Abdominal complications of ascariasis in childhood.

OBJECTIVE: Complications of ascariasis are a significant cause of abdominal pain in pediatric emergencies, especially where it is endemic. A literature review was conducted with the aim of improving diagnostic and therapeutic approaches for these patients. DATA SOURCES: A PubMed search was conducted using the key terms "ascariasis complications" and "hepatobiliary ascariasis". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, case reports, and reviews published up to December 2023. SUMMARY OF FINDINGS: Obstruction of the small bowel is the most common complication. Others that are, rarer and more difficult to properly identify and treat, such as biliary, hepatic, and pancreatic complications, acute appendicitis, Meckel's diverticulitis, or peritoneal granulomas. Hepatic and pancreatic complications are rarer and more serious in children than in adults. While plain radiography is usually the only option in cases of intestinal obstruction, ultrasonography is the examination of choice in cases of hepatobiliary, pancreatic, and appendicular ascariasis complications in childhood. The treatment is clinical and conservative in most patients. Surgical treatment is indicated if conservative therapy fails, or if there are signs of complications. Laparoscopy has been used as an excellent technical alternative in adults with hepatobiliary complications of ascariasis, but further studies on its use in children are still needed. CONCLUSION: The creation of protocols and greater debate on this subject should be encouraged for a better understanding of the disease and to establish an early diagnosis and adequate treatment for children with complications resulting from massive infestation by Ascaris lumbricoides.

Autochthonous Ascariasis, Mississippi, USA.

We describe a case of a 2-year-old child who expelled a single adult female Ascaris lumbricoides worm. The patient is from a rural county in Mississippi, USA, with no reported travel outside of the United States. The caregivers in the home practice good sanitation. Exposure to domestic pigs is the likely source of infection.

Increase in acute pancreatitis, especially gallstone related, as the cause for emergency admissions: Temporal trend from Kashmir, India.

BACKGROUND: The incidence of acute pancreatitis is increasing globally. Gallstones (GS) and ascariasis are the major causes for acute pancreatitis in the Kashmiri population. In recent years, we have observed an increase in the admission rate of acute pancreatitis. Many patients who present first time as gallstone pancreatitis have asymptomatic gallstones. We aimed at studying the etiology and yearly admission rate of acute pancreatitis with main focus on gallstone pancreatitis and the contribution of asymptomatic gallstones. METHODS: This was a hospital-based, prospective, observational study from January 2015 to December 2019 for a period of five years. Patients of acute pancreatitis were evaluated for etiology and yearly admission rate. Patients of gallstone pancreatitis were evaluated in terms of clinical profile, risk factors, nature (symptomatic/asymptomatic, known/unknown gallstones), size of stones, treatment and outcome in terms of severity and mortality. The data was analyzed by Statistical Package for the Social Sciences (SPSS) version 20.0, as mean (SD), frequencies and percentages. RESULTS: As many as 702 (8.5%) patients of acute pancreatitis were admitted among 8245 gastrointestinal emergencies in five years. The yearly admission rate of acute pancreatitis was 5.6%, 7.3%, 8.7%, 9.5% and 10.3%, respectively (p = 0.013). Gallstones, Ascariasis, alcohol and idiopathic acute pancreatitis were 47.7%, 6.9%, 1.2% and 33.7%, respectively. Gallstone pancreatitis increased from 31% in 2015 to 52.4% in 2019 (p = 0.045) and ascariasis-related acute pancreatitis declined from 14.4% to 1.6% (p = 0.034). Asymptomatic gallstones constituted 87.7% of cases. Known/unknown asymptomatic gallstones and symptomatic gallstones were 24.4%, 63.2% and 12.2%, respectively. Gallstones < 5 mm and > 5 mm were76.1% and 23.8% respectively (p = 0.027). Cholecystectomy rate in index admission was 4.7%. Mild, moderate and severe gallstone pancreatitis was 60.2%, 18.8% and 20.8%, respectively. Mortality in gallstone pancreatitis was 10.4%. CONCLUSION: The incidence of acute pancreatitis is increasing due to gallstone pancreatitis. Ascariasis-related acute pancreatitis has declined. There is significant contribution of asymptomatic gallstones in patients who present for the first time as acute pancreatitis. Small gallstones < 5 mm are likely to be the risk factors for gallstone pancreatitis.

