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Cite as: "a rare case report of intestinal hymenolepiasis and ascariasis double infection in a symptomatic immuno-competent host from south india".; vol. 2 issue 11 pg:1443-1447

International Journal Of Medical Science And Clinical Inventions
Volume 2 issue 11 2015 page no. 1443-1447 e-ISSN: 2348-991X p-ISSN: 2454-9576
"A Rare Case Report Of Intestinal Hymenolepiasis And Ascariasis
Double Infection In A Symptomatic Immuno-Competent Host
From South India".
Dr. R. Someshwaran1, SM. Nachammai2, Dr. Anbu N. Aravazhi3
Corresponding author: Dr. R. Someshwaran
Department of Microbiology, Karpagam Faculty of Medical Sciences and Research, Coimbatore, Tamil Nadu 641032 India Abstract:
A 30 year old immuno-competent female, a home maker by occupation, belonging to class III Modified Prasad's
classification presented to medicine out-patient department with complaints of diarrhea 6-8 episodes per day, anal pruritus,
lower abdominal pain, vomiting and nausea for about 10 days. Patient also complained of malaise and low grade fever on
and off for the past two weeks. No other history of similar complaints in the family. On examination patient was afebrile and
had moderate pallor. Routine laboratory blood investigations revealed profound eosinophilia and moderate anemia. Stool
specimen was sent to Diagnostic Microbiology Laboratory for microscopic examination which revealed presence of
helminthic co-infection namely Hymenolepis nana and Ascaris lumbricoides. Patient was de-wormed with specific anti-
helminthic therapy and the patient improved symptomatically and was subsequently discharged. Follow up microscopic stool
re-examination done at 10 days and 18 days after the treatment revealed no parasitic ova or cyst.
Key words: Geohelminthiasis - Hymenolepis nana - Ascaris lumbricoides - Polyparasitosis – Immunocompetent female –
Anemia.

Introduction:
and also among high risk ethnic groups. Moderate loads of parasitic infection could cause delayed physical and symmetrical elongated, flat or round worm-like soil impaired cognitive development especially in school age transmitted parasites. Geohelminths are broadly classified children10, 11. STH is the leading infectious cause for illness, into Platyhelminths and Nemahelminths. Platyhelminths absenteeism12 and lost Disability Adjusted Life Years include a) flat tape like cestodes or tape worms and b) flat leaf-like trematodes or flukes whereas Nemahelminths includes elongated cylindrical nematodes (round worms). "Double and triple infections" Geohelminthiasis1 or Soil Transmitted Helminthic (STH) „Polyparasitosis‟ are accidental infections but not so Ancylostoma duodenale, uncommon and they occur due to i) availability of the americanus, Ascaris lumbricoides2 and Trichuris trichiura infective forms of different parasites in the same place and etc., still remains as the most common worm infestations during the same time of exposure; ii) direct person to person feco-oral transmission; iii) through contaminated soil, water gastrointestinal tract4 and are found ubiquitous in tropical or food without involving intermediate host; iv) Parasitic and sub-tropical temperate zones posing significant public symbiosis; v) Immunocompromised host; vi) Parasitic health problem5, 6 to humans. Estimated prevalence of geo- synergism. Complex etiology of these parasites and helminthiasis is around 2 billion cases comprising 28.6% of variation in distribution15, 16 makes it very difficult to the world‟s population1. Among them Ascariasis alone consolidate the „cause and effect‟ indices where these STH accounts for one billion cases worldwide. The developing infections has a negative impact over physical and mental countries contribute to about 10% of these parasitic agility of the patient17 thwarting the efforts of a country to infections7. The prevalence rate of intestinal helminthic provide basic amenities of the community like free school infections in India is 12.5% but a higher incidence of up to education18, mid-day meal program and other health related 66% has been reported8, 9, where individual parasitic 20. Feco-oral transmission of incidence may vary among different geographical locations Hymenolepis nana and Ascaris lumbricoides by ingestion of DOI: 10.18535/ijmsci/v2i11.04

Cite As: "A Rare Case Report Of Intestinal Hymenolepiasis And Ascariasis Double Infection In A
Symptomatic Immuno-Competent Host From South India".; Vol. 2 Issue 11 Pg:1443-1447 2015
