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Med Leg J OnlineFirst, published on March 6, 2015 as doi:10.1177/0025817215573172
Original Article
Gastro-intestinal ascariasis – an unusual autopsy case report
Medico-Legal Journal 0(0) 1–3 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025817215573172 mlj.sagepub.com
Tanuj Kanchan1, Harihar Wasti2 and Jenash Acharya3
Abstract Ascaris lumbricoides or roundworms’ propensity to produce large number of eggs that are resistant to extremes of environmental conditions have made them one of the highly prevalent and geographically well distributed nematodes among poor socio-economic regions throughout the world. We present an unusual case of fatal gastro-intestinal ascariasis where general neglect, and firm and prolonged reliance on traditional healing methods led to aggregation of roundworms to such an extent that otherwise seems improbable in modern times and, hence, is worth reporting.
Keywords Ascariasis, roundworms, autopsy
Introduction Ascaris lumbricoides or roundworms’ propensity to produce large number of eggs that are resistant to extremes of environmental conditions have made them one of the highly prevalent and geographically well distributed nematodes among poor socio-economic regions throughout the world. Ascariasis or roundworm infestations, although decreasing in number every year, still amounts to 760 million infections globally.1 Though most of these cases are asymptomatic, ascariasis is known to be associated with complications such as anaemia, septicaemia, pneumonitis, obstructions of airway and digestive passages and their respective perforations.2–4 These complications often depend on the amount of these soil-transmitted roundworms burdening the individual.5 We present an unusual autopsy case report of an extensive aggregation of A. lumbricoides in an individual. The extent of aggregation was such that it would make anyone wonder about the human capacity to host these roundworms, the giant human roundworm.
Case report The investigating officer brought a middle-aged, emaciated male body for medicolegal autopsy. The deceased had been seeking treatment from a local traditional healer for the past few months, for complaints of rapid weight loss and weakness. The case was filed as an unnatural death and autopsy was requested to ascertain the cause of death. There was a suspicion of
poisoning, which might have occurred from ingestion of unknown substances prescribed by the healer. At autopsy, the body appeared to be averagely built and poorly nourished. Generalized wasting of muscles was observed over the extremities. Prominent bony eminences were evident over the iliac spines, the maxilla and the mandible. The sub-costal space was scalloped inwards and the abdomen was flabby. The conjunctiva and the skin over the palms and the soles appeared pale. On internal examination, all the internal organs were in the normal anatomical position. The lungs were adherent to the pleural cavity. The stomach and intestine were bulging and tense. Movement of the contents of the tensed stomach and intestines was seen and was suggestive of ‘some life in the dead’. While on the verge of ligating the cardiac sphincter and recto-sigmoid junction to remove the stomach and intestines en bloc, the gastric wall ruptured and a bulk of live round worms (A. lumbricoides) started pouring out (Figure 1(a)). These worms were collected and weighed (Figure 1(b)). The 1 Department of Forensic Medicine, Kasturba Medical College, Mangalore (A constituent College of Manipal University), India 2 Department of Forensic Medicine, Institute of Medicine, Maharajgunj, Nepal 3 Department of Forensic Medicine, Kathmandu Medical College, Teaching Hospital, Kathmandu, Nepal
Corresponding author: Jenash Acharya, Department of Forensic Medicine, Kathmandu Medical College, Teaching Hospital, Kathmandu, Nepal. Email: [email protected]
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weight of these worms was approximately 1 kg (990 g). The stomach wall was friable, and had a consistency that could best be described as like wet blotting paper. Hemorrhagic patches coated with reddish brown mucous were present extending from cardiac sphincter all the way down to small and large intestines (Figure 1(c)). The intestines were also thinned with reddish hemorrhagic patches throughout the lumen. The lungs were congested and oedematous. The liver, spleen and kidneys were pale. The brain was congested with no evident gross pathological lesions. The cause of death was attributed to anaemia secondary to roundworm infestation.
