322
Letters to the Editor
fumigatus, and Mycobacterium chelonei. 1--' The presence of a mixed, anaerobic infection with organisms that are known flora of the mouth lead us to suspect that the origin of the infection in this case was the throat. Persistence of remnants of the thyroglossal duct are not unusual and can provide a direct condiut for throat flora into the thyroid. This case emphasizes the need for continued close observation of patients believed to have nonsuppurative thyroiditis and for prompt and appropriate treatment of suppurative complications. Lateral neck roentgenograms indicated the presence o f infection with gas-forming organisms and helped in choosing appropriate antibiotic therapy. Yvonne C. Bussman, M,D. Michael L. Wong, M.D. Martin J. Bell, M.D. Julio V. Santiago, M.D. Divisions of Endocrinology, Metabolism, and Infectious Disease Edward Mallinckrodt Department of Pediatrics Division of Pediatric Surge(y Department of Surgery' Washington Universi(y School of Medicine and St. Louis Children's Hospital St. Louis, Mo. 63110
The Journal o f Pediatrics Februarv 1977
Fig. !. Case 1: A larval fragment (arrows) lies twisted in the center of a myocardial granuloma. (Original magnification x 950.)
REFERENCES
1. Sharma RK, and Rapkin RH: Acute suppurative thyroiditis caused by Bacteroides melaninogenicus, JAMA 229:1470, 1974 2. Halazan JF, Anast CS, and Lukens JN: Thyrotoxicosis associated with aspergillus thyroiditis in chronic granulomatous disease, J PEDIATR 80:106, 1972. 3. Gutman S, Handwerger S, Zwady KP, Abranowsky CR, and Rodgers M: Thyroiditis due to myobacterium chelonei, Rev Resp Dis 110:807, 1974. 4. Jaffe N, and Schamroth L: Gas-forming infection of the thyroid gland, Clin Radiol 17:95, 1966. 5. Gaafar H, and E1-Garem F: Acute thyroiditis with gas formation, J Laryngol Otol 89:323, 1975.
Myocarditis due to visceral larva migrans To the Editor: Visceral larva migrans (VLM) occurs frequently in children who eat dirt contaminated by the ova of the common dog roundworm, Toxocara canis. 1 ' Though most often clinically benign,' ~ VLM has occasionally been reported to cause myocarditis.'-" We have observed myoearditis associated with VLM in three children. The diagnoses of VLM were based on histories of Supported in part by Grant No. HL-5756 from the National Institutes of Health United States Public Health Service and by USPH Grant RR-OO188 from the General Clinical Research Branch National Institutes of Health.
Fig. 2. Case 3: Eosinophils, lymphocytes, and plasma cells form a dense infiltrate in the myocardial interstitium. (Original magnification x 460.)
pica and profound eosinophilia; they were confirmed by finding VLM granulomas on microscopic sections of biopsy or autopsy material. In the two children who died, myocarditis was histologically documented at autopsy. In one child it was the cause of death and. in the other, it was an incidental autopsy finding. In the third child, myocarditis was diagnosed by its clinical manifestations. CASE REPORTS Case 1. An asymptomatic 2-year-old boy was seen at Texas Children's Hospital for evaluation of eosinophilia. VLM was diagnosed, and he was discharged. Three months later he died from a volvulus around the Meckel diverticulum. At autopsy, characteristic VLM granulomas were present in the myocardium. A remnant of a Toxocara larva was found within one granuloma (Fig. 1). Approximately 10% of the
Volume 90 Number 2
myocardium was infiltrated by a mixed inflammatory population of eosinophils, plasma cells, and lymphocytes. Case 2. An acutely ill 2-year-old girl was hospitalized because of labored, rapid respirations. She had tachycardia, gallop rhythm, orthopnea, r~les, generalized edema, and hepatomegaly. Chest roentgenograms revealed cardiomegaly and pulmonary edema. The electrocardiogram showed low-voltage QRS complexes and T waves. Treatment for congestive heart failure brought about rapid clinical improvement, and physical examination one month later was normal except for persistent hepatomegaly. She was transferred to Texas Children's Hospital for percutaneous liver biopsy. The biopsy revealed granulomas due to VLM. Case 3. A 20-month-old girl was admitted to Texas Children's Hospital