History

Fact Explanation
Abdominal pain Diphyllobothriasis is an infection of the cestode called Diphyllobothrium latum or Diphyllobothrium nihonkaiense. This disease is more common in Europe, North Asia, North America and South America. Diphyllobothriasis (Fish tape worm infestation) is a potential zoonosis. Human is the main host and is infected by eating raw, infected fish. Other fish eating mammals may also be infected. Patients are usually asymptomatic. Symptoms of Diphyllobothrium are related to the worm burden. Abdominal pain may attributed to the trauma to the intestinal wall caused by adult worm. Rarely, patients may develop intestinal obstruction with severe mechanical occlusion of the lumen. In such cases severe abdominal pain in the peri umbilical area with nausea, vomiting or constipation may occur. [1,2,3,4,5]
Diarrhea Diarrhea is a very rare presentation of fish tapeworm infestation. When occurs it is insidious and watery in type. Diarrhea may be accompanied with nausea, vomiting and loss of appetite. [2,4,5,6]
Restlessness at night Passage of proglottids to the peri anal region causes restlessness and prutitus ani at night. [1,3,4]
Indigestion/ dyspeptic symptoms The characteristic symptoms of dyspepsia are upper abdominal pain, bloating, fullness and tenderness on palpation. [2,6,7,8]
Anaemic features Vitamin B12 deficiency with subsequent megaloblastic anemia may occur. This is thought to be due to utilization of vitamin B12 and/or folic acid by the parasites in the intestine or blood. Anemic patients can present with symptoms depending on severity including breathlessness, and neurologic symptoms such as numbness, weakness, and disturbances in coordination.. [1,6,7,8]
References
  1. ARIZONO N, YAMADA M, NAKAMURA-UCHIYAMA F, OHNISHI K. Diphyllobothriasis associated with eating raw pacific salmon. Emerg Infect Dis [online] 2009 Jun, 15(6):866-70 [viewed 31 July 2014] Available from: doi:10.3201/eid1506.090132
  2. SAMPAIO JL, DE ANDRADE VP, LUCAS MDA C, FUNG L, GAGLIARDI SM, SANTOS SR, MENDES CM, EDUARDO MB, DICK T. Diphyllobothriasis, Brazil. Emerg Infect Dis [online] 2005 Oct, 11(10):1598-600 [viewed 31 July 2014] Available from: doi:10.3201/eid1110.050377
  3. LEE KW, SUHK HC, PAI KS, SHIN HJ, JUNG SY, HAN ET, CHAI JY. Diphyllobothrium latum infection after eating domestic salmon flesh. Korean J Parasitol [online] 2001 Dec, 39(4):319-21 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11775333
  4. SEMENAS L, KREITER A, URBANSKI J. New cases of human diphyllobothriasis in Patagonia, Argentina. Rev Saude Publica [online] 2001 Apr, 35(2):214-6 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11359210
  5. RAMANA K, RAO S, VINAYKUMAR M, KRISHNAPPA M, REDDY R, SARFARAZ M, KONDLE V, RATNAMANI M, RAO R. Diphyllobothriasis in a nine-year-old child in India: a case report. J Med Case Rep [online] 2011 Jul 29:332 [viewed 31 July 2014] Available from: doi:10.1186/1752-1947-5-332
  6. CRAIG N. Fish tapeworm and sushi. Can Fam Physician [online] 2012 Jun, 58(6):654-8 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22859629
  7. CHOI HJ, LEE J, YANG HJ. Four human cases of Diphyllobothrium latum infection. Korean J Parasitol [online] 2012 Jun, 50(2):143-6 [viewed 31 July 2014] Available from: doi:10.3347/kjp.2012.50.2.143
  8. NAKAJI K, NAKAE Y, KUMAMOTO M, SUZUMURA S. Diphyllobothriasis. Intern Med [online] 2009, 48(16):1479 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19687603

