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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.


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].

Fever
  • A 22-years-old man living in Hyuga City, Miyazaki Prefecture, Japan, developed high fever, respiratory distress, and pleural effusion after consumption of raw fish.[ncbi.nlm.nih.gov]
  • 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]
  • Symptoms include Abdominal pain, nausea, vomiting, abdominal distention, diarrhea, blood and mucus in stool, and mild fever Treatment can be done by endoscopy or surgery by removing worms from the body[omicsonline.org]
  • Gastroenterology, Hospital da Luz, Lisboa, Portugal Correspondence to Dr Joana Carmo, joanavcarmo{at}gmail.com Statistics from Altmetric.com Description A previously healthy man, aged 32 years, was admitted with severe epigastric pain, vomiting and low-grade fever[casereports.bmj.com]
  • Symptoms of anisakiasis include nausea, vomiting, abdominal distention and pain, diarrhea, blood and/or mucus in the stool, and fever. Allergic reactions can also occur.[medicinenet.com]
High Fever
  • A 22-years-old man living in Hyuga City, Miyazaki Prefecture, Japan, developed high fever, respiratory distress, and pleural effusion after consumption of raw fish.[ncbi.nlm.nih.gov]
Splenectomy
  • Surgical treatment was performed successfully and consisted of excision of the gastric lesion and splenectomy.[ncbi.nlm.nih.gov]
Hemoptysis
  • Epigastric pain was most commonly manifested in almost all cases, and hemoptysis and hematemesis were seen in 1 case each. Symptom manifestations began at 10-12 hr after eating fish in 73.3% cases.[ncbi.nlm.nih.gov]
  • Other reported presentations include severe hematemesis in patients with gastric ulcer and hemoptysis.[symptoma.com]
Respiratory Distress
  • A 22-years-old man living in Hyuga City, Miyazaki Prefecture, Japan, developed high fever, respiratory distress, and pleural effusion after consumption of raw fish.[ncbi.nlm.nih.gov]
Vomiting
  • A 68-year-old woman residing in Busan, Korea, had epigastric pain with severe vomiting about 5 hours after eating raw anchovies.[ncbi.nlm.nih.gov]
  • It is frequently characterized by severe epigastric pain, nausea and vomiting caused by the penetration of the larvae into the gastric wall. Acute gastric anisakiasis with severe chest discomfort is rarely reported in Italy.[ncbi.nlm.nih.gov]
  • The patients presented with abdominal pain, nausea and vomiting after consuming raw marine fish, and visited our gastroenterology outpatient department.[ncbi.nlm.nih.gov]
  • In our department, we observed 3 cases, all in women who were urgently hospitalized following intense epigastric pain and vomiting, developed after the ingestion of raw fish. The patients underwent urgent gastroscopy within a few hours.[ncbi.nlm.nih.gov]
  • If misdiagnosed, it can become chronic, with intermittent abdominal pain, nausea and vomiting lasting from weeks to several years.[orpha.net]
Nausea
  • It is frequently characterized by severe epigastric pain, nausea and vomiting caused by the penetration of the larvae into the gastric wall. Acute gastric anisakiasis with severe chest discomfort is rarely reported in Italy.[ncbi.nlm.nih.gov]
  • The patients presented with abdominal pain, nausea and vomiting after consuming raw marine fish, and visited our gastroenterology outpatient department.[ncbi.nlm.nih.gov]
  • Given the non-specific clinical presentation of acute abdomen, nausea, and vomiting these patients are often subject to radiologic imaging.[ncbi.nlm.nih.gov]
  • If misdiagnosed, it can become chronic, with intermittent abdominal pain, nausea and vomiting lasting from weeks to several years.[orpha.net]
Abdominal Pain
  • The 1st patient was a 48-year-old female presenting with abdominal pain. An abdominal computed tomography scan showed a dilated small intestine and accumulation of ascites.[ncbi.nlm.nih.gov]
  • The symptoms, typically abdominal pain, develop within 5-7 days after the fish intake. The diagnosis may be suspected based on common anamnesis (unfrozen fish intake) with abdominal pain or bowel obstruction and confirmed by blood serology.[ncbi.nlm.nih.gov]
