip the villus of intestinal mucosa. The worm secretes an anticoagulant that facilitates ingestion of blood and juices from the host. They periodically change their location, leaving bleeding points. This can lead to multiple, different stage ulcers.  A. duodenale is transmitted by contact with soil contaminated with human feces; the most common mode of transmission is through feco-oral route.
The eggs of A. duodenale pass in feces of infected individual. They develop in soil and the rhabditiform larvae hatch out. They further develop into filariform larvae which are infective. Skin penetration by filariform larvae results in a local pruritic, erythematous, papular rash known as "ground itch".  Larvae penetrate skin and enter bloodstream, then reach heart and enter lung capillaries and alveolar spaces. They crawl up the bronchial tree, enter the esophagus and descend down the gastrointestinal tract, where the larvae molt twice and develop to the adult stage. Each adult female hookworm can produce thousands of eggs daily and repeat the life cycle. 
The most common site of localization of adult A. duodenale is the duodenum and jejunum. Finding adults in the stomach is a rarity.
The most common hookworm-related disease in man is IDA, as was seen in our patient. This occurs when the adult parasites cause intestinal blood loss. The mechanism of blood loss is not only mechanical through mucosal injury by worm suck but also chemical. The adult hookworms release anti-clotting agents (one of these, a novel factor VIIa/tissue factor inhibitor).  Each worm sucks between 0.1 and 0.4 mL of blood/day. It can be responsible for a blood loss of up to 250 mL/day in heavy infection. The severity of blood loss in hookworm disease depends on the acuteness and magnitude of infestation.  Acute heavy infection is usually presented as bloody or tarry stools, whereas chronic infestation is usually associated with occult bleeding only.
Usually, the diagnosis of intestinal parasites is made by the characteristic findings such as identification of characteristic oval shaped eggs on fecal examination and eosinophilia.  However; the diagnosis may be missed due to the absence of eggs of the parasites in single stool specimen. The eosinophilia also may not be marked. Repeated stool examination coupled with stool concentration is easy, cheap and reliable to establish the diagnosis. Upper gastroscopy is a very important tool for the diagnosis of gastrointestinal problems, and there are some reports of parasitic diagnosis during routine upper gastrointestinal gastroscopy. ,
When a worm is found during gastrointestinal gastroscopy, it is important to identify the type of the worm by microscopic examination for appropriate treatment.
Hookworm species are mainly differentiated by their buccal capsule. The buccal capsule of A. duodenale has two pairs of curved teeth on the ventral wall of the capsule.
A. duodenale may also be transmitted through ingestion of larvae. They can develop into mature worms directly in the intestine without migrating through the lung. This disease, named Wakana disease, is characterized by nausea, vomiting, dyspnea, pharyngeal irritation, cough, and hoarseness of voice. 
This disease occurs after the oral ingestion of a large number of infective A. duodenale larvae. This patient did not have any of the above symptoms. The possible infection route for this patient remains through the skin.
The patient was treated with mebendazole and hematinics. His hemoglobin gradually increased, and it remained stable 3 months later.
| Conclusion|| |
Hookworm infection represents an important public health problem in developing countries. Parasites are not common findings during upper digestive endoscopic procedures, and should be suspected in patients with anemia and persistent epigastric pain. The endoscopist must remember to closely examine the stomach and small bowel mucosa and be alert for unsuspected parasitic infestation.
Although it is less common than other diseases such as neoplasm and ulcer, parasite infestation should always be considered as a differential diagnosis in patients with iron-deficiency anemia and unexplained gastrointestinal blood loss.
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[Figure 1], [Figure 2], [Figure 3]