Anisakiasis (Anisakiases)

Anisakiasis is a rare parasitic disease in humans who eat raw marine fish and squid. It is caused by Anisakis nematodes when their larvae invade the gastrointestinal mucous membrane to cause inflammatory symptoms. Upper gastrointestinal endoscopy along with radiological investigations like ultrasonography and computed tomography help confirm the diagnosis.

Anisakiasis is induced by the following process: infectious.

Presentation

Anisakiasis is a rare parasitic disease which occurs when the larvae of the nematode Anisakis are ingested by humans through raw or undercooked fish or squid [1] [2]. The larvae invade the gastrointestinal lining leading to the symptoms of anisakiasis. The highest incidence of the illness has been reported to be in winter [3] due to the high consumption of raw fish in that season. The symptoms depend on the site invaded by the larvae and can be classified as gastric, intestinal, and ectopic anisakiasis [1] [4] [5]. A majority of the patients have gastric anisakiasis.

Symptoms of gastric anisakiasis typically start within 12 hours of ingestion of infected raw fish or squid [3] while those of intestinal anisakiasis have been reported to occur up to a week after ingestion [1] [6]. The commonest symptom is sudden onset severe abdominal or epigastric pain resembling an acute abdomen. This is accompanied by nausea and vomiting. Intestinal anisakiasis can present with symptoms resembling Crohn's disease with an inflammatory mass. Other reported presentations include severe hematemesis in patients with gastric ulcer and hemoptysis [3] [7] [8] [9] [10]. The Anisakis larvae do not survive for long in the human gastrointestinal tract and therefore the symptoms subside in a couple of weeks with medical management [11]. However, a few cases of intestinal strangulation and obstruction requiring surgical intervention have been reported [12] [13].

