History

Fact Explanation
Diarrhea Fasciolopsiasis is caused by the trematoda called Fasciolopsis buski or the "Intestinal fluke". It is Found naturally in pigs, humans and dogs. The parasite infects an amphibious snail after being released by infected feces. Metacercaria released from the snails encyst on the fruits and roots of water plants such as water caltrop, water chestnut and lotus. These cysts will be ingested along with the edible water plants which are eaten raw by pigs and humans. The adult parasite normally develops and inhabits the duodenal and jejunal mucosa. Clinical features are related to the parasitic load. Most infections are mild and asymptomatic. Heavy infection causes extensive intestinal and duodenal erosion, ulceration, haemorrhage, abscess and catarrhal inflammation as the adult parasites attach to intestinal mucosa using their ventral suckers. These pathologies cause insidious onset diarrhea. These are usually watery in nature. Diarrhea may be alternating with constipation and hunger pangs. Malabsorption may lead to steatorrhea as well. [1,2,3,4,5]
Abdominal pain Abdominal pain may be attributed to several causes. Severe parasitic load can cause widespread intestinal erosions, ulceration and rarely perforations. This abdominal pain in more common in the morning and relieved by food. Patient may develop intestinal obstruction with severe mechanical occlusion of the lumen. In such cases severe abdominal pain in the periumbilical area is accompanied by constipation and/ or poor appetite, nausea and vomiting. [1,2,3]
Abdominal swelling Severe inflammation of the intestinal wall and rarely intestinal perforation cause inflammatory reactions in the peritoneal cavity causing extravasation of tissue fluids. [1,2,3]
Facial Oedema Intestinal trauma caused by adult parasite triggers a localized and generalized allergic reaction. Generalized allergic reaction is characterized by a facial edema. [2,4,5]
Hives Generalized toxic and allergic reactions causes red, itchy, raised areas of skin that appear in varying shapes and sizes. [2,5]
History of travel to endemic araes The patient may have a history of travelling in asian countries including China, Taiwan, South-East Asia, Indonesia, Malaysia and India or places where there is a suitable snail host (Segmentina nitidella) are at a higher risk. Humans eat uncooked watercress and other aquatic plants in uncooked/under cooked forms as in salads or on sandwiches may also get infested. [1,2,3,5]
References
  1. WIWANITKIT V, SUWANSAKSRI J, CHAIYAKHUN Y. High prevalence of Fasciolopsis buski in an endemic area of liver fluke infection in Thailand. MedGenMed [online] 2002 Jul 9, 4(3):6 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12466749
  2. BHATTACHARJEE HK, YADAV D, BAGGA D. Fasciolopsiasis presenting as intestinal perforation: a case report. Trop Gastroenterol [online] 2009 Jan-Mar, 30(1):40-1 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19624087
  3. MURALIDHAR S, SRIVASTAVA L, AGGARWAL P, JAIN N, SHARMA DK. Fasciolopsiasis--a persisting problem in eastern U.P.--a case report. Indian J Pathol Microbiol [online] 2000 Jan, 43(1):69-71 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12583424
  4. CHAI JY, SHIN EH, LEE SH, RIM HJ. Foodborne intestinal flukes in Southeast Asia. Korean J Parasitol [online] 2009 Oct:S69-102 [viewed 27 July 2014] Available from: doi:10.3347/kjp.2009.47.S.S69
  5. GUPTA A, XESS A, SHARMA HP, DAYAL VM, PRASAD KM, SHAHI SK. Fasciolopsis buski (giant intestinal fluke)--a case report. Indian J Pathol Microbiol [online] 1999 Jul, 42(3):359-60 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10862298

