내과의사를위한위장관기생충질환 기생충학박사에게듣는위장관기생충질환 성균관대학교의과대학내과이준행 기생충학박사이준행 기생충김치파동 (2005) 소 150 여마리폐사 뇌척수사상충증 - 제주특별자치도수의사회다음카페 1
妓生2 2012-04-05 http://www.merriam-webster.com/dictionary/parasite A case of hypochondriac
오늘의질문 위장관기생충을 10 개이상나열하시오. Schmidt & Robert s Foundations of Parasitology (7 th ) p14 기생생활 : 한생물체가다른생물체의체내, 체표에일시적또는영구적으로서식하면서영양물을탈취하는생활양식 기생체 ( 넓은의미의 parasite): 기생생활을영위하는생물체 기생충 ( 좁은의미의 parasite): 기생체가운데동물계에속하는것 기생충학에서다루는동물의종류 회충, 간흡충, 유구조충과같이조직과기관이발달한후생동물 (metazoa) 인윤충 (helminth) 이질아메바, 람블편모충과같이단세포양단위 (single cell-like unit) 로된원생동물 (protozoa) 머릿니, 빈대와같은절지동물 윤충 (helminth) 의분류 선충 (nematode = roundworm): 회충, 요충과같이긴원통과같은모양이며체강이있는윤충 흡충 (trematode = fluke): 간흡충, 폐흡충과같이편평한나뭇잎모양이며체절이없는윤충 조충 (cestode = tapeworm): 유구조충, 무구조충과같이편평한띠모양이고체절이있는윤충 A. lumbricoides T. solium http://dna.naver.com/viewer/index.nhn?editno=1&printcount=1&publishdate=1972-02-17&officeid=00009&pageno=6&printno=1830&publishtype=00020&articleid=1972021700099206001 3
장내기생충실태조사 : 충란양성률 (%) 제 1 차 (1971) 제 2 차 (1976) 제 3 차 (1981) 제 4 차 (1986) 제 5 차 (1992) 제 6 차 (1997) 총피검자수 24,887 27,178 35,018 43,590 46,912 45,832 총충란양성자 84.3 63.2 41.1 12.9 3.8 2.4 축적양성자 147.1 89.6 54.5 14.9 3.9 2.4 회충 54.9 41.0 13.0 2.1 0.3 0.06 구충 10.7 2.2 0.5 0.1 0.01 0.007 편충 64.5 42.0 23.4 4.8 0.2 0.04 간흡충 4.6 1.8 2.6 2.7 2.2 1.4 유무구조충 1.9 0.7 1.1 0.3 0.06 0.02 요충 * 12.0 3.6 0.9 0.6 http://healthcenter.kihasa.re.kr/pannel/100-29.jpg * 어린이대상항문도말검사 Return of the parasite (2005. 5.) Annual positive rates of total intestinal parasites, helminthic eggs and protozoan cysts from 2000 to 2007 (SMCHPC) 대한내과학회지 2009 2009-1-19 4
기생충질환증가이유 (1/2) 말라리아가재유행하고있음 생선회등음식을통하여전파되는기생충질환이꾸준히진단되고있음 국내거주외국인및해외여행객이증가하고있어해외유입기생충질환이증가 기생충질환증가이유 (2/2) 애완동물에서감염되는인수공통감염증증가 면역억제환자가많아지면서과거에는희귀했던기생충질환이증가 유기합성농약과화학비료를사용하지않는농산물이선호되고있음 기생충질환은계속증가할것인가? 의료진과환자들의기생충증에대한관심이감소되었음 기생충증에대한적절한검진, 진단및치료가이루어지지않고있음 음식물을통한해외유입기생충증이증가할가능성이있음 실제로최근전국적인 survey 와본병원건진데이터에서증가추세가확연함 적극적으로대처하지않을경우기생충증이다시만연할가능성이매우높음 아직기생충으로크게고생하는환자가있다 성균관대학교의과대학내과이준행 Gastric anisakiasis 한국에서네번째진단된장카필라리아증 42 세남자 3 개월전부터수양성설사, 복통, 체중감소 (83 45 kg), 미열 내월 6 개월전태평양의사이판섬에여행을다녀왔고여행지에서민물장어회를먹음 Lab: WBC 5,200/mm 3, eosinophil 1% 첫대변검사에서충란 (-) 크론병의심하에스테로이드투여 (2 주 ). 처음에는증상호전이있는듯하다가다시증상이악화되어재입원후시행한대변검사에서충란발견 이석호, 이풍렬. 대한소화기학회지 1999;34:542-546 5
Hyperinfection syndrome 기생충은반드시나쁜것인가? http://www.cdfound.to.it/html/rep_str.htm 정인수. 대한내과학회지 2008;74:S7-S11 선충 (round worm) 성균관대학교의과대학내과이준행 정인수. 대한내과학회지 2008;74:S7-S11 What is the diagnosis? http://health.chosun.com/site/data/html_dir/2001/02/10/20010210000018.html 6