because of acute respiratory distress. A gallop rhythm was present. An electrocardiogram showed low-voltage QRS complexes and T waves. Cineangiocardiography disclosed a poorly contracting, dilated left ventricle. The patient's cardiac decompensation proved uncontrollable, and she died after five months of unsuccessful therapy. Autopsy revealed cardiac hypertrophy and dilatation. The heart contained several VLM granulomas. The myocardium was infiltrated with multiple microscopic foci of inflammation (Fig. 2). The lungs contained hemosiderin-laden macrophages indicative of chronic heart failure. DISCUSSION During the 22 years since Texas Children's Hospital was founded, VLM was diagnosed in 20 children. Thus, the incidence of clinically significant myocarditis in this series is 10% or, if one includes the patient who was incidentally noted to have myocarditis at autopsy, 15%. One can only speculate as to how many children with VLM have subclinical or unrecognized myocarditis. Respiratory symptoms are common in patients with VLM and are usually attributed to Toxocara larvae invading the lung? Our
Letters to the Editor
323
experience also indicates that respiratory distress may be caused by heart failure secondary to myocarditis. We thank Drs. Michael N. Goldberg, Mollie Stephens, and Julius J. Burianek of Houston for referring these three patients. Thomas A. Vargo, M.D. Don B. Singer, M.D. Paul C. Gillette, M.D. Donald J. Fernbach, M.D. Sections of Cardiology and Hematology Department of Pediatrics Department of Pathology Baylor College of Medicine Texas Children's Hospital 6621 Fannin Houston, TX 77030 REFERENCES
1. Kissane JM: Pathology of infancy and childhood, ed 2, St. Louis, 1975, The CV Mosby Company, pp 126-129. 2. Brill R, Churg J, and Beaver PC: Allergic granulomatosis associated with larva migrans: Case report with autopsy findings of Toxocara infection in a child, Am J Clin Pathol 23:1208, 1953. 3. Dent JH, Nichols RL. Beaver PC, Carrera GM, and Staggers R J: Visceral larva migrans: with a case report, Am J Pathol 32:777, 1956. 4. Friedman S, and Hervada AR: Severe myocarditis with recovery in a child with visceral larva migrans, J PEDJATR 56:91, 1960. 5. Becroft DMO: Infection by the dog roundworm Toxocara canis and fatal myocarditis, NZ Med J 63:729, 1964. 6. Snyder CH: Visceral larva migrans: Ten years' experience, Pediatrics 28:85, 1961.
Letters to the Editor
fumigatus, and Mycobacterium chelonei. 1--' The presence of a mixed, anaerobic infection with organisms that are known flora of the mouth lead us to suspect that the origin of the infection in this case was the throat. Persistence of remnants of the thyroglossal duct are not unusual and can provide a direct condiut for throat flora into the thyroid. This case emphasizes the need for continued close observation of patients believed to have nonsuppurative thyroiditis and for prompt and appropriate treatment of suppurative complications. Lateral neck roentgenograms indicated the presence o f infection with gas-forming organisms and helped in choosing appropriate antibiotic therapy. Yvonne C. Bussman, M,D. Michael L. Wong, M.D. Martin J. Bell, M.D. Julio V. Santiago, M.D. Divisions of Endocrinology, Metabolism, and Infectious Disease Edward Mallinckrodt Department of Pediatrics Division of Pediatric Surge(y Department of Surgery' Washington Universi(y School of Medicine and St. Louis Children's Hospital St. Louis, Mo. 63110
The Journal o f Pediatrics Februarv 1977
Fig. !. Case 1: A larval fragment (arrows) lies twisted in the center of a myocardial granuloma. (Original magnification x 950.)
REFERENCES
1. Sharma RK, and Rapkin RH: Acute suppurative thyroiditis caused by Bacteroides melaninogenicus, JAMA 229:1470, 1974 2. Halazan JF, Anast CS, and Lukens JN: Thyrotoxicosis associated with aspergillus thyroiditis in chronic granulomatous disease, J PEDIATR 80:106, 1972. 3. Gutman S, Handwerger S, Zwady KP, Abranowsky CR, and Rodgers M: Thyroiditis due to myobacterium chelonei, Rev Resp Dis 110:807, 1974. 4. Jaffe N, and Schamroth L: Gas-forming infection of the thyroid gland, Clin Radiol 17:95, 1966. 5. Gaafar H, and E1-Garem F: Acute thyroiditis with gas formation, J Laryngol Otol 89:323, 1975.
