Question

    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].

    Entire body system
    Fever
    • A fibrous mass (granuloma) forms in the intestine causing fever, colic and intermittent obstruction.[medical-dictionary.thefreedictionary.com]
    • At physical examination the patient had good general condition, no fever without spontaneous pain.[journalmc.org]
    • Symptoms Common signs and symptoms of Anisakiasis are: Abdominal distention Vomiting abdominal pain nausea Blood and secretion in stool, and delicate fever.[soundhealthsolution.com]
    • She had had during two days acute abdominal pain, diarrhea, meteorism, selective pain palpatation in the right ileum fossa, no nausea, vomit or fever and Blumberg sign negative.[memorias.ioc.fiocruz.br]
    • When infected fish are consumed raw or poorly cooked by human, these parasites can cause acute gastrointestinal diseases (abdominal pain, vomiting, diarrhea and mild fever).[turkiyeklinikleri.com]
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  • gastrointestinal
    Abdominal Pain
    • 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]
    • Symptoms and Signs Symptoms of anisakiasis typically include abdominal pain, nausea, and vomiting within hours of ingesting the larvae.[merckmanuals.com]
    • 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]
    • pain, nausea , and vomiting .[en.wiktionary.org]
    Acute Abdomen
    • The commonest symptom is sudden onset severe abdominal or epigastric pain resembling an acute abdomen.[symptoma.com]
    • Because symptoms are vague, this disease is often misdiagnosed as appendicitis, acute abdomen, stomach ulcers, or ileitis.[streetdirectory.com]
    • "Intestinal Localization of Anisakiasis Manifested as Acute Abdomen."[web.stanford.edu]
    • Acute abdomen, anisakidosis and surgery: Value of history, physical examination and non immunological diagnostic procedures .[nature.com]
    Colic
    Diarrhea
    • The chronic intestinal symptoms include weight loss, mild cramping, abdominal pain, and diarrhea, lasting for months or years.[orpha.net]
    • Diarrhea, allergic reactions with rash and itchiness, and often, anaphylaxis, can even occur.[soundhealthsolution.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]
    • Symptoms include vomiting, diarrhea, nausea, and severe abdominal pain that may resemble appendicitis, so cases are often misdiagnosed.[encyclopedia.com]
    • Invasive gastric anisakiasis is characterized by the abrupt onset of abdominal pain, nausea, sometimes vomiting or diarrhea with signs of peritoneal irritation and incomplete ileus of the small intestine [12].[web.stanford.edu]
    Epigastric Pain
    • The commonest symptom is sudden onset severe abdominal or epigastric pain resembling an acute abdomen.[symptoma.com]
    • The larvae may invade the stomach wall, causing ulceration with nausea , vomiting , epigastric pain, and haematemesis (vomiting of blood).[wikihow.com]
    • The highly variable clinical manifestations, digestive disorders are more common as right iliac fossa pain, obstruction, abdominal pain, vomiting, epigastric pain and bleeding.[journalmc.org]
    Nausea
    • If misdiagnosed, it can become chronic, with intermittent abdominal pain, nausea and vomiting lasting from weeks to several years.[orpha.net]
    • Symptoms and Signs Symptoms of anisakiasis typically include abdominal pain, nausea, and vomiting within hours of ingesting the larvae.[merckmanuals.com]
    • [ edit ] Anisakis ‎ -iasis Noun [ edit ] anisakiasis ( uncountable ) Wikipedia has an article on: anisakiasis Wikipedia The disease caused by infection with Anisakis worms (usually through eating raw fish ), characterised by violent abdominal pain, nausea[en.wiktionary.org]
    • This is accompanied by nausea and vomiting.[symptoma.com]
    • […] pickled can result in anisakiasis , an infection that is most common in Japan … but becoming more frequent in the United States … — The Alameda (California) Times-Star , 30 Sept. 2002 Note: The symptoms of anisakiasis include severe abdominal pain, nausea[merriam-webster.com]
    Vomiting
    • If misdiagnosed, it can become chronic, with intermittent abdominal pain, nausea and vomiting lasting from weeks to several years.[orpha.net]
    • Symptoms and Signs Symptoms of anisakiasis typically include abdominal pain, nausea, and vomiting within hours of ingesting the larvae.[merckmanuals.com]
    • Intestinal anisakiasis clinically resembles appendicitis, with right lower quadrant pain, nausea, and vomiting.[histopathology-india.net]
    • Symptoms of Anisakiasis embrace violent abdominal pain, nausea, and vomiting.[soundhealthsolution.com]
    • The larvae may invade the stomach wall, causing ulceration with nausea , vomiting , epigastric pain, and haematemesis (vomiting of blood).[wikihow.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

    Biopsy
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  • Other Pathologies
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  • Test Results

    Gastroscopy
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  • Laboratory

    Serum
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  • Stool
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  • Treatment

    Prognosis

    Complications

    Colitis
    • 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]
    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]
    • Compared with gastric anisakiasis, more patients with small-intestinal anisakiasis exhibited leukocytosis (76.7%), eosinophilia (43.3%), and elevated C-reactive protein levels ( mg/dL) [ 9 ].[hindawi.com]
    • The intra-peritoneal form is characterized by the penetration of the intestinal wall by the larva and migration to the mesenteries, lymph nodes, great omentum, liver pancreas, ovary and gallbladder, causing a visceral larva migrans-like syndrome with eosinophilia[antimicrobe.org]
    Eosinophilic Gastroenteritis
    • Eosinophilic gastroenteritis and anisakis.[antimicrobe.org]
    • "Anisakis Infestation: A Case of Acute Abdomen Mimicking Crohn's Disease and Eosinophilic Gastroenteritis."[web.stanford.edu]
    Gastritis
    • A man with unsuspected marine eosinophilic gastritis .[nature.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]
    • […] infection with the third-stage larval forms causes two clinical syndromes: severe gastrointestinal manifestations such as nausea, vomiting, and abdominal pain; and allergic manifestations including immediate allergic reactions in the form of anaphylaxis or urticaria[antimicrobe.org]
    • Acute allergic manifestations such as urticaria and anaphylaxis may occur with or without accompanying gastrointestinal symptoms.[web.stanford.edu]
    • Also in some cases, serious allergic reactions such as urticaria, angioedema and anaphylaxis can ocur due to the allergens that have been identified in anisakis larvae.[turkiyeklinikleri.com]
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  • Etiology

    Epidemiology

    Sex distribution
    Age distribution

    Pathophysiology

    Prevention

    Summary

    Patient Information

    Self-assessment

    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.

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    • Acute gastric anisakiasis - A Muraoka, I Suehiro, M Fujii, K Nagata - Digestive diseases and , 1996 - Springer

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