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].

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]
  • On the other hand, gastro-allergic anisakiasis with rash, urticaria and isolated angioedema [10,11] or anaphylaxis is a clinical entity that has been described only recently.[oatext.com]
  • […] 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]
  • Se han hallado hasta un 36% de enfermos sensibilizados a Anisakis simplex que sufren urticaria y angioedema tras la toma de pescado crudo.[elsevier.es]
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  • gastrointestinal
    Vomiting
    • 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]
    • Vomiting can also be a symptom after consuming the parasites, and this may also expel the worm.[medicinenet.com]
    • ., and Masahi Nishikawa, M.D. 2 Citing Articles A 36-year-old previously healthy woman presented with a 2-day history of severe chest pain and epigastric pain associated with nausea and vomiting.[nejm.org]
    • Symptoms and Signs Symptoms of anisakiasis typically include abdominal pain, nausea, and vomiting within hours of ingesting the larvae.[merckmanuals.com]
    Nausea
    • If misdiagnosed, it can become chronic, with intermittent abdominal pain, nausea and vomiting lasting from weeks to several years.[orpha.net]
    • Posted in: Men's Health News Medical Science News Women's Health News Disease/Infection News Tags: Bleeding , Blood , Blood Test , Diet , Endoscopy , Fever , Fish , Healthcare , Inflammation , Laboratory , Nausea , Pain , Stomach , Sushi , Vomiting[news-medical.net]
    • ., and Masahi Nishikawa, M.D. 2 Citing Articles A 36-year-old previously healthy woman presented with a 2-day history of severe chest pain and epigastric pain associated with nausea and vomiting.[nejm.org]
    • 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]
    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]
    • 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]
    • 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]
    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]
    • […] 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]
    • The signs and symptoms of anisakiasis are abdominal pain, nausea, vomiting, abdominal distention, diarrhea, blood and mucus in stool, and mild fever.[cdc.gov]
    Epigastric Pain
    • ., and Masahi Nishikawa, M.D. 2 Citing Articles A 36-year-old previously healthy woman presented with a 2-day history of severe chest pain and epigastric pain associated with nausea and vomiting.[nejm.org]
    • 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]
    • 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]
    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.[books.google.com]
    • Because symptoms are vague, this disease is often misdiagnosed as appendicitis, acute abdomen, stomach ulcers, or ileitis.[streetdirectory.com]
    • Acute abdomen due to small bowel anisakiasis Dig Liver Dis 2005 37 65 7 . 4 Gastrointestinal anisakiasis.[academic.oup.com]
    • abdomen. ( 28004963 ) SA![malacards.org]
    • Acute abdomen due to small bowel anisakiasis.Digestive and Liver Disease,37(1), 65-67. doi:10.1016/j.dld.2004.06.018 Pontone, S., Leonetti, G., Guaitoli, E., Mocini, R., Manfredelli, S., Catania, A., . . .[dovemed.com]
    Food Poisoning
    • The differential diagnosis includes food poisoning, acute gastritis, and acute pancreatitis.[unboundmedicine.com]
    • 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 Images 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]
    Abdominal Cramps
    • 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[academic.oup.com]
    • 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]
    Colic
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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]
    • Symptoms of anisakiasis include nausea , vomiting , abdominal distention and pain , diarrhea , blood and/or mucus in the stool , and fever .[medicinenet.com]
    • He complained of severe upper gut pain, and also vomited and had a fever.[pulseheadlines.com]
    • A team of doctors from Portugal raised concerns after a 32-year old man was admitted to hospital complaining of pain in his abdomen just below his ribs, vomiting and had a slight fever, all of which had lasted for a week.[theguardian.com]
    • The authors draw a portrait of the illness from the experience of a previously healthy 32-year-old man who developed severe upper gut pain, vomiting and fever that lasted a week before he entered the hospital.[cnn.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
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  • Colonoscopy
    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]
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  • 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]
    • Symptoms of anisakiasis include nausea , vomiting , abdominal distention and pain , diarrhea , blood and/or mucus in the stool , and fever .[medicinenet.com]
    • He complained of severe upper gut pain, and also vomited and had a fever.[pulseheadlines.com]
    • A team of doctors from Portugal raised concerns after a 32-year old man was admitted to hospital complaining of pain in his abdomen just below his ribs, vomiting and had a slight fever, all of which had lasted for a week.[theguardian.com]
    • The authors draw a portrait of the illness from the experience of a previously healthy 32-year-old man who developed severe upper gut pain, vomiting and fever that lasted a week before he entered the hospital.[cnn.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]
    • On the other hand, gastro-allergic anisakiasis with rash, urticaria and isolated angioedema [10,11] or anaphylaxis is a clinical entity that has been described only recently.[oatext.com]
    • […] 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]
    • Se han hallado hasta un 36% de enfermos sensibilizados a Anisakis simplex que sufren urticaria y angioedema tras la toma de pescado crudo.[elsevier.es]
    Gastritis
    • The differential diagnosis includes food poisoning, acute gastritis, and acute pancreatitis.[unboundmedicine.com]
    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]
    Food Poisoning
    • The differential diagnosis includes food poisoning, acute gastritis, and acute pancreatitis.[unboundmedicine.com]
    • 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 Images 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]
    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