  • RESULTS: All patients had presented with the acute onset of severe abdominal pain as well as a history of having recently eaten raw fish. The mean time interval from eating the fish to the onset of abdominal pain was 1.7 days.[ncbi.nlm.nih.gov]
  • A 54-year-old man presented with suddenly developed diffuse abdominal pain after ingestion of raw fish. The peripheral blood examination showed leukocytosis without eosinophilia.[ncbi.nlm.nih.gov]
  • Abstract A 31-year old salesman living in Seoul developed suddenly abdominal pain due to intestinal obstruction. Exploratory laparotomy exhibited segmental jejunal cellulitis caused by penetrating Anisakis larva. The patient had eaten raw fish.[ncbi.nlm.nih.gov]
Acute Abdomen
  • We suggest that anisakiasis should be considered in the differential diagnosis of patients with acute abdomen.[ncbi.nlm.nih.gov]
  • We report a case of acute abdomen due to terminal ileum involvement. Microscopic examination of the resected segment showed the presence of helminthic sections consistent with larvae of Anisakis spp. A history of raw fish ingestion was recorded.[ncbi.nlm.nih.gov]
  • We report a case of acute abdomen due to Anisakis simplex infection that caused small bowel obstruction.[ncbi.nlm.nih.gov]
  • The intestinal localization resulted in occlusive acute abdomen which required an emergency surgical treatment.[ncbi.nlm.nih.gov]
Diarrhea
  • A 69-year-old man was admitted for abdominal pain, diarrhea, and urticaria. Right hemicolectomy was performed because of an obstruction of the ascending colon and a palpable tumor of the right lower abdomen.[ncbi.nlm.nih.gov]
  • The patient, male, 56 years old, Dalian citizen, was admitted into the hospital with vomiting, peripheral umbilicus and abdominal distension, and frequent mucous diarrhea.[ncbi.nlm.nih.gov]
  • Two different clinical situations are recognized: the first, known as a gastrointestinal disease, varying from an asymptomatic episode to vomiting and diarrhea, and the second, classified as an adverse reaction to food, characterized by a wide spectrum[ncbi.nlm.nih.gov]
  • The chronic intestinal symptoms include weight loss, mild cramping, abdominal pain, and diarrhea, lasting for months or years.[orpha.net]
Hypotension
  • […] gastrointestinal disease, varying from an asymptomatic episode to vomiting and diarrhea, and the second, classified as an adverse reaction to food, characterized by a wide spectrum of allergic reactions like rhinitis, conjunctivitis, or even anaphylaxis causing hypotension[ncbi.nlm.nih.gov]
Urticaria
  • A 69-year-old man was admitted for abdominal pain, diarrhea, and urticaria. Right hemicolectomy was performed because of an obstruction of the ascending colon and a palpable tumor of the right lower abdomen.[ncbi.nlm.nih.gov]
  • Abstract Anisakis pathology is due mainly to two mechanisms: allergic reactions (from isolated urticaria and angioedema to life-threatening anaphylactic shock associated with gastrointestinal symptoms or 'gastroallergic anisakiasis'), and direct tissue[ncbi.nlm.nih.gov]
  • On the other hand, gastro-allergic anisakiasis with rash, urticaria and isolated angioedema or anaphylaxis is a clinical entity that has been described only recently.[ncbi.nlm.nih.gov]
  • Allergic responses, including urticaria, were found in seven (3.5%) patients. Fourteen (7.0%) cases underwent open surgery. Three (1.5%) underwent colonoscopic removal of Anisakis larvae. The average length of stay in the hospital was 9.6 days.[ncbi.nlm.nih.gov]
  • IgE sensitization to Anisakis pegreffii in Italian subjects suffering from gastro-allergic anisakiasis (GAA) (N 5), or showing chronic urticaria (CU ) after fish consumption (N 100), was investigated. A control group (N 5) was also included.[ncbi.nlm.nih.gov]
Forgetful
  • 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.[symptoma.com]
  • Rev Esp Enferm Dig 104: 607-610. [ Crossref ] Zullo A, Hassan C, Scaccianoce G, Lorenzetti R, Campo SM, et al. (2010) Gastric anisakiasis: do not forget the clinical history![oatext.com]

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].

