Image of the Month
A 17-year-old girl, vertically infected with HIV, was repeatedly admitted in the AIDS unit for the past 12 months with abdominal pain, nausea, recurrent hyperamylasemia, diarrhea, and severe dehydration. Her serum electrolytes, especially potassium, were disproportionately low considering the losses. The patient was on highly active antiretroviral treatment with poor compliance due to her GI symptoms. The CD4/CD8 was 0.1 and the viral load was 100,000 vc/mL. Renal and adrenal functions were normal, repeated stool cultures and stool examinations for parasites were negative. Upper and lower endoscopies were normal, whereas biopsies from upper and lower GI tracts revealed mild eosinophilic infiltration. Due to the persistence of symptoms, investigation of the small bowel was performed by endoscopic capsule, which revealed a picture compatible with ascariasis (Fig. 1). Based on this finding the patient was treated with albedazole 400 mg daily for 3 days and her improvement was remarkable. Her diarrhea ceased, serum potassium and amylase levels returned to normal, her appetite improved, and she gained 3 kg in 1 month. She regularly follows her antiretroviral treatment.
This case illustrates that ascariasis in an HIV patient can cause severe electrolyte disturbances and recurrent pancreatitis. Ascariasis is the most frequent helminthic infection in settings with high HIV-1 seroprevalence (1). Recent data support the correlation of coinfection with HIV-1 disease progression (2). Mature Ascaris lumbricoides is the most common parasite causing pancreatitis by entering the biliary tree and/or pancreatic duct via the ampulla (3–5). In our case, inspection of Vater's ampulla with the standard endoscope missed Ascaris, which could presumably have invaded the pancreatic duct. According to wireless capsule endoscopy results, the parasites appeared on the capsule images 6 hours after capsule ingestion and probably located in jejunum and ileum. The absence of parasites in the patient's stool remains unclear, although Ascaris eggs in the stools had not been found in other cases. The incidence of pancreatitis in HIV patients is about 5%, mostly related to antiretroviral treatment (6). When co-infection with ascaris occurs the percentage is expected to be much higher because pancreatitis is common in highly endemic areas of ascariasis (3,7). Wireless capsule endoscopy is useful in cases wherein parasites are not identified on upper and lower GI endoscopy.
The authors report no conflicts of interest.
Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.
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