    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]
    • The culprit: Anisakiasis , a disease caused by parasitic worms.[cbsnews.com]
    • The parasite is transmitted to human when eating raw or undercooked fish or squid.[medicinenet.com]
    • ICD-10-CM Codes › A00-B99 Certain infectious and parasitic diseases › B65-B83 Helminthiases › B81- Other intestinal helminthiases, not elsewhere classified › Anisakiasis 2016 2017 2018 Billable/Specific Code B81.0 is a billable/specific ICD-10-CM code[icd10data.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.

    1. Acute abdomen due to small bowel anisakiasis - M Pellegrini, R Occhini, G Tordini, C Vindigni - Digestive and liver , 2005 - Elsevier
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    7. [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
    8. [Contribution to the morphology and pathogenesis of eosinophilic colitis (author's transl)] - K Dumke, K Janitschke - Zeitschrift fur Gastroenterologie, 1981 - ukpmc.ac.uk
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    10. [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
    11. Acute abdomen due to small bowel anisakiasis - M Pellegrini, R Occhini, G Tordini, C Vindigni - Digestive and liver , 2005 - Elsevier
    12. A case of anisakiasis as a cause of ileum obstruction - T Tobe - Dig Surg, 1989 - content.karger.com
    13. Acute abdomen due to small bowel anisakiasis - M Pellegrini, R Occhini, G Tordini, C Vindigni - Digestive and liver , 2005 - Elsevier
    14. AMERICAN COLLEGE OF PHYSYCIANS - PR CHAPTER - prhsj.rcm.upr.edu
    15. Anisakis pegreffii experimental challenge in Dicentrarchus labrax: An endoscopic study - F Macrì, G Lanteri, G Rapisarda, A Costa, F Marino - Aquaculture, 2012 - Elsevier
    16. Anisakiasis. - JA Sakanari, JH McKerrow - Clinical microbiology reviews, 1989 - Am Soc Microbiol
    17. 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
    18. . 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
    19. A Case of Duodenal Anisakiasis with Duodenal Ulcer - D Hwang, SI Park, SC Pack, KS Lee - Chonnam Medical , 2012 - synapse.koreamed.org
    20. Case 20-1992 - RC Cabot, RE Scully, EJ Mark - England Journal of , 1992 - Mass Medical Soc
    21. A Case of chronic gastric anisakiasis with massive bleeding - HS Lee, KS Park, KT Jung, SJ Yoo, JH Kho - Korean Journal of , 1993 - KoreaMed
    22. 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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