Enterobius vermicularis 요충 Enterobius vermicularis in the cecum http://www.gastrolab.net/pa-160.htm 요충치료원칙 가족또는단체구성원모두를동시에치료 20일간격으로 3회이상반복치료 (mebendazole 100mg x1, pyrantel pamoate 10mg/kg x1) 손톱을잘깎고, 목욕과손을자주씻는다. 내복과침구의일광소독 방안의먼지를깨끗이청소 좌변기를비누로매일청소 알벤다졸원내처방가능 2011-6-28 Ascaris lumbricoides - human and pig round worm 소화기내과교수님들께, Albendazole 400 mg 경구제제에대한코드를신설하여외래에서처방할수있게되었습니다. 기존에는대변검사에서기생충이발견되었을때환자에게약국에서직접사드시도록교육하였는데, 처방전을발생하는것이외래에서환자안내하기에더좋을것같아서처방코드를신설하였습니다. 일반약이지만원외처방전을발생할수있으므로필요시외래에서처방하시기바랍니다. ( 원내보유하지는않습니다.) 강철인드림. http://www.biosci.ohio-state.edu/~parasite/ascaris.html 7
57 YO male, alcoholics, diabetic - Bronchopneumonia with empyema Ascariasis in a LC patient with esophageal cancer (M/66) 유기농을즐겨드시는 81 세남자 4 일전붕장어 ( 아나고 ) 드신후복통있어서내시경을하여 SMT 의심으로왔으나 Anisakis 감염증으로진단된예 Massive bleeding by Anisarkis A bleeding gastric ulcer on a vanishing tumor (54 M) 1 month later 1 month later 3 months later Gastrointest Endosc 2000;52:559-551 8
Parasitic eosinophic granuloma treated by submucosal tumorectomy Chronic abdominal pain mimicking Crohn s disease (M/41) 평소생선회를즐겨먹던 49 세여자가건진에서발견된위점막하종양으로의뢰됨 최종원, 정재복. 대한소화기내시경학회지 2005;30:267-272 Right sided colon과 terminal ileum을 resection하고 Crohn s disease로진단하고 mesalazine으로치료하였으나설사가지속되어처음병리조직을다른병리과의사에게보내어다시검토한결과 helminth worm을발견하고 pyrantel pamoate, paromomycin, metronidazole, steroid로치료후호전 He had eaten raw fish (marinated sardines: 정어리 ) about 7 days before the onset of initial abdominal symptoms Montalto. Dig Liver Dis 2005;37:62-64 Surgery due to acute abdomen (M/33) 홍어회 ( 쓸개 ) 드시고급성복통 - r/o phlegmon-forming type intestinal anisakiasis Ansakis simplex larva in the jejunal section He had eaten pickled anchovies ( 지중해산멸치 ) a few days before. 10 days later Pellegrini M. Dig Liver Dis 2005;37:65-67 Sometimes, the diagnosis may be difficult In intestinal anisakiasis, or cases in which the worm has fully penetrated into submucosa or migrated beyond the gastrointestinal tract, diagnosis is more problematic. Conditions mimicked by anisakiasis Peptic ulcer, gastritis, vanishing gastric tumor Giant gastric folds Subacute intestinal obstruction Acute abdomen, appendicitis Crohn s disease Carcinoma Tuberculous peritonitis Hemorrhagic gastritis Eosinophilic gastroenteritis Foundations of parasitology. Seventh ed. p440 Akbar A. Dig Liver Dis 2005;37:7-9 9
Trichuris trichiura T.trichiura during colonoscopy http://www.med.sc.edu:85/para-lab2/trichuris.htm Hookworm detected by capsule endoscopy Strongyloides stercolaris A 36-year-old Latin American man presented to Thomason General Hospital in El Paso, Texas, complaining of shortness of breath, palpitations, and chest pain on exertion. He was an immigrant from El Salvador and had lived across the border in Ciudad Juarez, Mexico. Physical examination was remarkable for skin pallor. The hematocrit was 19.5% (normal: 36.0%-47.0%) and white blood cell count was 10,170/mm3 (4500-11,000/mm3) with 27% eosinophils (1%-5%). Serum