| Abstract|| |
Ascariasis is one of the commonest parasitic infestations in tropical countries. Main symptoms are pain in abdomen, weight loss, diarrhea and passage of worms in stool. If acute, it may present as intestinal obstruction, perforation, cholangitis, appendicitis and pancreatitis. The incidence of hepato-biliary ascariasis is probably underestimated. We report a case which presented to us with fever, abdominal pain and weight loss of a month's duration, mimicking abdominal tuberculosis. On investigations, patient was found to have ascariasis of gall bladder, terminal ileum, caecum and appendix, causing simultaneous inflammation of all these structures.
Keywords: Abdominal pain, appendix, ascariasis, fever, gall bladder, intestine
|How to cite this article:|
Diwan AG, Dabadghao VS, Najeeb T A, Dave P. An unusual case of fever and abdominal pain. Ann Trop Med Public Health 2012;5:265-7
|How to cite this URL:|
Diwan AG, Dabadghao VS, Najeeb T A, Dave P. An unusual case of fever and abdominal pain. Ann Trop Med Public Health [serial online] 2012 [cited 2018 May 22];5:265-7. Available from: http://www.atmph.org/text.asp?2012/5/3/265/98635
| Introduction|| |
Ascariasis is one of the commonest worm infestations in regions of poor sanitation like the tropics. Presentations of ascariasis may be acute or chronic. Patients with ascariasis may be asymptomatic.  Pain in abdomen may be mild and vague when the onset is insidious, or severe and colicky when the roundworms cause intestinal obstruction. Other symptoms are weight loss, loss of appetite, diarrhea and passage of worms in stool when the disease is chronic. Parasite migration to extraintestinal organs can sometimes be dangerous. Migration of ascaris into biliary duct may cause acute jaundice, fever, cholangitis, pancreatitis. , Here is a case in whom there was roundworm infestation of gallbladder, caecum and terminal ileum, which is a relatively rare condition and can mimic symptoms of inflammation and obstruction.
This case presented as fever, lower abdominal pain and weight loss, mimicking abdominal tuberculosis. There was no jaundice. Stool examination was normal. Ultrasound showed adult roundworm in gall bladder, caecum and terminal ileum, but definite diagnosis of intestinal and gall bladder ascariasis was made on CT scan. There was no evidence of biliary duct ascaris or abdominal tuberculosis. The patient responded fully to albendazole and mebendazole. Cases with gall bladder and intestinal ascariasis have been reported but simultaneous inflammation of terminal ileum, caecum, gall bladder and appendix with roundworm has been rarely reported in literature. Invasion of gall bladder with ascaris is rare, 2.1% of all hepatobiliary ascariasis in endemic areas  and as low as 1.6% in an Indian study. 
This patient was cured by medical management and this line of treatment should be tried before resorting to invasive measures. 
| Case Report|| |
A 32-year-old lady, not a known case of any illness, came to this hospital with complaints of pain in right upper and lower abdomen, low grade, evening rise fever on and off for past one month and weight loss of 4 kg in past six months. She also complained of loss of appetite. There was no history of diarrhea, vomiting, black colored stool, worms in stool, jaundice, night sweats, cough with expectoration, urinary complaints. She had a history of menorrhagia but no irregularity in menses.
On examination, she was mildly febrile (temperature was 99°F), pulse was 98/min and blood pressure was 110/70 mm Hg. She had mild pallor, and inguinal lymph nodes were palpable 1.5 cm on right side, non tender and mobile. On abdominal examination, feel was soft, with vague tenderness in right hypochondrium, right iliac fossa and hypogastrium with mild guarding. There was no organomegaly.
A provisional diagnosis of abdominal tuberculosis was made.
On investigations, her hemoglobin was 11.3 g/dl with total leukocyte count of 7700/mm 3 (cubic mm). Eosinophilia was present (11%). Platelet count was normal. Her blood sugar was 73 mg/dl, renal function tests and electrolytes were within normal limits, total serum bilirubin was 0.5 mg/dl, SGOT was 21 IU/L and SGPT was 19 IU/L, proteins were in normal range with normal albumin globulin ratio. Widal test for typhoid was negative. Urine and stool routine did not show any abnormality.
Her erythrocyte sedimentation rate was 51 mm by Wintrobe method, normal for sex is 0-20 mm. Tuberculin test was negative. She was HIV, HBsAg negative.
Her inguinal node FNAC was done, which showed reactive lymphadenitis with no granulomas. Keeping in mind her long history of fever, blood culture and bone marrow aspiration was done. Cultures revealed no growth and marrow showed a reactive aspirate.
Her tuberculosis IgG and IgM were negative. Due to financial constraints, polymerase chain reaction for tuberculosis (PCR TB) was not sent. Ultrasound of abdomen showed some echogenic strip-like structures with central anechoic tube in the caecum, and infundus of gall bladder, suggestive of roundworm.
