A surgical case of inflammatory pseudotumor by hepatic anisakiasis

Anisakiasis is a parasitic infection caused by the ingestion of raw or undercooked seafood infected with Anisakis larvae. It generally affects the gastrointestinal tract, particularly the stomach, but very rare cases have been reported in which infection of the liver leads to the formation of inflammatory pseudotumors. We herein report an extremely rare case of an inflammatory pseudotumor induced by hepatic anisakiasis that was laparoscopically resected for the purpose of both diagnosis and treatment. A 51-year-old woman underwent a routine medical checkup by ultrasound examination, which incidentally detected a 15-mm mass on the surface of S6 of the liver. Because a malignant tumor could not be ruled out on several preoperative imaging studies, laparoscopic partial resection of the liver was performed. Histopathological examination revealed Anisakis larva in the inflammatory pseudotumor, suggesting hepatic anisakiasis. This report describes an extremely rare case of an inflammatory pseudotumor induced by hepatic anisakiasis. Because the preoperative diagnosis could not be obtained by several imaging modalities, laparoscopic liver resection with a sufficient margin might be suitable for diagnosis and treatment of this disease.

Sliding Flap for the Wide Upper Eyelid Margin Defect After Cancer Removal

BACKGROUND

Reconstruction of eyelid margin defects following resection of upper-eyelid skin malignancies is typically performed using a lower eyelid switch flap, including eyelash reconstruction. However, a subsequent procedure for flap separation, and prolonged swelling of the flap may occur as a complication.

OBJECTIVE

The authors performed anterior lamellar reconstruction using a sliding flap with excess upper eyelid skin, a procedure that is a less invasive and simpler.

MATERIALS AND METHODS

The authors performed anterior lamellar reconstruction using a sliding flap in 7 patients with full-thickness upper eyelid margin defect after skin cancer resection. The mean age of the patients was 76.0 years. The horizontal width of the defect in our cohort ranged from 11 to 25 mm and the vertical width ranged from 5 to 10 mm.

RESULTS

All the flaps and mucosal grafts were well taken, and none of the patients complained of lack of eyelash reconstruction. However, eyelid margin irregularity, possibly due to flap or mucosal graft contraction, was observed in 2 patients, and 1 patient developed keratoconjunctivitis.

CONCLUSIONS

The sliding flap technique is a minimally invasive and simple procedure for wide eyelid margin reconstruction. However, 2 patients developed eyelid margin irregularities and 1 patient developed keratoconjunctivitis. Those complications might have occurred owing to the condition of posterior lamellar reconstruction. Therefore, for the successful use of a sliding flap for anterior lamellar reconstruction, the form of the eyelid edge and the choice of posterior lamellar reconstruction are key considerations. In future, we plan to establish a better reconstructive technique by accumulating more evidence.

Anisakiasis in the Small Intestine with Excessive Bleeding That Was Difficult to Diagnose Endoscopically

Anisakiasis involves the stomach in most cases and occurs rarely in the small intestine. Anisakiasis in the small intestine is associated with abdominal pain and obstruction and is rarely associated with intestinal bleeding. Unlike in the stomach, anisakiasis in the small intestine is difficult to diagnose anatomically. The patient in this case study developed hypovolemic shock due to excessive bleeding and underwent emergency surgery. With the recent increase in the consumption of raw fish around the world, this report provides an important finding of bleeding in the small intestine due to an unknown cause.

A Case Study of Anisakiasis in the Palatine Tonsils

Anisakidosis is a nematode infection caused by the ingestion of larvae-infected raw or undercooked fish. Although gastric anisakiasis is a common disease in Japan due to the popularity of eating raw and undercooked fish, reports of anisakiasis in the tonsils are extremely rare. A 68-year-old man presenting with clinical features of peritonsillitis was admitted for examination. The right peritonsillar region exhibited slight edematous swelling and rash, and a white foreign body was observed. This foreign body was removed, and pathological examination revealed Anisakis.

[Acute abdomen caused by eosinophilic enteritis: six observations]

BACKGROUND

Eosinophilic enteritis is a rather rare condition characterized by infiltration of the gastrointestinal tract by eosinophils; as a casue of acute abdomen it is really exceptional. The etiology is unclear and its description in the literature is sparse, but associations have been made with collagen vascular disease, inflammatory bowel disease, food allergy and parasitic infections as it was confirmed in one of our pathologic studies.

