A case of polyparasitic infection due to hookworm, Strongyloides stercoralis, and Giardia intestinalis: The need for a stringent behavioral modification

Srujana Mohanty; Geetarani Purohit; Anupam Dey

doi:10.4103/jopcs.jopcs_16_22

CASE REPORT

Year : 2023 | Volume : 4 | Issue : 1 | Page : 35-37

A case of polyparasitic infection due to hookworm, Strongyloides stercoralis, and Giardia intestinalis: The need for a stringent behavioral modification

Srujana Mohanty¹, Geetarani Purohit¹, Anupam Dey²
¹ Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
² Department of General Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission	07-Jul-2022
Date of Decision	17-Oct-2022
Date of Acceptance	23-Oct-2022
Date of Web Publication	03-Jan-2023

Correspondence Address:
Dr. Srujana Mohanty
Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jopcs.jopcs_16_22

Abstract

In developing countries like India, unhygienic practices such as open-air defecation, keeping untrimmed nails, or eating food fallen on the ground have been observed to be important risk factors for parasitic infections such as soil-transmitted helminths. We report a case of polyparasitic infection with hookworm, Strongyloides stercoralis, and Giardia intestinalis in an adult who resorted to open defecation with the "use of open footwear" in the fields despite having a toilet at home, to re-emphasize the harmful health effects of such unhygienic practices, and create awareness for stringent behavioral modifications for leading a healthy life and establishment of a safe and hygienic community.

Keywords: Giardia intestinalis, hookworm, polyparasitic, Strongyloides stercoralis

How to cite this article:
Mohanty S, Purohit G, Dey A. A case of polyparasitic infection due to hookworm, Strongyloides stercoralis, and Giardia intestinalis: The need for a stringent behavioral modification. J Prim Care Spec 2023;4:35-7

How to cite this URL:
Mohanty S, Purohit G, Dey A. A case of polyparasitic infection due to hookworm, Strongyloides stercoralis, and Giardia intestinalis: The need for a stringent behavioral modification. J Prim Care Spec [serial online] 2023 [cited 2023 Jun 6];4:35-7. Available from: https://www.jpcsonline.org/text.asp?2023/4/1/35/366810

Introduction

Intestinal parasitic infections are a major cause of morbidity and mortality in the developing world, including India. Of three main intestinal nematodes affecting humans, hookworm is the major contributor to the Global Burden of Disease with an estimated 22.1 million disability-adjusted life years lost due to the infection (the other two being Ascaris lumbricoides and Trichuris trichiura).^[1] Strongyloides stercoralis is the fourth most important intestinal nematode infection, which together with hookworm represents 2% of the global diseases attended.^[1],[2] Giardia intestinalis is the most common intestinal protozoan parasite, causing an estimated 280 million cases of acute watery diarrhea each year.^[3] All three parasites are associated with the serious threat of development of micronutrient malnutrition, such as iron-deficiency anemia, Vitamin A deficiency, and protein-calorie malnutrition, which affects work and productivity in adults, and learning and school performance in children.^[1],[2],[3] Strongyloides infestation can also lead to complications such as hyperinfection syndrome and disseminated infection, especially in immunocompromised hosts.^[1],[2],[4]

Unhygienic practices such as open-air defecation, keeping untrimmed nails, or eating food fallen on the ground are important risk factors for human parasitic infections.^[5] We report a case of polyparasitic infection with hookworm, S. stercoralis, and G. intestinalis, to re-emphasize the harmful health effects of such unhygienic practices, and create awareness for stringent behavioral modifications for leading a healthy life and establishment of a safe and hygienic community.

