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Asian Journal of Healthy and Science
p-ISSN: 2980-4302
e-ISSN: 2980-4310
Vol. 2 No. 9 September 2023
ANCYLOSTOMIOSIS TRIGGERS HEART FAILURE
(CASE STUDY IN ELDERLY PATIENTS)
I Made Herdinata Sudiartana, Ni Made Dewi Arimas
Rumah Sakit Umum Daerah (RSUD) Buleleng, Indonesia
Email: herdinatasudiartana@gmail.com, dewiarimas@ymail.com
Anclyostomiasis is a disease caused by infection with the parasitic worms
Anclyostoma duodenale or Necator americanus. Infection with these worms can
occur through contact with soil contaminated with worm eggs or through
consumption of contaminated food. The disease can cause serious health problems
in humans, especially in the elderly population who have more vulnerable immune
systems. One of the serious complications that can arise from anclyostomiasis
infection is heart failure. The aim of this study was to investigate whether
anclyostomiasis infection can lead to heart failure in elderly patients. This research
used a case study approach. The data obtained was analyzed using a qualitative
analysis approach. The results showed that based on case studies ancylostomiosis in
the elderly can cause severe anemia accompanied by iron deficiency anemia and
heart failure. Overall, ancylostomiosis cases have a good prognosis if they get fast
and proper treatment. Ancylostomiosis can be prevented by implementing a clean
and healthy lifestyle.
Keywords: Ancylostomiosis; heart failure; Elderly Patients
INTRODUCTION
The prevalence of helminthiasis is a very common health problem in Indonesia,
especially among underprivileged communities living in areas with poor sanitation.
The prevalence of hookworm infection ranges from 2.5% to 62%, showing significant
variation across regions.
Hookworms that infect the Indonesian population are caused by Necator
americanus which causes necatoriasis and Ancylostoma duodenale which causes
ankylostomiasis (Loukas et al., 2016).
Ancylostoma duodenale, a type of human hookworm, is the prevailing parasitic
infection in countries with limited access to clean water, proper sanitation, and good
hygiene practices (Hu et al., 2002). A. duodenale, along with other soil-transmitted
helminths (STH), is transmitted through direct contact with soil contaminated by
infectious larvae. Adult worms in the intestine continuously suck blood from the
patient. One adult Necator americanus worm can cause blood loss of up to 0.1 cc per
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day, while one Ancylostoma duodenale worm can cause blood loss of up to 0.34 cc
per day.
The following will report a case of a 62-year-old man who came to the
emergency department of Buleleng Regional General Hospital. The patient came
with complaints of weakness and fainting. The author raises this case because
ancylostomiasis in elderly people is a rare case but if not treated properly it will lead
to fatal complications, so it is hoped that readers will understand better how to
diagnose and treat ancylostomiasis.
RESEARCH METHODS
This research used a case study approach. The research data was collected
through direct observation of elderly patients. During the observation process, the
researcher records various information about the patient's medical history, symptoms
experienced, and the body's response to the parasitic worm infection. Data obtained
through observation will be analyzed using a qualitative analysis approach. The
researcher identifies and analyzes patterns or important findings that emerge from
the observation data. The results of the qualitative analysis will provide an in-depth
understanding of the role of ancylostomiasis in the occurrence of heart failure in the
elderly population, thus providing new insights in the field of health and medical
services.
Information on a 62-year-old male patient came to the emergency room of
Buleleng Regency Hospital with complaints of easy fatigue accompanied by spinning
dizziness and fainting, spinning dizziness worsens when walking, the patient works
as a traditional farm laborer and does not use footwear when farming, on physical
examination obtained vital signs within normal limits, anemic conjunctiva, pale
acral.
On complete blood count examination, leukopenia (Wbc 3.20x103/uL),
eosinophilia (0.87x103), anemia (Hb 2.8 g/dL), hemodelution (HCT 11.3%),
hypochromic (MCH 16.3pg), microcytic (MCV 65. 0fL), on electrocardiogram
examination obtained sinus rhythm with left ventricular hypertrophy, on thoracic
photo examination obtained cardiomegaly, on peripheral blood smear examination
obtained anisocytosis, microcytic, macrocytic, ovalocytes, hypochromic, pencil cells,
fragment cells, teardrop cells, polychromasia, impression of leukocyte countless
polymononuclear dominant, found hypersegmentation in neutrophils, lymphopenia,
absolute eosinophilia, on serum iron examination 41. 1µg/dL, UIBC 484 µg/dL,
ferritin 3.1ng/mL, feces examination revealed parasite infestation (ancylostoma
duodenale) (Matsumoto et al., 2020).