Examination

Fact Explanation
Pallor This is a rare finding and when present is owing to severe bleeding into the lumen or peritoneal cavity or nutritional deficiencies secondary to malabsorption. All these results in anemia which reflects as conjunctival pallor. [1,2,3,4]
Urticaria Red, itchy raised areas (hives) occur all over the body due to allergy. [3,4]
Loss of weight This is due to malabsorption syndrome due to severe parasite load and ulcerations. [4,5]
Abdominal swelling Intestinal inflammation or intestinal perforations rarely results in peritonitis. This leads to accumulation of fluids in the peritoneal cavity. [1,2,3]
Abdominal tenderness Peritoneal inflammation and intestinal perforation cause either generalized or centrally localized abdominal tenderness. [2,3]
References
  1. WIWANITKIT V, SUWANSAKSRI J, CHAIYAKHUN Y. High prevalence of Fasciolopsis buski in an endemic area of liver fluke infection in Thailand. MedGenMed [online] 2002 Jul 9, 4(3):6 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12466749
  2. GUPTA A, XESS A, SHARMA HP, DAYAL VM, PRASAD KM, SHAHI SK. Fasciolopsis buski (giant intestinal fluke)--a case report. Indian J Pathol Microbiol [online] 1999 Jul, 42(3):359-60 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10862298
  3. MURALIDHAR S, SRIVASTAVA L, AGGARWAL P, JAIN N, SHARMA DK. Fasciolopsiasis--a persisting problem in eastern U.P.--a case report. Indian J Pathol Microbiol [online] 2000 Jan, 43(1):69-71 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12583424
  4. CHAI JY, SHIN EH, LEE SH, RIM HJ. Foodborne intestinal flukes in Southeast Asia. Korean J Parasitol [online] 2009 Oct:S69-102 [viewed 27 July 2014] Available from: doi:10.3347/kjp.2009.47.S.S69
  5. BHATTACHARJEE HK, YADAV D, BAGGA D. Fasciolopsiasis presenting as intestinal perforation: a case report. Trop Gastroenterol [online] 2009 Jan-Mar, 30(1):40-1 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19624087

Differential Diagnoses

Fact Explanation
Amoebiasis Amoebiasis, or Amebiasis, refers to infection caused by the amoeba Entamoeba histolytica. Most infected people are asymptomatic. Severe amoebiasis infections (known as invasive or fulminant amoebiasis) occur in two major forms. Invasion of the intestinal lining causes amoebic dysentery or amoebic colitis. Symptoms can range from mild diarrhea to severe dysentery with blood and mucus. [1]
Ascariasis Ascariasis is caused by Ascaris lumbricoides (large roundworm of humans) It is extremely common infection worldwide and associated with poor sanitation (lack of latrines) in slum areas and estate line rooms. Ascariasis affects more in children than in adults. Mild infection of adult worms does not show symptoms or signs. Increasing worm loads result in worsening of chronic malnutrition especially in children with a poor diet, poor weight gain and stunting. Symptoms may include shortness of breath and fever in the beginning of the disease. These may be followed by symptoms of abdominal swelling, abdominal pain and diarrhea. [2]
Cysticercosis Cysticercosis is a parasitic tissue infection caused by larval cysts of the tapeworm Taenia solium. These larval cysts infect brain, muscle, or other tissue, and are a major cause of adult onset seizures in most low-income countries. Cysts in the brain or spinal cord result in neurocysticercosis which may be asymptomatic or cause serious complications such as seizures, confusion, difficulty with balance, brain swelling, stroke or death. Cysts in the muscles cause tender lumps. [3]
Viral gastroenteritis Most common cause of watery diarrhea.It is associated with abdominal pain,nausea and vomiting. [4]
Bacterial diarrhoea Usually watery diarrhea and sometimes blood and mucous diarrhea.Dehydration is common.Responds to antibacterial agents. [4]
Giardiasis Giardiasis is caused by Giardia intestinalis, a flagellate protozoan which decreases expression of brush-border enzymes namely disaccharidases and lipase. It causes impairment of carbohydrate and lipid digestion resulting osmotic diarrhea.Travelers to countries where giardiasis is common, People in child care settings, those who are in close contacts with patients, people who swallow contaminated or untreated water,men who have sex with men have a greater risk of becoming infected. Diarrhea is the most common symptom in acute giardiasis. It is more specifically, a steatorrhoea which contains pale, bulky, frothy, foul smelling stools which are floating in the lavatory pan due to fat content. [5]
References
  1. ARCHAMPONG EQ, CLARK CG. Surgical problems in amoebiasis. Ann R Coll Surg Engl [online] 1973 Jan, 52(1):36-48 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/4568445
  2. WANG J, PAN YL, XIE Y, WU KC, GUO XG. Biliary ascariasis in a bile duct stones-removed female patient. World J Gastroenterol [online] 2013 Sep 28, 19(36):6122-4 [viewed 27 July 2014] Available from: doi:10.3748/wjg.v19.i36.6122
  3. ZAMMARCHI L, STROHMEYER M, BARTALESI F, BRUNO E, MUñOZ J, BUONFRATE D, NICOLETTI A, GARCíA HH, POZIO E, BARTOLONI A, COHEMI PROJECT STUDY GROUP. Epidemiology and management of cysticercosis and Taenia solium taeniasis in Europe, systematic review 1990-2011. PLoS One [online] 2013, 8(7):e69537 [viewed 27 July 2014] Available from: doi:10.1371/journal.pone.0069537
  4. GODANA W, MENGISTIE B. Determinants of acute diarrhoea among children under five years of age in Derashe District, Southern Ethiopia. Rural Remote Health [online] 2013, 13(3):2329 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24016301
  5. VESY , PETERSON . Review article: the management of Giardiasis. Aliment Pharmacol Ther [online] 1999 July, 13(7):843-850 [viewed 27 July 2014] Available from: doi:10.1046/j.1365-2036.1999.00537.x