As a further confirmation, contrast CT of abdomen and pelvis was done, [Figure 1] and [Figure 2] which showed a distended gall bladder, enhancement of its wall, with a tubular structure in its fundal region, which was confirmed to be round worm (Ascaris lumbricoides). Sludge was also seen in gall bladder. Abnormal wall enhancement was seen in appendix. These findings suggested subacute appendicitis. Tubular filling defects were noted in caecum, terminal ileum and appendix. These too were identified as roundworms. There was abnormal enhancement of terminal ileal walls (reactive inflammation). There was no free fluid or mesenteric lymphadenopathy. Bilateral reactive inguinal lymph nodes were seen. The appendicitis and terminal ileitis was identified to be secondary to ascariasis. Hence there were no findings suggestive of abdominal tuberculosis on the scan.
The patient was initially given albendazole 400 mg as single dose, and then mebendazole 100 mg twice daily was given for three days. On third and fourth day, she noticed passage of worms in stool. She had complete symptomatic relief within a week. Her repeat ultrasound, done after a week, was normal. Albendazole was repeated after a week.
| Discussion|| |
Ascariasis is a common parasitic infestation in the tropical countries.  The organism travels through many organ systems during its life cycle. The larvae penetrate intestinal mucosa and after traversing portal vein, reach pulmonary alveoli. Then larvae migrate to larynx and are swallowed, reaching the intestines.  The usual site of involvement is the intestine and pain in abdomen is the commonest presentation.  Pain can be in periumbilical or hypogastric region or in right iliac fossa, mimicking appendicitis. Pain can be severe in complications like intestinal obstruction, perforation and appendicitis. , Passage of worms in stool, nausea, weight loss and diarrhea are other symptoms of intestinal ascariasis. , Biliary ascariasis is relatively uncommon but cases have been reported with cholangitis, cholecystitis, liver abscess and pancreatitis due to migration of worms. , In uncomplicated biliary ascariasis, there is mild fever, upper abdominal pain without jaundice, as was seen in this patient. The incidence of gall bladder invasion with ascaris is said to be 2.1% of hepatobiliary ascaris in endemic area  and in a study conducted in India, it was noted to be 1.6%.  In complicated biliary ascariasis, there is jaundice, high fever, tender hepatomegaly with raised liver enzymes. ,
Ultrasound is a relatively sensitive method to diagnose presence of roundworm in intestine and biliary tree. It can be especially used to monitor movement of the worms in the gall bladder and biliary tree. ,
Though intestinal and biliary ascariasis is common in tropics, presence of worm in caecum, terminal ileum, appendix and gall bladder together, causing inflammation of all these structures, is uncommon.
This patient presented with insidious onset of fever, weight loss and abdominal pain in right hypochondriac and hypogastric regions. This presentation mimicked abdominal tuberculosis. There was eosinophilia in blood, which is a feature of ascariasis.
Ultrasound showed presence of worms in intestine and gall bladder. Ultrasound features of roundworm are presence of two pairs of parallel lines with a central sonolucent line. 
CT scan showed presence of worms in gall bladder, terminal ileum, caecum and appendix causing inflammation of all three structures (ref images). The worms appeared as long, tubular structures outlined by contrast-filled small bowel. , It also effectively ruled out coexisting abdominal tuberculosis.
The patient responded well to medical management with anthelminthics as has been seen in other reports.  Conservative medical management should be the first line of treatment for uncomplicated gall bladder ascariasis.  This treatment worked well even when other organs were involved as in this case. Due to financial constraints, repeat CT scan was not done.
This entity of simultaneous gall bladder and intestinal ascariasis, leading to terminal ileitis, cholecystitis and subacute appendicitis is rare and should be kept in mind in any patient presenting with chronic abdominal pain and fever.
| References|| |
|1.||Ajao OG, Solanke TF. Surgical aspects of intestinal ascariasis. J Nat Med Assoc 1977;69:149-51. |
|2.||Hemmeyer SC, Hamill GS, Johnson JA. CT diagnosis of intestinal ascariasis. Abdom Imaging 1995;20:315-6. |
|3.||Bouree P, Barthod P, Chagnon S. Ascariasis in gall bladder: Report of a case and review. J Egypt Soc Parasitol 2005;35:491-6. |
|4.||Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary and pancreatic ascariasis in India. Lancet 1990;335:1503-6. |
|5.||Cha DY, Song IK, Choi HW, Chung EA, Shin BS, Song YW, et al. Successful elimination of Ascaris lumbricoides from gall bladder by conservative medical therapy. J Gastroenterol 2002;37:758-60. |
|6.||Mukhopadhya M. Biliary ascariasis in the Indian subcontinent: A study of forty two cases. Saudi J Gastroenterol 2009;15:121-4. |
|7.||Shetty B, Shetty PK, Sharma P. Ascaris cholecystitis: An unusual case. J Min Access Surg 2008;4:108-10. |
|8.||Misra S, Dwivedi M. Clinical features and management of biliary ascariasis in a non endemic area. Postgrad Med J 2000;76:29-32. |
|9.||Chawla A, Patwardhan V, Maheshwari M. Primary ascaridial perforation of small intestine: Sonographic diagnosis. J Clin Ultrasound 2003;31:211-3. |
Varsha S Dabadghao
C/O Air CMDE, SV Dabadghao, F 5/10, Salunke Vihar, Kondhwa Road, Pune-411 022, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]