Case of the Week 227

The following case was generously donated by Dr. Sandeep T from Bangalore, India.

The patient is a 27 yr old lady with complaints of puffy ankles and face and a loss of appetite. On examination, she was pale and had pedal edema extending up to her knees bilaterally. Laboratory investigations showed anemia with a normal WBC count. The preliminary diagnosis was renal insufficiency, but further questioning revealed intermittent diarrhea and one episode of vomiting a 'worm'.

Therefore, endoscopy was performed which revealed the following red brown parasites attached to the wall of intestine, extending from the duodenum to the colon.

http://www.youtube.com/watch?v=fzwCGw_ieQU&feature=youtu.be

Some of the smaller parasites were extracted and are shown below.  They ranged in size from 2 to 3.5 cm in length by 1.5 cm in width.

Stool ova and parasite exam revealed the following eggs (no size available)

Answer to Case 227

Answer:  Fasciolopsis buski, the intestinal fluke. 

The first step in making the diagnosis is recognizing that these objects are flukes - flat 'leaf-like' worms (member of the Platyhelminths) with an oral and ventral sucker as shown below.  The oral sucker isn't fully demonstrated in the photo.

The size of the fluke is also important.  As Lukus points out, the flukes that were obtained at microscopy are on the small side for F. buski (2 to 3.5 cm in length), but mature forms are larger (up to 7.5 cm!).  I believe we can see some larger flukes in the endoscopic video. 

Hans points out that there are also other intestinal flukes such as Metagonimus yokogawai and Heterophyes heterophyes to consider, but that they are much smaller in size and wouldn't be in the differential in this case.  Also, the larger thin-walled, operculated eggs (without a shouldered operculum) fits nicely with F. buski.

Of note, edema is a common presentation in individuals with heavy infection, as seen in this case. Other manifestations include diarrhea, fever, abdominal pain, and intestinal obstruction.

Answer to Case 409

Answer: Fasciolopsis buski, the intestinal fluke

Although this is an older case (Case of the Week 227), I thought it was worth showing it again for the newer readers who may not have seen it. This is a parasite that we don't often see in the United States, but is common in Asia where freshwater plants are ingested.

The first step in making the diagnosis is recognizing that these objects are flukes - flat 'leaf-like' worms with an oral and ventral sucker:

The size of the fluke is also important. As you can see from the video, these flukes are quite large (!), measuring up to 7.5 cm in length. Intestinal obstruction and malabsorption commonly occur with heavy infections, as well as diarrhea, fever, abdominal pain and edema. The eggs are also important for making the diagnosis. In this case, thin-walled operculate eggs support our morphologic diagnosis.

Thank you to everyone who wrote in on this case!