Examination

Fact Explanation
Stool examination Direct examination of the stools may help to observe white motile segments of Proglottids of Dipylidium caninum. Examination of the peri anal area may also useful as segments can be found as they crawl out of the anus. These are important findings in terms of diagnosis. [1,2,3,4,5]
Abdominal tenderness This may or may not be demonstrated in the epigastric region and is due to local allergic reaction of the intestine and rarely may be attributed to intestinal obstruction, in which case tenderness will be accompanied with abdominal distention. [2,3,4,5,6]
Neurological signs Vitamin B12 deficiency can lead to neurologic dysfunction. Patients may show a wide range of neurological manifestations ranging from numbness to the fingers and toes, difficulty walking, mood changes, depression, memory loss, disorientation and, in severe cases, dementia. [1,2,3,4,6]
Anemic features Pallor, glossitis, dyspnea and tachycardia are common in patients complicated with megaloblastic anemia. [2,4,5]
References
  1. ARIZONO N, YAMADA M, NAKAMURA-UCHIYAMA F, OHNISHI K. Diphyllobothriasis associated with eating raw pacific salmon. Emerg Infect Dis [online] 2009 Jun, 15(6):866-70 [viewed 31 July 2014] Available from: doi:10.3201/eid1506.090132
  2. CHOI HJ, LEE J, YANG HJ. Four human cases of Diphyllobothrium latum infection. Korean J Parasitol [online] 2012 Jun, 50(2):143-6 [viewed 31 July 2014] Available from: doi:10.3347/kjp.2012.50.2.143
  3. SAMPAIO JL, DE ANDRADE VP, LUCAS MDA C, FUNG L, GAGLIARDI SM, SANTOS SR, MENDES CM, EDUARDO MB, DICK T. Diphyllobothriasis, Brazil. Emerg Infect Dis [online] 2005 Oct, 11(10):1598-600 [viewed 31 July 2014] Available from: doi:10.3201/eid1110.050377
  4. RAMANA K, RAO S, VINAYKUMAR M, KRISHNAPPA M, REDDY R, SARFARAZ M, KONDLE V, RATNAMANI M, RAO R. Diphyllobothriasis in a nine-year-old child in India: a case report. J Med Case Rep [online] 2011 Jul 29:332 [viewed 31 July 2014] Available from: doi:10.1186/1752-1947-5-332
  5. CRAIG N. Fish tapeworm and sushi. Can Fam Physician [online] 2012 Jun, 58(6):654-8 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22859629
  6. NAKAJI K, NAKAE Y, KUMAMOTO M, SUZUMURA S. Diphyllobothriasis. Intern Med [online] 2009, 48(16):1479 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19687603

Differential Diagnoses

Fact Explanation
Hypothyroidism Hypothyroidism is a common endocrine disorder in which the thyroid gland does not produce enough thyroid hormone. It can cause a number of symptoms, such as tiredness, poor ability to tolerate cold, and weight gain. In children, hypothyroidism leads to delays in growth and intellectual development, which is called cretinism in severe cases. [1]
Pernicious Anemia Pernicious anemia is one of many types of the larger family of megaloblastic anemias. One way pernicious anemia can develop is by loss of gastric parietal cells, which are responsible, in part, for the secretion of intrinsic factor, a protein essential for subsequent absorption of vitamin B12 in the ileum. Common symptoms include anemia, fatigue, depression, low-grade fevers, nausea, gastrointestinal symptoms such as heartburn, diarrhea, dyspepsia, weight loss, neuropathic pain, jaundice, glossitis, angular cheilitis , brittle nails, and thinning and early greying of the hair. Rarely neurological dysfunction may occur. [2]
Taenia Infection Taeniasis in humans is a parasitic infection caused by the tapeworm species Taenia saginata (beef tapeworm), Taenia solium (pork tapeworm), and Taenia asiatica (Asian tapeworm). Humans can become infected with these tapeworms by eating raw or undercooked beef (T. saginata) or pork (T. solium and T. asiatica). People with taeniasis may not know they have a tapeworm infection because symptoms are usually mild or nonexistent. [3]
References
  1. BRENTA G, VAISMAN M, SGARBI JA, BERGOGLIO LM, ANDRADA NC, BRAVO PP, ORLANDI AM, GRAF H, TASK FORCE ON HYPOTHYROIDISM OF THE LATIN AMERICAN THYROID SOCIETY (LATS). Clinical practice guidelines for the management of hypothyroidism. Arq Bras Endocrinol Metabol [online] 2013 Jun, 57(4):265-91 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23828433
  2. ANDRES E, SERRAJ K. Optimal management of pernicious anemia. J Blood Med [online] 2012:97-103 [viewed 31 July 2014] Available from: doi:10.2147/JBM.S25620
  3. YANAGIDA T, SAKO Y, NAKAO M, NAKAYA K, ITO A. Taeniasis and cysticercosis due to Taenia solium in Japan. Parasit Vectors [online] 2012 Jan 17:18 [viewed 31 July 2014] Available from: doi:10.1186/1756-3305-5-18

