Visible Worms in a Crohn’s Patient Treated with Infliximab

Abstract

Question: A 23-year-old man presented with a complaint of visible worms seen after defecation. He has had small bowel and perianal Crohn’s disease diagnosed 6 months earlier, which required three abscess drainage procedures and hospitalizations. Initial treatment with a several antibiotic courses and 6-mercaptopurine lead to a slight improvement. Treatment with infliximab therapy (5 mg/kg) added to 6-mercaptopurine was instituted and resulted in marked improvement and decrease of his C-reactive protein to a near normal level. Before the fourth infliximab infusion, the patient reported visible worms, several centimeters long, seen in the toilet after defecation (Figure A). The patient had no fever, abdominal pain, rectal bleeding, anal pruritus, or skin rash. There was also no history of travel and no exacerbation of the Crohn’s disease. The infliximab infusion was deferred, and the patient was referred to our tropical clinic for consultation. Laboratory results were within normal limits. Blood eosinophils were not elevated. What is the diagnosis? What should be done next? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. A repeat thorough history taking at the tropical clinic revealed that his sister also saw worms, both in the toilet after bowel movements, but also while taking a bath. Taken together with the fact that the patient lives in a private ground floor house, it was postulated that the worms arose from the sewage water pipe system. To confirm this diagnosis, the worms were analyzed by the Ministry of Health central parasitology laboratory and identified as Earthworms (disambiguation). It is well-known that the risk of infections is increased in patients with inflammatory bowel disease treated with immunomodulator drugs such as infliximab.1Orlando A. Armuzzi A. Papi C. et al.The Italian Society of Gastroenterology (SIGE) and the Italian Group for the study of Inflammatory Bowel Disease (IG-IBD) Clinical Practice Guidelines: the use of tumor necrosis factor-alpha antagonist therapy in inflammatory bowel disease.Dig Liver Dis. 2011; 43: 929-934Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar Data on helminthic infections in such patients are lacking, and hardly described in the literature. Only a few case reports are available describing parasitic infections in patients receiving anti-tumor necrosis factor therapy. Some common parasitic infections that associated with these drugs are Toxoplasma, Strongyloides, and Giardia.2Ali T. Bronze Kaitha et al.Clinical use of anti-TNF therapy and increased risk of infections.Drug Healthc Patient Saf. 2013; 5: 79-99Crossref PubMed Google Scholar,3Ben-Horin S. Barshack I. Chowers Y. et al.Flare-up of ulcerative colitis after systemic corticosteroids: A strong case for Strongyloides.World J Gastroenterol. 2008; 14: 4413-4415Crossref PubMed Scopus (10) Google Scholar In conclusion, while being cognizant of opportunistic and helminthic infections in immunosuppressed patients with inflammatory bowel disease, physicians should also be aware that worms seen in the toilet may be innocuous earth worms in the piping system, especially in patients living in ground-floor houses in nonurban locales. Proper history taking may obviate an unnecessary excessive workup and prevent unjustified delays in biologics treatment or empiric anthelminthics therapy.