Suppression
  • The exposure of Seirogan suppressed the viability of Anisakis Larva in vitro dose dependently. The oral administration of medicine containing wood creosote might be effective as a first aid to ameliorate the symptoms of Anisakiasis.[ncbi.nlm.nih.gov]

Treatment

  • The clinical suspicion with a correct diagnosis of anisakiasis allows the establishment of a correct treatment; in most cases, the resolution is possible with conservative treatment, avoiding unnecessary surgery to the preoperative differential diagnosis[ncbi.nlm.nih.gov]
  • Laparoscopic examination is useful for diagnosis and treatment of this disorder.[ncbi.nlm.nih.gov]
  • The importance of colonoscopy for the diagnosis and treatment of this disease is briefly discussed.[ncbi.nlm.nih.gov]
  • The intestinal localization resulted in occlusive acute abdomen which required an emergency surgical treatment.[ncbi.nlm.nih.gov]
  • In two other patients awareness of the diagnosis permitted conservative treatment and spontaneous healing.[ncbi.nlm.nih.gov]

Etiology

  • One challenging issue in the diagnosis of anisakiasis is the molecular detection of the etiological agent even at very low quantity, such as in gastric or intestinal biopsy and granulomas.[ncbi.nlm.nih.gov]
  • Furthermore, we suggested that A. simplex s. str. is the most important etiological agent in Japan.[ncbi.nlm.nih.gov]
  • […] results are: i) attention should be given to the history, in particular when raw marinated anchovies, proven to be the main source of human anisakiasis in Italy, are consumed; ii) in order to assess correct epidemiological data, a confirmed and specific etiological[ncbi.nlm.nih.gov]
  • Etiology Anisakiasis is caused by the ingestion of third stage larvae of Anisakid nematodes of the genus Anisakis , present in viscera or muscle of fish or cephalopods which are eaten raw, insufficiently cooked, smoked or marinated.[orpha.net]

Epidemiology

  • Epidemiological data and clinical features were analysed. Particular attention was paid to the source of infection. In total, 73 cases were included in the analysis, while 34 were excluded.[ncbi.nlm.nih.gov]
  • By the present study, 15 cases of gastric anisakiasis are added as Korean cases, and some epidemiological characteristics of Korean anisakiasis were clarified. KEYWORDS: Anisakiasis; Anisakis type I larva; Korean anisakiasis; review[ncbi.nlm.nih.gov]
  • […] of Anisakis and Anisakiasis: An Ecological and Evolutionary Road Map. ( 29530312 ) Mattiucci S....Nascetti G. 2018 8 Human anisakiasis in Italy: a retrospective epidemiological study over two decades. ( 30058531 ) Guardone L...Bruschi F 2018 9 A Case[malacards.org]
  • Summary Epidemiology To date, more than 20,000 cases of anisakiasis have been reported worldwide, over 90% from Japan (2,000-3,000 cases reported annually), and the rest from the five continents: Asia (Korea), Europe (the Netherlands, Germany, France,[orpha.net]
Sex distribution
Age distribution

Prevention

  • Early diagnosis is very important as it could prevent unnecessary surgical procedures since the symptoms of intestinal anisakiasis may mimic other illnesses such as appendicitis, ileitis or peritonitis.[ncbi.nlm.nih.gov]
  • They're not cooking the fish so that is the only prevention method, keeping it cold," he said.[cbsnews.com]
  • However, most of the questionnaire respondents who ate untreated meals knew how to prevent Anisakis infection. The QRA suggests that previously reported figures of 500 anisakiasis per year in Europe is a considerable underestimate.[ncbi.nlm.nih.gov]
  • If suction fails, the worms must be removed surgically to prevent intestinal rupture or blockage. Surgery is often necessary for treatment of invasive anisakiasis. Treatment with anthelminthic drugs does not prevent reinfection.[streetdirectory.com]

References

Article

  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.

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Last updated: 2017-08-09 17:45