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  Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 35  |  Issue : 4  |  Page : 551-554
 

Fasciolopsiasis in children: Clinical, sociodemographic profile and outcome


1 Department of Pediatrics, Government Medical College, Bettiah, Bihar, India
2 Department of Community Medicine, Government Medical College, Bettiah, Bihar, India

Date of Web Publication1-Feb-2018

Correspondence Address:
Dr. Kumar Saurabh
Department of Pediatrics, Government Medical College, Bettiah, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_17_7

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 ~ Abstract 

Purpose: To describe the clinical and sociodemographic profile of fasciolopsiasis in children. Materials and Methods: A chart review of 56 children presenting with the passage of adult Fasciolopsis buski per stool from February 2015 to January 2016 was done for their clinical profile and risk factors for acquiring fasciolopsiasis in the Paediatric Unit of a medical college of Northern India. Results: The mean age of presentation was 8.2 years (2–14 years age group). Persistent diarrhoea (85.71%) was the most common presentation, whereas anaemia (71.42%) was the most common sign. Protein-energy malnutrition (PEM) and tuberculosis were well-associated comorbid conditions in this study. Polyparasitism was an important finding, Hymenolepis nana being the most common associated parasite. Patients were treated either with praziquantel or nitazoxanide. Conclusion: All patients recovered well except one who died due to severe PEM and disseminated tuberculosis and two cases presented with relapse. Most of the cases of polyparasitism were associated with tuberculosis.


Keywords: Diagnosis, Fasciolopsis buski, polyparasitism, sign


How to cite this article:
Saurabh K, Ranjan S. Fasciolopsiasis in children: Clinical, sociodemographic profile and outcome. Indian J Med Microbiol 2017;35:551-4

How to cite this URL:
Saurabh K, Ranjan S. Fasciolopsiasis in children: Clinical, sociodemographic profile and outcome. Indian J Med Microbiol [serial online] 2017 [cited 2018 Nov 17];35:551-4. Available from: http://www.ijmm.org/text.asp?2017/35/4/551/224440



 ~ Introduction Top


Fasciolopsis buski commonly known as giant intestinal fluke is a trematode of a Fasciolidae family. It is predominantly reported from Southeast Asia region including India.[1] In India, most of the cases have been reported from Eastern Uttar Pradesh (UP), Bihar, Bengal and Assam.[2],[3],[4],[5] This infestation is known to be limited and endemic in the areas where people consume contaminated water and uncooked aquatic plants such as lotus tubers, water chestnut (singhara), water caltrops and water bamboo. Snails act as intermediate host and harbour the infective metacercariae. Pigs and human are definitive hosts though pig mainly acts as reservoir of infection.[1],[6]

Fasciolopsiasis remains asymptomatic in most of the cases or may present with non-specific symptoms such as loose stool, abdominal pain, loss of weight and poor appetite.[1] Identifying or suspecting fasciolopsiasis on clinical ground is a challenge for a paediatrician even in endemic areas. Definitive diagnosis can be made only after examining the adult worm as ova of F. buski are indistinguishable from ova of Fasciola hepatica.[6],[7]

In spite of being prevalent in states of Bihar, Assam and UP, there is no study regarding the clinical profile and outcome of F. buski infestation from these areas in recent days. Only a handful of case reports are available on PubMed till now.[3],[8],[9],[10] Although in recent years an epidemiological study has been performed in neighbouring district on the basis of questionnaire, authors concluded it as an endemic focus of fasciolopsiasis.[11] The present study is first of its kind where we study a significant number of children who passed adult worm per stool.


 ~ Materials and Methods Top


A chart review (from February 2015 to January 2016) of children with age group of 2–14 years was done. Only those cases were included in the study who passed adult worm of F. buski in their stool either spontaneously or following chemotherapy.

