Abstract
Melaena due to hookworm infestation is a rare clinical presentation. It usually presents with symptoms of iron-deficiency anaemia owing to slow blood loss. Here we present a case of 45-year male who presented with a one-year history of intermittent melena requiring multiple blood transfusions. Preliminary endoscopies at different centres were normal. The presence of hookworm in the duodenum was only detected on repeat upper endoscopy as the cause of blood loss, and treatment with albendazole was successful in curing the patient.
Case report
A 45-year old, farmer by occupation from a remote village, presented with one week's history of black, tarry, loose stool. He also complained of easy fatiguability, generalised weakness and dizziness. He denied any history of fever, vomiting, abdominal pain, significant weight loss nor anorexia. He did not consume alcohol or smoke. He had no past medical history but gave an account of two similar episodes of melaena in the past year, which had required three units of packed red blood cell transfusion on each episode. On examination, he was pale, without lymphadenopathy. Vital signs were normal. Abdominal examination was unremarkable. The spleen and liver was not palpable. Digital rectal examination confirmed melena.
Laboratory investigations revealed a severe anaemia (haemoglobin 56 g/L), with normal leucocyte count but raised eosinophil level (8%). Further, liver and renal function tests, chest radiography and abdominal ultrasonography were normal.
Our patient was transfused three pints of packed red cells. The symptoms improved. An oesophago-gastroscopy was performed but revealed no pathology. An abdominal CT scan was likewise normal. After few days, a repeated endoscopy surprisingly revealed hookworms in the duodenal mucosal wall (Fig. 1). The remaining upper gastro-intestinal tract was normal. Our patient received eradication therapy with albendazole for three days. With this, he improved, and at 2 years of follow-up, he had a haemoglobin level of 120 g/L.
Upper gastrointestinal (GI) endoscopy showing hookworms attached to the duodenal mucosa (arrow).
Discussion
Hookworm infestation of the duodenum is a rare cause of melena among farmers, who walk barefoot. It usually presents with symptoms of iron-deficiency anaemia; but occasionally melena can be a presentation.1,2 A high index of suspicion is warranted in a non-alcoholic patient not otherwise unwell, where malignancy of both stomach and caecum has been excluded. 3 A useful mnemonic for disease confined to duodenum causing melena is “Three-Hs”: Haemobilia, Haemosuccus pancreaticus, and Hookworm infestation. 4 Such pathology may be missed on first time endoscopy; hence repeat endoscopy with these differentials in mind is advised to prevent a missed diagnosis.3,5
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Patient consent statement
The consent was taken from the patient for publication of the case report.
