A 60-year-old male farmer from South Asia presented with severe iron deficiency anemia, hemoglobin levels plunging to 4.2 g/dL, and physical manifestations of koilonychia—spoon-shaped nails. Medical investigators detailed how upper gastrointestinal endoscopy unexpectedly revealed live Ascaris lumbricoides worms inside the patient’s duodenum.
In Plain English: The Clinical Takeaway
- Severe Anemia: The patient’s hemoglobin—the protein in red blood cells that carries oxygen—dropped to 4.2 grams per deciliter, well below the normal healthy range.
- Koilonychia: This term describes concave, spoon-shaped fingernails and toenails, serving as a classic physical sign of chronic, prolonged iron deficiency.
- Duodenal Ascariasis: Endoscopy located parasitic roundworms residing in the duodenum, the first part of the small intestine, complicating the clinical picture of the patient’s iron depletion.
Clinical Evaluation of Severe Anemia and Nail Deformities
The patient sought medical evaluation after experiencing a month-long progression of exertional dyspnea, or shortness of breath during physical effort, generalized weakness, and noticeable weight loss. Clinicians also documented a 40-year history of smoking cigarettes and marijuana. Physical examinations identified generalized pallor alongside striking nail changes across multiple fingers and toes. Laboratory confirmation verified microcytic hypochromic anemia, characterized by abnormally small, pale red blood cells alongside depleted iron stores. Serum ferritin—a blood protein that contains iron—measured a scant 1.92 nanograms per milliliter, accompanied by plummeting serum iron and elevated total iron-binding capacity.
Because unexplained iron deficiency anemia in adult and elderly male patients warrants an aggressive search for gastrointestinal bleeding, malignancy, or malabsorption, physicians performed an upper gastrointestinal endoscopy. Rather than finding a bleeding ulcer or tumor, the procedure exposed multiple live Ascaris lumbricoides worms writhing within the duodenal lumen. Endoscopic visualization confirmed the dual burden of parasitic infestation and critical anemia.
Diagnostic Approach to Soil-Transmitted Helminths in Endemic Areas
Parasitic infections remain a significant clinical factor in regions plagued by poor sanitation, unsafe drinking water, and soil contaminated with human feces. While hookworm stands as the primary helminthic driver of chronic intestinal blood loss and anemia, ascariasis contributes differently. Ascaris lumbricoides impacts nutritional status through decreased dietary intake, impaired nutrient absorption, direct metabolic competition, and ongoing intestinal irritation.
Medical investigators noted that the patient engaged in risky agricultural hygiene habits, such as failing to consistently wash his hands or fruits prior to consumption. While koilonychia frequently points straight to chronic iron deficiency, it also appears in celiac disease, malnutrition, thyroid dysfunction, and systemic autoimmune disorders. Consequently, clinicians stressed that koilonychia functions as a diagnostic trigger demanding a broad systemic workup rather than acting as a standalone diagnosis.
Therapeutic Intervention and Three-Month Clinical Recovery
Healthcare providers treated the patient using a multifaceted medical regimen. Intervention included targeted antiparasitic therapy with albendazole, red cell concentrate transfusions tailored to his symptomatic clinical presentation, and oral iron supplementation to rebuild his depleted iron reserves. Follow-up evaluations conducted three months post-treatment revealed dramatic clinical, hematological, and biochemical reversals. The patient’s systemic symptoms resolved, his blood counts rebounded, and his characteristic spoon-shaped koilonychia nails showed visible structural improvement.
| Clinical Parameter | Initial Presentation | Three-Month Follow-Up |
|---|---|---|
| Hemoglobin (Hb) | 4.2 g/dL (Severe Depletion) | Marked Hematological Recovery |
| Serum Ferritin | 1.92 ng/mL (Depleted Stores) | Biochemical Normalization |
| Nail Morphology | Koilonychia (Spoon-Shaped) | Structural Resolution |
| Parasitic Status | Duodenal Ascariasis Detected | Treated via Albendazole |
References
- Severe Iron Deficiency Anemia With Koilonychia and Endoscopically Detected Duodenal Ascariasis in an Elderly Male: A Case Report.
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