Evaluation of reference genes for gene expression analysis by real-time quantitative PCR (qPCR) in different tissues from mice infected by Ascaris suum.

Human ascariasis is the most prevalent helminth infection, affecting 445 million people worldwide. To better understand the impact of the immune system on the pathophysiology of individuals infected with Ascaris suum, mice have been used as experimental models. The RT-qPCR technique is a critical auxiliary tool of investigation used to quantify mRNA levels. However, proper normalization using reference genes is essential to ensure reliable outcomes to avoid analytical errors and false results. Despite the importance of reference genes for experimental A. suum infection studies, no specific reference genes have been identified yet. Therefore, we conducted a study to assess five potential reference genes (GAPDH, 18s, ACTB, B2M, and HPRT1) in different tissues (liver, lungs, small and large intestines) affected by A. suum larval migration in C57BL/6j mice. Tissue collection was carried out to analyze parasite burden and confirm the presence of larvae during the peak of migration in each tissue. Upon confirmation, we analyzed different genes in the tissues and found no common gene with stable expression. Our results highlight the importance of analyzing different genes and using different software programs to ensure reliable relative expression results. Based on our findings, B2M was ranked as the ideal reference gene for the liver, while 18S was the most stable gene in the lung and small intestine. ACTB, or a combination of ACTB with GAPDH, was deemed suitable as reference genes for the large intestine due to their stable expression and less variation between the control and infected groups. To further demonstrate the impact of using different reference genes, we normalized the expression of a chemokine gene (CXCL9) in all tissues. Significant differences in CXCL9 expression levels were observed between different groups in all tissues except for the large intestine. This underscores the importance of selecting appropriate reference genes to avoid overestimating target gene expression levels and encountering normalization-related issues that can lead to false results. In conclusion, our study highlights the significance of using reliable reference genes for accurate RT-qPCR analysis, especially in the context of A. suum infection studies in different tissues. Proper normalization is crucial to ensure the validity of gene expression data and avoid potential pitfalls in interpreting results.

An update on the current and emerging pharmacotherapy for the treatment of human ascariasis.

INTRODUCTION: Globally, Ascaris lumbricoides is the commonest helminthic infection that affects people in underdeveloped countries and returning immigrants in industrialized nations. This article aims to provide latest updates on the epidemiology, clinical manifestations, and pharmacotherapy of ascariasis. AREAS COVERED: A PubMed search was conducted using Clinical Queries and the key terms 'human ascariasis' OR 'Ascaris lumbricoides.' Ascaris lumbricoides is highly endemic in tropical and subtropic regions and among returning immigrants in industrialized nations. Predisposing factors include poor sanitation and poverty. The prevalence is greatest in young children. Most infected patients are asymptomatic. Patients with A. lumbricoides infection should be treated with anti-helminthic drugs to prevent complications from migration of the worm. Mebendazole and albendazole are indicated for children and nonpregnant women. Pregnant individuals should be treated with pyrantel pamoate. EXPERT OPINION: Cure rates with anthelmintic treatment are high. No emerging pharmacotherapy can replace these existing drugs of good efficacy, safety profile and low cost for public health. It is opinioned that advances in the management of ascariasis include diagnostic accuracy at affordable costs, Emodepside is highly effective in single doses against ascarids in mammals and in human trials. The drug could be registered for human use in multiple neglected tropical diseases.

Coincidence of Ascariasis with Appendicitis in a Pediatric Patient with abdominal Pain; a Case Report.

