A 5-year-old girl is brought to the office by her mother due to 2 weeks of anorexia, nausea, epigastric discomfort, and loose bowel movements. She has had no fever or bloody stools. The patient recently returned from rural Brazil, where she spent the summer with family. She had no gastrointestinal symptoms during the trip but developed intensely pruritic eruptions between the toes of her right foot. The skin rash spontaneously resolved within a few days and was attributed to insect bites from walking barefoot in the fields. The patient has no prior medical conditions, takes no medications, and has received all age-appropriate vaccinations. On physical examination, the abdomen is soft and nontender with normoactive bowel sounds. Stool microscopy reveals smooth, thin-walled eggs. If left untreated, this patient's condition can lead to which of the following complications?

Question

A 5-year-old girl is brought to the office by her mother due to 2 weeks of anorexia, nausea, epigastric discomfort, and loose bowel movements.  She has had no fever or bloody stools.  The patient recently returned from rural Brazil, where she spent the summer with family.  She had no gastrointestinal symptoms during the trip but developed intensely pruritic eruptions between the toes of her right foot.  The skin rash spontaneously resolved within a few days and was attributed to insect bites from walking barefoot in the fields.  The patient has no prior medical conditions, takes no medications, and has received all age-appropriate vaccinations.  On physical examination, the abdomen is soft and nontender with normoactive bowel sounds.  Stool microscopy reveals smooth, thin-walled eggs.  If left untreated, this patient's condition can lead to which of the following complications?

Quizplus · Accepted Answer

11ec160b_383a_9f76_9249_3b323c3b6c07_MD0001_00 Human hookworm infection is caused by Necator americanus and Ancylostoma duodenale. These pathogens are called hookworms because the head of the worm is often curved away from the body, giving the organism a "hooked" appearance. Most cases occur in tropical and subtropical regions where sanitation is poor. Transmission occurs when egg-containing human feces is deposited into shady, warm, moist soil, which allows the eggs to hatch into larvae. Spread occurs when larvae come into direct contact with human skin (eg, when walking barefoot). Dermal penetration often results in a transient, pruritic, maculopapular or serpiginous rash at the entry site. The larvae then spread through the bloodstream to the lungs, where they rupture into the alveoli and are subsequently coughed up and swallowed. In the small intestine, the larvae mature into adults, attach to the gastrointestinal mucosa, and feed on human blood by lacerating capillaries. Because these organisms can live in the gastrointestinal tract for up to 14 years, total blood loss can be substantial. Therefore, the biggest risk of hookworm infection is iron-deficiency anemia (microcytic anemia) due to chronic blood loss. Although many patients with hookworm infection are asymptomatic for months or years, some individuals develop transient pulmonary symptoms (eg, cough) during pulmonary migration or gastrointestinal symptoms (eg, nausea, vomiting, diarrhea) during gastrointestinal migration. Diagnosis is generally made when smooth, thin-walled hookworm eggs are identified by stool microscopy. Peripheral eosinophilia is also an important diagnostic clue. (Choice A) Lymphatic filariasis is a mosquito-borne illness caused by roundworms (eg, Wuchereria bancrofti). Most patients are infected in childhood and remain asymptomatic, but a minority develops chronic lymphedema, which may result in elephantiasis. Eggs are not present in stool; diagnosis is made by serology or by identifying worms in the lymphatic system. (Choice B) Chagas disease is linked to dilated cardiomyopathy and is most common in Latin America. It is caused by the protozoa Trypanosoma cruzi. Transmission occurs during a triatomine bug bite. Although transient skin and gastrointestinal symptoms can occur during acute infection, eggs are not seen in the stool; diagnosis is made mostly by serology or by blood microscopy. (Choice C) Toxocariasis is caused by infection with dog or cat roundworms. Migrating larva cause a significant eosinophilic granulomatous response that can result in ocular (endophthalmitis) and organ damage. Diagnosis is made by serology; the organism does not shed eggs in the gastrointestinal tract. (Choice E) Diphyllobothriasis is caused by infection with a fish tapeworm and is classically linked with megaloblastic anemia due to vitamin B12 deficiency. Although the eggs can be seen on stool microscopy, they are distinguished by a lid-like opening (operculum). In addition, a transient skin rash would not be a feature of this disease. Educational objective: Hookworms are transmitted when human skin comes into contact with soil contaminated with human feces. The larvae penetrate the skin, travel to the lungs, are coughed up, and then subsequently swallowed. Adult hookworms live in the small intestine and feed on human blood. Therefore, chronic iron deficiency anemia (microcytic anemia) is the greatest complication. __________ References: Soil-transmitted helminth infections. (http://www.ncbi.nlm.nih.gov/pubmed/28882382)

A 5-Year-Old Girl Is Brought to the Office by Her