CAPILLARIA in MINDORO 2
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A 41-year-old man from Occidental Mindoro, Philippines presented with chronic diarrhea lasting over a year. Stool analysis revealed multiple intestinal parasites including Capillaria philippinensis, Strongyloides stercoralis, Entamoeba histolytica, and Candida albicans. He was also diagnosed with pulmonary tuberculosis and tuberculosis colitis. Treatment with albendazole, metronidazole, diloxanide, fluconazole, and anti-tuberculosis drugs resolved his symptoms. This case highlights the need for repeated stool analysis when evaluating chronic diarrhea, as key parasites may only be detected after multiple tests. It also represents the first reported case of intestinal capillariasis from
CAPILLARIA in MINDORO 2
- 1. Template provided by: posters4research.com A 41-year old male from Alacaak, Sta. Cruz, Occidental Mindoro presented with a year of watery diarrhea. Multiple consults done revealed unremarkable fecalyses. He was given antibiotics but this did not resolve his symptoms. Six months PTA, 4 men in their barangay died from chronic diarrhea and this prompted the patient to seek consult in Manila. Abdominal CT and colonoscopy were unremarkable. He had a history of inadequately treated PTB. He was fond of eating kilawin. He had no history of travel. The patient presented at the PGH-ER severely emaciated, unable to ambulate and with palpatory BP (Fig 1). He weighed 42 kg (BMI=16), had scaphoid abdomen, grade 2 bipedal non-pitting edema, and unremarkable DRE. Initial investigations revealed severe hypoalbuminemia, eosinophilia, and low electrolytes. His initial fecalysis was unremarkable. Investigation for PTB including a CXR and sputum AFB was normal. Stool was sent to the College of Public Health for FECT which revealed no parasites. Stool AFB was +1 on day 1 and day 2. Stool culture yielded Candida sp. However, diarrhea persisted. By the 3rd week, serial fecalyses revealed the presence of the following: Entamoeba histolytica cysts and Strongyloides stercoralis adult & larvae. The next stool sample had suspected Capillaria philippinensis ova, atypical because they did not possess bipolar plugs. Another stool sample was sent and the diagnosis of capillariasis was established when it revealed typical Capillaria ova with bipolar plugs (Fig 3). The patient was treated with the ff drugs: albendazole 400 mg bid x 10 days then repeated after 2 weeks ( this covered for both C. philippinensis & S. stercoralis ) ; Intestinal capillariasis is caused by a small nematode known as Capillaria philippinensis. Symptoms of this illness are diarrhea, borborygmi, and abdominal pain. This helminthic infection was virtually unknown until 1963 when Chitwood reported the first case, a schoolteacher from Bacarra, Ilocos Norte. He had a history of intractable diarrhea for 3 weeks with ascites, emaciation, and cachexia and later died at the Philippine General Hospital in Manila. In the 1960s, a capillariasis outbreak occurred in Tagudin, Ilocos Sur where almost a hundred died. Another epidemic was recorded in Southern Leyte in the early 1980s. In the recent past, this parasite was also isolated in Compostela Valley Province and Zamboanga del Norte in Western Mindanao. We present a case of chronic diarrhea secondary to multiple enteric pathogens, including Capillaria philippinensis in Occidental Mindoro, a possible newly- described endemic area. A 41-year old man from Occidental Mindoro was diagnosed with intestinal capillariasis at the Philippine General Hospital after a year of diarrhea and multiple hospital admissions. The patient was noted to be harboring Capillaria philippinensis, Strongyloides stercoralis, Entamoeba histolytica, Mycobacterium tuberculosis, and Candida albicans in his stool. He was treated with albendazole, metronidazole, diloxanide, fluconazole, and anti-Kochs. This case was reported to the Department of Health to pursue this site as a potential area for epidemiologic investigation. metronidazole 500 mg tabs q6 x 14 days; diloxanide 500 mg tab tid x 14 days; fluconazole 200 mg cap x 10 days; & anti- Kochs. By this time, the diarrhea of the patient was attributed to: 1.) TB colitis, 2.) C. philippinensis, 3.) S. stercoralis, 4.) E. histolytica, and 5.) C. albicans. After a week, the patient was discharged. A month after, the patient followed up weighing 49 kg (Fig 2). By the time he completed his 6 months of anti-Kochs, he was already back in Occidental Mindoro where he now drives his motorcycle for a living. Capillaria philippinensis causes mostly malabsorption and diarrhea. The life cycle (Fig 4) is incompletely understood, although freshwater fish contain larvae infectious to both humans and birds. C. philippinensis was first reported in 1963 in Ilocos Norte Province and has been endemic in that area ever since. Since then, additional endemic foci of C. philippinensis have been identified in Southern Leyte, in Compostela Valley, in Southern Mindanao, and in Zamboanga del Norte, Western Mindanao. To date, this is the first reported case of intestinal capillariasis from Occidental Mindoro, an island bounded by the Mindoro Strait and the Mamburao reef (Fig 5). People here are fond of eating kilawin, which is raw fish soaked in vinegar. The patient also reported that he is aware that some people practice open and indiscriminate defecation here. We believe that the patient may be an indigenous case. He had no history of travel, and there were already 4 deaths in their area attributed to diarrhea secondary to an undetermined cause. Our patient was unique because the Capillaria eggs only surfaced after more than 10 serial fecalyses done at our Institution. This is odd, since Capillaria infections are usually prolific. Eggs, larvae, and adults appear in great numbers in stool specimens. This is in contrast to S. stercoralis wherein worm load is low. In these cases, chances of finding the parasite is proportional to the number of occasions in which the stool is examined. The patient also had TB colitis, which is permissive for infection with C. philippinensis and S. stercoralis. Parasitic overgrowth rendered him susceptible to Candida as well. In these cases of polyparasitism, morbidity becomes additive and mortality subsequently is higher. The key then to the cure of our patient was clinching the correct diagnosis that facilitated correct treatment. Mary Ondinee U. Manalo, MD, Resident, Department of Medicine, UP-Philippine General Hospital Virgilio P. Ba単ez, MD, FCP, FPSG, Consultant & Assistant Training Officer, Section of Gastroenterology, UP-PGH Vicente Y. Belizario, Jr. MD, MTM&H, Deputy Director, National Institutes of Health, UP-Philippine General Hospital Professor, Department of Parasitology, College of Public Health, UP-Manila Fig 3. The Capillaria philippinensis ova that was recovered from the patient only after more than 10 serial fecalyses. Fig 4. The life cycle of Capillaria philippinensis. Fig 1. The patient upon arrival was emaciated and not able to walk. Fig 2. The patient a month after discharge was already ambulant and had gained 8 kgs. In summary, we have presented a case of intestinal capillariasis from Mindoro, left undiagnosed for more than a year in different institutions. This case is unique because, even at the Philippine General Hospital, the parasite only surfaced after more than 10 serial fecalyses. This emphasizes the need to pursue further testing because the key diagnostic element is to identify the parasite. This case was reported to the Department of Health to pursue this site as a potential area for epidemiologic investigation. Accurate diagnosis will result in the appropriate treatment and provide information and evidence as basis for the control and prevention of this potentially fatal disease in the community. HE CASET BSTRACTA NTRODUCTIONI ISCUSSIOND ONCLUSIONC ECOMMENDATIONSR IGURESFHE CASET Fig 5. The municipality of Sta. Cruz. //