CLINICAL CASES

From 1997 to 2011 six cases of eosinophilic enteritis that involved a small bowel segment were diagnosed. A partial resection by an irreversible necrosis was necessary in three of them; in the other three only a biopsy was necessary due to the inflammatory aspect of the affected loop causing the acute abdomen.

CONCLUSIONS

Eosinophilic enteritis can originate acute abdomen processes where an urgent surgical treatment is necessary. The intraoperative aspect can be from a segment of small bowel with inflammatory signs up to a completely irrecoverable loop, where removing of the affected segment is the correct treatment, which can be done laparoscopically.

[Acute abdomen by anisakiasis and globalization]

OBJECTIVES

The AA report a case of a patient with acute abdomen caused by intestinal Anisakiasis, a fish-transmitted infection that results from ingestion of raw or improperly cooked fish contaminated by live larvae of Anisakis Simplex, a round worm from the order of Ascaridida.

MATERIAL AND METHODS

A 33-year-old man, presented to the emergency room with severe upper abdominal pain, nausea and vomiting, without fever. The patient revealed that he had eaten pickled anchovies a few days before.

RESULTS

On the exploratory laparotomy an edematous and stenotic tract of 15 cm of jejunum was found, and a segmental resection was performed. Histologically, the resected jejunum showed a conspicuous and diffuse inflammatory infiltration, predominantly made up of eosinophil granulocytes, numerous mucosal erosions and the presence in the submucosa of sections of parasites which were identified as Anisakis Simplex larvae.

DISCUSSION

The ingestion of fish contaminated by Anisakis larva is often followed by the appearance of systemic or gastrointestinal symptoms due respectively to the direct larva localization and the allergic reaction to some parasite components. Diagnosis is made frequently difficult by clinical manifestations that could mimic symptoms of other diseases more common in Italy.

CONCLUSIONS

Globalization has made Anisakiasis a more and more frequent disease worldwide, as increased mixture of different cultures and international travelling has allowed the spreading of risky feeding habits. That's why Anisakiasis should be considered in differential diagnosis of intestinal obstruction in patients with positive anamnesis for suspiciously cooked or conserved seafood eating.

Acute gastric anisakiasis: an Italian experience

Anisakidosis is a parasitic disease of the human gastrointestinal tract caused by ingestion of larvae of marine nematodes such as Anisakis spp. or, rarely, Pseudoterranova spp., present in raw or undercooked fish. We report the first series of gastric Anisakis infection (anisakiasis) from a single centre in Italy. In our department, we observed 3 cases, all in women who were urgently hospitalized following intense epigastric pain and vomiting, developed after the ingestion of raw fish. The patients underwent urgent gastroscopy within a few hours. In each, a worm was extracted from the gastric mucosa by means of biopsy forceps. This was followed by prompt clinical improvement. The worm was identified by its macroscopic and microscopic characteristics as an Anisakis spp. larva (L3). In 2 cases, laboratory tests revealed marked leukocytosis and eosinophilia in the peripheral blood 3-4 days after ingestion of the raw fish. The diagnosis of anisakiasis can be made by endoscopy, radiology and abdominal ultrasound, but is often made only at surgery. In the gastric form of the disease, urgent gastroscopy has both a diagnostic and a therapeutic role, because the worm can be removed by means of biopsy forceps.

Small bowel strangulation caused by parasitic peritoneal strand

A 51-year-old woman with a history of eating raw fish over a period of 2 weeks developed a progressive abdominal pain and leukocytosis with signs of small bowel obstruction. Eosinophilia was not detected in the peripheral blood. The patient underwent surgery to clarify the possibility of ileus. Partial small bowel near the ileum was trapped by a peritoneal strand and was strangulated for approximately 30 cm in length with congestion and edema. The removal of the strand easily released the strangulation and the small bowel returned to a normal appearance. Pathologically, the strand consisted of granulomatous inflammation with a wide zone of necrosis containing a dead ghost feature of a parasite in its center. The necrosis was surrounded by palisading spindle cells with largely lymphocytic infiltration and a few eosinophils. In the parasite, there presented the polymyalian type muscle layer, ventricles and Renette cells, which suggested that the parasite is compatible with the third stage larva of Anisakis type I, leading to the diagnosis of ectopic anisakidosis. It should be noted that, on rare occasions, Anisakis larva migrans can form a peritoneal strand with a wide zone of necrosis and cause strangulation ileus, especially in populations with the habit of eating raw fish.