Investigations - for Diagnosis

Fact Explanation
Full blood count Parasitic infestation is characterized by high degree of eosinophilia. Hemoglobin level and hematocrit low or at the lower end with Mean cell volume above or at the higher end of the reference ranges is indicative of macrocytic anemia. [1,2,3,4]
Stool examination for ova Identification of the operculated eggs in the stool is not difficult, as large quantity of eggs (≥1 million) produced each day. These eggs are oval or ellipsoidal, with at one end an operculum that can be inconspicuous. At the opposite (abopercular) end is a small knob that can be barely discernible. The eggs are passed in the stool unembryonated. [2,3,4,5]
Vitamin B12 and/ or Folate level Some strains absorb vitamin B12 leading to Vitamin B12 deficiency and megaloblastic anemia in the human host. [4,5,6]
References
  1. ARIZONO N, YAMADA M, NAKAMURA-UCHIYAMA F, OHNISHI K. Diphyllobothriasis associated with eating raw pacific salmon. Emerg Infect Dis [online] 2009 Jun, 15(6):866-70 [viewed 31 July 2014] Available from: doi:10.3201/eid1506.090132
  2. NAKAJI K, NAKAE Y, KUMAMOTO M, SUZUMURA S. Diphyllobothriasis. Intern Med [online] 2009, 48(16):1479 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19687603
  3. RAMANA K, RAO S, VINAYKUMAR M, KRISHNAPPA M, REDDY R, SARFARAZ M, KONDLE V, RATNAMANI M, RAO R. Diphyllobothriasis in a nine-year-old child in India: a case report. J Med Case Rep [online] 2011 Jul 29:332 [viewed 31 July 2014] Available from: doi:10.1186/1752-1947-5-332
  4. SAMPAIO JL, DE ANDRADE VP, LUCAS MDA C, FUNG L, GAGLIARDI SM, SANTOS SR, MENDES CM, EDUARDO MB, DICK T. Diphyllobothriasis, Brazil. Emerg Infect Dis [online] 2005 Oct, 11(10):1598-600 [viewed 31 July 2014] Available from: doi:10.3201/eid1110.050377
  5. SEMENAS L, KREITER A, URBANSKI J. New cases of human diphyllobothriasis in Patagonia, Argentina. Rev Saude Publica [online] 2001 Apr, 35(2):214-6 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11359210
  6. CHOI HJ, LEE J, YANG HJ. Four human cases of Diphyllobothrium latum infection. Korean J Parasitol [online] 2012 Jun, 50(2):143-6 [viewed 31 July 2014] Available from: doi:10.3347/kjp.2012.50.2.143

Management - General Measures

Fact Explanation
Prevention Prevention from consumption of raw fish specially when travel to endemic areas is the single best preventive method. Cooking fish to a temperature of 56 Celsius or more for more than 5 minutes or freezing to minus 18 Celsius for 24 hours will kills the plerocercoid larvae. Pickling fish in brine under very rigorous conditions will also kill the larva. The fish must be properly prepared before it is sampled . [1,2,3]
References
  1. CHOI HJ, LEE J, YANG HJ. Four human cases of Diphyllobothrium latum infection. Korean J Parasitol [online] 2012 Jun, 50(2):143-6 [viewed 31 July 2014] Available from: doi:10.3347/kjp.2012.50.2.143
  2. NAKAJI K, NAKAE Y, KUMAMOTO M, SUZUMURA S. Diphyllobothriasis. Intern Med [online] 2009, 48(16):1479 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19687603
  3. CRAIG N. Fish tapeworm and sushi. Can Fam Physician [online] 2012 Jun, 58(6):654-8 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22859629

Management - Specific Treatments

Fact Explanation
Praziquantel Praziquantel is the drug of choice for Diphyllobothriasis. Single dose of 10-20 mg/kg after a light breakfast is recommended. Frequently occurring side effects are dizziness, headache, and malaise. Approximately 90% of all patients have abdominal pain or cramps with or without nausea and vomiting. [1,2,3,4]
Niclosamide Niclosamide should be chewed thoroughly and be taken with water. 2g for adults as a single dose after a light breakfast is recommended. Dosage for children up to 2 years is 500mg and 1g for those between 3 to 6 years. This is an alternative to Praziquantel. [3,4,5]
Vitamin supplementation Vitamin B12 and/or folic acid may be required in severe cases. [1,4]
References
  1. NAKAJI K, NAKAE Y, KUMAMOTO M, SUZUMURA S. Diphyllobothriasis. Intern Med [online] 2009, 48(16):1479 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19687603
  2. CRAIG N. Fish tapeworm and sushi. Can Fam Physician [online] 2012 Jun, 58(6):654-8 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22859629
  3. SAMPAIO JL, DE ANDRADE VP, LUCAS MDA C, FUNG L, GAGLIARDI SM, SANTOS SR, MENDES CM, EDUARDO MB, DICK T. Diphyllobothriasis, Brazil. Emerg Infect Dis [online] 2005 Oct, 11(10):1598-600 [viewed 31 July 2014] Available from: doi:10.3201/eid1110.050377
  4. SEMENAS L, KREITER A, URBANSKI J. New cases of human diphyllobothriasis in Patagonia, Argentina. Rev Saude Publica [online] 2001 Apr, 35(2):214-6 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11359210
  5. RAMANA K, RAO S, VINAYKUMAR M, KRISHNAPPA M, REDDY R, SARFARAZ M, KONDLE V, RATNAMANI M, RAO R. Diphyllobothriasis in a nine-year-old child in India: a case report. J Med Case Rep [online] 2011 Jul 29:332 [viewed 31 July 2014] Available from: doi:10.1186/1752-1947-5-332