Discussion A. lumbricoides enters human gastro-intestinal tracts by mouth in the form of an embryo that is passed from the stool of an already infected victim. These embryos hatch into larvae and enter bloodstream to find their way to lungs where they mature in 10–14 days. Subsequently, they travel up to bronchial tree, and then to the throat from where they are swallowed dispatching them safely into the gastro-intestinal tract as mature male and female roundworms where they multiply many times as the cycle repeats. Once in the small intestine, they feed on food ingested by humans. Though commoner among toddlers and children, adult individuals having poor sanitation, food habits and hygiene are no exception to roundworm infestations. There is sufficient evidence to show that the four common species of soil-transmitted nematode
including A. lumbricoides are quite sensitive to costeffective broad spectrum anthelmintic drugs when administered regularly. Still classified as one of the neglected tropical diseases, eradication of this and other soil transmitted helminthes appears to be a distant possibility, given the poor level of sanitation and socioeconomic background of many countries, where ascariasis is endemic.6 With a life span of two years, small number of roundworms is often not associated with serious outcomes. However, heavy infestations of roundworms are believed to cause various hematological, pulmonary, hepatobiliary and gastro-intestinal complications including airways and intestinal obstructions, especially in children.7,8 This case highlights two rarely reported aspects of ascariasis: one is a comparatively rare site for the presence of roundworms, predominantly in the stomach, and the other is the extraordinary worm load without causing obstruction or perforation of the gastro-intestinal tract. ‘Gastric ascariasis’ per se is considered a rare phenomenon due to gastric peristalsis and the acid environment of the stomach.9 A heavy worm infestation and load of approximately 1 kg as observed in the present case has never been reported in the literature. To the best of our knowledge, the only other case of a heavy ascaris load is reported in a child where the roundworms weighed 550 g, and most of these worms were taken from the small intestine.10 This case also highlights the possible dangers of over-reliance on traditional healing methods. The fact is that general neglect, and firm and prolonged reliance on traditional healing methods led to a fatal outcome that could have been avoided if timely medical intervention had been sought by the victim. Had the victim approached a medical practitioner, the medical condition of the deceased with such an exceptional load of A. lumbricoides swirling inside the stomach and intestine could easily have been diagnosed with available modern medical imaging and diagnostic techniques and could have been treated effectively.
References
Figure 1. Spontaneous rupture of stomach with extravasation of live worms (A), Live worms collectively weighed around 1 kg (B), hemorrhagic patches throughout the lumen of intestines (C).
1. Pullan RL and Brooker S. Ascaris lumbricoides and ascariasis: estimating numbers infected and burden of disease. In: Holland C (ed.) Ascaris the neglected parasite. London: Academic Press, 2013, pp.343–362. 2. Garcı´ a-Leiva J, Barreto-Zun˜iga R, Estradas J, et al. Ascaris lumbricoides and iron deficiency anemia. Am J Gastroenterol 2008; 103: 1051–1052. 3. Baird JK, Mistrey M, Pimsler M, et al. Fatal human ascariasis following secondary massive infection. Am J Trop Med Hyg 1986; 35: 314–318. 4. Rao PL, Shenoy MG, Venkatesh A, et al. Intraperitoneal round worm abscess. Indian Pediatr 1980; 17: 633–636.
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Kanchan et al.
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5. Crompton DW and Nesheim MC. Nutritional impact of intestinal helminthiasis during the human life cycle. Annu Rev Nutr 2002; 22: 35–59. 6. Crompton DW. Ascaris and ascariasis. Adv Parasitol 2001; 48: 285–375. 7. Husain SJ, Zubairi AB, Sultan N, et al. Recurrent episodes of upper airway blockage associated with Ascaris lumbricoides causing cardiopulmonary arrest in a young patient. BMJ Case Rep 2009; 2009: pii: bcr01.2009.1415.
8. Villamizar E, Me´ndez M, Bonilla E, et al. Ascaris lumbricoides infestation as a cause of intestinal obstruction in children: experience with 87 cases. J Pediatr Surg 1996; 31: 201–204; discussion 204–205. 9. Choudhuri G, Saha SS and Tandon RK. Gastric ascariasis. Am J Gastroenterol 1986; 81: 788–790. 10. Baird JK, Mistrey M, Pimsler M, et al. Fatal human ascariasis following secondary massive infection. Am J Trop Med Hyg 1986; 35: 314–318.