A total of 6038 cases admitted during this 1-year time interval, in which 56 patients had a history of passing adult F. buski in their stools. Among 56 patients positive for F. buski infestation, 32 patients brought adult F. buski containing stool by themselves. Other 24 were diagnosed by macroscopic examination of stool. Stool of all identified cases was examined microscopically for ova of F. buski for 3 consecutive days. Ova were identified as large, oval, unsegmented, bile stained with the presence of operculum at one end. All cases were positive for ova of F. buski. The ova of F. buski and F. hepatica are indistinguishable, so identification of adult worm is necessary for final diagnosis. An adult parasite was identified by open eye as dorsoventrally flattened structure, non-segmented and reddish brown with prominent ventral sucker [Figure 1]. The absence of cephalic cone ruled out the possibility of the parasite being F. hepatica. A complete history and systemic examination were done, and clinical signs of vitamin deficiencies were assessed. At the same time, various comorbid conditions in these children were recorded. Evidence of tuberculosis in patients was established after assessing history of contacts with Koch's patients, abnormal X-ray film (hilar shadow, cavity and hilar lymphadenopathy), positive Mantoux test and demonstration of acid-fast bacilli in the sputum or gastric aspirate.
Figure 1: Live adult worm of Fasciolopsis buski

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All diagnosed cases were treated with drugs either praziquantel or nitazoxanide. All children passed a significant number of adult worm, following chemotherapy. Children were followed up every 1, 3, 6 and 12 months. They were assessed for improvement of symptoms, resolution of diarrhoea, and weight gain. During follow-up, cases were managed with medical treatment, blood transfusion and antituberculous treatment.

We assessed the sociodemographic profile associated with F. buski infestation and also compared these children in terms of malnutrition


 ~ Results Top


Fifty-six children with F. buski were identified. The mean age of presentation was 8.2 (range 2–14) years. Clinical manifestations are shown in [Table 1]. Persistent diarrhoea (85.71%) was the most common presentation followed by pain abdomen (78.57%). Only four children presented with signs of some dehydration.
Table 1: Clinical features of children with fasciolopsiasis

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Among 56 cases of F. buski infestation, 12 children used well water, 20 used pond water and 24 used tube well as a source of drinking water [Table 2]. A history of contacts with cattle's or domestic animals was present in 44 cases (78.57%). Around six children were severely malnourished [Table 3].
Table 2: Sociodemographic profile of children with fasciolopsiasis

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Table 3: Associated comorbidities in children

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Polyparasitism is a common problem in tropics. We also found this in our study. Out of 56 stool samples, 14 samples were co-infected with Hymenolepis nana, tapeworm or Ascaris lumbricoides. H. nana was the most common parasite associated.


 ~ Discussion Top


High parasitic load and passage of adult F. buski are not uncommon in endemic areas of Bihar. Repeated cycles of re-infestation, polyparasitism, and co-infection with tuberculosis lead to high morbidity in these children. All these factors contribute to vicious cycle of protein-energy malnutrition (PEM).

F. buski is a well-known endemic parasite of Southeast Asia region. Infection is acquired by peeling raw water chestnut, eating partially cooked snails and other aquatic plants on which F. buski metacercariae have encysted. These metacercariae do not replicate inside the human gut, so parasite load depends upon number of cysts ingested. Although, in most of the cases reported from India, patients of the study belonged to the state of Bihar,[3],[8],[9],[10] in this present study, general people of this area are well aware of this parasite, so they themselves bring these parasites along with them.

In a classical teaching, F. buski infestation remains asymptomatic in most circumstances and passage of live adult worm is very rare in stool and vomitus. However, actually, this is not so uncommon in our study.

In this study, persistent diarrhoea (85.71%) was the most common presentation followed by low-grade pain abdomen (78.57%). Signs of dehydration were rare in this study. Anaemia was the most common sign. Sign of PEM was also present. Signs of allergy in the form of oedema and urticaria were present in four cases. One case died due to severe anaemia and heavy parasitic infestation associated with disseminated tuberculous infection.

Tuberculosis and respiratory tract infection were the commonly associated comorbidities, most probably due to associated polyparasitism and PEM.

The well-known risk factor associated with this infestation includes ingestion of snails, raw aquatic plants (lotus buds and tubers, water chestnut, water caltrops, water lily and water bamboo), drinking untreated river or pond water and contact with domestic cattle.

However, in view of changing epidemiological profile, these risk factors were not universally associated with all patients. Our few cases belonged to high-income family who do not have these risk factors associated. Hence, other modes of transmission may also be possible.