Based on patient information and examination, the patient can be diagnosed
with severe anemia with the cause of hookworm infection, iron deficiency anemia,
congestive heart failure, etiological diagnosis of acylostomiasis (Hermans et al.,
2013).
This patient was given a PRC transfusion of 1 colf / day with furosemide 20mg
premedication, with a total administration of 4 colf, administration of antihelmintics
namely albendazole 400mg every 12 hours, for 3 days, administration of iron
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preparations Ferrous Fumarate 60mg every 24 hours for 1 month, administration of
folic acid 400mcg every 24 hours for 1 month, administration of ascorbic acid 50mg
every 8 hours for 1 month, administration of bisoprolol 1 25mg every 24 hours,
spironolactone 25mg every 24 hours, flunarizine 5mg every 12 hours.
On the fourth day of treatment, a therapy evaluation was performed, and the
patient's clinical condition showed significant improvement with reduced
complaints. Vital signs were stable, and complete blood work showed improvement,
with increased hemoglobin and MCHC (Mean Corpuscular Hemoglobin
Concentration), and decreased eosinophils.
Figure 1. AP thorax photo
Figure 2. Electrocardiogram
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Hookworms are widely distributed throughout the world, especially in tropical
and subtropical regions with hot temperatures and high humidity. Hookworm
infection is prevalent among mine workers in Europe, China, and Japan, earning
them the name "hookworms." In Indonesia, the population is affected by two types
of hookworms: Necator americanus, which leads to necatoriasis, and Ancylostoma
duodenale, causing ankylostomiasis (Harmening, 2002).
Ancylostoma duodenale and Necator americanus adult worms reside in the
human small intestine, particularly in the jejunum and duodenum. They attach
themselves to the mucous membrane by using their teeth to bite and feed on the host's
blood from the bite wound. Adult worms in the intestine continuously suck the blood
of the patient. A single adult Necator americanus worm can cause blood loss of up
to 0.1 cc per day, while a single Ancylostoma duodenale worm can cause blood loss
of up to 0.34 cc per day (Harmening, 2002).
The pathological abnormalities caused by adult hookworms and their larvae
cause many complaints and clinical symptoms that are not typical. To determine the
exact diagnosis of hookworm infection, microscopic examination of feces is required
to find worm eggs.
Patient complaints and clinical features of hookworm infection may include:
(1) microcytic hypochromic anemia and a general picture of blood deficiency
(2) indigestion in the form of epigastric malaise, constipation, diarrhea or steatorrhea,
(3) ground-itch (itching of the skin at the site of entry of filariform larvae), and
(4) bronchitis symptoms due to the presence of larvae in the lungs that cause
coughing, sometimes accompanied by bloody sputum (Bernadette & Elaine,
2012).
Blood tests of patients with hookworm infection show a picture: hemoglobin
which decreases to less than 11.5 g/dl in female patients and less than 13.5 g/dl in
male patients. In addition, the blood picture also shows MCHC (Mean Corpuscular
Hemoglobin Concentration) which is less than 31-36 g/dl. Peripheral blood smear
shows a picture: hypochromic microcytosis, leukopenia with relative lymphocytosis,
with leukocyte counts less than 4,000/ml, eosinophilia which can reach 30% and
anisocytosis, or poikilocytosis (Kurniati, 2020; Wysocka & Turowski, 2000).
In this case, a 62-year-old man working as a rice farmer, from the anamnesis
conducted at the emergency department of RSUD Buleleng, the patient admitted to
weakness and fainting, the patient did not complain of limb weakness and fever. Vital
signs were found to be within normal limits. Physical examination found anemic
conjunctiva and pale acral (Santoso, 2023). Then an electrocardiographic
examination was performed and found sinus rhythm with left ventricular
hypertrophy. CT-scan examination without contrast was obtained brain atrophy.
