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A RARE CASE OF DIPHYLLOBOTHRIASIS FROM PONDICHERRY,SOUTH INDIA

C Sheela Devi, Shashikala, S Srinivasan, UC Murmu, P Barman, *R Kanungo

AbstractDiphyllobothriasis is an intestinal parasitic infection caused by the ingestion of raw fresh-water Þ sh containing the infectious larvae of Diphyllobothrium spp. This infection is uncommon in India. We report a case of diphyllobothriasis that occurred in Pondicherry, India, in a 5-year-old boy hailing from a Þ shing community. He attended the Pediatric OPD with spontaneous discharge of segments of the adult parasite. The segments (macroscopically and microscopically) were identiÞ ed as those of Diphyllobothrium latum. The stool examination also revealed characteristic oval eggs.

Key words: Child, D. latum, Diphyllobothriasis

*Corresponding author (email: <rebakanungo2001@yahoo.com>)Departments of Clinical Microbiology (CSD, S, SS, RK), Paediatrics (UCM) and Pathology (PB), Pondicherry Institute of Medical Sciences, Pondicherry - 605 014, IndiaReceived : 25-04-06 Accepted : 05-05-06

Indian Journal of Medical Microbiology, (2007) 25 (2):152-4

Diphyllobothriasis is an intestinal parasitic infection caused by the ingestion of raw or partially cooked Þ sh containing the larvae of Diphyllobothrium spp. Four recognized species are known to infect humans - Diphyllobothrium latum, D. pacifi cum, D. klebnoviskii and D. nihonkaiense.1 Diphyllobothrium latum is most commonly associated with human infections. Many species are also known to infect Þ sh-eating birds, dogs, foxes and bears.2 Human diphyllobothriasis has been reported from Europe,1 Korea,3,4 Japan,5 Malaysia,6 Peru, Chile, Argentina,2 Brazil,7 etc. The first case of diphyllobothriasis from India was reported in 1998 from Vellore, South India.8

Case Report

A 5-year-old boy reported to the pediatric clinic of Pondicherry Institute of Medical Sciences, Pondicherry, in November 2005 with a history of spontaneous discharge of light-colored segments in stool. He also gave history of similar episodes over the last one year. Every episode of passage of segments was accompanied by abdominal pain. There was no history of diarrhoea, vomiting or pica. He was a non-vegetarian with unremarkable dietary habits. He belonged to a Þ shing community; therefore, handling of raw Þ sh was an obvious risk factor. His hematological examination revealed hemoglobin of 10.4 gm/dL, PCV - 32.0%, RBC count - 4.47/cu. mm, MCV - 72 ß , MCH - 23.2 pg. Total leukocyte count was 8,200/cu. mm and total eosinophil count was 16%. Peripheral blood smear examination revealed microcytic hypochromic anemia with moderate eosinophilia.

The piece of worm passed by the boy was creamy white

in color and measuring 5 cm in length and 1.5 cm in breadth (Fig. 1). Each segment was broader (15 mm) than longer (3 mm). There was no identiÞ able scolex. Histopathological examination of the adult worm revealed gravid segments Þ lled with characteristic oval operculated eggs (Fig. 2). Stool examination by formol ether sedimentation technique revealed characteristic oval eggs measuring 70 × 45 µm. The egg was operculated with a knob on the opposite side (Fig. 3). Based on the macroscopic and microscopic features of the segments and the morphological characteristics of the egg, Diphyllobothrium latum was identiÞ ed. The patient was treated with praziquantel 400 mg single dose.

Discussion

The life cycle of D. latum is complex, with two intermediate hosts. The plerocercoid larvae, the infective form for humans, dogs and other Þ sh-eating animals, are present in the second intermediate host. This plerocercoid larvae of Diphyllobothrium spp. have been demonstrated in domestic salmon, cherry salmon, red-lip mullet, pike, perch, rainbow trout, lake trout, burbot,1,4,5 etc. Reports of diphyllobothriasis

Case Report

Figure 1: Proglottid of the adult worm showing each segment with width more than length

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after the ingestion of food with raw domestic salmon Þ sh4; red-lip mullet3; shushimi, a Japanese raw Þ sh; and sushi6 have been documented.

Diphyllobothriasis is not associated with specific symptoms. General complaints of nausea, diarrhea, abdominal pain or discomfort may be reported by some patients. Most infections manifest with eosinophilia. Prolonged or heavy D. latum infections may cause megaloblastic anemia due to parasite-mediated dissociation of vitamin B12 intrinsic factor complex within the gut lumen, making B12 unavailable to the host.9 The present case had only non-speciÞ c symptoms. Eosinophilia was marked with a differential count of 16%. Peripheral blood smear examination of the patient did not reveal megaloblastic anemia, which is commonly associated with this infection. Case reports of non-speciÞ c symptoms without megaloblastic anemia have been documented.3-5 A survey conducted in Brazil7 in 2004 found that abdominal discomfort and intermittent diarrhea were the commonest symptoms, while some cases were asymptomatic. Parasite was eliminated in 22% of these cases.

