intestinal capillariasis , caused by capillaria philippinensis , was first recognized in an autopsy case occurred in ilocos norte , luzon island , the philippines . since the first case report in the philippines , this nematode infections have been subsequently reported from other parts of asia ( thailand , japan , iran , taiwan , egypt , indonesia , united arab emirates , korea , india , and lao pdr ) [ 3 - 12 ] , and even from non - endemic areas ( south america ) . in the republic of korea , the first case , with severe emaciation and malnutrition due to long - lasting diarrhea , was found in 1991 by detecting worm sections from the biopsied intestine , and also by identifying the eggs in fecal samples . after the first case report , 1 indeginous ( namwon - si , jeollabuk - do ) and 3 imported cases ( from bali in indonesia and saipan island ) were added [ 14 - 16 ] . in the present study , we describe clinical and parasitological findings of an intestinal capillariasis case with protein - losing enteropathy occurred in an inland area of korea . a 37-year old man , residing in sacheon - si , gyeongsangnam - do , visited the gyeongsang national university hospital ( gnuh ) for his long - lasting diarrhea and general edema on july 2010 . he had been treated at a private clinic before visiting gnuh , but symptoms aggravated gradually . at that time , the total serum protein and albumin levels were 5.0 and 2.4 g / dl , respectively , urine protein was negative , and thyroid function test was normal . in routine stool examinations , clonorchis sinensis eggs were detected ; therefore , we prescribed him praziquantel . ten months later , he admitted to our hospital because of persistent diarrhea , abdominal pain , general edema , and 15 kg weight loss for a year . he said that he frequently ate raw fish , especially common blackish goby ( acanthogobius flavimanus ) and has never been abroad . we observed tenderness around periumbilical area and general edema on physical examination . in the initial laboratory findings , the total serum protein and albumin levels were 3.7 and 1.3 mg / dl , respectively . the results of thyroid function test were 90.81 ng / dl of t3 , 0.91 ng / dl of free t4 , and 13.35 miu / l of tsh , but all of autoantibodies such as anti - thyroglobulin , anti - tpo , tsh - receptor - ab were negative . synthyroid 0.05 mg was given to him for 2 weeks , but serum albumin was still low as 1.2 g / dl , and diarrhea and general edema were not improved . in the abdominal ct , there was proximal small bowel wall thickening and transient intussusception . diffuse effacement of small bowel folds from the mid - jejunum to terminal ileum was seen at a small bowel double contrast study . there was diffuse mucosal edema and large amount of whitish exudates at the jejunum and terminal ileum . however , the lesion was not ulcerative and without mass in the whole small bowel mucosa by small bowel capsule endoscopy . esophagogastroduodenoscopic and colonoscopic findings were non - specific except for mild mucosal edema at the terminal ileum . blind random biopsy was performed at 10 cm and 30 cm proximal from the ileocecal valve . the intestinal villi were atrophic and there was an intense infiltration of plasma cells in the lamina propria . sectioned nematode worms were seen in the epithelial layer . some cross - sectioned worms ( n=9 ) were 25 - 30 ( av . 27 ) m and 33 - 38 ( 35 ) m in diameter , and revealed the characteristic features of c. philippinensis ( stichocytes and male and female genital organs ) ( fig . 1 ) . we could make the diagnosis as intestinal capillariasis and prescribed albendazole 400 mg daily for 3 days . a month later , all symptoms disappeared and the total serum protein and albumin levels were normalized to 6.4 and 3.8 mg / dl , respectively . adults and eggs of c. philippinensis were recovered in the diarrheic stools collected before and after treatment . male worms ( n=10 ) were 1,770 - 2,150 ( 1,872 in average ) m long and 27.5 - 30.0 ( 28.0 in average ) m wide , and had a characteristically long esophagus ( 950 - 1,150 m long ) with a chain of stichocytes and a long spicule within a sheath ( fig . 2a ) . female worms ( n=10 ) were 2,290 - 2,970 ( 2,556 in average ) m long and 30 - 38 ( 35 in average ) m wide , and had a long esophagus ( 1,150 - 1,450 m long ) with a chain of stichocytes and immature eggs ( 35 - 4418 - 23 m size ) in the uterus . their posterior ends were more blunt than anterior ends , and vulva openings were located posteriorly at 38 - 45 m from the esophago - intestinal junction ( fig . mature eggs ( n=5 ) detected in the diarrheic stools were 42.5 - 45.0 ( av . 43.3 ) m long and 20.0 - 21.3 ( 20.4 ) m wide , and had characteristic mucoid plugs at both ends ( fig . 