2618 The Immigrant With Chronic Abdominal Pain: A Diagnosis of Ascaris lumbricoides

Abstract

INTRODUCTION: Ascaris lumbricoides (A. lumbricoides), a nematode affecting millions globally, is asymptomatic for years until development of high worm load when patients present with symptoms of small bowel obstruction. High suspicion is required for accurate diagnosis, especially when managing the immigrant patient. We present the case of a Pakistani immigrant who endorsed abdominal pain, lower extremity skin lesions and joint pain for several months prior to capsule endoscopy diagnosis with A. lumbricoides. CASE DESCRIPTION/METHODS: A 50-year-old Pakistani female with history of hypertension presented with chronic, bandlike, postprandial right upper quadrant abdominal pain associated with nausea. She also endorsed left lower extremity skin lesions and small joint pain. Basic laboratory values were normal except ALT 118. Extensive rheumatologic workup was also normal. Right upper quadrant ultrasound was benign. CT abdomen and pelvis with contrast showed irregular filling defects, with retroperitoneal and pelvic adenopathy; however, colonoscopy revealed no mass. Skin biopsy confirmed erythema nodosum (EN). A few weeks later, the patient re-presented with similar complaints and followed up in Gastroenterology clinic. EGD was without pathology, but capsule endoscopy revealed parasites in the small bowel, likely A. lumbricoides as both adult worm and blastocyst stages were seen in the small bowel. The patient was treated successfully with Albendazole. DISCUSSION: Infecting the pulmonary, hepatobiliary, and small intestine systems, A. lumbricoides is a common helminth infection, especially in endemic areas including the Western Pacific, South East Asia and Africa. Poor hygiene facilitates fecal-oral transmission. Humans ingest embryonated eggs, and larvae in the intestine migrate to the lungs where they are coughed up and swallowed to molt into adult form within the intestine. As the infection is largely asymptomatic, patients can carry the helminth for years. Skin manifestations, including EN, are a rare manifestation of ascariasis, with only a few case reports cited in the literature. Capsule endoscopy can be a diagnostic tool but is more expensive than stool testing. Treatment is with Albendazole. Infection with A. lumbricoides should be considered in immigrant patient populations presenting with chronic abdominal pain and atypical features such as erythema nodosum, as accurate diagnosis can lead to treatable disease.