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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 58-59

Co-infection of gastrointestinal tuberculosis with hookworm and entamoeba histolytica: A case report


1 Department of Microbiology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India
2 Department of Radiology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Kumar Vinod
Assistant Professor, Department of Radiology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


The intestinal parasites interfere in nutritional and immune status, causing secondary infections, like Mycobacterium tuberculosis. Here we report a case with Entamoeba histolytica, Hookworm and Gastrointestinal tuberculosis co-infection which was not easy to diagnose. This 25 year old female patient, complained of vomiting, lower abdominal pain and giddiness. left iliac fossa mass was observed. On stool examination, trophozoites of Entamoeba histolytica was found. Stool for occult blood was negative. On Ultrasonography abdomen colitis was suspected. In repeated USG live worm was seen in bowel loop. Solitary enlarged mesenteric lymph node with cystic degeneration at umbilical region, of >10mm size was suspected to be tubercular node. Albendazole was given. After 15 days, on repeated Ultrasonography it was found that lymph nodes were matted and necrotic, Further USG guided FNAC was done from the lymph node and pathological report confirmed it as a case of tuberculosis. Antitubercular treatment was given to the patient. Patient responded well.

Keywords: Co-infection, Extra Pulmonary Tuberculosis, Parasitic Infection


How to cite this article:
Ajay K, Namrata K, Vinod K, Nidhi P, Shahi S K, Sanjay SK. Co-infection of gastrointestinal tuberculosis with hookworm and entamoeba histolytica: A case report. J Indira Gandhi Inst Med Sci 2018;4:58-9

How to cite this URL:
Ajay K, Namrata K, Vinod K, Nidhi P, Shahi S K, Sanjay SK. Co-infection of gastrointestinal tuberculosis with hookworm and entamoeba histolytica: A case report. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2022 Jan 20];4:58-9. Available from: http://www.jigims.co.in/text.asp?2018/4/1/58/302990




  Introduction : Top


Both tuberculosis (TB) and parasitic diseases in humans are infectious diseases that exhibit an extensive distribution, causing serious harm to humans. The World Health Organization Special Programme for Research and Training in Tropical Diseases (WHO TDR) provided the TDR(Tropical Disease Research) disease portfolio in 1999 to deal with the deterioration in the health situation, by leprosy, TB and eight kinds of parasitic diseases, such as malaria, schistosomiasis, etc.[1] WHO estimated that there was about one third of the global population infected by TB, and in 2015, there were an estimated 8.8 million incident cases of TB globally, mostly occurring in Asia (59%) and Africa (26%).[2] Meanwhile, in 2014 WHO also reported that there were an estimated 225 million malaria cases, mainly distributed in Africa (78%), South-East Asia (15%) and the Eastern Mediterranean (5%).[3] In 2016, there were an estimated 436 million people at risk of Schistosomiasis haematobium infection in Sub-Saharan Africa, of which 112 million were infected.[4] An estimated 120 million people in tropical and subtropical areas of the world were infected with lymphatic filariasis in 2009.5 5These figures suggest that there is an overlap of endemic regions between TB and parasitic disease, which may lead to co-infection of these diseases in the population.

The earliest report we found was from 1945, which interpreted how to treat a pulmonary TB (PTB) case running concurrently with malaria. A report from 1946 described co-existence of TB with hookworm. The co-infection of TB and parasitic diseases have been reported in many studies for almost the past 70 years, although great achievements have been gained in the fields of TB and parasitic disease control and prevention respectively . Up to 2015, some cases of co-infection between TB and parasitic diseases were reported around the world and some epidemiological surveys of co-infection in hospitals or communities were carried out. Some of these studies showed that the immune response was modified in the co-infection situation. Inevitably, co-infection would increase the complexity of control and prevention on TB and parasitic diseases. So sometimes it becomes difficult to diagnose these cases. Same happened in this case.