Tropical areas are well known for polyparasitism and our study reflects the same.[8],[9],[12] It was seen in forteen cases (25%). H. nana was the most commonly associated parasite. Polyparasitism is predisposed to increased susceptibility to other infections such as tuberculosis. Surprisingly, all ten cases of tuberculous co-infection were also associated with polyparasitism. It is well known that helminthic infection, especially polyparasitism, predisposes to infections such as tuberculosis, HIV and malaria.[13],[14],[15] Epidemiological studies indicate that patients with polyparasitism often have higher worm load than the patients infested with single parasite.[12] It has been proposed that co-infestation with helminths can immunomodulate and alter the background immune profile of host to predispose tuberculous infection.[14],[15]

The clinical manifestation of F. buski infestation mainly depends on parasitic load, atypical local inflammatory changes in the gut and absorption of toxic metabolites as well as the altered immune system of the patient. Most of the time, patients remain asymptomatic or may present with diarrhoea, abdominal pain, poor appetite or vomiting. In some cases, if the parasitic load is very high, patient can present with intestinal obstruction and perforation. Ascitis, anasarca, acute renal failure and death are reported in severe case.[10],[16],[17],[18]

Out of 56 patients, 38 patients were treated with praziquantel, a drug of choice for this parasitic infestation.[7] However, 18 patients were treated with nitazoxanide in recommended doses due to unavailability of praziquantel during the initial period of study. Praziquantel (Distocide) an oral anthelminthic agent was given as 25 mg/kg three times per day. Nitazoxanide is supposed to be the second-line drug. It has a broad-spectrum activity against parasitic infestation and especially useful in case of polyparasitism.[3],[19],[20]

All patients expelled a significant number of adult parasites per stool. A few patients passed as many as hundreds of adult worm for consecutive 1–5 days. The patients recovered well after this therapy, became asymptomatic and were discharged with proper advice except for one patient, who died due to associated disseminated tuberculosis and malnutrition. Out of 56 patients, only 42 patients came for follow-up. Their stool samples were negative for F. buski. After 12 months of interval, two patients came with symptoms of diarrhoea and pain abdomen. Their stool samples were positive for F. buski ova. Both patients were previously treated with nitazoxanide. This is difficult to say whether this was a case of treatment failure or they again ingested the cyst. These two cases of relapse were treated with praziquantel and patient recovered well.

Limitation of our study is that the study is a hospital-based chart review and no epidemiological data were obtained to focus the real pockets of Fasciolopsis endemicity in this area. Poor follow-up was another negative aspect of this study. Few cases were treated with nitazoxanide drug due to unavailability of praziquantel during the initial phase of study, this was another limitation. The total number of children diagnosed of having fasciolopsiasis was also small. However, it is the largest data on fasciolopsiasis in children from a single centre.

This study observes that major cause of fasciolopsiasis infestation in this area is due to consumption of raw lotus flower buds (lotus tubers). This was also observed that consumption of snail in this area is also very common due to the presence of numerous paddy fields and ponds. Hence, to check the further transmission of this disease, an integrated control and intersectoral collaboration between agriculture, medicine, veterinary and education system is a must.

Control of disease requires not only medical treatment but also strong government support to these areas in the form of education, health to all and proper sanitation. In spite of Swachh Bharat Abhiyan of the Government of India, this study shows that in this area only 42.85% of cases have proper safe drinking water available. 78.58% of cases are passing stool in open places.


 ~ Conclusion Top


Fasciolopsiasis should be considered in differential diagnosis of patients presenting with persistent diarrhoea and dull-aching abdominal pain in these endemic areas, especially in children with associated malnutrition. Polyparasitism is a commonly associated problem which predisposes to other infections. Majority of children have a benign course with good recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ~ References Top

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Mahajan RK, Duggal S, Biswas NK, Duggal N, Hans C. A finding of live Fasciolopsis buski in an ileostomy opening. J Infect Dev Ctries 2010;4:401-3.  Back to cited text no. 3
    
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Bhattacharya S, Khurana S, Bhatti HS, Singhi S, Malla N. Polyparasitism: Fasciolopsis buski, Ascaris lumbricoides and discussion hookworm coinfection in a child. Trop Gastroenterol 2010;31:126-7.  Back to cited text no. 9
    
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Elias D, Britton S, Kassu A, Akuffo H. Chronic helminth infections may negatively influence immunity against tuberculosis and other diseases of public health importance. Expert Rev Anti Infect Ther 2007;5:475-84.  Back to cited text no. 14
    
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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