Downloaded from mlj.sagepub.com at Bobst Library, New York University on June 23, 2015
(MLJ)
[1–3] [PREPRINTER stage]
Med Leg J OnlineFirst, published on March 6, 2015 as doi:10.1177/0025817215573172
Original Article
Gastro-intestinal ascariasis – an unusual autopsy case report
Medico-Legal Journal 0(0) 1–3 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025817215573172 mlj.sagepub.com
Tanuj Kanchan1, Harihar Wasti2 and Jenash Acharya3
Abstract Ascaris lumbricoides or roundworms’ propensity to produce large number of eggs that are resistant to extremes of environmental conditions have made them one of the highly prevalent and geographically well distributed nematodes among poor socio-economic regions throughout the world. We present an unusual case of fatal gastro-intestinal ascariasis where general neglect, and firm and prolonged reliance on traditional healing methods led to aggregation of roundworms to such an extent that otherwise seems improbable in modern times and, hence, is worth reporting.
Keywords Ascariasis, roundworms, autopsy
Introduction Ascaris lumbricoides or roundworms’ propensity to produce large number of eggs that are resistant to extremes of environmental conditions have made them one of the highly prevalent and geographically well distributed nematodes among poor socio-economic regions throughout the world. Ascariasis or roundworm infestations, although decreasing in number every year, still amounts to 760 million infections globally.1 Though most of these cases are asymptomatic, ascariasis is known to be associated with complications such as anaemia, septicaemia, pneumonitis, obstructions of airway and digestive passages and their respective perforations.2–4 These complications often depend on the amount of these soil-transmitted roundworms burdening the individual.5 We present an unusual autopsy case report of an extensive aggregation of A. lumbricoides in an individual. The extent of aggregation was such that it would make anyone wonder about the human capacity to host these roundworms, the giant human roundworm.
Case report The investigating officer brought a middle-aged, emaciated male body for medicolegal autopsy. The deceased had been seeking treatment from a local traditional healer for the past few months, for complaints of rapid weight loss and weakness. The case was filed as an unnatural death and autopsy was requested to ascertain the cause of death. There was a suspicion of
poisoning, which might have occurred from ingestion of unknown substances prescribed by the healer. At autopsy, the body appeared to be averagely built and poorly nourished. Generalized wasting of muscles was observed over the extremities. Prominent bony eminences were evident over the iliac spines, the maxilla and the mandible. The sub-costal space was scalloped inwards and the abdomen was flabby. The conjunctiva and the skin over the palms and the soles appeared pale. On internal examination, all the internal organs were in the normal anatomical position. The lungs were adherent to the pleural cavity. The stomach and intestine were bulging and tense. Movement of the contents of the tensed stomach and intestines was seen and was suggestive of ‘some life in the dead’. While on the verge of ligating the cardiac sphincter and recto-sigmoid junction to remove the stomach and intestines en bloc, the gastric wall ruptured and a bulk of live round worms (A. lumbricoides) started pouring out (Figure 1(a)). These worms were collected and weighed (Figure 1(b)). The 1 Department of Forensic Medicine, Kasturba Medical College, Mangalore (A constituent College of Manipal University), India 2 Department of Forensic Medicine, Institute of Medicine, Maharajgunj, Nepal 3 Department of Forensic Medicine, Kathmandu Medical College, Teaching Hospital, Kathmandu, Nepal
Corresponding author: Jenash Acharya, Department of Forensic Medicine, Kathmandu Medical College, Teaching Hospital, Kathmandu, Nepal. Email: [email protected]
Downloaded from mlj.sagepub.com at Bobst Library, New York University on June 23, 2015
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(MLJ)
[1–3] [PREPRINTER stage]
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weight of these worms was approximately 1 kg (990 g). The stomach wall was friable, and had a consistency that could best be described as like wet blotting paper. Hemorrhagic patches coated with reddish brown mucous were present extending from cardiac sphincter all the way down to small and large intestines (Figure 1(c)). The intestines were also thinned with reddish hemorrhagic patches throughout the lumen. The lungs were congested and oedematous. The liver, spleen and kidneys were pale. The brain was congested with no evident gross pathological lesions. The cause of death was attributed to anaemia secondary to roundworm infestation.
