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| Case of the Week Thursday 10/10/2006 |
Presented by Dr. Ahmed Khairy.
Click here to download a power point presentation for the case.
Staff of the Unit:
Prof.Dr. Mahasen Abdel-Rahman
Dr.Abdel-Maged Kasem
Dr.Hisham El-Makhazangy
Dr.Naglaa Zayed
Dr.Sherif Hamdy
Dr.Mohamed Seif
Dr. Rabab Salama
Dr Khaled El-Sherif
Resident.Hadel gamal
Resident.Ahmed Khairy
Capillaria philippinensis
Personal history
• Female patient.
• 32 years old.
• Housewife.
• Married 10 years ago with 3 children, the youngest is 6 years old.
• Born and living in El-Saf, Giza .
• History of contact with canal water and patient received anti-schistosomal therapy in the form of tablets.
• Menarche at 15 years old with regular cycles for 4 days every 28 days.
• Contraceptive history: Hormonal injections for 3 years, stopped 1 year ago.
Complaint
Frequent loose stools of 6 months duration
Present history
• The condition started 6 months ago with gradual onset and progressive course of painless watery diarrhea 6-10 motions/d awakening the patient from night sleep , this was not affected by fasting.
• this was associated with significant weight loss (15kg in 6 months), Moreover , she started to develop bilateral lower limb swelling later in the course of illness .
• The condition was associated with vomiting 4 to 5 times/d following meals.
• In the last two months she started to develop exertional dyspnea and palpitation yet no orthopnea, PND or wheezes
• There was no mucus, blood or tenesmus.
• No history of night sweats or night fever.
• No history of skin rash, joint pain, perception of body swellings or oral ulcers
• No symptoms suggestive of other system affection.
• During the course of illness , she sought repeated medical advice with no improvement of her condition. 4 months ago, she had Colonoscopy with terminal ileal biopsy done and was given treatment in the form of Salofalk for two months with inadequate response ( still 6 motions/ day) and she stopped ttt by her self and was then referred to our department.
During hospital admission:
• The patient developed yellowish discoloration of sclera, dark colored urine, normal colored stool.
• But no fever, pruritus, bleeding tendency or disturbed conscious level.
Past history
• No history blood transfusion apart from one unit of blood during hospital admission.
• Cesarean section 6 years ago.
• Not known to be diabetic or hypertensive.
• No history of specific drug intake in the last 6months.
Family history
• No similar conditions.
General examination
• The patient is fully conscious, of average intelligence and lying comfortably on bed.
• Pulse: 90 bpm regular.
• Blood pressure: 100/70 .
• Temperature: afebrile all through the hospital stay.
• BMI : 51 /(1.65)2 = 18.7(underweight)
• No palpable lymph nodes.
• Head & neck:
• Pallor.
• Jaundice only After hospital admission.
• No cyanosis.
• Thyroid glands is not enlarged.
• Neck veins are not congested.
• Upper limb examination: free.
• Mild bilateral pitting lower limb edema just below knee .
• Cardiological: accentuated 1st heart sound, No additional sounds.
• Chest and neurological examination: free.
Abdominal examination
Inspection:
• Subcostal angle: not widened.
• Recti: not divaricated.
• Umbilicus: normal site and shape and no expansile impulse on cough.
• No hernias or abnormal pigmentation.
• Transverse lower abdominal scar, 10 cm, healed by primary intention.
Palpation:
• Liver :
• Upper border: 5th space in the right MCL.
• Lower border:
• Right lobe: 7 cm below the costal margin in the midclavicular line.
• Left lobe: 5 cm in midline by light percussion.
• smooth, firm, not tender with rounded edge.
• Spleen: not felt, resonant Traub ' s area .
• No ascites: detected by shifting dullness
In summary
• Diarrhea for 6 months.
• Loss of weight.
• Pallor, dyspnea and palpitation on exertion.
• Lower limb edema.
• Hepatomegaly.
• Jaundice.
D.D. of chronic diarrhea:
• Infections: HIV, TB, parasitic infestations.
• Malabsorption syndrome: Celiac disease, pancreatic disorders.
• Inflammatory bowel diseases.
• Malignancy: lymphoma, cancer colon, carcinoid.
• Others: IBS, hyperthyroidism, microscopic colitis.
HIV1,2 : Negative
Urinalysis: Normal .
Repeated stool analysis, culture, Z-N stain:
Negative
E.S.R
• First hour: 12
• Second hour: 22
C.B.C
• WBCs: 6400 /ul
B: 0%
E: 2%
Staff: 5%
Seg: 56%
Lymph: 35%
Mono: 2%
• HGB: 6.2 g/dl
HCT : 24.5%
MCV: 89.7 fL
MCH: 30 pg
MCHC: 33.4 g/dl
• Platelets: 231,000 /uL
Liver biochemical profile
• Bilirubin: - total : 0.8 mg/dl (0.1-1)
- direct:0.36 mg/dl (0.0-0.3)
• AST: 45 U/L (0-37)
• ALT: 37 U/L (0-32)
• ALP: 202 U/L (35-104)
• GGT: 38 (0-50)
• Total proteins: 4.2 g/dl (6.4-8.3)
• Albumin: 1.4 g/dl (3.4-5.2)
• PC: 71% PT: 16 sec INR: 1.3
• K: 2.6 (3.5-5.5)
• Na: 141 (132-145)
• Ca: 6.93 (8.4-10.2)
• Creatinine: 0.8 (0.7 -1.2)
• Urea: 21 (10 - 50 )
• Fasting blood sugar: 77 (60- 110)
• D-xylose test: 0.2 ( low ) • Anti-endomysial & Anti-gliadin Abs : -ve .
