IRON-DEFICIENCY ANEMIA DUE TO HOOKWORM INFECTION
CASE REPORT
A 50-year-old male complained of
continuous watery diarrhea that had started 2
weeks ago. The patient had been healthy and
no history of major surgeries and diseases.
Two weeks before admission, watery
diarrhea had begun and the frequency of the
diarrhea had increased from 3 times per day
to 10 times per day. Fever and general
weakness had developed after 3 days. He did
not have any other symptoms and had no
recent history of travel or animal contact.
At the emergency department,
leukocytosis with eosinophilia were noted
and he was admitted for monitoring. After
admission, stool examination was
performed, but everything tested negative.
Empirical oral levofloxacin was prescribed
initially to treat the suspected bacterial
enteritis. However, the diarrhea persisted.
Four times of stool examinations, and still,
nothing was found. As a part of an extended
investigation, sigmoidoscopy was decided to
be used. A single protruding mass consisting
of an adult hookworm was found moving on
the surface at 80 cm from the anal verge. A
biopsy was conducted and this confirmed
hookworm infection by histopathological
examination. Stool examination was then
repeated and hookworm ova were seen.
Based on these findings, oral mebendazole
100 mg twice a day for 3 days was
prescribed.
The diarrhea and eosinophilia
subsided after this treatment. Five days after
treatment with mebendazole, the patient was
discharged from hospital. No further
diarrhea occurred and no stool ova was
found at subsequent outpatient visits.
DISCUSSION
Necator americanus and
Ancyclostoma duodenale are transmitted
through contact with contaminated soil.
After the infective hookworm larvae enter
the host by skin penetration, the larvae
receive a host-derived signal that causes
them to resume development. At this point,
the larvae are carried first by the venules to
the right heart and then to the lungs. In the
lung, the larvae rupture and enter the alveoli,
migrating to the bronchioles, bronchi, and
trachea. After being swallowed, the larvae
enter the gastrointestinal tract, where they
develop to the adult stage. It requires
approximately 6-8 weeks from the larvae
infecting humans to the development of
sexual maturity and mating.
How did the hookworm infect this
patient? Tracing this patient’s history, it was
found that he had drunk spring water from
the a park for many years. Furthermore, the
patient is a businessman who had sold fruit
for 17 years at a wholesale market. In this
context, he often forgot to wash his hands
during work. He might have contracted the
infective hookworm larvae either while
drinking the spring water or during his work.
Repeated exposure to hookworm larvae may
results in a local pruritic, erythematous,
popular rash known as "ground itch".
However, this patient denied that he had
suffered from any ground itch of the feet or
hands in the past. Therefore, although the
common infection route is through the skin,
there was another route of infection with this
patient. Ancyclostoma duodenale may also
be transmitted through ingestion of larvae.
They can develop into mature worms in the
intestine without migrating through the lung
to the intestine.
In this context, the possible infection
route for this patient remains through the
skin. This patient was admitted because of
watery diarrhea and his bacterial stool
culture was negative for Vibrio, Salmonella,
and Shigella. Detection of parasite ova by
the concentration method was negative four
times and only positive when conducted a
fifth time. This case report indicates that
stool examinations for ova may be negative
during the early stage of hookworm.
However, according to the literature, we
should be able to detect ova about two
months after dermal acquisition of a N.
americanus infection and at up to 38 weeks
after A. duodenale infection. Therefore it
was important that stool examination are
repeated, with at a total of five times being
needed to make the diagnosis with this case.
Incidentally, the patient in that study
had also suffered from watery diarrhea up to
10 times a day for 2 weeks before expelling
a bloody stool later.
Hookworm species are mainly
differentiated by their buccal capsule. The
buccal capsule of A.duodenale has two pairs
of curved teeth on the ventral wall of the
capsule. In contrast, N.americanus has a
conspicuous pair of semilunar cutting plates
on the dorsal wall.
According to previous reports, the
peak eosinophil counts ranged from 1,350
cells/mL to 3,828 cells/mL. It is well known
that the allergic, infectious, neoplastic, and
idiopathic diseases are associated with
eosinophilia. This patient had persistent
eosinophilia after admission; however there
was no finding of parasitic infection during
Chun-Hao Wang, S.-C. L.-S.-C. (2011). Hookworm infection in a healthy adult that manifested as severe
eosinphilia and diarrhea. Journal of Microbiology, Immunology and Infection, 44(6), 484-487.
doi:https://doi.org/10.1016/j.jmii.2011.04.010
CUTANEOUS LARVA MIGRANS
the initial investigations. Based on the
present case, it is therefore important to keep
in mind the possibility that a parasite
infection is present in the patients and
causing the eosinophilia. However, the
absence of eosinophilia does not mean the
patient does not suffer from a parasite
infection. Therefore, it is important to note
that eosinophilia cannot be used as a
diagnostic criterion for parasite infection.
TREATMENT
The hookworm infection was treated
with mebendazole (100 mg orally BID for 3
days or 500 mg once) as a first choice. It
would also possible to use either pyrantel
pamoate (11 mg/kg per day for 3 days) or
albendazole (400 mg once) as alternative
agents.31,32 The drugs usually reduce the
hookworm burden to a level below the
threshold that causes disease. After treating
this patient with mebendazole for the
hookworm infection, his diarrhea
disappeared. This case report should also
remind endoscopists and physicians to keep
living hookworms as specimens to conduct
further detailed examinations so that they
can attempt to confirm accurately the
species of the hookworm that is infecting
their patient.
