A Case of Filariasis Reported from Southern Iran.

1.2 MB·English

by  Hajiani, E

Case Report 59
A Case of Filariasis Reported from Southern Iran
E Hajiani1*, P Alavinejad2
AbstrAct
1. Division of Gastroenterology and
A 56 year-old man with recurrent gastrointestinal bleeding is
Hepatology, Department of Internal
Medicine, Ahwaz Jundishapur University reported. The patient had constant crampy pain in his epigastrium,
of Medical Sciences, Imam Hospital, right upper quadrant and periumbilical area. Upper-gastrointestinal
Ahwaz, Iran. endoscopy was normal. Colonoscopy showed a soft-tissue muco-
2. Fellowship of Gastroenterology and
sal lesion in the rectum which was determined to be a worm that
Hepatology, Department of Internal
extended into the lumen of the rectum with no bleeding. The
Medicine, Ahwaz Jundishapur University
pathology was microfilaria in the rectal glands. Filariasis should
of Medical Sciences, Imam Hospital,
Ahwaz, Iran. be taken into consideration in the differential diagnosis of recurrent
gastrointestinal bleeding conditions in our area.
Keywords
Gastrointestinal bleeding; Filariasis; Microfilaria; Proctitis
nearly constant crampy, non-
IntroductIon
radiating pain in his epigas-
Filariae are nematodes that live
trium, right upper quadrant,
as adults in various human tis-
and periumbilical area; the pain
sues. These agents cause vari-
was exacerbated by eating and
ous clinical syndromes. They
accompanied by nausea. He
are a major cause of disfigure-
also began to have intermittent
ment and disability in endemic
areas, leading to significant loose bloody stools without fre-
economic and psychosocial quent or voluminous diarrhea.
impact. Herein we reported a The patient developed right leg
case of filariasis with recurrent edema which extended up to
gastrointestinal bleeding and the knee and was accompanied
peripheral edema. by two distinct ulcers.
He was born and raised
cAse rePort
in Imam Port in Khuzestan
A 56 year-old man was ad-
Province. The patient was
mitted to the hospital for
employed as a shopkeeper.
evaluation of recurrent gastro-
His past medical history was
intestinal bleeding and periph-
*corresponding Author: unremarkable. There was no
Eskandar Hajiani, MD eral edema. He had been well history of chest pain, head-
Division of Gastroenterology and until 12 months earlier, when
ache, nausea or vomiting. At
Hepatology, Department of Internal
he had mid-epigastric pain
Medicine, Ahwaz Jundishapur University the time of admission, the
of Medical Sciences, Imam Hospital, and passed black-red stools
temperature was 37°C, pulse
P.O. Box 89, Ahwaz, Iran.
that were positive for occult
Tel: [phone] was 82 beats per minute, re-
Fax: [phone] blood. He was anemic and spiratory rate was 14 breaths
Email: [email protected] admitted to the hospital for
per minute and he had a blood
Received: 10 Oct. 2010
evaluation. The patient had
Accepted: 10 Jan. 2011 pressure of 110/80 mm Hg.
Middle East Journal of Digestive Diseases/ Vol.3/ No.1/ March 2011
60 Intestinal Filariasis
The patient weighed 82 kg. Physical examina- or helminthic ova were found. Upper-gastroin-
tion revealed no abnormalities except for right testinal endoscopy showed a normal esopha-
leg edema which extended up to the knee and gus, striped erythematous mucosa in the distal
was accompanied by two distinct ulcers (Figures esophagus consistent with reflux esophagitis, a
1 and 2). Left leg was normal. normal duodenum and normal stomach.
Colonoscopy showed a soft-tissue mucosal
lesion in the rectum which was determined to
be a worm that extended into the lumen of the
rectum with no bleeding (Figures 3and 4).
table 1: Laboratory data.
Hb (gr/dL) 12.8 (13.5-16.5)
MCV (fl) 82.4 (80-100)
Platelets (/μL) 165000 (150000-450000)
ALT (IU/L) 52 (9-40)
AST (IU/L) 64 (10-35)
ALP (IU/L) 92 (30-120)
Fig. 1: right leg edema accompanied by two
ESR (mm/h) 20 (<20)
distinct ulcers.
Fig. 2: right leg edema and ulcer containing a
Fig. 3: A worm extending into the lumen of the
worm.
rectum.
No rash or lymphadenopathy were noted.
There was no evidence of ascitic fluid. The re-
sults of the rectal examination were unremark-
able. The levels of serum electrolytes, amylase
and lipase were normal, as were the results
of urinalysis and liver function studies. Other
laboratory data are shown in Table 1. A stool