2c ) . the present study is the 6th korean case of intestinal capillariasis and the 3rd case indigenously occurred in korea . the outbreak place of the present case , sacheon - si , gyeongsangnam - do , is not so far from namwon - si , jeollabuk - do , in which 2 indigenous cases previously occurred . these indigenous cases suggest that the life cycle of c. philippinensis is maintained in the southern regions of the korean peninsula , such as namwon - si and sacheon - si . accordingly , studies on epidemiologic characteristics of c. philippinensis , especially on the source of human infections , transmission modes , fish intermediate hosts , and natural reservoir ( definitive ) hosts , should be performed in the near future . on the other hand , the remaining 3 cases were imported from bali in indonesia and saipan island [ 14 - 16 ] . recently , in some asian countries ( india , egypt , lao pdr , thailand , taiwan , and the philippines ) , intestinal capillariasis is regarded as the emerging and/or reemerging parasitic disease , and it 's outbreaks have been frequently reported [ 12,17 - 21 ] . protein - losing enteropathy is a complication frequently manifested in the intestinal capillariasis [ 16 - 18 ] . it is a result of direct mucosal invasion by the adult worms , which is sometimes exacerbated by the host inflammatory responses . although the intestinal tract frequently has grossly normal appearance , histopathologic examinations of the biopsied intestines reveal villus atropy , crypt hyperplasia , and occasional infiltration of inflammatory cells . in the present study , although mild mucosal edema was observed at the terminal ileum , ulcerative or mass lesion was not found in the whole small bowel mucosa . however , in the biopsied specimens , villus atrophy , an intense infiltration of plasma cells , and sectioned nematode worms were seen in the epithelial layer . numerous worms embedded in the intestinal mucosa may be associated with ulcerative and degenerative changes , and the protein - losing enteropathy may be provoked as a result . regarding the diagnosis of intestinal capillariasis , characteristic clinical symptoms , including long - lasting diarrhea , abdominal pain , severe weight loss , and low serum albumin level , may be considerable factors in the first step . a definite diagnosis can be made by detection of worms and eggs in the diarrheic stools . however , histopathologic findings of biopsied intestines , including villus atrophy , crypt hyperplasia , intense infiltration of inflammatory cells , and worm sections , may be useful as the second - step diagnostic procedure . however , the exact sampling of intestines is not easy because endoscopic examinations are not applicable to the jejunum of humans , the normal habitat of c. philippinensis . in the present study , biopsy was performed at the terminal ileum through colonoscopy , and diagnostic clues were found in the biopsy specimens before the recovery of worms and eggs in the stool samples . diagnosed their case i by detection of worms and eggs in the biopsy specimens of the terminal ileum , like in our case , whereas kwon et al .   found worm sections in the biopsied jejunum . all korean cases were definitely diagnosed by the detection of eggs and/or worms in the diarrheic stools of patients [ 10,14 - 16 ] . cases indigenously occurred in namwon - si experienced consuming raw freshwater fish , i.e. , several species of cyprinoid fish and rainbow trout . the present case recalled that he frequently ate raw goby ( acanthogobius flavimanus ) , which could be easily captured in the seashore near his residential place . however , he was mixed - infected with c. sinensis , which is an evidence of eating raw freshwater fish also . accordingly , some fish species , including the common blackish goby , must be the source of human infections , and this should be clarified in the near future in korea .
we encountered an indigenous case of intestinal capillariasis with protein - losing enteropathy in the republic of korea . a 37-year - old man , residing in sacheon - si 
 , gyeongsangnam - do , admitted to the gyeongsang national university hospital ( gnuh ) due to long - lasting diarrhea , abdominal pain , anasarca , and weight loss . 
 he recalled that he frequently ate raw fish , especially the common blackish goby ( acanthogobius flavimanus ) and has never been abroad . under the suspicion of protein - losing enteropathy 
 , he received various kinds of medical examinations , and was diagnosed as intestinal capillariasis based on characteristic sectional findings of nematode worms in the biopsied small intestine . 
 adults , juvenile worms , and eggs were also detected in the diarrheic stools collected before and after medication . 
 the clinical symptoms became much better after treatment with albendazole 400 mg daily for 3 days , and all findings were in normal range in laboratory examinations performed after 1 month . 
 the present study is the 6th korean case of intestinal capillariasis and the 3rd indigenous one in the republic of korea .