Small bowel anisakiosis: A report of two cases

Small bowel stenosis is a serious complication of intestinal anisakiosis. The aim of this report is to investigate whether severe stenosis of the small intestine can be conservatively managed. We treated two patients with severe stenosis of the small intestine caused by anisakiosis. Surgical intervention was eventually performed on the 23^rd and 35^th in the hospital, respectively. Histopathological examination of the resected specimens revealed that the intestinal wall had been completely damaged by the inflammatory reaction of anisakiosis, and that the damage was irreversible, thereby suggesting that laparotomy is needed in cases of severe small bowel stenosis caused by intestinal anisakiosis, even if a long period of conservative treatment for the intestinal anisakiosis allowed the patient to pass successfully through the acute phase.

Chronic Anisakiasis of the Ascending Colon Associated with Carcinoma

Chronic anisakiasis of the colon is rare and difficult to diagnose. We report a case of chronic anisakiasis associated with advanced colonic carcinoma. A 69-year-old man was admitted for abdominal pain, diarrhea, and urticaria. Right hemicolectomy was performed because of an obstruction of the ascending colon and a palpable tumor of the right lower abdomen. The lesion was thought to be located in the deeper layers of the ascending colon. Preoperative examinations failed to detect the coexistence of anisakiasis and carcinoma of the colon. The anisakis was identified morphologically in the intestinal wall of the resected specimen and by an elevated titer of an IgE antibody specific to the parasite. Seventy-five cases of colonic and rectal anisakiasis, including the present case, have been reported in Japan. This is the only reported case of anisakiasis to appear in association with colonic carcinoma.

[Anisakiasis presenting as perforated ulcer of the cecum]

A case of cecal anisakiasis is presented. Symptoms were compatible with appendicitis. The patient was operated and a perforated ulcer of the cecum was found. Ileocolic resection was performed. The histologic result showed the presence of Anisakis simplex larva in the muscle of the cecum. The patient was discharged the fifth day without complications. At present he is asymptomatic. He had eaten uncooked anchovies some days before the onset of the disease.

Intestinal anisakiasis in Italy: a case treated by emergency surgery

Anisakiasis is a fish-borne zoonotic disease. A case of intestinal anisakiasis in a woman who had consumed raw marinated anchovies was reported. The intestinal localization resulted in occlusive acute abdomen which required an emergency surgical treatment. The histological examination of the eosinophilic granuloma removed from the resected colon revealed the presence of larval nematodes of the genus Anisakis as causative agents.

[Anisakiasis: an infestation to be known by surgeons]

BACKGROUND

Anisakis infestation is related to the consumption of raw or undercooked fish. It can cause allergic reactions, or abdominal pain when the gastrointestinal tube is involved. Its incidence is rising in Europe.

OBJECTIVE

To analyze a group of patients complaining of right iliac fossa pain with ileitis or colitis and establish its relationship with Anisakis spp. infection.

PATIENTS AND METHODS

During a 3-months period, 28 patients with abdominal pain were referred to the hospital with a diagnosis of ileitis or colitis by imaging, endoscopy or surgery. Specific serology for Anisakis was performed in all of them.

RESULTS

At imaging study, 14 patients had ileitis or colitis, three intestinal obstruction and one acute appendicitis. Fourteen patients were operated on and 7 of them underwent resection; histopathologic diagnosis were eosinophilic ileitis (2 cases) or colitis (3 cases), non specific ileitis (1 case) and Crohn's disease (1 case). Another patient had an endoscopic biopsy that concluded eosinophilic colitis. Anisakis serology was positive in 25 (89%), negative in two and unknown in one. All patients were discharged uneventfully.

CONCLUSIONS

Digestive anisakiasis may present as acute abdomen. Surgeons should know and consider this diagnosis in patients with ileitis or colitis, moreover if an antecedent of raw or undercooked fish ingestion is present. A conservative approach is best performed but the clinical picture can require an emergent laparotomy.

Acute abdomen due to small bowel anisakiasis

The popularity in Western countries of dishes based on raw fish has led to an increased incidence of anisakiasis, a human parasitic disease caused by the ingestion of live anisakid larvae. The entire digestive tract may be involved, but the stomach and the small intestine are the most frequently affected sites. We report a case of acute abdomen due to Anisakis simplex infection that caused small bowel obstruction.

