By: Elisha Gay C.

Hidalgo, RND

Primary Disease: Capillariasis (underlying condition) Co-Morbid Conditions: Cachexia and Chronic Diarrhea Nutrition Diagnosis Statement:

Inadequate Nutrient Intake as evidenced by excessive weight loss and muscle wasting due to loss of appetite, chronic diarrhea and poor intestinal absorption due to intestinal parasitism. Primary Concern in Dietary Management: Reversal of Cachexia

Histopathology: In 1962, the first reported case of human intestinal capillariasis occurred in a previously healthy young man from Luzon in the Philippines, who subsequently died. At autopsy, a large number of 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 is usually by C. philippinensis, which infests the intestines and causes severe diarrhea, malabsorption, and often death. More rarely, infection with C. hepatica can cause human hepatic capillariasis, and C. aerophila can cause human pulmonary capillariasis. Is an infection with a type of roundworm (Capillaria phillipinensis) found in the Philipines and Thailand. Infection can occur by eating raw contaminated freshwater fish.

The nematode (roundworm) Capillaria philippinensis causes human intestinal capillariasis. Two other Capillaria species parasitize animals, with rare reported instances of human infections. They are C. hepatica, which causes in humans hepatic capillariasis, and C. aerophila, which causes in humans pulmonary capillariasis. C. philippinensis is a tiny nematode first described in the 1960 s as a pathogen causing severe diarrheal syndromes in humans.

The life cycle of C. philippinensis is not completely known, but infection is probably acquired by ingesting eggs or infective larvae in small fish. The organisms embed in the mucosa of the jejunum and interfere with absorption. Larvae released from the female cause autoinfection. Adults, larvae and eggs of C. philippinensis are in the crypts and lamina propria of the duodenum, jejunum, and upper ileum. The diagnosis is made by identifying characteristic C. philippinensis eggs in the stool. C. hepatica is parasite of mammals. Adult worms in the definitive host (the rat) deposit eggs in the liver. If this host is eaten by a cat or dog, the eggs pass with the animal faeces. Eggs in the soil are eaten by humans and hatch in the small intestine. The larvae penetrate the intestinal wall and migrate to the liver, where they mature. C. hepatica in adults are the foci of intense granulomatous reactions. The diagnosis is made by identifying eggs or adult worms in the liver.

The underlying condition in this case is Intestinal Capillariasis. The list of signs and symptoms mentioned in various sources for Intestinal capillariasis includes the 9 symptoms listed below: Watery diarrhea Protein-losing enteropathy Malabsorption Vomiting Edema Muscle weakness Muscle wasting Abdominal pain Electrolyte loss COMORBID CONDITION PRESENT INTHE PATIENT: CACHEXIA

C. Philippinesis causes a malabsorption enteropathy that may be severe and even fatal. The organisms embed in the mucosa of the jejunum and interfere 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 vomiting and intractable diarrhea, leading to severe malabsorption, cachexia, and death. The combination of muscular wasting, and loss of body fat makes intestinal peristalsis visible and outlines muscles and tendons through the skin. At autopsy the small intestine is indurated, thickened, and distended 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.

Fewer than 15 autopsies have been done on Filipinos who died of intestinal capillariasis. Their bodies were emaciated, dehydrated, and pale. Numerous worms in all stages were found in the lumen and in the intestinal mucosa. In 1 liter of bowel fluid from one autopsy an estimated 200,000 worms were recovered. Although most worms are found in the jejunum, some are found throughout the digestive tract, probably as a result of postmortem migration. The parasite was found once in extraintestinal tissue, in a section of liver. In gerbil tissue taken at necropsy and studied by electron microscopy, the following changes were seen: microulcers in the epithelium, compressive degeneration and mechanical compression of cells, and homogeneous material at the anterior end of the worm. These ulcerative and degenerative lesions in the intestinal mucosa may account in part for the malabsorption with loss of fluids, protein, and electrolytes .

The mortality ranges from 7% to 20%. The drug of choice is mebendazole*, and albendazole* is an alternative.

