Hookworm Infection: A Neglected Cause of Overt Obscure Gastrointestinal Bleeding

Hookworm infestation as a rare cause of melaena in tropics: A case report

Melaena due to hookworm infestation is a rare clinical presentation. It usually presents with symptoms of iron-deficiency anaemia owing to slow blood loss. Here we present a case of 45-year male who presented with a one-year history of intermittent melena requiring multiple blood transfusions. Preliminary endoscopies at different centres were normal. The presence of hookworm in the duodenum was only detected on repeat upper endoscopy as the cause of blood loss, and treatment with albendazole was successful in curing the patient.

Endoscopic Diagnosis of Hookworm Disease in a Patient with Severe Iron Deficiency Anemia: A Case Report

Hookworm infection is an important cause of iron deficiency anemia, especially in heavily infected high-risk populations residing in underdeveloped tropical countries. Stool examination is the main method used for hookworm diagnosis; however, its sensitivity is relatively low. Hookworm infections have been incidentally diagnosed during routine upper gastrointestinal endoscopies. We present the case of a 60-year-old Ethiopian farmer who had severe iron deficiency anemia and positive occult blood in the stool. Repeated stool examinations revealed no ova or parasites. Esophagogastroduodenoscopy revealed the presence of hookworms in the duodenum. The patient was treated with albendazole and ferrous sulfate. Careful endoscopic examination of the duodenum is crucial for identifying unsuspected hookworm infection responsible for chronic gastrointestinal bleeding and iron deficiency anemia.

Intestinal Parasitic Infections in 2023

Intestinal parasites include intestinal protozoa and intestinal helminths. Intestinal parasitic infections (IPIs) pose a global health problem affecting over one billion people worldwide. Although these infections are predominantly seen in the developing world, they are frequently seen in the developed countries, particularly in immunocompromised patients. Patients' clinical presentations generally include diarrhea, dysentery, abdominal pain, nausea, vomiting, nutritional deficiency, iron deficiency anemia, anal and perianal itching, and rarely intestinal obstruction. The intestinal parasites have similarities in their mode of transmission and life cycle. The stool test is the primary way of diagnosing IPIs. Treatment is given with various anti-parasitic agents. However, appropriate preventive measures are essential for successfully controlling the IPIs.

Chronic Hemorrhagic Anemia Caused by Hookworm Infection: A Case Report

PURPOSE

Hookworm infection is one of the causes of long-term chronic hemorrhagic anemia in patients. This article reports a case of chronic severe anemia caused by hookworm infection.

METHODS

The capsule endoscopy showed that there were a large number of hookworms in the small intestine of a patient. At the same time, using the technique of saturated brine floatation and the automatic stool analyzer, hookworm eggs were detected.

RESULTS

The patient's anemia was caused by hookworm infection and was significantly improved after anti-hookworm treatment.

CONCLUSION

Hookworm infection cannot be ignored in the differential diagnosis of patients with chronic anemia. Capsule endoscopy combined with stool detection haves an important clinical value for the diagnosis of hookworm disease.

Unusual Cause of Persistent Epistaxis with Severe Anemia in a Child

Epistaxis in children can be caused by different systemic and local pathologies. Respiratory infections, nasal mucosa dryness, and foreign bodies are some local causes of bleeding from the nose. In developing countries, infestations still contribute a significant proportion of anemia in children. But it is very unusual for leech-causing persistent epistaxis with a consequence of severe anemia. We herein report a rare cause of severe anemia in a 5-year-old child presented to our clinic for persistent epistaxis. A leech was taken out with forceps, and his anemia was treated accordingly.

Evaluation of Hookworm Diagnosis Techniques from Patients in Debre Elias and Sanja Districts of the Amhara Region, Ethiopia

BACKGROUND

Inappropriate diagnosis could intimidate the prevention and control of hookworm infection. Thus, this study was aimed at evaluating the performance of hookworm diagnosis methods.

METHODS

An institution-based cross-sectional study was conducted from patients in Debre Elias and Sanja districts of the Amhara region, Ethiopia, from November 2019 to January 2020. The study subjects were selected conveniently. After the data was entered into Statistical Package for the Social Sciences (SPSS), sensitivity, specificity, predictive values, test accuracy, and agreement of the different hookworm diagnosis methods, namely, test tube flotation technique (TFT), McMaster (MM), formol-ether concentration (FEC), Kato-Katz (KK), and direct wet mount microscopy (DWMM), were calculated by using SPSS software. The composite reference standard (CRS) was used as the gold standard method. The kappa (κ) test was used to measure the level of agreement between diagnosis tests.