Intestinal anisakiasis in Italy: case report

A case of intestinal anisakiasis caused by Anisakis sp. larva type I in a woman from Italy who consumed raw marinated anchovies, is reported. The diagnosis was based on the morphological features characteristic of anisakid larval stages, which were readily recognized in a large granuloma removed after emergency surgical treatment.

CT findings of surgically verified acute invasive small bowel anisakiasis resulting in small bowel obstruction

Acute invasive small bowel anisakiasis is an extremely rare cause of small bowel obstruction. The authors report a case of surgically verified small bowel anisakiasis resulting in small bowel obstruction. A 54-year-old man presented with suddenly developed diffuse abdominal pain after ingestion of raw fish. The peripheral blood examination showed leukocytosis without eosinophilia. CT showed a long segment of thickened small bowel accompanied by a focal narrowed portion and combined with ascites. When these findings are noted in patients with a history of recent ingestion of raw or undercooked fish, the diagnosis of small bowel anisakiasis should be considered in order to avoid application of unnecessary surgical treatment, in spite of the severity of the abdominal pain and bowel obstruction.

Intussusception due to intestinal anisakiasis: a case report

This report describes our experience of intussusception due to intestinal anisakiasis which was treated by laparoscopy-assisted surgery. The unique sonographic findings of this complication were a pseudokidney sign and a target sign with an edema of Kerckring's folds in the intussusceptum. Surgeons should know about intussusception as a rare complication of intestinal anisakiasis. Sonography, computed tomography and laparoscopy are helpful in diagnosing and treating this complication.

Human intestinal anisakiosis due to consumption of raw salmon

Anisakiosis is a parasitic infection that follows consumption of raw or insufficiently pickled, salted, smoked, or cooked wild marine fish infected with Anisakis sp. larvae. We report a case of intestinal anisakiosis in a 50-year-old man from Quebec who presented with abdominal pain and peripheral eosinophilia after eating raw wild-caught salmon from the Pacific Ocean off Canada. Abdominal CT scan showed bowel distension proximal to a segmental jejunal wall thickening, which was resected. The jejunum segment showed a localized area of serositis with mucosal edema and a submucosal abscess rich in eosinophils surrounding a parasite consistent with the third larval stage of Anisakis sp. Diagnostic morphologic characteristics included an unpaired excretory gland (renette cell), Y-shaped lateral epidermal cords, no apparent reproductive system, and a ventriculus (glandular esophagus). These features and the absence of lateral alae excluded Ascaris sp. The absence of ventricular appendage and intestinal cecum excluded other anisakids of the genera Pseudoterranova and Contracaecum. As the popularity of eating raw fish is growing in North America, anisakiosis may be diagnosed more frequently in surgical specimens. This parasitic infection should be considered in the differential diagnosis of acute abdominal syndromes and eosinophilic infiltrates of the stomach, small intestine, colon, omentum, and mesentery, especially with a history of raw marine fish consumption.

Small bowel obstruction caused by anisakiasis of the small intestine: report of a case

Enteric anisakiasis is a relatively rare disease that is difficult to diagnose preoperatively. We report a case of small bowel obstruction caused by enteric anisakiasis in a 59-year-old Japanese man who presented with abdominal pain a few hours after eating sliced, raw fish. Because of signs of an intestinal obstruction, a laparotomy was performed. Focal thickening and stenosis of the ileocecal region were seen about 100 cm from the end of the ileum and the lesion was excised. We found a moving anisakis thrusting its head into the mucosa of the excised small intestine. Histopathological examination revealed the infiltration of eosinophils in all layers of the intestinal wall and severe edema. Enteric anisakiasis is very rare, and its diagnosis is usually only made after laparotomy. Nevertheless, when signs of acute abdomen develop after the ingestion of raw fish, such as sushi or sashimi, the possibility of enteric anisakiasis should be borne in mind.

A case of acute gastric anisakiasis provoking severe clinical problems by multiple infection

Acute gastric anisakiasis with multiple anisakid larvae infection is reported. A 68-year-old woman residing in Busan, Korea, had epigastric pain with severe vomiting about 5 hours after eating raw anchovies. Four nematode larvae penetrating the gastric mucosae in the great curvature of the middle body and fundus were found and removed during gastro-endoscopic examination. Another one thread-like moving larva was found in the great curvature of upper body on the following day. On the basis of their morphology, the worms were identified as the 3rd stage larvae of Anisakis simplex. This case is acute gastric anisakiasis provoking severe clinical problems by the multiple infection and the greatest number of anisakid larvae found in a patient in Korea.