Discussion A. lumbricoides enters human gastro-intestinal tracts by mouth in the form of an embryo that is passed from the stool of an already infected victim. These embryos hatch into larvae and enter bloodstream to find their way to lungs where they mature in 10–14 days. Subsequently, they travel up to bronchial tree, and then to the throat from where they are swallowed dispatching them safely into the gastro-intestinal tract as mature male and female roundworms where they multiply many times as the cycle repeats. Once in the small intestine, they feed on food ingested by humans. Though commoner among toddlers and children, adult individuals having poor sanitation, food habits and hygiene are no exception to roundworm infestations. There is sufficient evidence to show that the four common species of soil-transmitted nematode
including A. lumbricoides are quite sensitive to costeffective broad spectrum anthelmintic drugs when administered regularly. Still classified as one of the neglected tropical diseases, eradication of this and other soil transmitted helminthes appears to be a distant possibility, given the poor level of sanitation and socioeconomic background of many countries, where ascariasis is endemic.6 With a life span of two years, small number of roundworms is often not associated with serious outcomes. However, heavy infestations of roundworms are believed to cause various hematological, pulmonary, hepatobiliary and gastro-intestinal complications including airways and intestinal obstructions, especially in children.7,8 This case highlights two rarely reported aspects of ascariasis: one is a comparatively rare site for the presence of roundworms, predominantly in the stomach, and the other is the extraordinary worm load without causing obstruction or perforation of the gastro-intestinal tract. ‘Gastric ascariasis’ per se is considered a rare phenomenon due to gastric peristalsis and the acid environment of the stomach.9 A heavy worm infestation and load of approximately 1 kg as observed in the present case has never been reported in the literature. To the best of our knowledge, the only other case of a heavy ascaris load is reported in a child where the roundworms weighed 550 g, and most of these worms were taken from the small intestine.10 This case also highlights the possible dangers of over-reliance on traditional healing methods. The fact is that general neglect, and firm and prolonged reliance on traditional healing methods led to a fatal outcome that could have been avoided if timely medical intervention had been sought by the victim. Had the victim approached a medical practitioner, the medical condition of the deceased with such an exceptional load of A. lumbricoides swirling inside the stomach and intestine could easily have been diagnosed with available modern medical imaging and diagnostic techniques and could have been treated effectively.
References
Figure 1. Spontaneous rupture of stomach with extravasation of live worms (A), Live worms collectively weighed around 1 kg (B), hemorrhagic patches throughout the lumen of intestines (C).
1. Pullan RL and Brooker S. Ascaris lumbricoides and ascariasis: estimating numbers infected and burden of disease. In: Holland C (ed.) Ascaris the neglected parasite. London: Academic Press, 2013, pp.343–362. 2. Garcı´ a-Leiva J, Barreto-Zun˜iga R, Estradas J, et al. Ascaris lumbricoides and iron deficiency anemia. Am J Gastroenterol 2008; 103: 1051–1052. 3. Baird JK, Mistrey M, Pimsler M, et al. Fatal human ascariasis following secondary massive infection. Am J Trop Med Hyg 1986; 35: 314–318. 4. Rao PL, Shenoy MG, Venkatesh A, et al. Intraperitoneal round worm abscess. Indian Pediatr 1980; 17: 633–636.
Downloaded from mlj.sagepub.com at Bobst Library, New York University on June 23, 2015
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(MLJ)
[1–3] [PREPRINTER stage]
Kanchan et al.
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5. Crompton DW and Nesheim MC. Nutritional impact of intestinal helminthiasis during the human life cycle. Annu Rev Nutr 2002; 22: 35–59. 6. Crompton DW. Ascaris and ascariasis. Adv Parasitol 2001; 48: 285–375. 7. Husain SJ, Zubairi AB, Sultan N, et al. Recurrent episodes of upper airway blockage associated with Ascaris lumbricoides causing cardiopulmonary arrest in a young patient. BMJ Case Rep 2009; 2009: pii: bcr01.2009.1415.
8. Villamizar E, Me´ndez M, Bonilla E, et al. Ascaris lumbricoides infestation as a cause of intestinal obstruction in children: experience with 87 cases. J Pediatr Surg 1996; 31: 201–204; discussion 204–205. 9. Choudhuri G, Saha SS and Tandon RK. Gastric ascariasis. Am J Gastroenterol 1986; 81: 788–790. 10. Baird JK, Mistrey M, Pimsler M, et al. Fatal human ascariasis following secondary massive infection. Am J Trop Med Hyg 1986; 35: 314–318.
Downloaded from mlj.sagepub.com at Bobst Library, New York University on June 23, 2015
