Image of the Month Iron-Deficiency Anemia Caused by Hookworm Infestation ONOFRE ALARCON–FERNANDEZ, JUAN–SALVADOR BAUDET, and ANTONIO SANCHEZ DEL RIO Gastroenterology Service, Hospiten Rambla, Santa Cruz de Tenerife, Canary Island, Spain A 58-year-old man with iron-deficiency anemia was referred to our unit for a wireless capsule endos- copy examination. He had undergone a full colonos- copy, upper endoscopy, and small-bowel series previ- ously, all with negative results. Celiac disease also was ruled out previously and a hematologic consultation did not show any other specific condition. A capsule endoscopy was performed, showing multi- ple round small ulcers, some appearing nonreactive (Fig- ure A) and some covered with a black clot (Figure B), along the distal jejunum and ileum. In the ileum, several small white filiform figures were found attached to the bowel wall. They showed a slightly dilated reddish por- tion at the anchorage point (Figure C). A diagnosis of hookworm disease was suspected and was confirmed with a direct fecal examination. Hookworm infection is a worldwide intestinal para- sitic disease affecting more than 1 billion people. 1 It is caused by the nematodes Ancylostoma duodenale, Ne- cator americanus, and Ancylostoma ceylonicum. They are white cylindric worms .8- to 1.5-cm long. Adult hookworms anchor themselves in the mucosa of the small intestine. The worm secretes an anticoagulant that facilitates the ingestion of blood and juices from its host. They periodically change their location, which explains the multiple, different-stage ulcers we found in the cap- sule examination. 1–3 The diagnosis of hookworm infection usually is based on finding the characteristic eggs in the stool. Treatment with iron repletion and anthelmintic ther- apy with albendazole was started. Three months later the anemia resolved. The clinical symptoms may include skin irritation, pruritus, cough, wheezing, epigastric pain, or abdominal tenderness. 1–3 However, the hallmark of chronic hook- worm disease is iron-deficiency anemia, 1 as was the case of our patient. References 1. Hotez PJ, Brooker S, Bethony JM, et al. Hookworm Infection. N Engl J Med 2004;351:799 – 807. 2. Roca C, Balanzo X, Sauca G, et al. Imported hookworm infection in African immigrants in Spain. A study of 285 patients. Med Clin (Barc) 2003;121:139 –141. 3. Bungiro R, Cappello M. Hookworm infection: new developments and prospects for control. Curr Opin Infect Dis 2004;17:421– 426. © 2006 by the American Gastroenterological Association Institute 1542-3565/06/$32.00 doi:10.1016/j.cgh.2006.01.009 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2006;4:xxxii
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