Skin
Urticaria
  • In some cases anisakiasis is accompanied by an allergic response, such as urticaria, angioedema and anaphylactic shock.[orpha.net]
  • Anisakis-induced urticaria is seen in about one in five cases. [ 6 ] Ingestion of dead worms in fish can cause severe hypersensitivity reactions.[patient.info]
  • Some affected persons may present with allergic symptoms such as urticaria, angioedema, pruritus, or tingling of the back of the throat immediately after ingestion of the infected raw fish.[visualdx.com]
  • Symptoms range from urticaria and isolated angioedema to anaphylaxis, and gastrointestinal symptoms can also occur.[med-chem.com]
  • Nonspecific prodromal symptoms, such as malaise, fever, urticaria, and nausea, may be observed shortly after ingestion of larvae.[academic.oup.com]
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  • gastrointestinal
    Vomiting
    • She initially experienced vomiting, diarrhoea and right-sided abdominal pain.[mja.com.au]
    • If misdiagnosed, it can become chronic, with intermittent abdominal pain, nausea and vomiting lasting from weeks to several years.[orpha.net]
    • The warning from doctors came after they provided treatment to a 32-year old healthy man who had severe epigastric pain (pain in the upper abdomen), vomiting, and fever for a week.[news-medical.net]
    • Gastrointestinal symptoms include abdominal pain, nausea and vomiting and complications like digestive bleeding, bowel obstruction, perforation and peritonitis can also arise."[cosmopolitan.com]
    • Vomiting can also be a symptom after consuming the parasites, and this may also expel the worm.[medicinenet.com]
    Nausea
    • If misdiagnosed, it can become chronic, with intermittent abdominal pain, nausea and vomiting lasting from weeks to several years.[orpha.net]
    • They further added that the disease is growing in western countries and advised healthcare professionals to think about the condition in patients with pain, nausea, vomiting, and other complications such as bowel obstruction and bleeding, who have recently[news-medical.net]
    • Symptoms and Signs Symptoms of anisakiasis typically include abdominal pain, nausea, and vomiting within hours of ingesting the larvae.[merckmanuals.com]
    • Gastrointestinal symptoms include abdominal pain, nausea and vomiting and complications like digestive bleeding, bowel obstruction, perforation and peritonitis can also arise."[cosmopolitan.com]
    • Symptoms include acute epigastric pain, nausea, and vomiting.[ofid.oxfordjournals.org]
    Abdominal Pain
    • pain, nausea, diarrhea Raw clams 2–3 days CT 4 days Ex lap, SBR Distal ileum Yes/Yes Yes Takano (2013) 63/M Abdominal pain, vomiting Raw fish 2 days AXR, CT NA Nonoperative therapy with ileus tube Small bowel NA NA Kojima (2013) 61/M Abdominal pain NA[ofid.oxfordjournals.org]
    • The chronic intestinal symptoms include weight loss, mild cramping, abdominal pain, and diarrhea, lasting for months or years.[orpha.net]
    • Symptoms of Anisakiasis embrace violent abdominal pain, nausea, and vomiting.[soundhealthsolution.com]
    • pain and an allergic reaction.[patient.info]
    • Symptoms and Signs Symptoms of anisakiasis typically include abdominal pain, nausea, and vomiting within hours of ingesting the larvae.[merckmanuals.com]
    Diarrhea
    • The chronic intestinal symptoms include weight loss, mild cramping, abdominal pain, and diarrhea, lasting for months or years.[orpha.net]
    • Symptoms of anisakiasis include nausea , vomiting , abdominal distention and pain , diarrhea , blood and/or mucus in the stool , and fever .[medicinenet.com]
    • The signs and symptoms of anisakiasis are abdominal pain, nausea, vomiting, abdominal distention, diarrhea, blood and mucus in stool, and mild fever.[outbreaknewstoday.com]
    • […] eating raw fish–eg, sushi; the larval stage of Anisakis simplex and Phocanema – Pseudoterranova decipiens account for all US cases of anisakiasis; another anasakine, Contracecum, may rarely cause anisakiasis Clinical A simplex –abdominal pain, N&V, diarrhea[medical-dictionary.thefreedictionary.com]
    Acute Abdomen
    • In 1960, in the Netherlands, van Thiel et al. found a worm in the intestinal wall of a patient who had eaten raw herring and had suffered symptoms of acute abdomen.[springer.com]
    • Because symptoms are vague, this disease is often misdiagnosed as appendicitis, acute abdomen, stomach ulcers, or ileitis.[streetdirectory.com]
    • References 1 Anisakidae and anisakidosis , Prog Clin Parasitol , 1993 , vol. 3 (pg. 43 - 102 ) 2 Study of 13 cases of anisakiasis in the province of Cordoba [in Spanish] , Med Clin (Barc) , 2000 , vol. 114 (pg. 177 - 80 ) 3 Acute abdomen due to small[doi.org]
    Epigastric Pain
    • Generally, removal of the larvae at endoscopy is curative for acute gastric anisakiasis and the severe epigastric pain disappears rapidly.[oatext.com]
    • The warning from doctors came after they provided treatment to a 32-year old healthy man who had severe epigastric pain (pain in the upper abdomen), vomiting, and fever for a week.[news-medical.net]
    • The larvae may invade the stomach wall, causing ulceration with nausea , vomiting , epigastric pain, and haematemesis (vomiting of blood).[wikihow.com]
    • pain, vomiting and low-grade fever since the previous week.[casereports.bmj.com]
    Food Poisoning
    • Researchers estimate that the number of anisakiasis cases occurring annually in Japan was approximately 7,000 and the anisakiasis cases reported to the Food Poisoning Statistics could be a tip of the iceberg.[outbreaknewstoday.com]
    • Getty The NHS warns that eating fish that is not fresh or that has not been stored and prepared hygienically can lead to food poisoning.[cosmopolitan.com]
    • The consumption of raw fish meat is more popular in winter season rather than in summer season in Korea because of the anxiety for food poisoning.[pubmedcentralcanada.ca]
    Abdominal Cramps
    • Ten days later, she developed nausea, vomiting, right-sided abdominal cramps associated with a sore throat, rhinorrhoea, nasal congestion, cough with production of yellow sputum, myalgia, fevers, chills and sweats.[mja.com.au]
    • Although treatment of intestinal obstruction with intravenous fluid and gastric decompression reduced the abdominal cramps and the radiological signs of intestinal obstruction [ 4 ], surgery is usually indicated when the disease is refractory to a conservative[doi.org]
    Colic
    • A fibrous mass (granuloma) forms in the intestine causing fever, colic and intermittent obstruction.[medical-dictionary.thefreedictionary.com]
    • Anisakidae Look For Subscription Required Diagnostic Pearls Subscription Required Differential Diagnosis & Pitfalls Gastric and intestinal anisakiasis may mimic: Peptic ulcer disease Primary eosinophilic gastroenteritis Gastrointestinal tuberculosis Biliary colic[visualdx.com]
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  • Entire body system
    Fever
    • The warning from doctors came after they provided treatment to a 32-year old healthy man who had severe epigastric pain (pain in the upper abdomen), vomiting, and fever for a week.[news-medical.net]
    • […] da Luz , Lisboa , Portugal Correspondence to Dr Joana Carmo, joanavcarmo{at}gmail.com Accepted 12 March 2017 Published 11 May 2017 Description A previously healthy man, aged 32 years, was admitted with severe epigastric pain, vomiting and low-grade fever[casereports.bmj.com]
    • He complained of severe upper gut pain, and also vomited and had a fever.[pulseheadlines.com]
    • Symptoms of anisakiasis include nausea , vomiting , abdominal distention and pain , diarrhea , blood and/or mucus in the stool , and fever .[medicinenet.com]
    • He had been suffering stomach pain, vomiting and fever for a week.[bbc.com]
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  • Workup