The simultaneous occurrence of intestinal ascariasis and appendicitis presents a challenge in diagnosing pediatric abdominal emergencies due to overlapping symptoms. We present the case of an 8-year-old boy who experienced acute abdominal pain, characterized by a severe cramp in the mid and lower right abdomen, with pain rated 7 out of 10, a mild fever, and continuous nausea. The initial evaluation suggested appendicitis, supported by an Alvarado score of 9. However, ultrasonography did not conclusively confirm appendicitis but revealed an Ascaris worm in the ileum. This finding highlights the importance of careful diagnostic processes that combine clinical assessment with imaging techniques, while being mindful of their limitations. Surgical exploration confirmed retrocecal appendicitis coexisting with an Ascaris lumbricoides infection. The treatment involved surgical removal of the affected appendix and pharmacological expulsion of the parasitic worm using albendazole, which proved effective. This report emphasizes the consideration of ascariasis in diagnosing appendicitis, particularly in areas where intestinal parasites are common. It also demonstrated the improved diagnostic accuracy achieved through clinical scoring and imaging, thus reducing the risk of missing dual pathologies in young patients with acute abdominal pain.

My 40-Year Encounter with ERCP: A Saga of Service, Syndromes, and Solutions.

Endoscopic retrograde cholangiopancreatography (ERCP) has been a significant development in gastrointestinal endoscopy. I did my first ERCP at SKIMS on December 5, 1982, and over the last 40 years, I have performed 10,100 ERCP procedures, including 600 Sphincter of Oddi manometries (SOM), and 3200 therapeutic ERCPs. We were confronted with many clinical challenges that needed answers by applying ERCP as a primary diagnostic tool. These studies gave birth to and/or recognition of several clinical syndromes. The hepatobiliary and pancreatic ascariasis (HBPA) as a clinical disease was recognized in 1985. The nematode, Ascaris lumbricoides, was the most common cause of hepatobiliary and pancreatic diseases in Kashmir, and its impact on healthcare, clinical profile, management policies, and control measures was identified. Kashmir was recognized as an endemic zone for recurrent pyogenic cholangitis (RPC), which constituted 12.5% of all biliary diseases. RPC in this population was found essentially to be an aftermath of HBPA. A subset of patients with hepatic hydatidosis with rupture into the biliary tract was recognized at ERCP and primarily treated by endotherapy. Cholangiographic abnormalities in children with portal cavernoma evolved into the recognition of portal biliopathy. Extensive studies of the sphincter of Oddi manometry in patients with unexplained biliary and/or pancreatic pain following cholecystectomy identified the entity of the sphincter of Oddi dyskinesia (SOD). In a cross-over trial, Nifedipine, compared with a placebo, showed a significant clinical response in 20 of 28 such patients. ERCP studies done in patients with tropical calcific pancreatitis showed an anomalous union of bile and pancreatic ducts. Forty of the 220 patients with liver transplantation had biliary complications namely biliary leaks, bile duct strictures, SOD, and recurrence of underlying primary biliary cholangitis. Biliary complications caused considerable morbidity and mortality in patients with liver transplantation.

Intrabiliary Ascariasis: A Case Report of an Uncommon Cause of Acute Abdomen and Obstructive Jaundice in Children.

Background: Intrabiliary ascariasis is an uncommon cause of biliary colic and obstructive jaundice among children due to the small size of the ampullary orifice. A high index of suspicion for patients living in an endemic area and radiologic examination are crucial for diagnosis and treatment. Case Presentation: A 12-year-old male Ethiopian child presented with colicky right upper quadrant pain, nausea, and vomiting for 3 days. Physical examination showed slightly icteric sclera and slightly tender hepatomegaly. Laboratory and ultrasound examinations were suggestive of obstructive jaundice secondary to intra-biliary ascariasis. The child was admitted and followed by conservative management including maintenance fluid, nil per mouth, and analgesics. The abdominal pain and icterus resolved on his second and third day of admission, respectively. A follow-up ultrasound showed that the worm had migrated from the common bile duct. The patient was dewormed with a single dose of oral albendazole 400mg and discharged home. Currently, the patient is well and attending school. Conclusion: Although biliary ascariasis is an uncommon cause of acute abdomen and obstructive jaundice, it should be suspected among patients from endemic areas presenting with suggestive clinical and laboratory features. Conservative treatment is the treatment of choice for uncomplicated biliary ascariasis patients.

Botanicals against some important nematodal diseases: Ascariasis and hookworm infections.

