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Case Report
 
Human Intestinal Capillariasis: A Rare Cause of Chronic Diarrhoea In India
Keywords :
Sandhra Papparath Usman1, Sojan George Kunnathuparambil2, Deepti Ramakrishnan1, Joy Augustine1, Kundoly V Susheela3
1Department of Pathology, 2Department of Gastroenterology, 3Department of Microbiology, Amala Institute of Medical Sciences, Amalanagar, Thrissur-680555, Kerela, India.


Corresponding Author
:
Dr Sandhra Papparath Usman
Email: snu.usman@gmail.com


DOI: http://dx.doi.org/10.7869/tg.653

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Human  intestinal  capilliariasis  is  a  disease  endemic  to  the  Philippines  and  Thailand1,2. The  disease  causing  agent,  Capillaria  philippinensis  is  an  intestinal  nematode  belonging  to  the  superfamily,  Trichinelloidae.  Infection  ensues  as  a  result  of  ingestion  of  raw  or  insufficiently  cooked  fish,  harboring  larvae.  Small  intestine,  especially  the  jejunum  is  usually  the  affected  organ,  resulting  in  chronic  diarrhea,  malabsorption,  abdominal  pain  and  borborgymi.  It  may  be  misdiagnosed  as  malabsorption  disorder  in  non-endemic  areas,  especially  since  the  eggs  are  excreted  sporadically  in  feces  and  maybe  missed  unless  multiple  samples  are examined.  Microscopic  examination  of  jejunal  biopsy  and  aspirated  content  may  help  establish  the  diagnosis.  India  is  non  endemic  for  C. philippinensis  infestation.  To our knowledge, this is the fourth reported  case  of  Capillariasis from  India.

Case Report

A  34  year  old  male  presented  with  an  8  month  history  of  chronic  watery  diarrhea,  associated  with  right iliac fossa pain.  He  also  experienced  loss of  appetite  and  weight  loss  of  over  20  kilograms  over  the  last  8  months.
There  was  no history  of  recent  travel. The  patient was a  non-vegetarian  and  had a history of   frequenting  roadside  stalls  serving  shell fish  and  mussels. The  patient  was  also  an  alcoholic.    
On examination, he had hypotension (68/40 mm  Hg in the right upper limb) and  Bilateral pitting pedal  oedema. Abdominal  examination  revealed  diffuse  tenderness  with  no  organomegaly.  
His haemogram and RFT were  within  normal  limits.  However, he had hypoalbuminemia (1.4 g/dL)  and  hypokalemia (serum  potassium: 2.4mmol/L) with a  CRP value of 15.6mg/L. Ultrasound abdomen  and  CT  abdomen  showed  features  of  which could possibly suggest an  Inflammatory  Bowel  disease.  Colonoscopic imaging revealed edematous mucosa in the caecum and ascending colon with a healed ulcer in the ileum, from which biopsies were taken.
Histopathological  examination  of  biopsy  taken  from  the  ileum  and  caecum  showed  moderate  degree  of  chronic  inflammation  with  focal  flattening  of  villi and body  parts  of  nematode  parasite. 
The  stool  sample  microscopy  showed  plenty  of  bile  stained  barrel  and  oval  shaped  ova  with  mucous  plugs.  These  features  were  consistent  with  Capillaria philippinensis.  
A diagnosis of Intestinal capillariasis was made and  the patient  was  treated with  Albendazole (400  mg) a day for 10 days along  with  correction of fluid  and  electrolyte  imbalance. Dietary advice was given.
On  follow up  after one month, diarrhoea  had  subsided.  Weight gain of 11 kgs was noted. Stool examination did not show any ova.