    Clinical suspicion is very vital in the work up for anisakiasis. The first step in the diagnosis is to obtain a history of ingestion of raw or undercooked fish or squid, if possible, as patients may forget details about their meals. After a thorough physical examination, the next step is to order routine laboratory tests like complete blood count, erythrocyte sedimentation rate, serum electrolytes and stool test for larvae, although stool test is not useful in most cases.

    Currently, upper gastrointestinal endoscopy forms the mainstay of the diagnosis and requires accurate interpretation of the clinical images to identify the causative worm sticking to the stomach wall. Intestinal anisakiasis is difficult to diagnose as the small intestine cannot be accessed with the endoscope [14]. Capsule endoscopy or double balloon endoscopy may not be available universally. Another method to diagnose anisakiasis is by examining Anisakis-specific immunoglobulin (Ig) A, IgG, and IgE. These tests have a high sensitivity [15] [16] but do not provide results immediately and are therefore not useful in practice.

    Radiological tests can help to confirm the diagnosis of anisakiasis. On ultrasonography, features of anisakiasis include severe localized Kerckring’s fold edema (corn sign), and dilatation of the proximal small intestine with the accumulation of fluid [14]. Computed tomography scan findings show partial small bowel edema and dilatation of the small intestine with fluid collection on the cranial side of the lesion [12] [17] [18].

    Pathology

    Other Pathologies
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  • Biopsy
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  • Laboratory

    Stool
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  • Serum
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  • Test Results

    Gastroscopy
  • more...
  • Colonoscopy
    Colitis
    • Gastric and intestinal anisakiasis may mimic: Peptic ulcer disease Primary eosinophilic gastroenteritis Gastrointestinal tuberculosis Biliary colic Cholecystitis Diverticulitis Appendicitis Inflammatory bowel disease (eg, Crohn disease , ulcerative colitis[visualdx.com]
    • Untreated anisakiasis may cause persistent inflammatory responses targeting remains of the larvae and can produce symptoms consistent with colitis, appendicitis, cholecystitis, or dyspepsia (12).[antimicrobe.org]
  • more...
  • Treatment

