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Case report
A finding of live Fasciolopsis buski in an ileostomy opening
Rakesh K. Mahajan1, Shalini Duggal2, Niraj K. Biswas3, Nandini Duggal1, Charoo Hans1 1Department of Microbiology, Dr Ram Manohar Lohia Hospital, New Delhi, India 2Department of Microbiology, Dr B. L. Kapur Memorial Hospital, Delhi, India 3Jhalawar Medical College, Jhalawar, Rajasthan, India

Abstract
A pair of live Fasciolopsis buski wriggled their way out through the ileostomy opening in a young adult male who had recently migrated to
Delhi and had met with a road traffic accident. Finding this parasite in the national capital, a non endemic area for Fasciolopsiasis, prompted
us to emphasize the importance of changes in the ecology, human demography, and human behaviour that may provide an environment
conducive to their adaptability to the new geographical requirements. Awareness of Fasciolopsiasis, which is endemic in some regions of
India, especially in rural settings, is an important issue because early diagnosis is essential. Hence, a surveillance mechanism among the
migratory population to institute preventive interventions is necessary.

Key words: endemic, intestinal trematode, plant-borne, migratory population

J Infect Dev Ctries 2010; 4(6):401-403.
(Received 3 July 2009 – Accepted 30 November 2009) Copyright 2010 Mahajan et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction
Fasciolopsis buski (F. buski), also called giant give history of passing greenish yellow, extremely intestinal fluke, is a duodenal digenetic trematode, of malodorous stools and there may be associated the Fasciolidae family. It was described for the first edema of the face and limbs, generalized abdominal time by Busk in the duodenum of a sailor in 1843 in pain, ascitis and even death [4]. Adult worms at the London and its life cycle in humans was first site of attachment cause deep inflammatory described by Barlow in 1925 [1]. F. buski is found ulcerations and their metabolites on absorption may mainly in southeast Asian countries including India. also induce toxic and sensitization reactions. It seems to be restricted to areas where water plants The present case is first of its kind where an such as water chestnut, water caltrops, water bamboo, ileostomy opening acted as a corridor for the escape etc. are cultivated and in communities that consume of adult Fasciolopsis buski. these water plants uncooked. Aquatic snails act as intermediate host for the Case report
parasite and harbor the infective metacercariae that An 18-year-old boy fell down from a moving encyst on water plants after being released into the vehicle and was brought to the surgical emergency of water. The mature fluke develops and starts laying our hospital. In the accident, he sustained a fracture at eggs within three to four months after infective the neck of the femur as well as a blunt injury to the metacercariae have been ingested [2]. Two species of abdomen, resulting in peritonitis. Ultrasonography the snails, Segmentina (Polypylis) hemisphaerula and abdomen revealed a significant amount of free fluid Segmentina (Trochorbis) trochoides, have been in the peritoneal cavity. particularly found to play an important role in disease The patient was taken for an exploratory transmission. Though pigs and humans both act as laparotomy. About a 20 cm length of ileum was definitive hosts, pigs appear to be the only reservoir found gangrenous and an ileostomy was undertaken of infection [3]. after resecting the dead portion. About 500 ml of Clinically, fasciolopsiasis may present with fecal fluid was also removed. occasional loose stools, loss of weight and abdominal About one month after the surgery, while pain. As the worm burden increases, the patient may replacing the ileostomy bag with a fresh one, the