References
CASE REPORT
An 18-year old, male patient from Tagaytay
City was referred to Olivarez General
Hospital due to severe itchiness of most part
of his body and raised red lines in the skin
few days after having a Family outing in a
beach resort in Batangas. The patient
reported that he had been buried up to his
neck in the sand for 5 minutes and feel
itchiness right after. A visible red itchy rash
covered his back as well as his legs and feet
by the evening, which he overlooked since
he thought that it was just a bug bite. As the
days passed, the patient noticed that the red
rashes have worsened then becomes
apparent until the 4th to 7th day before he was
admitted, and it started to swell and irritates
terribly. In addition, the said resort has a
policy of allowing pets in the vicinity, but
the owners are held reliable for any
inconvenience.
SIGNS AND SYMPTOMS
Severe itchiness and raised red lines can
form as part of the reaction to the larva in
the skin.
LAB TESTS RESULTS
Peripheral eosinophilia on a CBC count
(590/µl) and increased immunoglobulin E
(IgE) levels on total serum immunoglobulin
determinations.
DIAGNOSIS
Patient made an emergency appointment
with a dermatologist and performed
cryotheraphy but was not completed since
he urged the doctor to stop, saying he felt as
though he could feel it moving. He was then
referred to hospital for further diagnosis. He
was diagnosed with cutaneous larvae migran
by clinical examination that causes the red,
raised tracks in the skin that is very itchy.
Uncontrollable, frequent scratching caused
acute cellulitis (bacterial infection).
TREATMENT
Oral albendazole, oral ivermectin, or topical
ivermectin are the usual treatment choices,
along with perhaps thiabendazole.
Albendazole at 400 mg/day for 3 days is
recommended. Alternatively, ivermectin can
be administered as a 12-mg dose and
repeated the next day. It is also
recommended trying topical treatment with
topical thiabendazole compounded in a 10%
suspension used for four times daily. If
effective, the topical therapies are expected
to resolve the condition in 1 week. For the
mild case of cellulitis, cefalexin was advised
to be taken.
PREVENTION AND CONTROL
Wearing shoes and taking other protective
measures to avoid skin contact with sand or
soil will prevent infection with zoonotic
hookworms. Travelers to tropical and
subtropical climates, especially where beach
exposures are likely, should be advised to
wear shoes and use protective mats or other
coverings to prevent direct skin contact with
sand or soil. Routine veterinary care of dogs
and cats, including regular deworming, will
reduce environmental contamination with
zoonotic hookworm eggs and larvae. Prompt
disposal of animal feces prevents eggs from
hatching and contaminating soil — which
makes it important for control of this
parasitic infection.
DISCUSSION
Some zoonotic hookworm species are
capable of infecting humans, but they
typically do not develop in the intestine and
instead infect extraintestinal sites like the
skin. Cutaneous larvae migrans (CLM) has
been associated with Ancylostoma caninum
& A.braziliense, which are all hookworms of
dogs and cats. Cutaneous larva migrans (also
known as creeping eruption) is a zoonotic
infection with hookworm species that do not
use humans as a definitive host, the most
common being Ancylostoma braziliense and
A. caninum. The cycle in the definitive host
is very similar to the cycle for the human
species, which involves tracheal migration
to the small intestine. Some larvae become
arrested in the tissues and serve as the
source of infection for pups via
transmammary (and possibly transplacental)
routes. The patient becomes infected when
filariform larvae penetrate the skin while he
has been buried in the sand where infected
dogs and cats have defecated. With most
species, the larvae cannot mature further in
the human host and migrate aimlessly within
the epidermis, sometimes as much as several
centimeters a day. Some larvae may become
arrested in deeper tissue after skin migration.
This penetration of larvae causes the
itchiness and the visible raised, red traces on
the skin.
Laboratory tests were performed only to
confirm the diagnosis. The eosinophilia is
defined as a peripheral blood eosinophil
count > 500/mcL. Causes and associated
disorders are myriad but often represent an
allergic reaction or a parasitic infection
which confirms the patient’s diagnosis, as
well as the increased level of IgE antibodies
that are normally found in small amounts in obvious; the breach may involve
the blood, but higher amounts can be a sign microscopic skin changes or invasive
that the body is fighting off an infection qualities of certain bacteria such as
from a parasite. The zoonotic hookworm streptococci and Staphylococcus aureus.
larvae that cause cutaneous larva migrans The patient might have acquired it due to
(CLM) usually do not survive more than 5 – excessive and frequent scratching of the
6 weeks in the human host. In most patients skin.
with CLM, the signs and symptoms resolve
without medical treatment. However,
treatment may help control symptoms and
help prevent secondary bacterial infections. REFERENCE

As for the patient undergoing cryotherapy CDC - Zoonotic Hookworm – Treatment.

without consultation or diagnosis first is not https://www.cdc.gov/parasites/zoono

recommendable since it is a commonly used tichookworm/treatment.html.

in-office procedure for the treatment of a Cellulitis: Practice Essentials, Background,

variety of benign and malignant lesions. Pathophysiology.

Most doctors use liquid nitrogen, which can https://emedicine.medscape.com/arti

cle/214222-overview.
reach temperatures as low as -320 F. The
mechanism of destruction in cryotherapy is
necrosis, which results from the freezing and
thawing of cells. This process does not
really ensure to eliminate the larvae but it
may lead to more complications if not
careful.

The patient was also diagnosed with

Cellulitis which indicates a nonnecrotizing
inflammation of the skin and subcutaneous
tissues, usually from acute infection.
Cellulitis usually follows a breach in the
skin, although a portal of entry may not be