    Prognosis

    Complications

    Fever
    • The warning from doctors came after they provided treatment to a 32-year old healthy man who had severe epigastric pain (pain in the upper abdomen), vomiting, and fever for a week.[news-medical.net]
    • […] da Luz , Lisboa , Portugal Correspondence to Dr Joana Carmo, joanavcarmo{at}gmail.com Accepted 12 March 2017 Published 11 May 2017 Description A previously healthy man, aged 32 years, was admitted with severe epigastric pain, vomiting and low-grade fever[casereports.bmj.com]
    • He complained of severe upper gut pain, and also vomited and had a fever.[pulseheadlines.com]
    • Symptoms of anisakiasis include nausea , vomiting , abdominal distention and pain , diarrhea , blood and/or mucus in the stool , and fever .[medicinenet.com]
    • He had been suffering stomach pain, vomiting and fever for a week.[bbc.com]
    Urticaria
    • In some cases anisakiasis is accompanied by an allergic response, such as urticaria, angioedema and anaphylactic shock.[orpha.net]
    • Anisakis-induced urticaria is seen in about one in five cases. [ 6 ] Ingestion of dead worms in fish can cause severe hypersensitivity reactions.[patient.info]
    • Some affected persons may present with allergic symptoms such as urticaria, angioedema, pruritus, or tingling of the back of the throat immediately after ingestion of the infected raw fish.[visualdx.com]
    • Symptoms range from urticaria and isolated angioedema to anaphylaxis, and gastrointestinal symptoms can also occur.[med-chem.com]
    • Nonspecific prodromal symptoms, such as malaise, fever, urticaria, and nausea, may be observed shortly after ingestion of larvae.[academic.oup.com]
    Gastritis
    • A man with unsuspected marine eosinophilic gastritis .[nature.com]
    Colitis
    • Gastric and intestinal anisakiasis may mimic: Peptic ulcer disease Primary eosinophilic gastroenteritis Gastrointestinal tuberculosis Biliary colic Cholecystitis Diverticulitis Appendicitis Inflammatory bowel disease (eg, Crohn disease , ulcerative colitis[visualdx.com]
    • Untreated anisakiasis may cause persistent inflammatory responses targeting remains of the larvae and can produce symptoms consistent with colitis, appendicitis, cholecystitis, or dyspepsia (12).[antimicrobe.org]
    Food Poisoning
    • Researchers estimate that the number of anisakiasis cases occurring annually in Japan was approximately 7,000 and the anisakiasis cases reported to the Food Poisoning Statistics could be a tip of the iceberg.[outbreaknewstoday.com]
    • Getty The NHS warns that eating fish that is not fresh or that has not been stored and prepared hygienically can lead to food poisoning.[cosmopolitan.com]
    • The consumption of raw fish meat is more popular in winter season rather than in summer season in Korea because of the anxiety for food poisoning.[pubmedcentralcanada.ca]
    Eosinophilia
    • Clinical findings A simplex (abdominal pain, nausea, vomiting, diarrhoea) eosinophilia with occult blood in stool if gastric anisakiasis; leukocytosis without eosinophilia if intestinal anisakiasis.[medical-dictionary.thefreedictionary.com]
    • Laboratory tests showed 12,000 leukocytes without neutrophilia or eosinophilia.[journalmc.org]
    • […] symptoms include abdominal pain, nausea and vomiting and complications like digestive bleeding, bowel obstruction, perforation and peritonitis can also arise. 1 Patients can have a low-grade fever. 1 A severe leucocytosis can be present, but peripheral eosinophilia[casereports.bmj.com]
    • Eosinophilia occurs by the time a skin lesion begins to develop.[academic.oup.com]
    Eosinophilic Gastroenteritis
    • Eosinophilic gastroenteritis and anisakis.[antimicrobe.org]
    • gastroenteritis Gastrointestinal tuberculosis Biliary colic Cholecystitis Diverticulitis Appendicitis Inflammatory bowel disease (eg, Crohn disease , ulcerative colitis ) Intestinal obstruction ( small bowel , large bowel ) Bowel tumor Clinical differentiation[visualdx.com]
    • "Anisakis Infestation: A Case of Acute Abdomen Mimicking Crohn's Disease and Eosinophilic Gastroenteritis."[web.stanford.edu]

