HidalgoElishaGay_CaseStudy

7/30/2019 HidalgoElishaGay_CaseStudy

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By: Elisha Gay C. Hidalgo, RND


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Primary Disease: Capillariasis(underlying condition)Co-Morbid Conditions: Cachexia andChronic DiarrheaNutrition Diagnosis Statement:Inadequate Nutrient Intake as

evidenced by excessive weight lossand muscle wasting due to loss ofappetite, chronic diarrhea and poorintestinal absorption due to intestinalparasitism.Primary Concern in DietaryManagement: Reversal of Cachexia


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Histopathology:

In 1962, the first reported case of human intestinal capillariasisoccurred in a previously healthy young man from Luzon in thePhilippines, who subsequently died. At autopsy, a large numberof worms were found in the large and small intestines.

Definition: Is an infection with nematodes of the genus Capillaria, species of

which attack various different animals. Human infection isusually by C. philippinensis, which infests the intestines andcauses severe diarrhea, malabsorption, and often death. Morerarely, infection with C. hepaticacan cause human hepaticcapillariasis, and C. aerophilacan cause human pulmonary

capillariasis. Is an infection with a type of roundworm (Capillaria

phillipinensis) found in the Philipines and Thailand. Infection canoccur by eating raw contaminated freshwater fish.


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The nematode (roundworm)Capillaria philippinensis causeshuman intestinal capillariasis. Twoother Capillaria species parasitizeanimals, with rare reportedinstances of human infections. Theyare C. hepatica, which causes inhumans hepatic capillariasis, and C.aerophila, which causes in humanspulmonary capillariasis.

C. philippinensis is a tiny nematodefirst described in the 1960 s as apathogen causing severe diarrhealsyndromes in humans.
http://upload.wikimedia.org/wikipedia/en/9/9c/CapillariaPhilippEgg.jpg


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The life cycle of C. philippinensis is notcompletely known, but infection isprobably acquired by ingesting eggs orinfective larvae in small fish.

The organisms embed in the mucosa ofthe jejunum and interfere with

absorption. Larvae released from the female cause

autoinfection. Adults, larvae and eggs of C.

philippinensis are in the crypts andlamina propria of the duodenum,

jejunum, and upper ileum.The diagnosis is made by identifying

characteristic C. philippinensis eggs inthe stool. C. hepatica is parasite of mammals. Adult

worms in the definitive host (the rat)deposit eggs in the liver. If this host iseaten by a cat or dog, the eggs pass withthe animal faeces. Eggs in the soil areeaten by humans and hatch in the smallintestine. The larvae penetrate theintestinal wall and migrate to the liver,where they mature.C. hepatica in adults are the foci ofintense granulomatous reactions.The diagnosis is made by identifyingeggs or adult worms in the liver.
http://medpediamedia.com/u/Capillaria_LifeCycle.jpg/Capillaria_LifeCycle.jpg


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The underlying condition in thiscase is Intestinal Capillariasis. Thelist of signs and symptomsmentioned in various sources forIntestinal capillariasis includes the9 symptoms listed below:

Watery diarrhea Protein-losing enteropathy Malabsorption Vomiting Edema Muscle weakness

Muscle wasting Abdominal pain Electrolyte loss

COMORBID CONDITION PRESENTINTHE PATIENT:

CACHEXIA
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C. Philippinesis causes a malabsorption enteropathy that may besevere and even fatal.

The organisms embed in the mucosa of the jejunum andinterfere with absorption.

Fatal infections are caused by extraordinarily heavy worm

infestation. In severe infections generalized abdominal pain, diarrhea and

pronounced borborygmi are followed by nausea and vomitingand intractable diarrhea, leading to severe malabsorption,cachexia, and death.

The combination of muscular wasting, and loss of body fatmakes intestinal peristalsis visible and outlines muscles andtendons through the skin.

At autopsy the small intestine is indurated, thickened, anddistended with fluid.

One liter of fluid may contain 200,000 adults and larvae. Adults, larvae and eggs of C. philippinensis are in the crypts and

lamina propria of the duodenum, jejunum, and upper ileum.


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Fewer than 15 autopsies have been done on Filipinos who died ofintestinal capillariasis. Their bodies were emaciated, dehydrated,and pale.

Numerous worms in all stages were found in the lumen and inthe intestinal mucosa. In 1 liter of bowel fluid from one autopsyan estimated 200,000 worms were recovered. Although most

worms are found in the jejunum, some are found throughout thedigestive tract, probably as a result of postmortem migration.The parasite was found once in extraintestinal tissue, in a sectionof liver.

In gerbil tissue taken at necropsy and studied by electronmicroscopy, the following changes were seen: microulcers in theepithelium, compressive degeneration and mechanical

compression of cells, and homogeneous material at the anteriorend of the worm. These ulcerative and degenerative lesions inthe intestinal mucosa may account in part for the malabsorptionwith loss of fluids, protein, and electrolytes.