RESULT

A total of 389 stool samples were collected from patients in the study. The overall prevalence of hookworm was 63.24%. The test tube flotation technique (TFT) was found to be the highest both in terms of sensitivity and diagnostic accuracy (100%). McMaster (MM) was the second most sensitive test (68.7%), followed by FEC (44.3%) and KK (38.2%). On the other hand, DWMM had the lowest sensitivity (37.4%), and its diagnostic accuracy was also the least (60%). Only TFT had a perfect agreement (agreement = 100%, kappa = 1) with the CRS. The sensitivity of DWMM, KK, and FEC showed a kind of linear function with the intensity of infection, but TFT and MM methods were not affected by the infection intensity.

CONCLUSION

Hookworm is still a public health problem in the study area. TFT is by far more sensitive than MM, FEC, KK, and DWMM techniques.

Perceptions of women, their husbands and healthcare providers about anemia in rural Pakistan: Findings from a qualitative exploratory study

BACKGROUND

In Pakistan, there is a dearth of literature on the perceptions of anemia among women of reproductive age (WRA). This study was undertaken to explore the perceptions of women, their husbands, and healthcare providers about anemia, its possible causes, and how anemia impacts maternal and child health in Thatta, Pakistan.

METHODS

A qualitative study was conducted in Thatta, Pakistan from September to December 2018. Using a pre-tested semi-structured interview (SSI), we collected data to understand their definitions of anemia through ten focus group discussions (FGDs) with women and their partners and ten primary informant interviews (KIIs) with healthcare providers. We identified six major themes: (I) Knowledge and awareness of anemia, (II) Causes and consequences of Anemia, (III) Dietary practices, (IV) Knowledge and practices regarding the use of iron-folic acid supplements, (V) Factors influencing prevention and control of anemia and (VI) Women's health behavior. We analyzed the data through thematic analysis using NVivo 10 software.

RESULTS

Most community members were not aware of the term anemia but described anemia as a condition characterized by 'blood deficiency' in the body. All study participants perceived anemia as an important health problem tending to cause adverse outcomes among WRA and their children. Study participants perceived gutka (chewable tobacco) consumption as an important cause of anemia. Healthcare providers identified short inter-pregnancy intervals, lack of family planning, poor health-seeking behavior, and consumption of unhealthy food as causes of anemia in the district. Consumption of unhealthy food might not be related to related to a poorer knowledge of iron-deficient foods, but economic constraints. This was further endorsed by the healthcare providers who mentioned that most women were too poor to afford iron-rich foods. All men and women were generally well versed with the sources of good nutrition to be consumed by WRA to prevent anemia.

CONCLUSION

The findings suggest that the government should plan to develop strategies for poverty-stricken and vulnerable rural women and plan health awareness programs to improve dietary practices, compliance with supplements, and health-seeking behavior among women of reproductive age. There is a need to develop effective counseling strategies and context-specific health education sessions to improve the health-seeking behavior of women and men in the Thatta district of Pakistan. Besides, there is need to address social determinants of health such as poverty that pushes women of poorer socioeconomic strata to eat less nutritious foods and have more anaemia. Therefore, a comprehensive and robust strategic plan need to be adopted by government that focuses not only on the awareness programs, but also aim to reduce inequities that lead to pregnant women eat iron-poor foods, which, in turn, forces them to become anemic.

Haematological abnormalities in children with sickle cell disease and non-severe malaria infection in western Kenya

Background

In Plasmodium falciparum infection, clinical conditions such as anaemia, thrombocytopenia and leukocytosis are common. Mutation in haemoglobin sub-unit beta gene (HBB) may be a genetic factor responsible for these haematological changes during infection. However, the contributions of the carriage of different HBB genotypes on these changes remain largely unknown.

Methodology

In this cross-sectional study, we evaluated haematological abnormalities in P. falciparum-infected children (n = 217, aged 1–192 months) with different haemoglobin sub-unit beta (HBB) genotypes (HbAA, HbAS and HbSS). Children with acute febrile conditions were recruited at Jaramogi Oginga Odinga Teaching and Referral Hospital at the outpatient clinic. Haematological parameters were determined using Beckman Coulter counter ACTdiff2™ while HBB genotyping was done using TaqMan® SNP genotyping assay. Chi-square (χ²) was used to determine differences between proportions. Differences in haematological parameters were compared across groups using Kruskal Wallis test and between groups using Mann Whitney U test. Partial correlation test was used to determine correlation between haematological parameters and sickle cell genotypes while controlling for age and sex.

Results

Haemoglobin (Hb), [median (IQR); 7.3 (1.3), P = 0.001], haematocrit (HCT), [median (IQR); 26.4 (4.4), P = 0.009], red blood cells (RBC), [median (IQR); 3.2 (1.7), P = 0.048] were markedly reduced in HbSS, however, red cell distribution with (RDW) [median (IQR); 14.9 (3.3), P = 0.030] was increased in malaria infected children with HbSS. Severe anaemia was highest in HbSS (23.1%) followed by HbAA (8.6%) and HbAS (7.1%). There were no differences in platelet count (P = 0.399) hence no severe thrombocytopeania across the genotypes. Leukocytosis was highest in HbSS (69.2%), 42% in HbAS and 31% in HbAA. The RBC, HCT and Hb had negative correlation with RDW in HbSS in malarial-infected children (r = − 0.725, P = 0.008), (r = − 0.718, P = 0.009) and (r = − 0.792, P = 0.002), respectively.