iron was 7 µg/dl (26-170 µg/dl), total iron-binding capacity was 378 µg/dl (240-480 µg/dl), and ferritin was 1 ng/ml (20-200 ng/ml). Stool examination to evaluate eosinophilia was negative for ova and parasites. The patient was transfused with two units of packed red blood cells. EGD showed multiple gastric erosions and a duodenal ulcer with a white base. Colonoscopy was normal. A capsule endoscopy done to further evaluate the patient for iron deficiency anemia and eosinophilia showed multiple (approximately 70) worms throughout the small bowel, in some cases with hemorrhagic areas at points of attachment to the mucosa (A and B). A subsequent enteroscopy (SIF-100; Olympus America Inc, Melville, NY) the next day visualized several worms about 5 to 10 mm long in the distal duodenum and the proximal jejunum (C and D). They moved actively away as the endoscope was advanced. A specimen was retrieved with biopsy forceps and was identified on microscopic examination as a hookworm, Necator americanus. Treatment on discharge consisted of a course of oral mebendazole and iron supplementation. Female worm, bar = 0.5 mm Filariform larva, 600 µm Gastrointest Endosc 2005;62:782 http://cpl.yonsei.ac.kr/micro/para/p0_0_0.htm 회충 Duodenal biopsy 요충, 편충 분선충 Concha R. J Clin Gastroenterol 2005:39(3):203-211 10
http://www.mgm.ufl.edu/~gulig/mmid/strongyloides-life-cycle.jpg 내시경적조직검사로진단된위분선충증 Case 1: Colon ulcers multiple erythemas Case 2: Duodenal fold thickening 66 세남자 1 개월전시작된상복부통증 Lab: 백혈구 6,700/mm 3, 호산구 18% Albendazola 400 mg/day, 7 일투여 Case 3: Erythematous gastric mucosa, thickened fold, red-brown discoloration Case 2: Helminthic larvae between crypts Thompson BF. Gastrointest Endosc 2004;59:906-910 이석호, 이규택. 대한소화기내시경학회지 1999;19:249-253 Atypical gastric presentation of strongyloidiasis in HIV-infected patient 소세포폐암으로항암치료를받던환자에서발생된분선충증에의한급성폐포출혈 Meine GC. Digestive Liver Dis 2004;36(11):760-762 11
Hyperinfection syndrome Hyperinfection syndrome It is essential to include strongyloidiasis in the differential diagnosis when patients present with the GI symptomes and have traveled to or reside within regions where Strongyloides is endemic, and in patients with peripheral or tissue eosinophilia. Immunocompromised patients with hyperinfection syndrome should be treated with thiabendazole. Strongyloides stercoralis in sputum Eosinophilic liver abscess in a patient with gastric cancer (Toxocara canis) 천엽 가래에피가섞이면 : 咯血 가래에기생충이있으면 : 咯寄生蟲 Reconstructed coronal CT images - 19 months follow-up 1 2 3 4 Jae Hoon Lim. Abdom Imaging 2008;33:151-12
