Incidental detection of an Anisakis larva in continuous ambulatory peritoneal dialysis effluent
Chung-Ho Yeum1,
Seong-Kwon Ma2,
Soo-Wan Kim2,
Nam-Ho Kim2,
Jin Kim3 and
Ki-Chul Choi2,
1 Department of Internal Medicine, Cheju National University Medical School, Jeju, Jeju, Korea,
2 Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Gwangju, Korea and
3 Department of Parasitology, Seonam University College of Medicine, Namwon, Jeonbuk, Korea
Keywords: Anisakis larvae; CAPD; extragastrointestinal anisakiasis; seafood
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Introduction
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Anisakiasis is a parasitic disease of the gastrointestinal tract caused by ingestion of Anisakis larvae present in raw or undercooked fish such as sashimi, sushi, ceviche, and lomi-lomi. This disease is not uncommon in Korea, where people habitually eat raw fish [1].
Anisakis larvae commonly lodge in the wall of the stomach, intestine, or colon, causing an inflammatory response and acute symptoms such as sudden abdominal pain, fever, nausea, vomiting, and diarrhoea [2]. Extragastrointestinal anisakiasis is caused by a larva, which escapes the gastrointestinal wall to make lesions in the abdominal cavity, pancreas, ovary, utero-cervix, lymph node, liver, lung, or subcutaneous tissues [3]. It is a rare disease with less specific manifestations and can resemble other intestinal conditions. Recently, a case of continuous ambulatory peritoneal dialysis (CAPD) peritonitis caused by Anisakis larvae was reported [4]. However, we observed a patient presenting with Anisakis larva in CAPD effluent that had no evidence of peritonitis. He had been showing good tolerance of CAPD except for the development of mild abdominal discomfort 4 weeks previously.
Here we report a case of incidental Anisakis larva detection in CAPD effluent with no evidence of peritonitis.
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Case
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A 30-year-old man, who had been treated with CAPD for 3 years, reported to Chonnam National University Hospital because of incidental detection of a worm in the CAPD effluent (Figure 1A
). He had noticed a living white worm floating in the dialysate effluent during dialysis, which began moving about after recovering from the fluid.

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Fig. 1. An Anisakis larva (arrow) floating in the CAPD effluent (A, no stain, magnification x40), and its transverse section (B, hematoxylin and eosin stain, magnification x100).
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The patient had eaten raw seafood 4 weeks before his visit and had experienced mild abdominal discomfort with feelings of fullness thereafter. Physical examination was unremarkable. Laboratory findings showed a slight elevation of white blood cells (11 000/mm3) with mild eosinophilia (eosinophils, 6.6%), elevated erythrocyte sedimentation rate (114 mm/h), and negative C-reactive protein. The CAPD effluent was clear, and there were no white blood cells in the peritoneal fluid during three separate examinations. Gastroduodenofiberscopy showed no worms and no evidence of gastric erosion or haemorrhage. Results from an upper gastrointestinal series and a follow-up small bowel study were also unremarkable.
The retrieved worm was 28.4x0.5 mm in size and had a circular thread-like appearance. The anterior end of the larva, the straight oesophagus, ventriculus, and intestine were visible; however, the intestinal caecum and ventricular appendage were not observed. In cross section, the cuticle was thin with a uniform thickness, and muscle cells were of the polymyarian type. Internal organs were composed of the lobular wing-like lateral cord, the excretory cell (renette cell), and the circular intestine (Figure 1B
). These morphologic features were diagnostic for the larva of Anisakis simplex.
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Discussion
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Anisakiasis is a common parasitic infection in Korea and Japan, where uncooked fish are commonly consumed in the form of sushi and sashimi [1,2]. Although the most common sites of involvement are the stomach and small bowel, a few cases of large intestine infestation have been described [2]. In extragastrointestinal cases, the larvae escape the wall, producing a more insidious disease. Other peritoneal cases have been reported, but none had described visible lesions upon radiologic study, probably because of its small size [3]. In agreement, the present case showed no visible lesions during gastrofiberscopy and small bowel tests.
Muraoka et al. [5] demonstrated a relationship between the activities of Anisakis larvae and the pH in the stomach. Acidity in the stomach appears to facilitate Anisakis larvae growth, and the acidic medium of the CAPD fluid in our study, Gambrosol (Gambro, USA) with pH 5.5, might have provided good milieu for the survival of Anisakis larva.
Ohta et al. [4] reported a case of CAPD peritonitis caused by Anisakis larva. In the present case, however, there was no evidence of peritonitis. Therefore, we should keep in mind that the Anisakis larva can be detected incidentally in CAPD effluent without inflammation, especially in areas where dietary habits include eating raw or improperly cooked seafoods.
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Notes
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Correspondence and offprint requests to: Ki-Chul Choi, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Gwangju, Korea. Email: choikc@chonnam.ac.kr 
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References
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- Im KI, Yong TS, Shin HJ, Kim BH, Moon SI. Gastric anisakiasis in Korea with review of 47 cases. Yonsei Rep Trop Med1990; 21: 1
- Matsui T, Iida M, Murakami M et al. Intestinal anisakiasis: clinical and radiologic features. Radiology1985; 157: 299[Abstract]
- Cespedes M, Saez A, Rodriguez I, Pinto JM, Rodriguez R. Chronic anisakiasis presenting as a mesenteric mass. Abdom Imaging2000; 25: 548[ISI][Medline]
- Ohta M, Ikeda K, Miyakoshi H et al. A very rare case of continuous ambulatory peritoneal dialysis peritonitis caused by Anisakis larva. Am J Gastroenterol1995; 90: 1902[ISI][Medline]
- Muraoka A, Suehiro I, Fujii M et al. Acute gastric anisakiasis: 28 cases during the last 10 years. Dig Dis Sci1996; 41: 2362[ISI][Medline]
Received for publication: 20. 2.02
Accepted in revised form: 27. 3.02