specimen was black but not tarry and positive
for occult blood. Stool cultures were negative
for enteric pathogens, protozoa and helminths.
Microscopic examination of the stool dis-
closed an excessive number of undigested Fig. 4: the site of extraction of the worm from
muscle fibers and abundant yeasts; no protozoa the mucosa with oozing.
Middle East Journal of Digestive Diseases/ Vol.3/ No.1/ March 2011
Hajiani et al. 61
After extraction of the worm from the mucosa dermatitis; migrating filariae of these species
and biopsy specimen obtaining the pathol- can cause ocular damage.
ogy was positive for inflammatory infiltration In this case presentation, the patient presented
of an intermediate density in the rectum with with recurrent gastrointestinal bleeding and
nonviable microfilaria in the rectal glands. The peripheral lower extremity edema. Parasitic in-
species of the microfilaria could not be exactly festation involving the gastrointestinal system
identified, but was probably W. bancrofti. Upon is very rare. As with most helminth infections,
detailed questioning of the patient’s relatives, the adult parasite does not replicate within the
it was undetermined whether the patient had human host.
been outside of Iran in recent years.
Thus, the adult worm burden (as opposed to
The patient remained hemodynamically the microfilarial burden) cannot increase once
stable with no further gastrointestinal bleeding. an individual is no longer exposed to infective
Chest radiographs revealed bilateral promi- larvae, such as after leaving an endemic re-
nence of interstitial markings. An ultrasono- gion. Since mosquito vectors are not efficient
graphic examination of the abdomen showed transmitters of filariasis, a relatively prolonged
a normal texture liver and that the intrahepatic stay in an endemic area is usually required for
ducts and common bile duct were of normal the acquisition of infection.It is unclear that
diameter. The gallbladder was partially col- the patient had been outside Iran. Travelers
lapsed; the pancreas appeared normal. and expatriates do not usually have sufficient
A two week course of albedazole was pre- exposure to filariasis to develop the chronic
scribed. During the first 48 hours after medica- complications of infection that are seen with
tion, the patient reported improvement and his high worm burdens. Rather, these individuals
right leg edema disappeared. can demonstrate an allergic-type reaction to
developing larvae that rarely occurs in endem-
ic persons.
dIscussIon
This is the first case of filariasis reported in a
Filariae are nematodes that live as adults in
patient with recurrent gastrointestinal bleeding.
various human tissues. They do not lay eggs,
In the literature there are only a few filariasis
but constantly produce enormous numbers of
cases diagnosed via gastrointestinal cytology.1,2
larvae (microfilariae) in humans. These are
An allergic proctitis due to microfilaria may
found in the skin or blood. Human-to-human
have caused the ulceration and bleeding in our
transmission occurs via insects: the parasites
case. Even rare, parasitic diseases should be
are thus “arthropod-borne”. Animal reservoirs
taken into consideration in the differential di-
play no role of significance in most places,
agnosis of recurrent gastrointestinal bleeding
except in subperiodic Brugia malayi.
conditions in our area.
Filarial diseases are a major health problem
in many tropical and subtropical areas. The
conFLIct oF Interest
disease produced by a filarial worm depends
The authors declare no conflict of interest related
on the tissue location preferred by adults and
to this work.
microfilariae. The adults of the lymphatic

filariae inhabit lymph vessels, where block-
reFerences
age and host reaction can result in lymphatic
1. Whitaker D, Reed WD, Shilkin KB. A case of filariasis
inflammation and dysfunction, and even-
diagnosed on gastric cytology. Pathology 1980;12:483-6.
tually in lymphedema and fibrosis. Other
2. Singh M, Mehrotra R, Shukla J, Nigam DK. Diagnosis
filariae mature in the skin and subcutaneous
of microfilaria in gastric brush cytology: A case report.
tissues, where ey induce nodule formation and Acta Cytol 1999;43:853 -5.
Middle East Journal of Digestive Diseases/ Vol.3/ No.1/ March 2011