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    16 3 2010 0350 0351 PDF

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    Sandi Apriadi
    1. A 78-year-old Italian woman presented with fever, abdominal pain, and pancreatitis. Imaging revealed pancreatic swelling and fluid in the abdomen and lungs. 2. She underwent surgery to address the pancreatitis, but later developed eosinophilia and vomited an Ascaris lumbricoides worm. Treatment with an anti-parasitic drug resolved her symptoms. 3. While ascariasis is common in the Mediterranean, this case highlights how the worm can unexpectedly cause severe illness like pancreatitis, even in non-travelers, through local contamination of vegetables or soil. The presence of eosinophilia should have earlier suggested a parasitic infection.

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    16 3 2010 0350 0351 PDF

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    Sandi Apriadi
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    1. A 78-year-old Italian woman presented with fever, abdominal pain, and pancreatitis. Imaging revealed pancreatic swelling and fluid in the abdomen and lungs. 2. She underwent surgery to address the pancreatitis, but later developed eosinophilia and vomited an Ascaris lumbricoides worm. Treatment with an anti-parasitic drug resolved her symptoms. 3. While ascariasis is common in the Mediterranean, this case highlights how the worm can unexpectedly cause severe illness like pancreatitis, even in non-travelers, through local contamination of vegetables or soil. The presence of eosinophilia should have earlier suggested a parasitic infection.

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    1. A 78-year-old Italian woman presented with fever, abdominal pain, and pancreatitis. Imaging revealed pancreatic swelling and fluid in the abdomen and lungs. 2. She underwent surgery to address the pancreatitis, but later developed eosinophilia and vomited an Ascaris lumbricoides worm. Treatment with an anti-parasitic drug resolved her symptoms. 3. While ascariasis is common in the Mediterranean, this case highlights how the worm can unexpectedly cause severe illness like pancreatitis, even in non-travelers, through local contamination of vegetables or soil. The presence of eosinophilia should have earlier suggested a parasitic infection.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    19 views2 pages

    16 3 2010 0350 0351 PDF

    Uploaded by

    Sandi Apriadi
    1. A 78-year-old Italian woman presented with fever, abdominal pain, and pancreatitis. Imaging revealed pancreatic swelling and fluid in the abdomen and lungs. 2. She underwent surgery to address the pancreatitis, but later developed eosinophilia and vomited an Ascaris lumbricoides worm. Treatment with an anti-parasitic drug resolved her symptoms. 3. While ascariasis is common in the Mediterranean, this case highlights how the worm can unexpectedly cause severe illness like pancreatitis, even in non-travelers, through local contamination of vegetables or soil. The presence of eosinophilia should have earlier suggested a parasitic infection.

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    of 2

    EMHJ Vol. 16 No.