Ascariasis and intestinal parasitic nematodes are the leading cause of mass mortality infecting many people across the globe. In light of the various deleterious side effects of modern chemical-based allopathic drugs, our preferences have currently shifted towards the use of traditional plant-based drugs or botanicals for treating diseases. The defensive propensities in the botanicals against parasites have probably evolved during their co-habitation with parasites, humans and plants in nature and hence their combative interference in one another's defensive mechanisms has occurred naturally ultimately being very effective in treating diseases. This article broadly outlines the utility of plant-based compounds or botanicals prepared from various medicinal herbs that have the potential to be developed as effective therapies against the important parasites causing ascariasis and intestinal hookworm infections leading to ascariasis & infections and thereby human mortality, wherein allopathic treatments are less effective and causes enormous side-effects.

An unusual finding: Biliary ascariasis in a pregnant patient managed conservatively-a case report.

Introduction and importance: Biliary ascariasis, caused by Ascaris lumbricoides, is a rare condition, especially in non-endemic areas. However, it can present with complications such as biliary obstruction, requiring prompt diagnosis and management. This case report highlights the incidental detection and successful management of biliary ascariasis in a pregnant patient. Case presentation: A 26-year-old primigravida woman at 24 weeks gestation presented with mild icterus, anorexia, and gastrointestinal symptoms. Laboratory tests showed elevated bilirubin levels and peripheral eosinophilia. Abdominal ultrasound revealed the presence of roundworms in the gallbladder and common bile duct. The patient was managed conservatively with an anti-helminthic agent, resulting in the passing of a dead worm and the resolution of symptoms. Clinical discussion: Biliary ascariasis is a rare condition in non-endemic areas but should be considered in pregnant patients presenting with biliary symptoms. Prompt diagnosis is crucial, and imaging modalities such as abdominal ultrasound play a vital role. Conservative management with appropriate anti-helminthic therapy can effectively resolve symptoms and eliminate the infection. Conclusion: This case report emphasizes the importance of considering biliary ascariasis in pregnant patients with biliary symptoms. Timely diagnosis, utilizing imaging modalities, and initiating conservative management with anti-helminthic therapy can lead to successful treatment outcomes. Increased awareness and understanding of this condition can aid clinicians in providing optimal care to similar patients.

Ascariasis causing small bowel obstruction in an adult female: A case report.

INTRODUCTION AND IMPORTANCE: Ascariasis is a helminthic infection of humans caused by Ascaris lumbricoides. Intestinal obstruction from ascariasis can result in a rare but severe and often fatal surgical emergency of intestinal perforation and peritonitis in endemic areas. There have been reports of ascariasis causing Small Bowel Obstruction (SBO) in children in endemic areas but this phenomenon has not been studied in adults. The objective of this study was to describe the case of ascariasis causing SBO in a 25-year-old female. CASE PRESENTATION: A 25-year-old female from southwest Ethiopia presented with a complaint of intermittent crampy abdominal pain of 02 days duration associated with vomiting of ingested matter of 02 to 03 episodes, progressive abdominal distension and failure to pass feces and flatus. On examination, she was acutely sick looking. She has mild abdominal distention and a hyperactive bowel sound. Subsequently, she was resuscitated, broad spectrum antibiotic started, consent taken & operated. Patient discharged on the 7th postoperative day. CLINICAL DISCUSSION: There have been reports of Ascariasis causing SBO in endemic areas of the tropics and sub-tropics. SBO secondary to the ascaris ball in an adult is very rare and is relevant to present as it adds key clinical lessons in the consideration as a differential diagnosis, investigation clues and patient management. CONCLUSION: In a patient presented with symptoms and signs suggestive of bowel obstruction, Ascariasis should be considered as a differential diagnosis for those from endemic areas. The treating physician should have a high index of suspicion.

A Rare Complication of Ascariasis: A Case of Acute Interstitial Nephritis.