[Gastrointestinal anisakiasis. Study of a series of 25 patients]

INTRODUCTION

Infection with the parasite Anisakis simplex is common in Japan and northern European countries. The number of reported cases in Spain has increased since the first description in 1991. The aim of the present study was to evaluate the incidence, clinical patterns, histopathological lesions, treatment, and outcome of Anisakis simplex infection in our environment.

MATERIAL AND METHOD

Cases of gastrointestinal anisakiasis diagnosed in our center from December 1999 to January 2002 were studied. Only patients with detection of the parasite in oral endoscopy or the surgical specimen and those with elevated levels of specific IgE to Anisakis simplex, a clinical picture compatible with anisakiasis, or a history of raw fish intake were included. Epidemiological, clinical and laboratory data, as well as diagnostic, histopathologic and therapeutic features, and outcome in these patients were recorded.

RESULTS

Twenty-five cases of gastrointestinal anisakiasis were diagnosed during the study period, representing an incidence of 3.87 cases per 100 000 inhabitants/year. All the patients had ingested raw anchovies. Two groups were observed. The first group was composed of 10 patients with a gastric form of the infection, in which the main symptom was epigastralgia (90%). Oral endoscopy was performed in all patients and the parasite was detected in five (50%). The second group was composed of 15 patients with intestinal involvement in which the main manifestations were symptoms mimicking appendicitis (80%). The most frequent finding of laparotomy and/or imaging tests (abdominal ultrasonography, intestinal transit, abdominal CAT) was terminal ileitis (80%). Seven patients underwent surgery: intestinal resection was performed in four with detection of Anisakis simplex in three. Eosinophilic infiltration was found in all surgical specimens. Treatment was symptomatic in most of the patients and outcome was favorable in all.

CONCLUSIONS

Infection with Anisakis simplex should be investigated in patients with abdominal pain after intake of raw fish, ileitis of unclear origin, or eosinophilic gastroenteritis.

[A case of human anisakiasis in Kamchatka]

The clinical symptoms of intestinal anisakiasis, the location of the larvae of nematodes in the intestine, and changes of the organ at the site of helminthic attachment are described. The causative agent of this parasitic disease has been detected. This is Anisakis sp. L III.

Anisakiasis presenting as an obstructive duodenal tumor. A Scandinavian case

A case of chronic anisakiasis presenting as an occluding duodenal tumor is described. Significant falls in Anisakis simplex-specific serum IgE and total IgE occurred after resection of the lesion. Histopathologic examination showed a chronic eosinophilic granulomatous infiltrate and a tubular sclerotic structure in the antral submucosa consistent with, but not diagnostic for, an A. simplex larva.

Gastrointestinal infection due to Anisakis simplex in southern Italy

The authors present four cases of infection due to Anisakis in an area where people are prone to infectious diseases transmitted by raw fish, but in which the presence of this parasite has never been reported. Three of four cases were discovered accidently during surgical procedures for co-existing abdominal pathologies. Raw fish was apparently not involved in all patients. Characteristics of the patients are discussed.

[Anisakiasis, rare pseudotumor colonic involvement. Apropos of a case]

History taking should search for intake of raw or uncooked fish in patients with acute abdominal symptoms. The colon is an uncommon localization of anisakiasis. We describe the case of a 31-year-old man with acute abdominal pain whose abdominal CT scan showed a pseudotumoral formation of the colon. History taking and endoscopic ablation gave the diagnosis of anisakiasis. Whole worm extraction led to restituo ad integrum or the colonic wall.

Anisakiasis of the tonsils

A six-year-old Indian girl presenting with clinical features of chronic recurrent tonsillitis, had a tonsillectomy. Histopathology revealed a cross-section of an Anisakis worm in the tonsil. This report documents a new location in the human host for this rare parasite.

Intestinal anisakiasis: first reported case in Thailand

A case of intestinal anisakiasis is reported. The patient came with the symptoms of acute abdominal obstruction. The diagnosis was obtained by identification of the parasite in the tissue sections of the resected segment of the small intestine. This case appears to be the first reported case in Thailand.