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The mortality rangesfrom 7% to 20%.

The drug of choice ismebendazole*, andalbendazole* is analternative.


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Application of the NutritionCare Process


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"a systematic problem-solvingmethod that dieteticsprofessionals use to criticallythink and make decisions toaddress nutrition relatedproblems and provide safe andeffective quality nutrition care."

The Nutrition Care Processconsists of four distinct, butinterrelated and connectedsteps: (a) NutritionAssessment, (b) NutritionDiagnosis, (c) NutritionIntervention, and d) NutritionMonitoring and Evaluation.


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20 year old male, cachectic due tochronic diarrhea from capillariasis,referred for diet management. Primary Disease: Capillariasis

(underlying condition) Co-Morbid Conditions: Cachexia and

Chronic Diarrhea

Nutrition Diagnosis Statement:Inadequate Nutrient Intake asevidenced by excessive weight lossand muscle wasting due to loss ofappetite, chronic diarrhea and poor

intestinal absorption from intestinalparasitism. Primary Concern in Dietary

Management: Reversal of Cachexia


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1. Clinical History: underlying disease, duration ofillness, intake of nutrients, gastrointestinalsymptoms such as malabsorption, vomiting anddiarrhea.

2. Physical exam/Anthropometrics: Recent

unintentional loss of 10% to 20% of thepatients usual weight indicates moderateprotein-calorie malnutrition, and loss of morethan 20% indicates severe protein-caloriemalnutrition.

3. Labs - Measurements of serum protein levelsare used in conjunction with other assessmentparameters to determine the patients overallnutritional status.


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Inadequate Nutrient Intake as evidenced byexcessive weight loss and muscle wastingdue to loss of appetite, chronic diarrhea andpoor intestinal absorption due to intestinal

parasitism. Complications to consider in determining

type of nutrition intervention and route ofadministration in this case. Patient is

cachexic, suffering from chronic diarrhea;possible very poor absorption, protein, fluid,electrolyte and fluid losses; poor oral intakedue to nausea and fatigue.


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Intervention Objective: Prevent and reversemalnutrition, cachexia, impaired immunityand loss of lean body mass. Correctdehydration and electrolyte imbalance.

Route of Administration:

1. Nutrition Support Parenteral , toCombination feeding to Enteral

2. Progression from liquid to soft to full diet(High calorie, high protein, low fat, highfiber diet).


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Combination of cachexia,malabsorption, and chronicdiarrhea (possibly withvomiting) makes oral intakeinadequate for replenishment.Unless contraindicated, enteral

feeding should always bepreferred. In cases of severeintestinal malabsorption,diarrhea and vomiting,administration of short-termparenteral nutrition (3-5 days)is the choice for nutritionsupport. After clinicalimprovement of diarrhea andvomiting gradually switchfeeding to enteral nutrition.


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Start with estimates such as20-25 kcal/kg. Be careful notto overfeed and also avoidrefeeding syndrome.

Fat should be given daily asan energy source. Use ofOmega-3 fatty acids (EPA) iscontroversial, but somestudies suggest a role inmaintaining healthy immunefunction and increase in

weight for cachexic patients. Glutamine infusion maybe

helpful. Osmolality is important to

monitor.


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Liquid diet to Soft to Full Diet should be theorder of diet transition based on patientstolerance.

High Calorie, High Protein Diet to replenish

nutrient losses, for weight gain and to boostimmunity

Low Fat diet when diarrhea is still present (Fatsources containing Omega 3 fatty acids like

salmon or canola oil is preferable) High Fiber Diet to prevent recurrence of

infection


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For nutritional support to be effective, it is necessary to ensure that thenutrients being provided are adequate and are being used properly. It isimportant to determine whether the goals established in nutritionalassessment are being met.

Nitrogen balance may be the most responsive nutritional indicator.Anthropometric measurements are of limited value if performed morefrequently than monthly. In the absence of severe stress, serum proteinlevels change according to their individual half-lives. Thus,improvements in the prealbumin level may occur after 2 to 3 days, andimprovements in the transferrin level may occur after 7 to 10 days.

Parameters that are monitored include:1. Daily to every-other-day weight measurements to detect excess fluid

retention.2. Estimates of caloric and protein intakes to achieve nutritional goals.

3. Measurement of serum glucose level, acidbase balance, and serumlevels of electrolytes, calcium, magnesium, and phosphorus.4. Daily temperature to assess possibility of catheter-related infection.5. Weekly prothrombin time, partial thromboplastin time, and platelet

count to optimize catheter management.


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Prevent Recurrence ofIntestinalInfection/Parasitism: Teachpatient and family properfood handling, preparationand cooking practices.Prevention is as simple asavoiding eating small,whole, uncooked fish.

Meet and MaintainDesirable Body Weight byfollowing proper dietprescription. THANK YOU!

HidalgoElishaGay_CaseStudy

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