Acute interstitial nephritis (AIN) due to helminths is a rare cause of acute kidney injury (AKI). Helminthiases often progresses insidiously, making diagnosis difficult. This was the case of a 72-year-old man, who presented with renal failure, itching and diarrhoea. Urinalysis revealed leukocyturia, microhaematuria and mild proteinuria. A full blood count revealed leucocytosis with eosinophilia. A stool parasitological examination revealed fertilised eggs of Ascaris lumbricoides. Tubulointerstitial nephropathy secondary to A. lumbricoides infection was suspected. A percutaneous renal biopsy was not performed since the patient refused the anti-platelet therapy discontinuation. Mebendazole, albendazole and prednisone therapy was administered. After worm eradiation and discharge, recovery from the parasitosis, absence of pruritus and eosinophilia, and progressive improvement of renal function were observed, strongly suggesting a causal relationship between Ascaris infection and AIN. Parasite infection should be considered in the differential diagnosis of unexplained renal failure because early diagnosis and treatment are necessary to avoid irreversible complications.

Extra-intestinal complications of Ascaris lumbricoides infections in India: A systematic review and meta-analysis.

The aberrant migration of Ascaris lumbricoides may cause extra-intestinal ascariasis (EIA) involving hepato-biliary-pancreatic (HBP) or other extra-gastro-intestinal (EGI) organs. We performed a systematic review and meta-analysis to study the risk factors and clinical presentations of EIA, and differences in HBP and EGI ascariasis. Medline, Web of Science and Embase were searched for cases of EIA in the English language from India. From 1204 articles, 86 studies (105 cases) were included. The majority of the cases involved the HBP system (78%). Among HBP ascariasis, the most commonly involved site was the bile duct (53.6%). Females had 11.3 times higher odds (95% CI 2.852 to 44.856; p=0.001) of HBP ascariasis, while the pediatric population had lower odds (OR=0.323). Previous gallbladder disease was significantly associated with HBP ascariasis in adults (p=0.046), while a significantly higher number of cases of EGI ascariasis were observed among pediatric patients (p=0.003). Ocular symptoms occurred exclusively in the pediatric population (p=0.017). Overall, death was reported in 3.8% of patients (n=4). This review emphasizes the importance of the complications of EIA. It encourages future research into issues such as the reasons of higher gall bladder ascariasis in females and the implications of Ascaris-related complications following biliary tract interventions. It also suggests considering Ascaris as a differential diagnosis for airway obstuction in intubated critically ill patients.

Necrotising pneumonia caused by Curvularia hawaiiensis (syn. Bipolaris hawaiiensis) and Mycobacterium tuberculosis coinfection in a patient with ascariasis: a case report and review.

INTRODUCTION: Curvularia hawaiiensis (formerly Bipolaris hawaiiensis) is a plant pathogen often isolated from soil and vegetative material. However, only a few cases of opportunistic invasive infections in humans have been described. CASE: A 16-year-old female patient without comorbidities was admitted to the emergency department because of fever and chest pain. We described the first coinfection of Curvularia hawaiiensis and Mycobacterium tuberculosis necrotising pneumonia. DISCUSSION: Multiple infections can alter immune responses. However, immunosuppression is the most critical risk factor for infection with species of the genus Curvularia. Therefore, it is crucial to carefully examine patients with tuberculosis, as they may rarely be coinfected with unusual fungi.

Biliary ascariasis misidentified as a biliary stent in a patient undergoing liver resection.

Ascaris lumbricoides causes one of the most common soil-transmitted helminthiases globally. The worms mostly infect the human small intestine and elicit negligible or nonspecific symptoms, but there are reports of extraintestinal ectopic ascariasis. We describe a rare case of biliary ascariasis mistaken for biliary stent in a 72-year-old female patient with a history of liver resection. She visited our outpatient clinic complaining of right upper quadrant pain and fever for the past week. She had previously undergone left lateral sectionectomy for recurrent biliary and intrahepatic duct stones 2 years ago. Besides mildly elevated gamma-glutamyl transferase levels, her liver function tests were normal. Magnetic resonance cholangiopancreatography revealed a linear filling defect closely resembling an internal stent from the common bile duct to the right intrahepatic bile duct. A live female A. lumbricoides adult worm was removed by endoscopic retrograde cholangiopancreatography (ERCP). Despite a significant decrease of the ascariasis prevalence in Korea, cases of biliary ascariasis are still occasionally reported. In this study, a additional case of biliary ascariasis, which was radiologically misdiagnosed as the biliary stent, was described in a hepatic resection patient by the worm recovery with ERCP in Korea.

