Gourisankar P. Degala, MD, Osama Alaradi, MD., *Gastroenterology, Henry Ford Health System, Detroit, MI.
Purpose: A forty-four year old Caucasian female patient presented with few year history of recurrent abdominal pain and bouts of intestinal obstruction for which she underwent multiple abdominal surgeries. She was noted to have microcytic anemia on laboratory studies: Hemoglobin 9.9 g/dL, MCV 78.1 fl, Iron 14 ug/dL and ferritin of 7 ng/ml (Normal 10–120 ng/mL). Her endoscopic evaluation for GI blood loss included EGD and Colonoscopy. Both were normal. A small bowel follow-through evaluation showed post-surgical changes. Subsequently, a small bowel capsule endoscopy (Given Imaging, Yoqneam, Israel) was performed without any complication. An interpretation of the images revealed the results seen in Figure A.
Multiple adult worms were seen in the small intestine. Worms, worm fragments, and hooklets were seen in the distal small intestine. There were multiple erythematous areas where the worms were seen. The worms were present in the study for three hours and thirty minutes. The capsule did not make it into the colon by the end of the study but a subsequent abdominal film showed that it passed.
Two separate stool studies for ova and parasites were negative for helminthic eggs. The patient also denied ever passing worms in her stool. The patient had no significant travel history but did have worm infestation when she was seven years old. A microbiologist examined the pictures and confirmed that the morphology of the organisms was consistent with hookworms, likely Necator americanus. She was treated with two courses of albendazole.
This case is a demonstration of a significant abnormal finding in the small intestine diagnosed only with capsule endoscopy. The high worm load was clearly the source of iron deficiency anemia. The delayed capsule transit time also raises questions of whether the worm load delayed motility or caused a low-grade intestinal obstruction. This is the largest worm load we have seen compared to previously described cases.[figure1]