    Etiology

    Causes

    Parasite
    • parasites of the species, anisakis.[express.co.uk]
    • This way it will be possible to determine if the abundance of the parasite in certain areas varies with time, "which would allow to design and apply measures to limit human exposure to such parasites". ### Reference : Adela Valero / Francisco Javier Adroher[eurekalert.org]
    • Only when ingested by humans do the parasite cause such Anisakiasis.[bio390parasitology.blogspot.com]
    • Experts treated a 32-year-old man, in Lisbon, who was found to have parasite larvae on his gut lining.[bbc.com]
    • The culprit: Anisakiasis , a disease caused by parasitic worms.[cbsnews.com]

    Epidemiology

    Sex distribution
    Age distribution

    Pathophysiology

    Prevention

    Summary

    Patient Information

    Self-assessment

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    References

    1. Chai JY, Darwin Murrell K, Lymbery AJ. Fish-borne parasitic zoonoses: status and issues. Int J Parasitol. 2005;35:1233–1254.
    2. Sohn WM, Murrell JY. Anisakiosis (Anisakidosis) In: Palmer SR, Soulsby L, Torgerson PR, Brown DWG, editors. Oxford Textbook of Zoonoses-Biology, Clinical Practice, and Public Health Control. London, UK: Oxford University Press; 2011; pp. 774–786.
    3. Sohn WM, Na BK, Kim TH, Park TJ. Anisakiasis: report of 15 gastric cases caused by Anisakis Type I larvae and a brief review of Korean Anisakiasis cases. Korean J Parasitol. 2015 Aug; 53 (4): 465 -470
    4. Nawa Y, Hatz C, Blum J. Sushi delights and parasites: the risk of fishborne and foodborne parasitic zoonoses in Asia. Clin Infect Dis. 2005;41:1297–1303.
    5. Audicana MT, Kennedy MW. Anisakis simplex: from obscure infectious worm to inducer of immune hypersensitivity. Clin Microbiol Rev. 2008;21:360–379
    6. Shirahama M, Koga T, Ishibashi H, Uchida S, Ohta Y, Shimoda Y. Intestinal anisakiasis: US in diagnosis. Radiology. 1992;185:789–793.
    7. Lee EJ, Kim YC, Jeong HG, Lee OJ. The mucosal changes and influencing factors in upper gastrointestinal anisakiasis: analysis of 141 cases. Korean J Gastroenterol. 2009;53(2):90–97.
    8. Lee SH, Sin HG, Seol SY, Chung JM. A case of gastric anisakiasis causing severe gastric ulcer bleeding. Korean J Gastrointest Endosc. 1993;13:693–696.
    9. Lee HS, Park KS, Jung KT, et al. A case of chronic gastric anisakiasis with massive bleeding. Korean J Gastrointest Endosc. 1993;13:697–700.
    10. Kang DB, Park WC, Lee JK. Chronic gastric anisakiasis provoking a bleeding gastric ulcer. Ann Surg Treat Res. 2014;86:270–273.
    11. Matsui T, Iida M, Murakami M, et al. Intestinal anisakiasis: clinical and radiologic features. Radiology. 1985;157:299–302.
    12. Matsuo S, Azuma T, Susumu S, et al. Small bowel anisakiosis: a report of two cases. World J Gastroenterol. 2006;12:4106–4108
    13. Takabe K, Ohki S, Kunihiro O, et al. Anisakidosis: a cause of intestinal obstruction from eating sushi. Am J Gastroenterol. 1998;93:1172–1173.
    14. Shrestha S, Kisino A, Watanabe M, et al. Intestinal anisakiasis treated successfully with conservative therapy: importance of clinical diagnosis. Worl J Gastroenterol. 2014 Jan; 20 (2): 598 -602
    15. Suzuki T, Ishida K, Ishigaoka S, et al. Studies on the immunological diagnosis of Anisakiasis. Kiseichusi. 1975;24:184–191.
    16. Nisino C, Hayasaka H. Epidemiological Studies on Anisakiasis. Sapporoisi. 1977;46:73–88.
    17. Yoon SW, Yu JS, Park MS, et al. CT findings of surgically verified acute invasive small bowel anisakiasis resulting in small bowel obstruction. Yonsei Med J. 2004;45:739–742.
    18. Watanabe T, Ohta S, Iwamoto S, et al. Small bowel anisakiasis with self-limiting clinical course. Intern Med. 2008;47:2191–2192.