    3 2010 Eastern Mediterranean Health Journal


    La Revue de Sant de la Mditerrane orientale
    350
    Case report
    Ascaris lumbricoides infection: an unexpected cause
    of pancreatitis in a western Mediterranean country
    A. Galzerano,
    1
    E. Sabatini
    1
    and D. Dur
    2
    1
    Department of Anaesthesia and Intensive Care, Santa Maria della Misericordia Hospital, Perugia, Italy.
    2
    Department of Anaesthesia and Intensive Care, Sant Antonio Hospital, San Daniele del Friuli, Italy (Correspondence to D. Dur: dav.anestesia@
    gmail.com).
    Received: 13/01/08; accepted: 09/03/08
    Introduction
    Ascaris lumbricoides is a nematode
    parasite, endemic in the Middle East
    and South America, especially in rural
    countries. Ascariasis infection causes
    about 20 000 deaths every year [1],
    usually as a result of intestinal occlusion,
    and it contributes to infant malnutri-
    tion [2]. Poor sanitation is usually the
    most important risk factor for infection,
    and women are more afected because
    progesterone plays a role in inducing
    Oddis sphincter relaxation, allowing
    the nematode to access the biliary duct
    [3]. Although not common in devel-
    oped countries, ascariasis infection is
    increasingly likely to be encountered by
    clinicians because of the growing rates
    of travel to developing countries and
    increased migration.
    Case report
    We describe the case of a 78-year-old
    Italian woman who had never travelled
    abroad, who was admited to the surgi-
    cal ward of A. Murri Hospital, Fermo,
    Italy, with fever (temperature 38 C),
    leukocytosis (white blood cell count
    15.4 10
    3
    /L), hyperamylasaemia
    (serum amylase level 260 U/L) and
    abdominal pain.
    Te patient underwent abdominal
    ultrasonography and a computerized
    tomography (CT) scan of the abdomen
    and thorax, which revealed peritoneal
    efusion, pancreatic oedema, dilated
    gallbladder with a bile duct measuring
    1.1 cm with no lithiasis, lef pleural efu-
    sion and basal atelectasis. Endoscopic
    retrograde cholangiopancreatography
    showed a dilated bile duct with a patent
    ampulla with no lithiasis.
    Te day afer admission the patient
    underwent cholecystectomy, cholan-
    giogram, positioning of Kher drainage
    and pancreatic necrosectomy. Due to
    haemodynamic instability and respira-
    tory failure the patient was then admited
    to the intensive care unit. At admission
    she was apyretic and microbiological
    cultures from abdominal drainage spec-
    imens were negative. Afer weaning and
    extubation the patient was transferred to
    the surgical ward where she underwent
    an unremarkable recovery.
    About 20 days afer admission she
    developed fever, nausea, vomiting,
    marked eosinophilia that had not been
    noticed before (total leukocyte count
    11.8 10
    3
    /L, eosinophils 10%) and a
    maculopapular rash. On the hypothesis
    of iatrogenic allergic dermatitis, ster-
    oid and antihistamine treatments were
    started, with no beneft.
    One week later the patient vomited
    a 5 cm male ascarid nematode. Terapy
    with mebendazole 100 mg twice daily
    was started with prompt resolution of
    the pancreatic oedema, as documented
    by CT scans. Te patients subsequent
    recovery was uneventful and she was
    discharged 48 days afer initial admis-
    sion.
    Discussion
    Ascaris lumbricoides infestation is ac-
    quired through ingestion of eggs in raw
    vegetables. Te human is the defnitive
    host. Ingested larvae penetrate the intes-
    tinal lymphatic and venous vessels and
    through the portal vein reach the right
    heart, pulmonary circulation and the
    alveoli. Afer alveolar rupture they pass
    into the trachea and the pharynx, are
    then swallowed; afer about 2 months
    they reach maturity. In the bowel
    nematodes can perforate the intestinal
    wall, be ejected from the mouth or anus
    and penetrate the biliary ducts or the
    airways. Te infestation can present as
    a wide range of symptoms: intestinal
    perforation or occlusion, cholangitis,
    obstructive jaundice, acute pancreatitis
    or appendicitis, pneumonia and respira-
    tory failure and allergic reactions to the
    ascaris antigen. In most cases, however,
    patients present with unspecifc symp-
    toms and sometimes the diagnosis is
    incidental [3].
    Te diagnosis is usually made by
    abdominal ultrasonography, revealing
    biliary duct dilation and the presence
    of the parasite, a hyperechoic linear
    structure with a hypoechogenic line in-
    side, which is sometimes motile [35].
    Ultrasonography is also the gold stand-
    ard technique for follow-up. CT scan
    and nuclear magnetic resonance im-
    aging can also be helpful. Endoscopic
    retrograde cholangiopancreatogra-
    phy is the gold standard method for


    351
    identifying and removing the nematode
    from the duodenal, biliary or pancreatic
    tract [3].
    In this case neither CT scans nor
    endoscopic retrograde cholangiopan-
    creatography was able to reveal the
    presence of the parasite, which probably
    had already migrated to the lef lung,
    causing basal atelectasis and pleural
    Khuroo MS. Ascariasis. 1. Gastroenterology clinics of North Ameri-
    ca, 1996, 25:55377.
    Villamizar E et al. 2. Ascaris lumbricoides infestation as a cause of
    intestinal obstruction in children: experience with 87 cases.
    Journal of pediatric surgery, 1996, 31:2014.
    Misra SP, Dwivedi M. Clinical features and management of 3.
    biliary ascariasis in a non-endemic area. Postgraduate medical
    journal, 2000, 76:2932.
    Hoffmann H et al. 4. In vivo and in vitro studies on the sonographi-
    cal detection of Ascaris lumbricoides. Pediatric radiology, 1997,
    27:2269.
    Ferreyra NP, Cerri GG. Ascariasis of the alimentary tract, liver, 5.
    pancreas and biliary system: its diagnosis by ultrasonography.
    Hepatogastroenterology, 1998, 45:9327.
    Petit A et al. Lascaridiose: une cause dangiocholite peu 6.
    banale sous nos climats [Ascariasis: an unusual cause of cho-
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    efusion at the time the examinations
    were made.
    Although ascariasis is the most
    common human worm infection in the
    Mediterranean area, the development of
    a severe illness such as a pancreatitis due
    to this infestation is unusual [69]. Te
    origin of the infestation was not estab-
    lished. As the patient had not travelled
    to any endemic areas, our hypothesis is a
    contact with eggs through consumption
    of raw vegetables or contaminated soil.
    Te presence of eosinophilia should
    have raised suspicion of the possibility
    of a parasitic infection, even in a patient
    not travelling or migrating from endemic
    areas, but the rarity of this cause of acute
    abdomen was certainly misleading.

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