Discussion

Capillaria philippinensis  is  a  nematode  belonging  to  the  superfamily,  Trichinelloidae,  which  include  the  genera  Trichuris,  Trichinella  and  Capillaria2.  In  humans,  it  is  responsible  for  Intestinal  capillariasis,  which  was  first  reported  in  the  Philippines  in  1964.  Consequently many  sporadic  cases  have  been  recorded  in  Thailand  as  well,  making  these  two  nations  endemic  for  the  disease.  Further,  non  endemic  countries  like  Japan,  Iran,  Indonesia,  Taiwan,  Egypt,  Spain  and  Italy  have  also  reported  cases  of  Intestinal  capillariasis3.  In  India,  the  first  case  was  reported  in  a  45  year  old  female  patient  in  the  year  1994,  by  Kang  et  al. from  Vellore4.  Following  this,  2  more  cases  have  been  reported5,6.
Human  infection  occurs  as  a  consequence  of  ingesting  fresh water  fish  which  harbor  the  infective  stage  of  the  parasite  the  larval  stage.  Fish-eating  birds  are  the  natural  definite  hosts,  within  the  intestines  of  which  the  adult  worms  release  embryonated  eggs.  These may  be  dispersed  in  water bodies  through  bird  droppings,  where  they  further  infect  fish. Naturally  infested  fish  include  Hypseleotris  bipartite  and  Apagon  species  and  naturally  infected  birds  include  Ixobrychus  species7.  
In  experimental  studies  done  in  Mongolian  gerbils  and  some  monkeys,  the  phenomenon  of  auto infection  by  C.  philippinensis  was  established.  By  this  phenomenon,  offsprings  of  adult  worms  are  capable  of  reinfesting  the  same  host,  allowing  it  to  multiply  within  a  single  host.  This  can  lead  to  hyperinfection8.    
The  adult  worms  cause  infection  by  penetrating  the  mucosa  of  small  intestine  and  reentering  the  lumen.  Over  time,  the  mucosa  and  submucosa  may  degenerate.  As  a result,  infected  individuals  have  abdominal  pains,  diarrhea,  weight  loss,  malaise,  anorexia  and  emaciation.  Loss  of  proteins  and  electrolytes  and  malabsorption  of  fat  and  sugars  occur. Patients  usually  have  hypokalaemia  and  hypoalbuminaemia9. Biopsy  of  small  intestine  usually  show  atrophied  crypts,  flattened  villi,  and  leukocyte  infiltration  that  are  indicative  of  intestinal  cell  injury.  If  left  untreated,  it  may  prove  to  be  fatal.
In  our  case,  the  patient  may  have  acquired  the  disease  by  ingestion  of  endemic fresh water  and  brackish  water  fish  capable  of  harbouring  the  worm such  as  Anabas species.  He  showed  features  of  diarrhea,  abdominal  pain  and  weight  loss,  possibly  due  to  malabsorption.  Pedal  oedema  may  have  developed  due  to  hypoalbuminemia.  The  patient  had  no  travel  history  and  may  have  contracted  the  disease  by  ingestion  of  under cooked  fish,  which  was  part  of  his  diet.  Since  India  is  non-endemic  for  C. philippinensis,  the  disease  may  be  traced  back  to  infection  carrying  migratory  fish-eating  birds  from  endemic  areas.
Diagnosis  can  be  made  by  simple  wet  mount  examination  of  stool  sample  and  identification  of  ova,  larvae  and  adult  worms.  The  ova  of  Capillaria  can  be  distinguished  from  that  of  Trichuris  trichura  by  its  peanut  shaped  appearance,  flattened  mucous  plugs  and  striations  shell1.  Trichuris  ova  have  prominent  mucoid  bipolar  plugs.  Adult  male  worms  are  shorter (1.5-3.9 mm)  than  female  worms (2.3 - 5.3 mm).  They  have  a  muscular  oesophagus  called  stichosome,  surrounded  by  stichocytes. Male  worms  have  single  sheathed  spicule.  Female  worms  have  uterus  with  numerous  thick  and  thin  shelled  eggs.  The  eggs  may  be  with  or  without  larvae.  Larvae  in  stool  sample  are  difficult  to  be  identified  as  C. philippinensis due  to  its  resemblance  to  developmental  forms  of  other  nematodes.    
The  eggs  of  C. philippinensis are  excreted  sporadically  and  hence  multiple  stool  samples  may  be  required  to  establish  diagnosis.  Immunodiagnosis  may  help  diagnose  the  disease  before  eggs  or  larvae  are  identified  in  the  stool1.

Conclusion

C. philippinensis, although  non  endemic  to  India,  has  to  be  considered  in  the  diagnosis  of  patients  with  chronic  diarrhea  and  malabsorption  since  it  may prove  fatal  if  left  untreated.  If detected,  a  thorough  epidemiological  study  need  to  be  conducted  to  detect  the  source  and  prevent  further  transmission.  It is  also  important  to  encourage  proper  cooking  of  fish  before  consumption.    

References
  1. Cross JH. Intestinal capillariasis [Internet]. Vol. 5, Clinical Microbiology Reviews. Clin Microbiol Rev; 1992. p. 120-9. 
  2. Saichua P, Nithikathkul C, Kaewpitoon N. Human intestinal capillariasis in Thailand. Vol. 14, World Journal of Gastroenterology. World J Gastroenterol; 2008. p. 506–10. 
  3. Bair MJ, Hwang KP, Wang TE, Liou TC, Lin SC, Kao CR, et al. Clinical features of human intestinal capillariasis in Taiwan. World J Gastroenterol. 2004 Aug 15;10(16):2391–3. 
  4. Kang G, Mathan M, Ramakrishna BS, Mathai E, Sarada V. Human intestinal capillariasis: first report from India. Trans R Soc Trop Med Hyg. 1994 Mar ;88(2):204. 
  5. Rana SS, Bhasin DK, Bhatti HS, Gupta K, Gupta R, Nada R, et al. Human intestinal capillariasis: diagnosis by jejunal fluid analysis obtained at enteroscopy and reversal of subtotal villous atrophy after treatment. Endoscopy. 2009;41 Suppl 2:E102-3.
  6. Vasantha P, Leela Ks, Girish N. Human intestinal capillariasis: A rare case report from non-endemic area (Andhra Pradesh, India). Indian J Med Microbiol. 2012;30(2):236. 
  7. Cross JH, Basaca-Sevilla V. Experimental transmission of Capillaria philippinensis to birds. Trans R Soc Trop Med Hyg. 1983;77(4):511–4. 
  8. Cross JH, Banzon T, Singson C. Further studies on Capillaria philippinensis: development of the parasite in the Mongolian gerbil. J Parasitol. 1978;64(2):208–13. 
  9. Chunlertrith K, Mairiang P, Sukeepaisarnjaroen W. Intestinal capillariasis: A cause of chronic diarrhea and hypoalbuminemia. Southeast Asian J Trop Med Public Health. 1992  ;23(3):433–6.