    • Acute abdomen due to small bowel anisakiasis - M Pellegrini, R Occhini, G Tordini, C Vindigni - Digestive and liver , 2005 - Elsevier
    • A case of acute gastric anisakiasis provoking severe clinical problems by multiple infection - JH Noh, BJ Kim, SM Kim, MS Ock - The Korean journal , 2003 - synapse.koreamed.org
    • A Case of Acute Gastric Anisakiasis Causing Massive Hematemesis - R Chang, YW Chang, BH Kim, HJ Kim - Korean Journal of , 1999 - KoreaMed
    • [New data on anisakiasis] - JC Petithory - Bulletin de l'Académie nationale de médecine, 2007 - ukpmc.ac.uk
    • A Thai Man Present with Skin Rash, Abdominal Pain and Bright Red Stool for 1 Day - D Chavalitdhamrong, S Manatsathit - Thai J Gastroenterol, 2005 - thaigastro.com
    • Acute gastric anisakiasis - A Muraoka, I Suehiro, M Fujii, K Nagata - Digestive diseases and , 1996 - Springer
    • [Study of 13 cases of anisakiasis in the province of Cordoba] - PD López, OLM Ramírez, PR del Rosal, RF López - Medicina , 2000 - ukpmc.ac.uk
    • [Contribution to the morphology and pathogenesis of eosinophilic colitis (author's transl)] - K Dumke, K Janitschke - Zeitschrift fur Gastroenterologie, 1981 - ukpmc.ac.uk
    • Anisakiasis caused by herring in vinegar: a little known medical problem. - MA Verhamme, CH Ramboer - Gut, 1988 - gut.bmj.com
    • [Study of 13 cases of anisakiasis in the province of Cordoba] - PD López, OLM Ramírez, PR del Rosal, RF López - Medicina , 2000 - ukpmc.ac.uk
    • Acute abdomen due to small bowel anisakiasis - M Pellegrini, R Occhini, G Tordini, C Vindigni - Digestive and liver , 2005 - Elsevier
    • A case of anisakiasis as a cause of ileum obstruction - T Tobe - Dig Surg, 1989 - content.karger.com
    • Acute abdomen due to small bowel anisakiasis - M Pellegrini, R Occhini, G Tordini, C Vindigni - Digestive and liver , 2005 - Elsevier
    • AMERICAN COLLEGE OF PHYSYCIANS - PR CHAPTER - prhsj.rcm.upr.edu
    • Anisakis pegreffii experimental challenge in Dicentrarchus labrax: An endoscopic study - F Macrì, G Lanteri, G Rapisarda, A Costa, F Marino - Aquaculture, 2012 - Elsevier
    • Anisakiasis. - JA Sakanari, JH McKerrow - Clinical microbiology reviews, 1989 - Am Soc Microbiol
    • A case report of serologically diagnosed pulmonary anisakiasis with pleural effusion and multiple lesions. - H Matsuoka, T Nakama, H Kisanuki, H Uno - The American journal , 1994 - ukpmc.ac.uk
    • . Helminthiases. Acanthocephaliases and Nematodiases listed A to D (Acanathocephaliasis; Angiostrongyliasis; Anisakiasis; Ascariasis; Baylisascariasis; Capillariasis - PN Acha, B Szyfres - Diseases Common to Man and Animals. , 2003 - ingentaconnect.com
    • A Case of Duodenal Anisakiasis with Duodenal Ulcer - D Hwang, SI Park, SC Pack, KS Lee - Chonnam Medical , 2012 - synapse.koreamed.org
    • Case 20-1992 - RC Cabot, RE Scully, EJ Mark - England Journal of , 1992 - Mass Medical Soc
    • A Case of chronic gastric anisakiasis with massive bleeding - HS Lee, KS Park, KT Jung, SJ Yoo, JH Kho - Korean Journal of , 1993 - KoreaMed
    • Anisakis infestation: a case of acute abdomen mimicking Crohn's disease and eosinophilic gastroenteritis - M Montalto, L Miele, A Marcheggiano, L Santoro - Digestive and liver , 2005 - Elsevier

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