이환자의 Toxocariasis 를치료해야할까요? - 생간섭취력 (+), peripheral eosinophilia (10%), liver abscess (+), 혈액 Toxocariasis 항체 (+) Sparganum ( 孤蟲 ) inguinal area 의견 : 투약은필요없다고생각합니다. 아래 URL 을참조하세요. http://endoedu.com/src/source_cee/201_endotoday/20100701.pdf Thigh 에서도 sparganum 이나옴 편충 (fluke) 성균관대학교의과대학내과이준행 Hur. Korean J Med 2004;67:s917-s922 Hypereosinophilic syndrome 으로오인되었던폐흡충증 초가을에민물게장을먹었음. 11 월 fever, chill, cough 로감기치료 호전없었음 12 월초점차증상이악화되어폐렴이라는진단하에입원치료하였으나발열이지속되었음 병원을옮겨서검사한후 hypereosinophilic syndrome 진단하에 Pd 20mg/day 투약후증세호전됨 이듬해 2 월 pneumothorax 발생되어 tapping 과 C-tube insertion 등치료 3 월부터 hemoptysis 발생되어같은진단하에 Pd 40mg/day 증량하여투여받으셨고 Chest CT 에서전형적인 paragonimiasis 의소견을보였고 sputum 에서 parasite egg 가관찰되어 PW 로진단하고투약후호전 13
AGC and C. sinensis infestation ERCP 하다가발견된흡충 - 간흡충 간흡충의치료 간질은간흡충과비슷하지만약간크다 Praziquantel 은 25mg/kg 의용량을하루 3 회경구투여하는것을기본으로한다. 유행지에서는반복적인구충제투여가필요하다. 하루복용으로치유되지않는경우에같은용법으로반복투약한다. Albendazole 을사용하는경우하루에 5mg/kg 씩 2 회, 7 일간복용하여야효과가있다. 채종일. 임상기생충학 366 page J Gastroenterol Hepatol 2009;24:1309 Intestinal fascioliasis Liver abscess due to F. hepatica 14
Liver abscess due to F. hepatica - Chronic granulomatous inflammation with abscess and multiple eggs, consistent with larva migration 사람약은없어지고동물용만남았다??? Fasciola hepatica 의진단은혈청학적으로하는데녹십자수탁의뢰를하면되고 (parasite antibody ELISA 검사비고란에 Fasciola hepatica 검사를해달라고하면됩니다.) 문제는 triclabendazole 이치료약제인데이전에는국립의료원에서구할수있었으나근래에전세계적으로생산이중단되어몇달전제환자는결국수술을했습니다... Triclabendazole 이동물용으로는바이엘에있고성분이같다고하는데써도될까요? E. hortense - M/81, abdominal pain 호남지역에서내시경으로진단된호르텐스극구흡충감염 1 예 Size of the worm : 7.92 X 1.33 mm Cho CM ( 경북대 ). Korean J Parasitol 2003:41:117-120 박철주. 대한내과학회지 2006 만성간염환자에서우연히발견된기생충 Estimated cases of intestinal trematodes infection in Korean Chai JY. Parasitol Int 2002;51:129-54 15
2009 년내시경학회포스터 Colonoscopy 위해 bowel preparation 도중배출된 D. latum 조충 (tapeworm) 성균관대학교의과대학내과이준행 D. Latum Taenia asiatica http://www.atlas.or.kr/donation/donation_files/2_5.jpg 자료제공 : 제주대학교김흥업교수님 16
반복학습의효과 Amebic colitis in gastric cancer patient 애독자의편지 : 기생충반복학습덕분에제가명의가되었습니다. XX 세남자로작년부터항문이가렵고뭔가기어나와서당기면끊기는일을수차례경험하였다고합니다. 동네내과에서 2 차례기생충약을먹었습니다. 최근다시항문이물감으로내원하였습니다. 직장경에서긴 tapeworm( 조충 ) 을발견하였습니다. 당기다가중간에끊겨서좀아쉽지만 1 미터 50 센티는되는것같았습니다. 보호자는매우만족하여귀가했습니다. 감사합니다. EndoTODAY 답변 : 정말훌륭한일을하셨습니다. 충체의편절이넓은직사각형모양이고 uterus 와 ovary 가뭉쳐서둥글게보이므로 D. latum 일가능성이커보입니다. 기생충학교실로보내서확인하십시오. Praziqantel 10mg/kg 한번투약하십시오. 조금더드려도됩니다. 앞으로도무차별반복형주입식교육자료계속보내겠습니다. Giardia lamblia in stool examination 내시경검사에서기생충을만나면검체를어떻게접수시킬것인가 미생물검사실 (Tel:2697) 검사코드 : BL4411 의뢰방법 : saline을넣은검체 bottle에담는다. 검체 bottle은기생충크기에따라정한다. (culture tube, sputum tube, 증류수 bottle ). 주의사항 : 포도당 (DW) 나증류수에기생충을넣으면검사가불가능함 http://bugs.uah.ualberta.ca/webbug/parasite/artifact/giardia.htm 요약 : 내과의사를위한기생충질환 경청해주셔서감사합니다. 기생충질환이증가하고있다. 기생충질환으로죽거나심하게고생하는환자가아직도발생하고있다. 기생충이반드시나쁜것은아니다. 흔하고중요한소화관기생충질환에대한기본적인이해는필수적이다. 17
경청해주셔서감사합니다. 다음에도많은참석을부탁드립니다. SGEA 2012-5-14 ( 월 ) 7:30 삼성서울병원암센터지하 2 층중강당 : 18