fertilized eggs is the most common method of transmission. parasitic morphologies. One type was roughly 40µm Infections are generally asymptomatic in low burden cases diameter size, oval, colorless eggs (non-bile stained) with but in high burden cases the signs and symptoms may vary18 outer and inner membranes, 4-5 polar filaments, hexacanth viz., abdominal pain, nausea, vomiting, fever, weight loss, embryo with three pairs of hooklets (oncosphere) which was irritability, diarrhea, sleep disorders, pruritus etc. Estimated found to be Hymenolepis nana, a cestode and the other were mortality worldwide due to STH is 1,35,000 deaths per 60µm diameter size, Oval to sub-spherical golden brown 21. The complications of ascariasis and eggs (bile stained) with thick shell covered by albuminous hymenolepiasis hyper-infection17 include biliary tract coat and a large unsegmented ovum with crescentic area at obstruction, intestinal obstruction, failure to thrive, protein each pole which was confirmed as fertilized egg of Ascaris energy malnutrition, cognitive impairment, iron deficiency lumbricoides, an intestinal nematode. Also colorless, anemia, eosinophilic pneumonitis, appendicitis, peritonitis spherical, 15-20µm pentanucleate to octanucleate cyst (5-8 and death especially in case of those untreated patients 22, 23. nuclei) were present which was further identified as Mortality due to polyparasitosis had reduced due to anti- commensal cysts of Entamoeba coli. No evidence of helminthic self-medication24, 25. To reduce disease burden of trophozoites with ingested erythrocytes suggestive of STH, WHO recommends a feasible and cost effective Entamoeba histolytica. control strategy of parasitic infections by single dose chemotherapy for ascariasis, trichuriasis and hook worm Figure1: Stool microscopy for ova or cyst.
infestations especially targeting school age children18. a) Saline wet mount preparation (40X objective): Oval non-
bile stained egg of CASE DESCRIPTION:
Hymenolepis nana and spherical bile stained fertilized A 30 year old immuno-competent female presented egg of Ascaris lumbricoides. to the medicine out-patient department with chief complaints of passing loose stools 6-8 episodes per day, anal pruritus, lower abdominal pain, vomiting and nausea for 5-6 days. Patient revealed history of easy fatigability, irritability, excessive tiredness and loss of appetite for past 10 days. Patient also complained of malaise, low grade fever on and off for the past two weeks. No history of joint pain. Hymenolepis nana Ascaris lumbricoides No history of contact with animals. No history of similar complaints among the family members. No history of consuming deworming pills in the last six months. On b) Iodine wet mount preparation (40X objective): Eggs of
examination patient was afebrile, with mild-moderate pallor. Hymenolepis nana and Routine laboratory blood investigations revealed profound fertilized egg of Ascaris lumbricoides seen. Multiple cysts eosinophilia and moderate anemia. A working diagnosis of of Entamoeba coli suspected helminthic infection with anemia was made and were seen. stool specimen was sent to diagnostic microbiology
laboratory for examination.
Materials and methods:

Institutional Human Ethics Committee (IHEC) clearance and patient‟s informed consent were obtained. Entamoeba coli Hymenolepis ana Ascaris lumbricoides Stool sample was collected in a sterile wide mouthed screw (5-6µm) capped plastic container as per guidelines and was sent for microscopic and macroscopic examination to diagnostic Entamoeba coli microbiology laboratory, Karpagam Medical College Repeat stool re-examination for parasitic ova or cyst done (5-6µm) Hospital affiliated to Karpagam Faculty of Medical Sciences 10 days and 18 days after the course of treatment which & Research. Direct macroscopic examination revealed were negative for Hymenolepis nana and Ascaris loose, yellowish brown, malodorous soft stool mixed with lumbricoides. mucus. No evidence of admixed blood or worm segments seen. Stool microscopy by Saline wet mount and Iodine wet Discussion:
mount preparations revealed presence of two different In this patient, anemia (Serum Hemoglobin- 8.1g/dL) and eosinophilia were the hallmark blood findings DOI: 10.18535/ijmsci/v2i11.04
Cite As: "A Rare Case Report Of Intestinal Hymenolepiasis And Ascariasis Double Infection In A
Symptomatic Immuno-Competent Host From South India".; Vol. 2 Issue 11 Pg:1443-1447 2015
