History

Fact Explanation
Abdominal pain Heterophyiasis is a parasitic infection caused by intestinal flukes ( trematoda) called Heterophyes. Human becomes infected by ingesting undercooked or salted fish containing metacercariae. The metacercariae becomes an adult and get attached to the intestine. Each worm causes a mild inflammatory reaction at its site of contact with the intestine. In heavy infections which are common cause damage to the mucosa and produce abdominal pain. It is a severe and fluctuating abdominal pain that usually not localized. [1,2,3]
Diarrhea If the parasitic load is very high, the severe inflammation of the mucosa causes watery diarrhea. Nausea and vomiting are also accompanied. [1,2]
Chest pain Sometimes eggs can enter the blood and lymph vascular systems through mucosa go into the ectopic sites in the body. Rarely, when the eggs of the flukes move into the heart, fatal valvular and myocardial damage may occur. The resultant arrhythmias may manifest as a chest pain. Ultimately, myocarditis may lead to chronic heart failure. [1,2,3]
Neurological manifestations Very rarely, the eggs may cause cerebral embolism. In such instances, patents may present with various neurological symptoms from headache to paresis. [1,3]
At risk population ` The disease is endemic to some regions like Egypt, the Middle East, and Far East where the population lives near the river banks and those societies where fish plays a main role of their meal. Eating fish either undercooked, raw, or pickled carries a higher risk. [1,2]
References
  1. SCHMOLDT A, BENTHE HF, HABERLAND G. Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol [online] 1975 Sep 1, 24(17):1639-41 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10
  2. CHAI JY, KIM JL, SEO M. Four Human Cases of Acanthotrema felis (Digenea: Heterophyidae) Infection in Korea. Korean J Parasitol [online] 2014 Jun, 52(3):291-4 [viewed 09 August 2014] Available from: doi:10.3347/kjp.2014.52.3.291
  3. CHAI JONG YIL, SEO BYONG SEOL, LEE SOON HYUNG, HONG SUNG JONG, SOHN WOON MOK. Human infections by Heterophyes heterophyes and H. dispar imported from Saudi Arabia. Korean J Parasitol [online] 1986 December [viewed 09 August 2014] Available from: doi:10.3347/kjp.1986.24.1.82

Examination

Fact Explanation
Fever Fever is not common among the patients as the pathology is usually limited to a local inflammatory response off the intestine. [1,2,3]
Abdominal tenderness Mild abdominal tenderness is possible due to the inflammation of the bowel mucosa. [1,2]
Cardiac murmers Very rarely cardiac murmurs may be auscultated owing to the myocarditis and eventual heart failure. [2,3]
Neurological signs In rare instances, neurological signs such as paresis can be found, depending on the extent that the cerebral emboli is affected. [2,3]
References
  1. SCHMOLDT A, BENTHE HF, HABERLAND G. Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol [online] 1975 Sep 1, 24(17):1639-41 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10
  2. CHAI JY, KIM JL, SEO M. Four Human Cases of Acanthotrema felis (Digenea: Heterophyidae) Infection in Korea. Korean J Parasitol [online] 2014 Jun, 52(3):291-4 [viewed 09 August 2014] Available from: doi:10.3347/kjp.2014.52.3.291
  3. CHAI JONG YIL, SEO BYONG SEOL, LEE SOON HYUNG, HONG SUNG JONG, SOHN WOON MOK. Human infections by Heterophyes heterophyes and H. dispar imported from Saudi Arabia. Korean J Parasitol [online] 1986 December [viewed 09 August 2014] Available from: doi:10.3347/kjp.1986.24.1.82

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]
Fascioliasis Fasciola hepatica or the sheep liver fluke is a common parasite of sheep and cattle kept on damp pastures in many parts of the world, but is only occasionally found in men. Most cases have been reported from from sheep rearing countries such as South America, Europe and North America. The major symptoms includes fever, abdominal pain, gastrointestinal disturbances such as loss of appetite, flatulence, nausea, diarrhea and urticaria. [3]
Viral gastroenteritis Viral gastroenteritis is the most common cause of watery diarrhea.It is associated with abdominal pain,nausea and vomiting. Bacterial gastroenteritis usually results in watery diarrhea and sometimes blood and mucous diarrhea.Dehydration is common . Bacterial disease 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. ARADAğ-ÖNCEL E, OZSüREKçI Y, OZKAYA-PARLAKAY A, CELIK M, CENGIZ AB, HALILOğLU M, CEYHAN M, KARA A. Fasciola hepatica infection: clinical and radiological findings in pediatric patients. Turk J Pediatr [online] 2012 Jul-Aug, 54(4):362-7 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23692716
  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 anemia (rarely) may also occur. [1,2]
Stool examination The diagnosis depends on the demonstration of eggs in stool specimens. Concentration techniques and repeated examinations will increase the likelihood of detecting light infections. However, the eggs are indistinguishable from those of Metagonimus yokogawai and resemble those of Clonorchis and Opisthorchis. he eggs from Heterophyes are small, oval and brown, with embryo and operculum / lid. They are 28 to 30 microns long and 15 to 17 microns wide. [1,2]
References
  1. CHAI JY, KIM JL, SEO M. Four Human Cases of Acanthotrema felis (Digenea: Heterophyidae) Infection in Korea. Korean J Parasitol [online] 2014 Jun, 52(3):291-4 [viewed 09 August 2014] Available from: doi:10.3347/kjp.2014.52.3.291
  2. SCHMOLDT A, BENTHE HF, HABERLAND G. Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol [online] 1975 Sep 1, 24(17):1639-41 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10

Management - General Measures

Fact Explanation
Prevention Avoidance from having raw, undercooked or pickled wish is the best preventive method. Using molluscicides for snail (a host) control have been successful. [1,2]
References
  1. CHAI JY, KIM JL, SEO M. Four Human Cases of Acanthotrema felis (Digenea: Heterophyidae) Infection in Korea. Korean J Parasitol [online] 2014 Jun, 52(3):291-4 [viewed 09 August 2014] Available from: doi:10.3347/kjp.2014.52.3.291
  2. SCHMOLDT A, BENTHE HF, HABERLAND G. Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol [online] 1975 Sep 1, 24(17):1639-41 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10

Management - Specific Treatments

Fact Explanation
Praziquantel Praziquantel as a single dose (25 mg/kg or less) is the current treatment of choice. 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]
References
  1. CHAI JONG YIL, SEO BYONG SEOL, LEE SOON HYUNG, HONG SUNG JONG, SOHN WOON MOK. Human infections by Heterophyes heterophyes and H. dispar imported from Saudi Arabia. Korean J Parasitol [online] 1986 December [viewed 09 August 2014] Available from: doi:10.3347/kjp.1986.24.1.82
  2. SCHMOLDT A, BENTHE HF, HABERLAND G. Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol [online] 1975 Sep 1, 24(17):1639-41 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10