Then a complete blood test was obtained severe hypochromic microcytic anemia
with leukopenia, eosinophilia, anisocytosis. Examination continued with peripheral
blood smears found anisocytosis, microcytic, macrocytic, ovalocytes, hypochromic,
pencil cells, fragment cells, teardrop cells, polychromasia, neutropenia, neutrophil
hypersementation, lymphopenia, absolute eosinophilia. Ferritin, serum iron, UIBC
(Unsaturated Iron Binding Capacity) examinations were performed and iron
deficiency results were found (Adams et al., 2007).
The occurrence of iron deficiency anemia linked to hookworms varies based on
an individual's iron reserves, the severity of infection, and the specific infecting
species, with A. duodenale causing more blood loss than N. americanus. One of the
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ways hookworm infection contributes to iron deficiency anemia is through persistent
blood loss in the gastrointestinal tract. Adult hookworms will burrow into the upper
mucosa of the small intestine, feeding on tissue and blood, resulting in impaired
nutrient absorption. The hookworm also changes tissue and blood feeding sites every
4-6 hours. Primary blood loss is when blood passes through the intestine from the
hookworms as they feed. Secondary blood loss occurs from bleeding due to mucosal
damage (McCance & Huether, 2014).
Anemia causes abnormalities in cardiac function and structure. Peripheral
ischemia due to anemia causes vasodilation and a decrease in blood pressure. This
activates the renin angiotensin aldosterone system, leading to decreased renal blood
flow and glomerular filtration rate, and increased water and salt absorption.
Increased extracellular fluid volume due to fluid retention leads to hemodilution and
lower hemoglobin levels. The excess plasma causes an increased cardiac load and
results in ventricular dilatation. In the long run, left ventricular hypertrophy, heart
muscle death and heart failure occur which further worsens (Mazurek & Jessup,
2015; Members et al., 2012; Stoltzfus et al., 1997).
Patients with heart failure are at risk of iron deficiency due to disruption of iron
absorption in the small intestine. The mechanisms underlying this condition are
ischemia of the intestinal mucosa, thickening of the intestinal wall due to edema, and
the role of proinflammatory mediators that inhibit iron absorption (Allen et al.,
1998).
This patient was given PRC transfusion 1 colf / day with furosemide 20mg
premedication, with a total administration of 4 colf, administration of antihelmintic,
namely albendazole 400mg every 12 hours, for 3 days, administration of iron
preparation Ferrous Fumarate 60mg every 24 hours for 1 month, administration of
folic acid 400mcg every 24 hours for 1 month, administration of ascorbic acid 50mg
every 8 hours for 1 month, administration of bisoprolol 1. 25mg every 24 hours,
spironolactone 25mg every 24 hours, flunarizine 5mg every 12 hours. Proper
diagnosis can help in proper and rapid management to prevent serious impact on the
patient, in addition to the patient getting a good prognosis.
On the fourth day of treatment, a therapy evaluation was conducted, and the
patient's clinical condition showed significant improvement with notable relief in
complaints. Vital signs were stable, and the complete blood test results indicated
improvement, with increased hemoglobin and MCHC (Mean Corpuscular
Hemoglobin Concentration), as well as decreased eosinophils. The patient was
informed about the possibility of reinfection if clean and healthy living habits are not
maintained. Additionally, the importance of preventive measures, such as wearing
closed footwear while farming, and regular deworming every 6 months, was
explained to the patient.
CONCLUSION
Based on the case study above, ancylostomiosis in the elderly can cause severe
anemia accompanied by iron deficiency anemia and heart failure. Ancylostomiasis
in the elderly is a rare case, so proper treatment is very important. If proper treatment
can be done, it will give a good prognosis and not cause damage to other organs.
Although Ancylostomiosis is not considered a dangerous disease and has the
potential to cause death, in special conditions especially in elderly patients, if
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ancylostomiosis is not treated properly, it can cause serious problems such as heart
failure. Therefore, maintaining clean and healthy living habits and regularly taking
deworming medication are important steps to prevent the adverse effects of the
infection. If proper treatment can be done, it will give a good prognosis and not cause
damage to other organs.
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Copyright holders:
I Made Herdinata Sudiartana, Ni Made Dewi Arimas Pereira Moniz (2023)
First publication right:
AJHS - Asian Journal of Healthy and Science
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