Conclusion

Our study reveals that anaemia is the most common abnormality in malaria-infected children with carriage of HbSS. The RBC, HCT and Hb concentration decrease with increase in RDW levels in infected children with carriage of HbSS compared to other HBB genotypes. Therefore, carriage of HbSS genotype is correlated with severity of haematological abnormalities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06025-7.

Effect of Ancylostoma ceylanicum hookworm platelet inhibitor on platelet adhesion and peripheral blood mononuclear cell proliferation

Ancylostoma ceylanicum is a zoonotic parasitic nematode that can cause iron-deficiency anemia and malnutrition in humans. A. ceylanicum hookworm platelet inhibitor (Ace-HPI) can inhibit platelet aggregation in the host to facilitate blood sucking, but whether it possesses platelet adhesion inhibitory activity or immunomodulatory role is yet unknown. To explore the effect of Ace-HPI on platelet adhesion, we expressed the recombinant protein in two competent cells, BL21 (DE3) and Rosetta-gami2 (DE3), and incubated this protein with canine platelets in a 96-well microplate. Ace-HPI was used to stimulate peripheral blood mononuclear cells (PBMC) in vitro to investigate the effect on PBMC proliferation and cytokine expression. Results showed that Ace-HPI expressed in Rosetta-gami2 (DE3) strain was mostly soluble. The inhibitory effect of this protein on platelet adhesion was relatively weak (7-8%). This protein stimulated the proliferation of PBMC and promoted the expression of Treg and Th2 cytokines, such as IL-10 and IL-13. These results lay a foundation for exploring the role of Ace-HPI in hookworm disease pathogenesis and as a candidate molecule for hookworm vaccines.

Identification and localization of hookworm platelet inhibitor in Ancylostoma ceylanicum

Ancylostoma ceylanicum is a zoonotic hookworm, which mainly causes iron deficiency anemia (IDA) in humans and animals. Hookworm platelet inhibitor (HPI) has been isolated from adult Ancylostoma caninum and linked to the pathogenesis of hookworm associated intestinal hemorrhage and IDA. However, there is no available data about HPI from A. ceylanicum. To study the molecular characteristics of A. ceylanicum HPI (Ace-HPI), its corresponding cDNA was amplified from adult A. ceylanicum mRNA using the primers designed based on the Ac-HPI gene sequence, and its sequence homology and phylogenetic relationship were analyzed. The differential expression of Ace-hpi mRNA in the adult and third larval (L3) stages was compared using the quantitative real-time PCR. Ace-HPI reactivity and tissue localization were studied by Western blot and immunofluorescence, respectively. Platelet aggregation activity was monitored in a 96-well microplate reader. The results showed that the Ace-HPI encoding gene was 603 bp in length. Ace-HPI showed 91% homology to Ac-HPI, was closely related to Ac-ASP3, and belonged to the CAP superfamily. Ace-hpi transcripts were most abundant in the adult stage, followed by serum-stimulated infective larvae (ssL3), and finally in L3 stage, with a significant difference. Escherichia coli-expressed recombinant protein had good reactivity with the positive serum of A. ceylanicum-infected dogs. Immunolocalization indicated that Ace-HPI was located in the esophagus and cephalic glands of the adult. As well as, recombinant Ace-HPI inhibited the platelet aggregation in-vitro. HPI overexpression, anatomical location in adults, antigenicity and its in-vitro activity indicate its possible role in adult worm blood-feeding and as a valuable target for hookworm vaccine and drug development.

Hookworms in Emergency Department: The ＂Vampire＂ Within

Hookworms infection is a soil-transmitted helminthic disease particularly endemic in developing counties of tropical regions. It is attributed mainly to two human pathogens nematodes namely Necator americanus and Ancylostoma duodenale. Although the disease has been characterized as "neglected" is very diffi cult to be eliminated and the economic consequences are great. Worms are fed with blood of hosts in small intestine and cause typically iron deficiency anemia with relevant symptoms as well as eosinophilia. Patients admitted in emergency department claim often diffuse general symptoms, whereas cases with obscure gastrointestinal bleeding can be seen. Within this brief review, after introducing some basic elements of hookworms' epidemiology, taxonomy and socioeconomic problem is emphasized, pathogenesis, and life cycle of parasite are concisely explained. Furthermore, clinical manifestations often or rarely seen in emergency department are described. Therapeutic options are also enclosed. Awareness of the problem and critical thinking of patients coming from endemic regions could result to identifying more hookworm cases and their therapy will efficiently alleviate not only the patients per se but health system and societies as well.