Application of the Nutrition Care Process

"a

systematic problem-solving method that dietetics professionals use to critically think and make decisions to address nutrition related problems and provide safe and effective quality nutrition care." The Nutrition Care Process consists of four distinct, but interrelated and connected steps: (a) Nutrition Assessment, (b) Nutrition Diagnosis, (c) Nutrition Intervention, and d) Nutrition Monitoring and Evaluation.

20 year old male, cachectic due to chronic 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 as evidenced by excessive weight loss and muscle wasting due to loss of appetite, chronic diarrhea and poor intestinal absorption from intestinal parasitism. Primary Concern in Dietary Management: Reversal of Cachexia

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Clinical History: underlying disease, duration of illness, intake of nutrients, gastrointestinal symptoms such as malabsorption, vomiting and diarrhea. Physical exam/Anthropometrics: Recent unintentional loss of 10% to 20% of the patients usual weight indicates moderate protein-calorie malnutrition, and loss of more than 20% indicates severe protein-calorie malnutrition. Labs - Measurements of serum protein levels are used in conjunction with other assessment parameters to determine the patients overall nutritional status.

Inadequate Nutrient Intake as evidenced by excessive weight loss and muscle wasting due to loss of appetite, chronic diarrhea and poor intestinal absorption due to intestinal parasitism. Complications to consider in determining type of nutrition intervention and route of administration in this case. Patient is cachexic, suffering from chronic diarrhea; possible very poor absorption, protein, fluid, electrolyte and fluid losses; poor oral intake due to nausea and fatigue.

Intervention Objective: Prevent and reverse malnutrition, cachexia, impaired immunity and loss of lean body mass. Correct dehydration and electrolyte imbalance. Route of Administration: 1. Nutrition Support Parenteral , to Combination feeding to Enteral 2. Progression from liquid to soft to full diet (High calorie, high protein, low fat, high fiber diet).

Combination of cachexia, malabsorption, and chronic diarrhea (possibly with vomiting) makes oral intake inadequate for replenishment. Unless contraindicated, enteral feeding should always be preferred. In cases of severe intestinal malabsorption, diarrhea and vomiting, administration of short-term parenteral nutrition (3-5 days) is the choice for nutrition support. After clinical improvement of diarrhea and vomiting gradually switch feeding to enteral nutrition.

Start with estimates such as 20-25 kcal/kg. Be careful not to overfeed and also avoid refeeding syndrome. Fat should be given daily as an energy source. Use of Omega-3 fatty acids (EPA) is controversial, but some studies suggest a role in maintaining healthy immune function and increase in weight for cachexic patients. Glutamine infusion maybe helpful. Osmolality is important to monitor.

Liquid diet to Soft to Full Diet should be the order of diet transition based on patients tolerance. High Calorie, High Protein Diet to replenish nutrient losses, for weight gain and to boost immunity Low Fat diet when diarrhea is still present (Fat sources 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 the nutrients being provided are adequate and are being used properly. It is important to determine whether the goals established in nutritional assessment are being met. Nitrogen balance may be the most responsive nutritional indicator. Anthropometric measurements are of limited value if performed more frequently than monthly. In the absence of severe stress, serum protein levels change according to their individual half-lives. Thus, improvements in the prealbumin level may occur after 2 to 3 days, and improvements in the transferrin level may occur after 7 to 10 days. Parameters that are monitored include: Daily to every-other-day weight measurements to detect excess fluid retention. Estimates of caloric and protein intakes to achieve nutritional goals. Measurement of serum glucose level, acidbase balance, and serum levels of electrolytes, calcium, magnesium, and phosphorus. Daily temperature to assess possibility of catheter-related infection. Weekly prothrombin time, partial thromboplastin time, and platelet count to optimize catheter management.

Prevent Recurrence of Intestinal Infection/Parasitism: Teach patient and family proper food handling, preparation and cooking practices. Prevention is as simple as avoiding eating small, whole, uncooked fish. Meet and Maintain Desirable Body Weight by following proper diet prescription.

THANK YOU!