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EMHJ Vol. 16 No. 3 2010 Easern Medierranean Healh JournalLa Revue de San de la Mdierrane orienale

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Case report

Ascaris lumbricoides infection: an unexpected causeof pancreatitis in a western Mediterranean country

A. Galzerano,1

E. Sabatini1

and D. Dur2

1Department of Anaesthesia and Intensive Care, Santa Maria della Misericordia Hospital, Perugia, Italy.2Department 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

Asca ri s lu mbri co id es is a nematodeparasite, endemic in the Middle Eastand South America, especially in ruralcountries. Ascariasis inection causesabout 20 000 deaths every year [1],usually as a result o intestinal occlusion,

and it contributes to inant malnutri-tion [2]. Poor sanitation is usually themost important risk actor or inection,and women are more affected becauseprogesterone plays a role in inducingOddis sphincter relaxation, allowingthe nematode to access the biliary duct[3]. Although not common in devel-oped countries, ascariasis inection isincreasingly likely to be encountered byclinicians because o the growing rates

o travel to developing countries andincreased migration.

Case report

We describe the case of a 78-year-oldIalian woman who had never ravelledabroad, who was admited o he surgi-cal ward o A. Murri Hospial, Fermo,Italy, with fever (temperature 38 C),

leukocyosis (whie blood cell coun15.4 103/L), hyperamylasaemia(serum amylase level 260 U/L) andabdominal pain.

Te paien underwen abdominalulrasonography and a compuerizedomography (C) scan o he abdomenand horax, which revealed perioneal

effusion, pancreaic oedema, dilaedgallbladder wih a bile duc measuring1.1 cm wih no lihiasis, lef pleural effu-sion and basal aelecasis. Endoscopicrerograde cholangiopancreaographyshowed a dilaed bile duc wih a paenampulla wih no lihiasis.

Te day afer admission he paien

underwen cholecysecomy, cholan-giogram, posiioning o Kher drainageand pancreaic necrosecomy. Due ohaemodynamic insabiliy and respira-ory ailure he paien was hen admitedo he inensive care uni. A admissionshe was apyreic and microbiologicalculures rom abdominal drainage spec-imens were negaive. Afer weaning andexubaion he paien was ranserred ohe surgical ward where she underwen

an unremarkable recovery.About 20 days aer admission she

developed ever, nausea, vomiing,marked eosinophilia ha had no beennoiced beore (oal leukocye coun11.8 103/L, eosinophils 10%) and amaculopapular rash. On he hypohesiso iarogenic allergic dermaiis, ser-oid and anihisamine reamens werestarted, with no benet.

One week laer he paien vomieda 5 cm male ascarid nematode. Terapy

with mebendazole 100 mg twice dailywas sared wih promp resoluion ohe pancreaic oedema, as documened

by C scans. Te paiens subsequenrecovery was unevenul and she wasdischarged 48 days aer initial admis-sion.

Discussion

Ascaris lumbricoides inesaion is ac-quired hrough ingesion o eggs in raw

vegetables. Te human is the denitivehos. Ingesed larvae penerae he ines-inal lymphaic and venous vessels andhrough he poral vein reach he righ

hear, pulmonary circulaion and healveoli. Afer alveolar rupure hey passino he rachea and he pharynx, arethen swallowed; aer about 2 monthshey reach mauriy. In he bowelnemaodes can perorae he inesinal

wall, be ejeced rom he mouh or anusand penerae he biliary ducs or heairways. Te inesaion can presen asa wide range o sympoms: inesinalperoraion or occlusion, cholangiis,

obsrucive jaundice, acue pancreaiisor appendiciis, pneumonia and respira-ory ailure and allergic reacions o heascaris anigen. In mos cases, however,patients present with unspecic symp-oms and someimes he diagnosis isincidenal [3].

Te diagnosis is usually made byabdominal ulrasonography, revealing

biliary duc dilaion and he presenceo he parasie, a hyperechoic linear

srucure wih a hypoechogenic line in-side, which is someimes moile [35].Ulrasonography is also he gold sand-ard echnique or ollow-up. C scanand nuclear magneic resonance im-aging can also be helpul. Endoscopicrerograde cholangiopancreaogra-phy is he gold sandard mehod or

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ideniying and removing he nemaoderom he duodenal, biliary or pancreaicrac [3].

In this case neither CT scans norendoscopic retrograde cholangiopan-

creatography was able to reveal thepresence o the parasite, which probablyhad 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 lumbricoidesinfestation as a cause ofintestinal obstruction in children: experience with 87 cases.

Journal of pediatric surgery, 1996, 31:2014.Misra SP, Dwivedi M. Clinical features and management of3.biliary ascariasis in a non-endemic area. Postgraduate medicaljournal, 2000, 76:2932.

Hoffmann H et al.4. In vivoand in vitrostudies 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 peu6.banale sous nos climats [Ascariasis: an unusual cause of cho-

References

langitis in our climate]. Gastroentrologie clinique et biologique,

1991, 15:6601.

Moulinier C, Battin J, Giap G. Evolution du taux de prevalence7.

de quatre parasites intestinaux chez lenfant [Development

of the prevalence rate of four intestinal parasites in children].

Pediatrie, 1990, 45:12932.

Mosiello G et al. Ascaridiasi come possibile causa di addo-8.

me acuto anche in Italia: presentazione di un caso clinico

[Ascariasis as a cause of acute abdomen: a case report]. La

pediatria medica e chirurgica, 2003, 25:4524.

De la Cruz Alvarez J et al. Ascariasis biliopancretica: una en-9.

tida infrecuente en nuestro medio [Biliopancreatic ascariasis:

an infrequent disease in our environment]. Gastroenterologa y

hepatologa, 1996, 19:2102.

effusion at the time the examinationswere made.

Alhough ascariasis is he moscommon human worm inecion in heMedierranean area, he developmen o

a severe illness such as a pancreaiis dueo his inesaion is unusual [69]. Teorigin o he inesaion was no esab-lished. As he paien had no ravelled

o any endemic areas, our hypohesis is aconac wih eggs hrough consumpiono raw vegeables or conaminaed soil.Te presence o eosinophilia shouldhave raised suspicion o he possibiliy

o a parasiic inecion, even in a paienno ravelling or migraing rom endemicareas, bu he rariy o his cause o acueabdomen was cerainly misleading.