Ascaris lumbricoides a rare cause ileal perforation, a case report.

INTRODUCTION AND IMPORTANCE: Ascariasis is a helminthic infection of humans caused by Ascaris lumbricoides. Pediatric patients infected with Ascaris can develop multiple complications including appendicitis, gastrointestinal bleeding, hepatobiliary disease like cholangitis or obstructive jaundice, intussusception, and bowel obstruction among others. Ascaris is a rare cause of intestinal perforation even in endemic areas. CASE PRESENTATION: A 2-year-old female Ethiopian toddler who was presented with a complaint of non-bilious, non-projectile vomiting of 06 days duration, about two-three episodes per day. Associated with this she had had progressive abdominal distension, intermittent abdominal cramps and loss of appetite. On examination, she was acutely sick looking. She had signs of dehydration. Subsequently, she was resuscitated, broad spectrum antibiotic started and operated. Finally, the child was discharged improved after 7 days of hospital stay. CLINICAL DISCUSSION: The clinical presentation of ascariasis can vary from asymptomatic child to one with severe disease requiring surgical intervention like our patient. Severity of disease depends on the worm burden; heavy worm infestation produces a wide range of acute abdominal complications such as intestinal obstruction, intussusception, cholangiohepatitis, pancreatitis, and acute appendicitis. Intestinal ascariasis rarely causes volvulus and intestinal gangrene, perforation and peritonitis. CONCLUSION: Ascariasis must be considered in the differential diagnosis in patients presented with peritonitis especially those living or from temperate and tropical countries with a history of passage of worms. Ileum perforation is possible in patients with ascariasis due to pressing directly into the bowel wall, inflammatory reaction, or volvulus and intestinal wall necrosis.

Small bowel obstruction caused by massive ascariasis: two case reports.

Ascaris lumbricoides is an infestation that affects approximately one-seventh of the world's population. Ascaris lumbricoides is a common inhabitant of the intestines of people with low-socioeconomic incomes, especially in underdeveloped countries of the world. Ascaris lumbricoides infestation is more prone to infestation with serious complications such as intestinal obstruction, volvulus, intussusception, and intestinal necrosis at higher rates in children than in adults. Case presentation: The authors present here two cases of small bowel obstruction caused by massive Ascaris lumbricoides that were admitted to the pediatric surgery service after completing a clinical and physical examination, and we operated after rehydration. Both underwent surgical resection with an end-to-end anastomosis. The patient was discharged uneventfully with a plan for de-worming treatment in 6 weeks. Clinical discussion: Ascariasis is a round intestinal worm infestation transmitted by fecal or oral contamination. Eating and excreting ascaris eggs lead to ascariasis and excrete human feces, which contaminate foods, soil, and/or water in unsanitary environments. In contrast, in the first case of this study, the diagnosis was made by ultrasound and erect abdominal radiography, and, in the second case, an abdominal ultrasound result was equivocal and required an abdominal computed tomography scan for confirmation. Treatment of small bowel obstruction by roundworms is usually surgical, but in the absence of signs of peritonitis, medical management can give effective results, even in the case of total obstruction. Conclusion: The type of surgery undertaken is determined by the results of the laparotomy. If the bowel was found to be intact and the obstruction was at the ileum level, milking worms to the cecum can be done with caution to avoid trauma to the bowel wall. Primary anastomosis after resection of a necrotic bowel segment and removal of the worm bolus is a suitable method for treatment of the ascariasis obstruction.

Diagnosis of Asymptomatic Biliary Ascariasis by Abdominal Ultrasound in a Non-Endemic Area.

Biliary ascariasis is rare in non-endemic areas. This infection is associated with severe complications of the biliary tract, which can become a medical emergency. Treatment with oral anthelmintics is often effective, but, in some cases, surgery is required.  We describe an unusual case of ultrasound diagnosis of biliary ascariasis in the gallbladder in a patient who, besides residing in a low-prevalence area of the infection, did not present with biliary tract manifestations. We intend to raise awareness of this clinical entity in non-endemic areas, where this diagnosis is not usually considered. A brief review of the subject is also presented.