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Ancylostoma duodenale: Lost Its way into Appendix


Changela, Kinesh MD; Sharma, Santosh MD; Reddy, Madhavi MD, FACG

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American Journal of Gastroenterology: October 2017 - Volume 112 - Issue - p S776,S778
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Ancylostoma Duodenale (hook worm) is a parasitic infestation of the small bowel most commonly in the duodenum and terminal ileum. Majority of the cases are seen in natives and travelers visiting India and Indian sub-continent. It clinically manifests with non-specific symptoms like abdominal pain, diarrhea or rash. We would like to report an interesting case of Ancylostoma Duodenale infestation into the appendicular cavity which has never been reported in the past. A 62 years old Bengali female was referred to the Gastroenterology clinic for generalized abdominal pain, unintentional weight loss and mild iron deficiency anemia. Physical examination was unremarkable. Laboratory finding was significant for mild iron deficiency anemia. CT scan was unremarkable. Based on these clinical and imaging findings, it was decided to proceed for endoscopic work up. Esophagogastroduodenoscopy showed mild erythematous mucosa in antrum. Biopsies revealed Helicobacter-pylori associated gastritis. Colonoscopy was normal until striking findings were identified upon reaching the base of the cecum. Two small white worms were seen wiggling at the appendicular orifice. Both the worms were retrieved live with biopsy forceps and sent for microbiological exam along with aspirate. The worm was confirmed to be Ancylostoma Duodenale. The patient was successfully treated with single dose of Albendazole 400 mg. Lifecycle of this organism typically involves dermal penetration which usually manifests as “ground itch”. Larvae then reach the lungs via the lymphatic system. In the lungs, they are either coughed up or swallowed and finally get access to the gastrointestinal tract where they then mature into small intestine, colon typically not involved. Once matured in small intestine, adult worms attach to small intestinal mucosa where they consume the blood which clinically manifest as iron deficiency anemia. Once in the gastrointestinal tract, they usually form a burrow into the intervillous space and live there. Only few rare cases of cecal and terminal ileum manifestation have been reported in literature.To our knowledge, this is the first case showing direct endoscopic evidence of Ancylostoma Duodenale infestation into the appendicular cavity. In summary, the endoscopist should carefully look for uncommon sites of parasitic infestation in patients from endemic area presenting with unexplained abdominal pain and mild iron deficiency anemia.

Live hook worms in appendicular cavity.
Hook worm grasped live by biopsy forcep.
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