Case Report

A 30-year-old old man, farmer, and woodcutter by profession, presented with complaints of alternating and recurrent diarrhea and constipation for the past 2 years, associated with abdominal pain, occasional vomiting, loss of appetite, and progressive loss of weight. He had taken numerous nonspecific medications from multiple health-care facilities without any relief. The current episode consisted of loose watery stools (4–6 times/day without blood but with mucous) of 8-day duration along with vomiting and severe abdominal cramps. Past history was insignificant for any particular common disease such as diabetes, hypertension, or contact with known tuberculosis patients. He had no history of fever, neck stiffness, blurry vision, rash, trauma, or intake of corticosteroids or other immunosuppressive drugs in the recent past and no manifestations of respiratory tract or urinary tract infection. Upon probing, he admitted to routine open defecation (ODF) with "use of open footwear" in the fields despite having a toilet at home. He was afebrile, with a pulse rate of 88/min, blood pressure of 110/74 mm Hg, generalized weakness, and significant weight loss of 16–18 kg during the past 1 year. Laboratory investigations revealed a total leukocyte count of 7.6 × 10⁹/L (52% polymorphs, 37% lymphocytes, and 9% eosinophils), slightly raised absolute eosinophil count of 0.6 × 10⁹/L, red blood cell count of 5.6 × 10¹²/L, hematocrit of 46.0%, and hemoglobin level of 145 g/L [Table 1]. The reports of routine biochemical investigations were within normal limits, and anti-HIV-1/2 antibodies were negative.

Table 1: Summary of laboratory investigations

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A microscopic examination of a fresh stool sample revealed mixed infection with hookworm ova, S. steroralis larvae, and G. intestinalis cysts [Figure 1]a and [Figure 1]b. Semiquantitative count (modified Stoll dilution method) revealed a count of approximately 300 hookworm eggs/gram of feces, corresponding to a female worm burden of approximately 6 female hookworms/gram of feces. He was started on anti-parasitic therapy as follows: a single oral dose of ivermectin (200 μg/kg body weight) against S. stercoralis, a single oral dose of albendazole (400 mg) against hookworm, and a single oral dose of ornidazole (1 g) against Giardia. Further, he was counseled for behavioral modification against his habit of ODF and advised to use proper footwear for all outside activities. In the control visit at 4-month follow-up period, stool examination revealed no hookworm ova, few Giardia cysts, and few degenerated Strongyloides larvae [Figure 2]. A repeat of the previous therapy was advocated for a complete parasitological cure.

Figure 1: Stool examination on presentation showing (a) Larvae of Strongyloides stercoralis, ova of hookworm and cysts of Giardia intestinalis in saline wet-mount, ×400 and (b) Larvae of Strongyloides stercoralis and cysts of Giardia intestinalis in iodine wet-mount, ×400

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Figure 2: Stool examination at 4-month follow-up after therapy showing few cysts of Giardia intestinalis and few degenerated larvae of Strongyloides stercoralis, saline wet-mount, ×400

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Discussion

Infections with intestinal helminths, such as hookworm and S. stercoralis, are a major public health challenge in the developing world, including India. A key factor responsible is the behavioral aspect such as lack of proper maintenance of sanitation and hygiene, use of open footwear, and open defecation.^[5],[6] Lack of access to safe water and proper sanitary disposal of feces are important contributory factors. As per an estimate a few years back, around 520 million people (almost 40% of the total population) in India practiced ODF which accounted for nearly 2.5% of the national burden of disease and costed $54 billion annually due to health-care costs, losses in productivity, and losses in tourism.^[7] The present report highlights the reluctance in adapting to a behavioral change in the patient, as he was habituated to using open fields and open footwear, despite having a toilet at home. In a recent study, 54.8% (270/493) of respondents from a rural area defecated in the open despite having a household latrine and access to sanitation facilities.^[6]

Polyparasitic infections associated with open-field defecation have been reported from India and outside.^[8],[9] Analysis of factors associated with nonuse of existing sanitation facilities have included, inadequate design and incompletely constructed toilets, poor accessibility, and availability of water, preference and habitual for ODF, personal beliefs, sociocultural behaviors, family dynamics, lack of recognizing the health benefits of toilet use, and the majority of time stay away from home due to labor work.^[6],[7] However, exposure to government propaganda promoting safe sanitation practices, sensitizing people about the benefit of cleanliness, the benefit of using the toilet instead of ODF, detail about government subsidiary to construct a toilet, pamphlets distribution, stakeholders awareness, etc., was associated with significantly increased toilet use and other good hygienic practices.^[7],[10] After extensive efforts of behavior change communication activities, there was a 32.5% increase in toilet usage within the span of 3 years in a village in Gujarat.^[10]

Conclusion

An infected person not only is a health burden to self but also poses a significant health risk to the community by serving as a reservoir of infection. Strict behavior change communications and targeted interventions by consistent and regular use of the sanitary facilities with a focus on the facility (toilet) use rather than only on access and coverage will go a long way in achieving the sustainable development goal target 6 to end ODF by 2030.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms, in which the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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