Protein-losing enteropathy—vomiting the diagnosis

Excerpt

Protein-losing enteropathy is uncommonly due to intestinal worm infestations. The 20-year-old lady reported here presented with bilateral progressive pedal edema for 2 months without abdominal distension, facial puffiness, or other symptoms. Physical examination was unremarkable except for pedal edema. Her body mass index was 17.1 kg/m². Laboratory evaluation revealed microcytic anemia (hemoglobin 10.8 g/dL) and low levels of total protein (4.2 g/dL) and albumin (1.8 g/dL). Cardiac, thyroid, and renal functions were normal and there was no eosinophilia. Ultrasound abdomen revealed mild ascites. Before the malabsorption work up was done, while hospitalized, she vomited pink worms that gave us the diagnosis! Upper gastrointestinal endoscopy revealed multiple motile worms in the duodenum, which range from 1 to 5 cm long and from 0.5 to 2 cm wide (Fig. 1). Few adult worms were retrieved and identified as Fasciolopsis buski. Colonoscopy also revealed infestation in the terminal ileum and right colon (Fig. 2). The patient was treated with praziquantel (25 mg/kg, single dose). Repeat total protein and albumin levels were 5.8 and 2.5 g/dL, respectively, after 15 days. The infestation is acquired through eating raw or insufficiently cooked fish or molluscs and is usually asymptomatic. Heavy infestation may cause diarrhea, vomiting, malabsorption, intestinal obstruction, perforation, and eosinophilic leukocytosis [1, 2].

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