Diagnosis: Capillariasis associated with tubular narrowing of multiple small-bowel loops with fold effacement. The clinical and radiographic presentations of these cases are representative of Capillaria philippinensis infection. Infection with C. philippinensis is primarily acquired by ingestion of raw, undercooked, small, fresh- or brackish-water fish [1]. Capillaria philippinensis, first discovered in the Philippines, has subsequently been detected in Thailand, Japan, Iran, Egypt, and Taiwan, with major outbreaks reported in Thailand and the Philippines [2]. Typically, patients present with signs and symptoms of malabsorption inclusive of chronic diarrhea, edema, muscle wasting, and abdominal pain; laboratory data reveal low serum albumin and potassium [3–4]. The diagnosis of C. philippinensis is usually based on the detection of eggs (Figure 1), larva, and/or adult worms with or without egg in stool specimens (Figure 1), although excretion can be sporadic, necessitating multiple repeated stool examinations, with small intestinal aspiration or biopsy to confirm the diagnosis in some cases [1–2]. Notably, mortality has been reported in patients with C. philippinensis who did not have capillaria eggs or larva recovered from stool specimens [2–3]. The detection of the parasite’s stichosome (the posterior glandular esophagus) and stichocytes (large glandular cells) by hematoxylin and eosin stain are not diagnostic, as these can also be identified in biopsies of patients with Trichinella spiralis and Trichuris trichiura infection. The clinical presentations and locations of lesions can readily help in the differentiation and case detection of these 3 parasitic infections [5]. Whereas patients with C. philippinensis typically present with clinical manifestations of chronic watery diarrhea and malabsorption, those with T. trichiura usually present with prolonged diarrhea, blood-streaked stool, anemia, colitis, proctitis, and rectal prolapse (in patients with heavy infestation). Cases with T. spiralis usually have biphasic presentations that begin with clinical manifestations of nausea, vomiting, and diarrhea (intestinal phase) followed by intense myalgias and periorbital edema (muscular phase) [5]. Additionally, C. philippinensis typically involves the distal jejunum and proximal ileum, T. trichiura tends to cause lesions limited to the large bowel, and T. spiralis is typically associated with encysted larva that migrated to specific organ tissues (eg, muscle, myocardium, and brain). In each of our 4 reported cases, the initial stool specimen was negative for C. philippinensis. Subsequent stool specimens were positive for C. philippinensis in 2 patients, and all 4 had small-bowel biopsies remarkable for severe villous blunting, inflammatory cell infiltration, and visualization of nematodes in longitudinal sections with the identification of stichocytes
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