Upper gastrointestinal bleeding due to hookworms (Ancylostoma duodenale)--a case report

Worm infestation as a cause of severe anemia in a frail older adult: a case report

Introduction

Worm infestations are a common occurrence in low-income countries. Anemia due to iron deficiency can be brought on by human intestinal worms. The authors report a case of an 86-year-old frail older adult with upper gastrointestinal (GI) bleeding caused by a worm infestation most likely to be hookworm.

Case presentation

An 86-year-old male, presented to the Emergency Department with complaints of bilateral lower limb swelling and shortness of breath for 4 days associated with melena for 2 months. The authors made a provisional diagnosis of heart failure precipitated by anemia. Upper GI endoscopy revealed multiple whitish exudates, which are resistant to water jets. Multiple worms were noted in the second part of the duodenum. Based on clinical evaluation and endoscopy, the diagnosis of oesophagial candidiasis and iron deficiency anemia secondary to upper GI bleeding due to Hookworm infestation was made.

Clinical discussion

In low-income countries, especially those involving the tropical area, worm infestation should be considered as an important cause of obscure acute GI bleeding and severe anemia. Usually, malignancy is suspected in an older adult with severe anemia but hookworm infestation is a treatable disease with a good prognosis and complete recovery. The most commonly used drugs for treatment are mebendazole and albendazole. In a low-income country with a high burden of worm infestations, empirical treatment of iron deficiency anemia with single dose albendazole has been recommended.

Conclusion

Usually, severe anemia in an older adult is mostly attributed to an underlying malignancy. Our case serves as a good example of how a treatable condition can improve the quality of life in a frail older adult. Normally, there is a tendency to defer UGI endoscopy in frail elderly due to ageism. However, the diagnosis of a treatable cause of upper GI bleeding can be made by a simple upper GI endoscopy. Severe anemia due to hookworm infestation is treated effectively and quickly with albendazole and iron therapy.

In vivo endoscopic imaging of ancylostomiasis-induced gastrointestinal bleeding: clinical and biological profiles

Little data are available regarding the association of ancylostomiasis with overt gastrointestinal bleeding. This 6-year retrospective study describes the clinical and biological profiles of unexpectedly identified ancylostomiasis in a 4-month-old baby and four adults; they presented with melena and were referred for urgent diagnostic gastrointestinal endoscopy, which confirmed numerous small intestine injuries with surrounding blood pools caused by Ancylostoma duodenale worms. Gastric erosions were also encountered in one patient. Uniquely, worm biological activities were recorded live in vivo, including mucosal invasion through a vigorous, rapid piercing process, repeated bloodsucking habits, and gut appearance during the stages of feeding, digestion, and excretion in male and female worms. In conclusion, ancylostomiasis-induced melena may occur in all ages from infants to the elderly. Worm bloodfeeding occurs after quick mucosal piercing, with blood loss being aggravated by a repeated feeding behavior. After treatment is started, bleeding stops rapidly in response to anthelmintic therapy.

Endoscopic diagnosis of hookworm disease of the duodenum

Hookworm is one of the most common parasites in the world, but can be missed on stool examination. We report a 31-year-old man who was complaining of epigastric discomfort, with laboratory findings of iron-deficiency anemia and eosinophilia. He was found to be infected with hookworm (Ancylostoma duodenale), which was directly detected and retrieved from the duodenum with biopsy forceps during upper gastrointestinal endoscopy. We eliminated his infection successfully by the Damaso de Rivas-Kihara modified method and oral administration of pyrantel pamoate. This report indicates that it is important to check carefully even in the distal duodenum at routine upper gastrointestinal endoscopy whenever parasitic disease is suspected but is hard to diagnose because of a limited number of eggs in feces.