Myocarditis due to visceral larva migrans To the Editor: Visceral larva migrans (VLM) occurs frequently in children who eat dirt contaminated by the ova of the common dog roundworm, Toxocara canis. 1 ' Though most often clinically benign,' ~ VLM has occasionally been reported to cause myocarditis.'-" We have observed myoearditis associated with VLM in three children. The diagnoses of VLM were based on histories of Supported in part by Grant No. HL-5756 from the National Institutes of Health United States Public Health Service and by USPH Grant RR-OO188 from the General Clinical Research Branch National Institutes of Health.
Fig. 2. Case 3: Eosinophils, lymphocytes, and plasma cells form a dense infiltrate in the myocardial interstitium. (Original magnification x 460.)
pica and profound eosinophilia; they were confirmed by finding VLM granulomas on microscopic sections of biopsy or autopsy material. In the two children who died, myocarditis was histologically documented at autopsy. In one child it was the cause of death and. in the other, it was an incidental autopsy finding. In the third child, myocarditis was diagnosed by its clinical manifestations. CASE REPORTS Case 1. An asymptomatic 2-year-old boy was seen at Texas Children's Hospital for evaluation of eosinophilia. VLM was diagnosed, and he was discharged. Three months later he died from a volvulus around the Meckel diverticulum. At autopsy, characteristic VLM granulomas were present in the myocardium. A remnant of a Toxocara larva was found within one granuloma (Fig. 1). Approximately 10% of the
Volume 90 Number 2
myocardium was infiltrated by a mixed inflammatory population of eosinophils, plasma cells, and lymphocytes. Case 2. An acutely ill 2-year-old girl was hospitalized because of labored, rapid respirations. She had tachycardia, gallop rhythm, orthopnea, r~les, generalized edema, and hepatomegaly. Chest roentgenograms revealed cardiomegaly and pulmonary edema. The electrocardiogram showed low-voltage QRS complexes and T waves. Treatment for congestive heart failure brought about rapid clinical improvement, and physical examination one month later was normal except for persistent hepatomegaly. She was transferred to Texas Children's Hospital for percutaneous liver biopsy. The biopsy revealed granulomas due to VLM. Case 3. A 20-month-old girl was admitted to Texas Children's Hospital because of acute respiratory distress. A gallop rhythm was present. An electrocardiogram showed low-voltage QRS complexes and T waves. Cineangiocardiography disclosed a poorly contracting, dilated left ventricle. The patient's cardiac decompensation proved uncontrollable, and she died after five months of unsuccessful therapy. Autopsy revealed cardiac hypertrophy and dilatation. The heart contained several VLM granulomas. The myocardium was infiltrated with multiple microscopic foci of inflammation (Fig. 2). The lungs contained hemosiderin-laden macrophages indicative of chronic heart failure. DISCUSSION During the 22 years since Texas Children's Hospital was founded, VLM was diagnosed in 20 children. Thus, the incidence of clinically significant myocarditis in this series is 10% or, if one includes the patient who was incidentally noted to have myocarditis at autopsy, 15%. One can only speculate as to how many children with VLM have subclinical or unrecognized myocarditis. Respiratory symptoms are common in patients with VLM and are usually attributed to Toxocara larvae invading the lung? Our
Letters to the Editor
323
experience also indicates that respiratory distress may be caused by heart failure secondary to myocarditis. We thank Drs. Michael N. Goldberg, Mollie Stephens, and Julius J. Burianek of Houston for referring these three patients. Thomas A. Vargo, M.D. Don B. Singer, M.D. Paul C. Gillette, M.D. Donald J. Fernbach, M.D. Sections of Cardiology and Hematology Department of Pediatrics Department of Pathology Baylor College of Medicine Texas Children's Hospital 6621 Fannin Houston, TX 77030 REFERENCES
1. Kissane JM: Pathology of infancy and childhood, ed 2, St. Louis, 1975, The CV Mosby Company, pp 126-129. 2. Brill R, Churg J, and Beaver PC: Allergic granulomatosis associated with larva migrans: Case report with autopsy findings of Toxocara infection in a child, Am J Clin Pathol 23:1208, 1953. 3. Dent JH, Nichols RL. Beaver PC, Carrera GM, and Staggers R J: Visceral larva migrans: with a case report, Am J Pathol 32:777, 1956. 4. Friedman S, and Hervada AR: Severe myocarditis with recovery in a child with visceral larva migrans, J PEDJATR 56:91, 1960. 5. Becroft DMO: Infection by the dog roundworm Toxocara canis and fatal myocarditis, NZ Med J 63:729, 1964. 6. Snyder CH: Visceral larva migrans: Ten years' experience, Pediatrics 28:85, 1961.
