Case Report: A case of dipylidiasis in a first-trimester pregnant woman attending a routine antenatal clinic at Elmina health centre, Ghana

Dipylidiasis is a zoonotic parasitosis caused by a canine and feline tapeworm, Dipylidium caninum which rarely infects humans, usually infants and young children. The accidental ingestion of cysticercoid infected flea Ctenocephalides felis is the cause of this cestode infection in humans. Here we report the first and a rare case of adult dipylidiasis in a first-trimester pregnant woman in Ghana. She reported at the health facility for a routine antenatal check-up with apparently no symptoms or signs of the infection at the time of the visit. Her routine stool examination revealed a single egg packet of Dipylidium caninum and was treated with a single dose of praziquantel. It is important for pathologists and laboratory technicians to be aware of the emergence of human dipylidiasis in Ghana. A conscious effort should be aimed at the creation of awareness among pet owners and the general population of the public health importance of zoonotic parasites that infect pets and domestic animals.

Human dipylidiasis is usually asymptomatic with occasional nonspecific symptoms such as diarrhoea, nocturnal pruritus, anorexia, pruritus ani, urticaria, weight loss, epigastric pain, constipation and loss of appetite 2,15 . Heavily infected cats which are definitive host sometimes exhibit severe symptoms such as intestinal obstruction, epileptiform seizures and convulsion 16,17 . However, such severe forms of dipylidiasis have not been reported in human cases.
A typical clinical diagnosis of Dipylidium caninum is by the identification of characteristic proglottids or egg packets and the cucumber seed-like body segments of the adult worm in stool 18, 19 . However, egg packets rapidly disintegrated in the stools and can occasionally be found in fresh samples 11,19 . However, the uncommon nature, poor description by an immediate observer and little or no experience by laboratory professionals with Dipylidium caninum may render it undiagnosed 20 .
Although human dipylidiasis has occasionally been reported in young children it has rarely been reported in adults, with exception of a 26-year-old kidney transplanted patient and a 57-year old woman 8,9,21 . Until now, there has not been any case of dipylidiasis associated with pregnancy reported in literature.
In this article, we present the first case of dipylidiasis in a 27-year-old woman in her first trimester of pregnancy attending a routine antenatal care at Elmina healthcare centre, Ghana.

Case presentation
A 27-year-old first-trimester pregnant woman, a petty trader and an Akan from Komenda in Komenda-Edina-Eguafo-Abrem district in Central region of Ghana who visited the antenatal clinic in April 2013 for a routine antenatal check-up at Elimina healthcare centre in the Central Region of Ghana with no symptoms or signs of infection or abnormalities. She had experienced intermittent vomiting, slight headache and bloated stomach in the previous three weeks before visiting the antenatal clinic. Physical examination revealed she had a normal pregnancy with no clinical manifestation or any signs of threat to her health. A routine laboratory examination of full blood count (FBC), stool, urine, blood film for malaria parasites together with a serological test for syphilis and HIV were requested. She had no history of close contact with cats and dogs.

Discussion
There are sporadic reports of human dipylidiasis in recent times, although humans are not the natural host 22,23 . The majority of these reports have been in infants and young children making them a high-risk group for Dipylidium caninum infection [24][25][26][27][28] . In this report, we present the first and rare case of dipylidiasis in a pregnant woman in her first trimester with no clinical symptoms at the time of antenatal examination in Elmina, Ghana. Despite the fact that the patient does not own a cat or dog as a pet, and had no history of contact with these animals which are the sources of accidental infection, she however stays in an area where dogs and cats stray freely without being confined by their owners.
Dipylidium caninum is a worldwide neglected helminth infection of dogs and cats, its natural hosts 23,29 . A study conducted in the Greater Accra region of Ghana reported a high prevalence of Dipylidium caninum as one of three zoonotic helminths of dogs that are kept for hunting and security purposes without confinement 30 . The free-range breeding of dogs and cats in Ghana without any control creates room for the contamination of the vicinity with their stool. These animals are usually not subjected to veterinary check-up and treatment; coupled with the fact that they feed in unhygienic places results in them posing a great environmental challenge further facilitating the transmission of infective fleas 31  A conscious effort should be aimed at the creation of awareness among pet owners and the general population of the public health importance of zoonotic parasites that infect pets and domestic animals.

Conclusion
We report the first and a rare human diphylidiasis in pregnancy from Ghana. To our understanding, this is the first case of human and adult infection of Diphylidium caninum from Ghana which makes it a case of public health concern. Therefore, the high prevalence of Dipylidium caninum infection among unconfined pets in communities inhabited by quite a number of young children in Ghana should be a public health concern.
Consent A written consent was obtained from the patient for publication of this case report and its accompanying images.

Data availability
Underlying data All data underlying the results are available as part of the article and no additional source data are required.

Grant information
This work was supported by the Department of Biomedical Science, College of Allied Health Sciences, University of Cape Coast.