1459 A Curious Case of Progressive Iron Deficiency Anemia

Abstract

INTRODUCTION: Iron deficiency anemia is a common condition that often leads to evaluation of the gastrointestinal tract for sources of blood loss. Parasitic infections are uncommon causes of gastrointestinal blood loss. Here we present a case of progressive iron deficiency anemia due to Trichuris trichiura (whipworm) infection. CASE DESCRIPTION/METHODS: A 65-year-old male, originally from the Philippines, with a past medical history of hypertension and coronary artery disease (on aspirin and clopidogrel) presented with progressive worsening fatigue for four weeks with new onset small volume rectal bleeding for three days. Travel history was notable for a recent trip to Mexico complicated by a self-limited diarrheal illness six weeks prior to presentation as well as frequent travel to the Philippines. Physical exam was notable for pallor and a rectal exam with no evidence of external hemorrhoids and brown stool. Labs were notable for hemoglobin of 7.5 g/dL from a baseline of 14 g/dL one year prior to presentation. Other pertinent labs included a mean corpuscular volume of 80 fL, iron saturation of 4% with a ferritin of 7 ng/mL. An upper endoscopy and colonoscopy was performed. The upper endoscopy was unremarkable with no source of blood loss anemia. The colonoscopy was notable for internal hemorrhoids and evidence of worms found in the cecum. A worm was obtained and sent for microscopic evaluation with final speciation revealing T. trichiura (whipworm). The patient also underwent a video capsule endoscopy as an outpatient two weeks after discharge which was unremarkable. The patient was treated with a three day course of mebendazole and initiated on iron supplementation with interval outpatient follow up revealing resolution of iron deficiency anemia within 6 weeks post-treatment with subsequent hemoglobin of 13.7 g/dL. DISCUSSION: Parasitic infections, especially those without significant concurrent gastrointestinal symptoms, can lead to a diagnostic delay as a potential cause of iron deficiency anemia. Whipworm infections occurs through ingestion of whipworm eggs that are then passed in the feces of infected individuals. Many cases of T. trichiura infection are asymptomatic however a high worm burden can lead to diarrhea and anemia. The pathophysiology of resulting iron deficiency anemia from T. trichiura is thought to be from worm consumption of blood and possible colonic lesions leading to occult gastrointestinal bleeding. A thorough history, including travel history, remains crucial for diagnosis.