Investigations - for Diagnosis

Fact Explanation
Full blood count Parasitic infestation is characterized by high degree of eosinophilia. Leukocytosis and severe anemia may also occur. [1,2,3]
Erythrocyte sedimentation rate (ESR) Patients have an elevated erythrocyte sedimentation rate. [2,3,4]
Microscopic examination of stool Microscopic identification of the ova or adult worms in the stool or vomitus is the basis of specific diagnosis. However, the eggs of Fasciolopsis buski are indistinguishable from those of Fasciola hepatica. [1,2,3,4]
Enzyme-linked immunosorbent assay (ELISA) ELISA has a less importance in diagnosis and rarely performed. [2,4]
Polymerase chain reaction (PCR) assays PCR is used as a rapid diagnostic assay for Fasciolopsiasis. [2,4]
References
  1. GUPTA A, XESS A, SHARMA HP, DAYAL VM, PRASAD KM, SHAHI SK. Fasciolopsis buski (giant intestinal fluke)--a case report. Indian J Pathol Microbiol [online] 1999 Jul, 42(3):359-60 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10862298
  2. MURALIDHAR S, SRIVASTAVA L, AGGARWAL P, JAIN N, SHARMA DK. Fasciolopsiasis--a persisting problem in eastern U.P.--a case report. Indian J Pathol Microbiol [online] 2000 Jan, 43(1):69-71 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12583424
  3. WIWANITKIT V, SUWANSAKSRI J, CHAIYAKHUN Y. High prevalence of Fasciolopsis buski in an endemic area of liver fluke infection in Thailand. MedGenMed [online] 2002 Jul 9, 4(3):6 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12466749
  4. BHATTACHARJEE HK, YADAV D, BAGGA D. Fasciolopsiasis presenting as intestinal perforation: a case report. Trop Gastroenterol [online] 2009 Jan-Mar, 30(1):40-1 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19624087

Management - General Measures

Fact Explanation
Prevention roperly clean and process raw vegetables by immersing in boiling water for few seconds, then followed by peeling and washing in clean water, avoidance of eating water plants raw, in endemic areas, snail control, proper treatment of night soil using lime and copper sulfate and chemotherapy to decrease the human reservoir of infection are preferred methods of prevention. [1,2,3]
References
  1. GUPTA A, XESS A, SHARMA HP, DAYAL VM, PRASAD KM, SHAHI SK. Fasciolopsis buski (giant intestinal fluke)--a case report. Indian J Pathol Microbiol [online] 1999 Jul, 42(3):359-60 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10862298
  2. CHAI JY, SHIN EH, LEE SH, RIM HJ. Foodborne intestinal flukes in Southeast Asia. Korean J Parasitol [online] 2009 Oct:S69-102 [viewed 27 July 2014] Available from: doi:10.3347/kjp.2009.47.S.S69
  3. WIWANITKIT V, SUWANSAKSRI J, CHAIYAKHUN Y. High prevalence of Fasciolopsis buski in an endemic area of liver fluke infection in Thailand. MedGenMed [online] 2002 Jul 9, 4(3):6 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12466749

Management - Specific Treatments

Fact Explanation
Praziquantel Praziquantel is the drug of choice for treatment. Treatment is effective in early or light infections. Heavy infections are more difficult to treat. Praziquantel 20 mg/kg 8 hourly for 1 day is the recommended dose. Other anthelmintics that can be used include thiabendazole, mebendazole, levamisole and pyrantel pamoate are also effective. [1,2,3]
References
  1. WIWANITKIT V, SUWANSAKSRI J, CHAIYAKHUN Y. High prevalence of Fasciolopsis buski in an endemic area of liver fluke infection in Thailand. MedGenMed [online] 2002 Jul 9, 4(3):6 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12466749
  2. MURALIDHAR S, SRIVASTAVA L, AGGARWAL P, JAIN N, SHARMA DK. Fasciolopsiasis--a persisting problem in eastern U.P.--a case report. Indian J Pathol Microbiol [online] 2000 Jan, 43(1):69-71 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12583424
  3. BHATTACHARJEE HK, YADAV D, BAGGA D. Fasciolopsiasis presenting as intestinal perforation: a case report. Trop Gastroenterol [online] 2009 Jan-Mar, 30(1):40-1 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19624087