which could be explained due to complications26, 27 of Even today soil transmitted intestinal helminthiasis Hymenolepiasis and Ascariasis. The patient was treated with is a highly prevalent but neglected disease claiming global oral mebendazole 100mg bd for 3 days. Patient improved public health importance13. STH is the most common cause symptomatically and was discharged from the hospital. for chronic infection in humans in developing countries32. Mixed hymenolepiasis and ascariasis double infection are High parasitic infestation mirrors severe shortage in health far more reported outside India28. Only a few published care and education, transport and chronic poverty33. cases of mixed helminthic infections were reported Widespread use of anti-helminthic therapy had shown worldwide. No reports of helminthic polyparasitosis were remarkable reduction in burden of STH infection in South found in South India. Patients with intestinal parasitosis are India34.Risk of developing drug resistance due to frequent carriers transmitting the disease infection to nearby contacts anti-helminthic use leading to widespread drug resistance in and also to the community. According to a recent study nematodes35. Multiple parasitic infections are far more report, the prevalence rates of individual parasites like common than single or no infection17. Polyparasitism with Ascaris lumbricoides and Hymenolepis nana among people nematodes is a common occurrence 24. Polyparasitism living in high risk areas of South India were found to be 6.2% and 2.7% respectively29. „Deworming‟ is an essential tool of school health programs to control STH infections21. Following repeated deworming Risk factors for STH infections7, 8, 9, 18 at both once in 3-6 months, a rise in haemoglobin levels (0.1-2 g/dl) individual and at community levels is an amalgamation of has been observed after 1 year in some studies36, 37. complex and multivariate Demographic, Biological, Social, Environmental, Climatic, and Behavioral factors viz., i) Conclusion:
Over-crowding; ii) Illiteracy; iii) Unemployment iv) A precise, feasible and cost-effective a) Diagnostic, Poverty; v) Poor personal hygiene like hand hygiene, toilet b) Therapeutic and or c) Preventive strategy is mandatory as hygiene and sex hygiene; vi) Regional customs and a stepping stone for prevention of disease progression and or traditions; vii) Poor environmental sanitations; viii) Infected its complications is the strict adherence to regular or food handling expatriates; ix) Open air-defecation in drains, periodic health screening by microscopic stool examination fields or streets; x) Consuming raw vegetables like tubers especially in endemic areas and among high risk groups and greens; xi) Consuming undercooked consumables like which would be more helpful in the early diagnosis and vegetables and meat; xii) Unemployment, xiii) Lack of home or private toilet facility, xiv) Not washing hands after infections18. Periodic treatment with anti-helminthic drugs defecation, xv) Living in warm moist environment and also for control of intestinal parasitic infection for the community in shanty tribal , rural or urban area, xvi) History of contact is a highly effective and inexpensive tool but a more precise with animals (cattle and pig rearing; household pets like cats study emphasizing on the epidemiology of STH and its drug and dogs; pests like rats and mice), xvii) Consuming organic resistance before making large scale periodic treatment food (those untreated with insecticides); xviii) Post- schedules on a global basis is a borne necessity38. Preventive monsoon period (November to February) or rainy season; measures to control STH are health education, periodic xix) Due to consumption of improperly preserved or cooked, contaminated road side fast food and junk foods ; xx) environmental sanitation and personal hygiene, quality History of PICA, playing in the moist soil or mud. nutrition, political will and terminating the chain of disease Risk Groups (HRG) for Geo-helminthiasis are a) People transmission. Reporting any case of polyparasitosis and living in tropical and temperate regions; b) Dwellers of other complicated parasitic infections is important in order "Kuccha house" with thatched roof and cow dung flooring to understand their clinical spectrum, enhance the or in Field huts; c) School age children; d) walking with knowledge on epidemiology, adherence to standard bare foot in „Fecal fields‟; e) Habitual eaters of food that has treatment protocols and to combat the drug resistance 18. fallen on the ground, f) Occupation – Farmers, Veterinarians, Food handlers working in hotels, bakeries, References:
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Cite As: "A Rare Case Report Of Intestinal Hymenolepiasis And Ascariasis Double Infection In A
Symptomatic Immuno-Competent Host From South India".; Vol. 2 Issue 11 Pg:1443-1447 2015
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