Mahajan et al. - Fasciolopsis buski in an ileostomy opening J Infect Dev Ctries 2010; 4(6):401-403. Figure 1. Adult worm of Fasciolopsis buski recovered
Figure 2: Ova of Fasciolopsis buski recovered from
from the ileostomy opening. contents of ileostomy bag. patient felt two large fleshy structures crawling on needle to release the ova, which were again the abdominal wall around the ileostomy opening. visualized on microscopy. Immediately, he called for the resident doctor on Other laboratory investigations revealed Hb 7.2 duty, who collected them in a glass container and gm%, TLC 13,500/cu mm, DLC: P 78L13E9. Absolute referred the contents immediately to Microbiology Department for identification and immunoglobulin profile showed elevated levels of IgA at 602.0 mg/dL (reference range 90-310 mg/dL). When transferred to a petri dish, the contents To de-worm, the patient was given Nitazoxanide proved to be two large, fleshy worms whose leaf [5] 500 mg BD for five days. After taking just two shape doubtlessly pointed to their lineage of Flukes. doses of the drug, the patient passed five more worms This is the first report of fasciolopsiasis from our through the ileostomy opening. Three more stool tertiary care hospital and also the very first case samples were examined over the next week and none where live F. buski pushed their way out through an of them showed any evidence of ova/cyst. Thereafter, ileostomy opening. the patient did not complain of any such findings and The worms were dorsoventrally flattened, non was discharged after his wound healed. segmented and reddish brown in color. Absence of a cephalic cone ruled out the probability of the parasite Discussion
as being Fasciola hepatica. One of them measured Though fasciolopsiasis appears to be attracting about 36 mm × 24mm and the other about 40 mm × research interest, not much literature is available on 20mm in size. The ventral sucker was prominent in the subject topic. F. buski infestation has been both, while the oral sucker was clear in only one of reported in India from mainly from Bihar [6], Uttar them. The worms had morphology classical of Pradesh, and Maharashtra but also sporadically from Fasciolopsis buski (Figure 1). other states [7]. It appears to be affecting mainly rural To further assess further whether the patient was areas where certain water plants are eaten raw. This harboring more of F. buski or some other parasites, particular case migrated to Delhi just five days before contents of the ileostomy bag were examined macro- the accident from eastern Uttar Pradesh where he as well as microscopically. Formol ether worked as an agriculture farm laborer. There was a concentration of the sample showed a number of freshwater pond in his native village that has aquatic large, ovoid bile-stained ova morphologically plants such as water chestnut, and he gave history of resembling those of F. buski (Figure 2), though it was eating raw water chestnuts and vegetables washed in not possible to differentiate them from ova of F. the pond water. Snails abound in that pond and the hepatica. The parasites were fixed in formalin, and surrounding damp area. The patient had a significant their unbranched intestinal caeca and uterine segment past history of vague abdominal pain and passing examined under 40X. These were teased with a 25 G Mahajan et al. - Fasciolopsis buski in an ileostomy opening J Infect Dev Ctries 2010; 4(6):401-403. Delhi, the national capital, is emerging as a hot fertilizer etc. Such measures could go a long way in favorite for migrants in anticipation of some job preventing and controlling a battery of infectious opportunities. The migrant population is bringing diseases including fasciolopsiasis. Furthermore, the with them certain problems that have historically importance of continuing medical education to been endemic problems of their native areas. The medical personnel in areas of emerging and re- Yamuna River, which traverses practically the whole emerging problems in tropical countries to sensitize city, has certain sectors where edible water plants and them to current issues of public health cannot be snails are plenty; this situation can play a significant role in providing epidemiological support allowing this parasite to establish in this geographical area. References
This report of fasciolopsiasis from an area that is 1. Chi Hiong UGo, Burke AC. Intestinal flukes. Updated 14 completely non-endemic for this clinical entity underscores the need for a surveillance mechanism www.emedicine.com/med/topic1177.htm Accessed on 18 February 2009. through a high degree of suspicion among patients 2. Graczyk TK, Gilman RH, Fried B (2001) Fasciolopsiasis: Is from endemic areas with complaints compatible with it a controllable food-borne disease? Parasitol Res 87: 80- fasciolopsiasis. This case also raises another possibility as to 3. Manning GS and Ratanarat C (1970) Fasciolopsis buski (Lankester, 1857) in Thailand. Am J Trop Med Hyg 19: whether Nitazoxanide can be included in the treatment strategy of fasciolopsiasis as just two doses 4. Rabbani GH, Gilman RH, Kabir I, Mondel G (1985) The of the drug caused expulsion of five more worms treatment of Fasciolopsis buski infection in children: A after the initial two that were removed. Although the comparison of thiabendazole, mebendazole, levamisole, drug of choice is Praziquantel, the patient in this case pyrantel pamoate, hexaresorcinol and tetrachloroethylene. Trans R Soc Trop Med Hyg 79: 513-15. was treated with Nitazoxanide, a novel agent that has 5. DA Bobak (2006) Use of nitazoxanide for gastrointestinal a broad spectrum of activity against many other tract infections: treatment of protozoan parasitic infection gastrointestinal pathogens, as these cases may have and beyond. Curr Infect Dis Rep 8:91-95. multiple parasitic infestations [5,6]. Use of 6. Rai S, Wadhwa V, Kharbanda P, Uppal B (2007) A case of poly-parasitism involving a trematode and four different Nitazoxanide would definitely need more scientific nematodes in a migrant from Bihar. Indian J Med Microbiol support since some other unknown mechanism might have been operative in this subject case 7. CD Alert. Food borne trematode (Fluke) infections: A ileostomy opening. neglected health problem in India. November 2005, vol.9 no. 11. Given that the present distribution of parasitic diseases reflects the success of hygiene and control Corresponding author
measures in the more developed parts of the world rather than any clear geographical or ecological Department of Microbiology restriction, it becomes extremely pertinent to stress B.L.Kapur Memorial Hospital the need to disseminate health education at the Delhi, India [email protected] community level focused on measures such as the importance of properly cleaning and processing vegetables, discouraging the use of night soil as Conflict of interests: No conflict of interests is declared.

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