• Serum IgA: markedly low .
• B2 microglobulin : normal .
• Tuberculin: - ve.
• Chest x-ray: normal.
Hepatitis markers:
• HBsAg: Negative.
• Anti-HBs antibodies: Negative.
• Anti-HBc antibodies :Negative.
• Anti-HCV antibodies: Negative.
Abdominal ultra-sound
• Liver : Enlarged in size, bright echo pattern, regular surface, normal hepatic veins . No focal lesions or IHBRs dilatation. P.V is not dilated (12 mm).
• Gall bladder : is of average size and wall thickness. No stones or mud inside. CBD is not dilated.
• Spleen : is of average size (10 cm) and homogenous echo pattern.
• Kidneys : both are normal .
• Pancreas and midline structures : free.
• No ascites or masses.
• Conclusion : Bright hepatomegaly
Upper GIT Endoscopy:
• Esophagus: Normal mucosa. cardia is competent.
• Stomach: The whole gastric mucosa shows erythema, more profound in the corpus with edematous folds and friability. Multiple biopsies were taken.
• Pyloric Ring: Rounded and reactive.
• Duodenum: The mucosa down to the second part show mild diffuse edema. Multiple biopsies were taken as wall as a duodenal aspirate.
• Conclusion: Eryhtematous gastritis
Duodenal aspirate: -ve for Giardia & Cryptosporidium .
Histology:
• Examination of the specimen received mild gastritis (H. pylori infection associated) and mild edematous lamina propia.
• Duodennal biopsy, revealed the picture of moderate duodinitis. No villous atrophy.
Barium meal follow through:
• Free flow of the barium through the stomach, jujenal and ileal loops . The hallmark of the examination is the pathologic abnormality affecting the ileal loops as follows:
• Diffuse wall thickening of the ileal loops with irregular mucosal outline in the from of exaggerated Mucosal folds.
• No evidence of strictures or fistulae no ulceration or diverticular, obstructive lesions or filling defects.
• Normal appearance of the ileo-cecal junction
The radiologic finding suggests the diagnosis of MALABSORPTION SYNDROME.
Lower GIT Endoscopy:
• Colonoscopic examination was done up to the terminal ileum and revealed:
• Hyperemic ileal mucosa, multiple biopsies were taken from the terminal ileum.
• Internal piles.
HISTOLOGY:
• Microscopic:
Examination of the specimen (ileal fragments):
showing shortening & broadening of the villi (grade II villous atrophy). The lamina propria is edematous and moderately infiltrated by chronic inflammatory cells with eosinophils.
The larvae and eggs of parasite are detected intraglandular and at lamina propria.
DIAGNOSIS:
TERMINAL ILEAL BIOPSY: chronic inflammatory reaction with eosinophils, positive for thick shelled eggs and larva suggestive of
CAPILLARIA PHILIPPINENSIS.
After development of jaundice:
Liver biochemical profile:
• Bilirubin: - total : 6.6 mg/dl -direct: 5.3 mg/dl
• AST: 187 U/L (0-37)
• ALT: 78 U/L (0-32)
• ALP: 294 U/L (35-104)
• GGT: 250 ( 0-50 )
• Total proteins: 4.6 g/dl (6.4-8.3)
• Albumin: 2.4 g/dl (3.4-5.2)
• Repetition of abdominal ultrasound, hepatitis markers including HCV PCR, HAV IgM, HEV IgM, CMV , EBV and autoimmune profile were -ve.
Liver biopsy
• Microscopic picture:
Liver tissue with normal architexture and diffuse macrovesicular fatty degeneration.
DD of macrovesicular steatosis:
• HCV, HIV
• Drugs: corticosteroids, amiodarone ,Ca channel blocker
• DM, obesity, X-syndrome.
• Malnutrition
• Total parenteral nutrition with glucose.
Follow up
After treatment with albendazole, multivitamins, UDCA:
• Diarrhea stopped with improvement of general condition.
• Liver biochemical profile:
• Bilirubin(total):3.9 Direct:3.3
• Albumin: 2.4
• Total protein: 6
• AST: 177 ALT: 69
• Alkaline phosphatase : 124
• K : 4.2
Diagnosis:
A case of Capillaria philippinensis with fatty steatosis
Recommendations:
• Repeated stool examination by expert is recommended in patients of chronic diarrhea at risk (endemic area), clinical picture (watery painless diarrhea, loss of weight, edema lower limb), hypoalbuminemia, hypokalemia.
• If not conclusive, therapeutic trial with albendazole may be recommended as it is cheap, available with minimal side effects.
THANK YOU
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