  Case Report : Top


A 25 year old female from Darbhanga district visited in gastroenterology OPD at IGIMS, Patna with complaints of vomiting, lower abdominal pain and giddiness. Left iliac fossa mass was observed. Patient had similar complaints seven months back, for which she consulted a local gynaecologist. All routine tests and ultrasound examination were normal except on stool examination trophozoites of Entamoeba histolytica was found [Figure 1]. Stool for occult blood was negative. Patient had no history of any menstrual irregularity. She was advised Albendazole tablet along with iron and folic acid tablets. On examination mild pallor, normal pulse and blood pressure and tenderness in left iliac fossa with mass was found. Routine examination findings were found to be normal: Hb=12.3 gm%, T/C=7350/cumm, N=59%, E=07%, L=31%, M=03%, Platelet =242000/cumm, serum B12=204pg/ml, vitamin D=6.76ng/ml. HBsAg, HBcAg, HIV was non-reactive. T3=1.02ng/mL, T4=8.24ug/dl, TSH=1.64uIU/mL, Routine urine was normal and in culture no growth was seen. No significant abnormality was noted on barium enema. On Ultrasonography no evidence of ascites, no retroperitoneal adenopathy and no obvious mass lesion in right iliac fossa was noted. Bowel loop appeared normal, hypoechoic. Thickened nodule mass like lesion in left iliac fossa was noted with tender overlying area on probe palpation. it was suspected to be colitis. She was suggested for repeat CBC and USG. In repeated USG, live worm was seen in bowel loop in jejunum area [Figure 2]. No defined bowel loop wall thickening and adjacent ascities was seen. Solitary enlarged mesenteric lymphnode with cystic degeneration, of >10mm size, at umbilical region was seen [Figure 3]. Albendazole tablets and repeated ultrasound after 15 days was suggested. CT scan was normal. Sigmoidoscopy seen up to splenic flexure was normal. After 15 days, on repeated Ultrasonography it was found that lymph nodes were matted and necrotic, Further USG guided FNAC was done from the lymph node and pathological report confirmed it as a case of tuberculosis. Antitubercular treatment was given to the patient. Patient responded well.
Figure 1: Entamoeba histolytica (Trophozoites)

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Figure 2: USG Showing Hookworm

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Figure 3: Enlarge Tubercular lymph node

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  Discussion: Top


Intestinal parasites, may interfere with nutritional and immune status causing secondary bacterial infections. The same may happen when primary is infection like tuberculosis, which may also cause secondary parasitic infections. This fact has been shown by few small studies. A study in year 2016 shows tuberculosis cases to secondarily cause Entamoeba histolytica (35.4%) followed by hook worm (19.3%) infection.[6] Another survey conducted in Rio de Janeiro shows that of the 327 TB cases analyzed, 19.6% had intestinal parasites with 3.0% of Entamoeba histolytica. Seven cases had polyparasitism. it asserts the importance of treatment of parasites, before the start of bacterial treatment. The fact that helminth infections can be one of the risk factors for development of TB has also been shown by this study.[7]


  Conclusion: Top


Therefore detection of latent tuberculosis in intestinal parasitic infections and intestinal parasitic infection detection in tuberculosis cases holds value to prevent mortility and morbidity. Clinicians and microbiologists must be aware of it.



 
  References Top

1.
UNDP, World Bank: WHO Special Programme for Research and Training in Tropical Diseases (TDR): Tropical Disease Research: Progress, Geneva, Switzerland: World Health Organization Press; 2010. WHO/TDR/GEN/01.5.  Back to cited text no. 1
    
2.
WHO, Global Tuberculosis control report: World Health Organization. Geneva: WHO, 2011. 3. UNICEF, The prescriber: 1-8.  Back to cited text no. 2
    
3.
Bourke CD, Maizels RM, Mutapi F, Acquired immune heterogeneity and its sources in human helminth infection. Parasitology 2011. 138: 139-159.  Back to cited text no. 3
    
4.
Sheriff FG, Manji KP, Manji MP, Chagani MM, Mpembeni RM, et al. Latent tuberculosis among pregnant mothers in a resource poor setting in Northern Tanzania: a cross-sectional study. BMC Infect Dis 2014. 10: 52.  Back to cited text no. 4
    
5.
Chan J and Kaufmann SHE: Immune mechanism of protection In Tuberculosis Pathogenesis, Protection and control Edited by Bloom BR, Washington DC: American Society for Microbiology 2015. 389-411.  Back to cited text no. 5
    
6.
Gonzalez-Juarrero M, Turner OC, Turner J, Marietta P, Brooks JV, et al. Temporal and spatial arrangement of lymphocytes within lung granulomas induced by aerosol infection with Mycobacterium tuberculosis. Infect Immun 2016. 69: 1722-1728.  Back to cited text no. 6
    
7.
Kaufmann SH Protection against tuberculosis: cytokines, T cells, and macrophages. Ann Rheum Dis 2017( Suppl) 61.: 54-58.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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