Diphyllobothriasis is diagnosed by examining gravid

segments in addition to microscopic examination of stool for characteristic eggs. Macroscopically, the segment is broader than longer. Microscopic examination of the segment shows the uteri forming a rosette. The sagittal section of the adult worm in scanning electron microscope generally shows a cirrhus sac lying horizontally, with the seminal vesicle lying dorsocaudal to it.2 In this case, the segment did not show rosette-type uterine cavity. However, characteristic operculated eggs could be well deÞ ned in the cavity. The stool examination in diphyllobothriasis reveals operculated oval egg with a knob on the opposite side to the operculum. The eggs of D. pacifi cum are thick shelled, operculated, measuring 40-60 µm in length and 36-40 µm in diameter; thus they are smaller than those of D. latum, which is 58-76 µm in length and 40-50 µm in diameter.7 The egg present in the stool of this boy had similar features and measured 70 × 45 µm.

Scanty reports of diphyllobothriasis are available in literature from South India.8,10 Till date, there are no reports from the northern part of the country. This may be attributed to the fish-eating habit of the people in southern part of the country, which also has a large population of Þ shing community living in the coastal belt of the peninsular part of India. It is speculated that these infections may be misdiagnosed as taeniasis.

Diphyllobothriasis is associated with consumption of raw or marinated Þ sh. The changing culinary habits have resulted in dishes like carpaccio, sushi and other raw Þ sh recipes being served in the restaurants, especially in the European countries. This has led to an increasing incidence of diphyllobothriasis.1 In India, these recipes do not Þ nd favor with the general population. However, with introduction of multinational cuisine, there are increasing chances of acquiring this infection. Other tapeworm infections like taeniasis, hydatid disease and hymenolepsiasis are commonly found in India. It is therefore suggested that both macroscopic and microscopic examination of the segments should be done to differentiate the commonly encountered taenia infections and to detect diphyllobothriasis.

Acknowledgement

The authors wish to thank Prof. JC Samantray, All India Institute of Medical Sciences, New Delhi, for conÞ rming the identity of the parasite.

References

1. Dupouy-Camet J, Peduzzi, R. Current situation of human diphyllobothriasis in Europe. Eur Surveill 2004;9:31-5.

2. Dick TA, Nelson PA, Choudhury A. Diphyllobothriasis: Update on human cases, Foci, patterns and sources of human infections and future considerations. Southeast Asian J Trop Med Public Health 2001;32:59-76.

3. Chung PR, Sohn WM, Jung Y, Pai SH, Nam MS. Five human cases of Diphyllobothrium latum infection through eating raw

Indian Journal of Medical Microbiology

Figure 2: Stained section of the adult worm showing oval operculated eggs in the uterine cavity (Haematoxylin and eosin, ×40)

Figure 3: Egg of Diphyllobothrium latum measuring 70 × 45 µm, oval in shape with inconspicuous operculum, (x400)

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Devi et al - Diphyllobothriasis in Pondicherry

Announcement

Dr. J. C. Patel Birth Centenary Celebration Committee

The year 2008 is the Birth Centenary Year of Dr. J. C. Patel. Some of his students/admirers felt that it would be a good idea to celebrate this Centenary Year by organizing CMEs, Orations/Lectures, Conferences, etc. during the year. He was associated with many professional bodies, which meet regularly every year; during these annual meetings/ conferences, a lecture/symposium, etc can be organized as a part of Centenary celebrations. We would like to form a Dr. J. C. Patel Birth Centenary Celebrations Committee. All his past students/admirers are invited to join the committee (without any fi nancial commitment). Kindly communicate your name, designation, postal address, telephone number and E-mail ID to Dr. B. C. Mehta at Flat 504, Prachi Society, Juhu-Versova Link Road, Andheri (W0, Mumbai 400 053 (drmehta.bc@gmail.com).

ß esh of Red-lip mullet, Liza haemabacheila. Korean J parasitol 1997;35:283-9.

4. Lee KW, Suhk HC, Pai KS, Shin HJ, Jung SY, Han ET, et al. Diphyllobothrium latum infection after eating domestic salmon ß esh. Korean J Parasitol 2001;39:319-21.

5. Oshima T, Wakai R. Epidemiology of Diphyllobothrium latum infection in Japan, with special reference to infection of cherry salmon. Jpn J Antibiot 1983;36:566-72.

6. Rohela M, Jamaiah I, Chan KW, Yusoff WS. Diphyllobothriasis: The Þ rst case report from Malaysia. Southeast Asian J Trop Med Public Health 2002;33:229-30.

7. Sampaio JL, Piana de Andrade V, Lucas MC, Fung L, Gagliardi SM, Santos SR, et al. Diphyllobothriasis, Brazil. Emerg Infect Dis 2005;11:1598-600. Source of Support: Nil, Confl ict of Interest: None declared.

8. Panchratnam S, Jacob E, Kang G. Human diphyllobothriasis: First report from India. Trans R Soc Trop Med Hyg 1998;92:179-80.

9. King CH. Cestodes chapter 280. In: Mandell, Doughlas and Bennett�s Principles and Practices of infectious diseases. 6th ed. Mandell GL, Bennett JE, Raphael Dolin R, editors. Elsevier Churchill Livingstone: Philadelphia; 2005. p. 3286.

10. Kumar CS, Anand Kumar H, Sunita V, Kapur I. Prevalence of anaemia and worm infestation in school going girls at Gulbarga, Karnataka. Indian Pediatr 2003;40:70-2.

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