We report a rare case of diarrhea caused by Fasciolopsis buski, Taenia spp, and Aspergillus spp in a retro positive patient. A 41-year-old man presented to the gastroenterology department with complaints of bleeding per rectum. He had a history of retro positive illness for the past 15 years and is a known alcoholic. His physical and systemic examination revealed concern and laboratory tests showed values below normal range. Microbiological investigations were processed as per standard guidelines. The etiology of his diarrhea was identified as Fasciolopsis buski along with Taenia species and Aspergillus species. Following an appropriate treatment, his diarrhea resolved. To the best of our knowledge and PubMed search, this is the first case of a parasitic and fungal co-infection causing diarrhea in an immunocompromised (HIV) patient reported in literature from Manipal, India.
Keywords: Aspergillus species, Fasciolopsis buski, Retro positive patient, Taenia species
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Ballal M, Martena S. An unusual presentation of diarrhea by Fasciolopsis Buski, Taenia Spp. and Aspergillus Spp. In a retro positive patient. A first case report from rural coastal India – Manipal, Karnataka. Ann Trop Med Public Health 2012;5:543-5
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Ballal M, Martena S. An unusual presentation of diarrhea by Fasciolopsis Buski, Taenia Spp. and Aspergillus Spp. In a retro positive patient. A first case report from rural coastal India – Manipal, Karnataka. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Nov 24];5:543-5. Available from: https://www.atmph.org/text.asp?2012/5/5/543/105160
Fasciolopsiasis is a disease caused by the largest intestinal fluke, Fasciolopsis buski. The disease is confined to the Far east and South-east Asia including India, Taiwan, and Bangladesh. It occurs partially in areas where water plants are cultivated in ponds that are fertilized by pig or human feces.  Human beings acquire the infection by eating contaminated raw water plants, especially when peeling off the outer layers with their teeth.  Multiple parasitic infestation has become common as a result of improvements in laboratory diagnosis and growing population of immunocomprised individuals. We report a rare case of diarrhea caused by Fasciolopsis buski, Taeniaspp, and Aspergillus spp in a retro positive patient.
A 41-year-old man presented to the gastroenterology department of our tertiary care hospital with complaints of bleeding per rectum for 2 months, hemetesis for 4 months, chronic abdominal pain for 9 years, burning micturition, malena, and reduced sleep for 4 days. On physical examination, he was moderately-built and nourished and afebrile. He had a poor oral hygiene. He had a history of retro positive illness for the past 15 years and was a known alcoholic. Gastroduodenoscopy of stomach revealed antral erosions and whitish plaques of esophagus. Colonoscopy and sigmoidoscopy revealed grade II internal and external hemorrhoids. He was treated for hemorrhoids.
After an year, he was admitted again with complaints of bleeding per rectum since 11 months, fever, nausea, and chronic diarrhea for 6 months. His CD4 count was 102. His physical findings revealed B/L cervical and inguinal lymphadenopathy. Hemoglobin was 10, total cell count was 2600 cells/cumm, platelets were 55000 cells/cumm, ESR was 97. LDH was 905. Peripheral smear of blood showed sparse RBC in distribution, normocytic normochromic, amsopoikilocytosis (+), spherocytes (+), polychromasia (+). USG abdomen showed hemangioma in segment 8 of liver and UGI scopy showed esophageal candidiasis.
Stool, sputum, and serum specimens were received and subjected to standard techniques. Sputum acid fast bacilli and Pneumocystis jerovecii were negative. Mantoux test, hepatitis A virus, hepatitis B virus, hepatitis C virus, Toxoplasma Elisa and Rapid Plasma Reagin tests were negative. Sputum microscopy showed fungal elements and was confirmed by its growth in culture as Aspergillus species Esophageal scrapping showed abundant oval budding yeast cells with pseudohyphae and true hyphae, suggesting Candida species. Freshly passed formed stool was sent to the laboratory, and routine stool microscopy was done. Iodine mount revealed egg of Fasciolopsis buski [Figure 1] cyst of Taenia spp [Figure 2], and conidiophores with vesicle bearing conidia of Aspergillus species. [Figure 3]. These microscopical findings were confirmed by CDC, Atlanta. The patient was treated with fluconazole for esophageal candidiasis and praziquintal for intestinal helminthes. HAART was also started. The patient responded well to the treatment and was cured of his diarrhea.
||Figure 3: Iodine mount showing the conidiophore bearing the vesicle with conidia of Aspergillus species
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Fasciolopsiasis, as a food-borne parasitic zoonosis, which also infects farm pigs, remains a public health problem. It is most prevalent in school-age children. Control programs implemented for food-borne zoonosis are not fully successful for fasciolopsiasis because of century- old tradition of eating raw aquatic plants.  There are cases in India of the parasitic infections in pediatric and adult population. A case of a 10-year-old boy from the Barabanki district of Uttar Pradesh, India was reported with heavy infestation by Fasciolopsis buski causing intestinal perforation.  Another case of an 18- year- old boy, who had an ileostomy done a month ago, harbored the live flukes, which crawled over his abdomen.  A case of a 2-year-old pediatric child from Vietnam, vomiting adult live fluke.  Multiple parasitic infestation has become common as a result of improvements in laboratory diagnosis and growing population of immunocompromised individuals. A 7-year-old boy presented with multiple parasitic infestation of Fasciolopsis buski, Strongyloides stercoralis, Ascaris lumbricoides, Trichuris trichiuria and Ankylostoma duodenale. 
Immunocompromised status provides a suitable environment for the opportunistic infections. In our case, the patient was immunocompromised (retro positive illness) and had infection of the cestode Taenia species, trematode Fasciolopsis buski along with fungus Aspergillus species. The fungal infection could have been disseminated from the respiratory tract. Routine diagnostic microbiological examinations are very important as it helps to diagnose and aid in prompt treatment. Microscopy plays an essential role in identifying the possible pathogen from the clinical specimens. Our case is unique and different from all other cases of parasitic infections. The etiology being the trematode Fasciolopsis buski and the cestode Taenia species. Multiple parasitic infections of trematode and nematodes have been reported in the literature but not of a trematode and cestode co-infection. Review of literature revealed cases of live fluke or worm infestation in an otherwise healthy patient. Praziquantel identified from a group of heterocyclic pyrazino – isoquinolines was found to have unusually broad anthelmintic activity. The patient responded well to the drug. Our case of an unusual presentation of diarrhea by Fasciolopsis buski, Taenia species, and Aspergillus species in a retro positive patient seems to be the first case reported for its rarity. To conclude, direct microscopy of stool specimen is important in diagnosing the etiology of diarrhea, particularly in parasitic infestation where culture is not possible. Multiple infections and co-infections should be considered in immunocompromised patients. Prompt diagnosis and treatment would certainly contain the rise of opportunistic infections, especially in immunocompromised patients.
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Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]