Infection DOI 10.1007/s15010-014-0587-3

CASE REPORT

Pulmonary toxocariasis: a case report and literature review G. Ranasuriya • A. Mian • Z. Boujaoude C. Tsigrelis



Received: 19 November 2013 / Accepted: 9 January 2014 Ó Springer-Verlag Berlin Heidelberg 2014

Abstract Toxocariasis is a parasitic disease caused by Toxocara canis or T. cati. We report a patient with toxocariasis who presented with dyspnea, high-grade eosinophilia, and bilateral pulmonary nodules. To further characterize the pulmonary manifestations of toxocariasis, we have reviewed 11 previously published pulmonary toxocariasis cases. The most common pulmonary symptoms in our review were cough and dyspnea, and the most common finding on chest imaging was bilateral pulmonary nodules. Risk factors for Toxocara infection primarily included exposure to dogs. Most patients received albendazole and responded well. A high index of suspicion is needed to diagnose this otherwise preventable parasitic disease.

intestine and enter the systemic circulation and disseminate to various tissues (i.e., visceral larva migrans and/or ocular larva migrans if involving the eyes) leading to an intense inflammatory response and eosinophilia [1]. Larvae commonly migrate through the liver, and can involve almost any organ. Pulmonary disease can occur with Toxocara infection, leading to acute bronchiolitis, asthma, and/or pneumonitis [1]. To further characterize the pulmonary manifestations of toxocariasis, we report a case of pulmonary toxocariasis and present an updated review of previously published pulmonary toxocariasis cases.

Keywords Toxocara  Visceral larva migrans  Eosinophilia  Lung  Multiple pulmonary nodules

A 75-year-old female with end stage renal disease on hemodialysis was evaluated because of high-grade eosinophilia. On initial evaluation, she had dyspnea, but no cough, fever, chills, chest pain, or gastrointestinal symptoms. Upon further questioning, she reported having a kitten and dog that did not attend veterinary care, and she used diapers on her pets. She lived in New Jersey and her only travel outside of the USA was a trip to the Caribbean 15 years prior. She did not consume undercooked pork or game meat. At the time of initial evaluation, she did not have fever and her pulse oximetry was 90 % while breathing room air. Laboratory examination revealed a peak absolute eosinophil count of 11,880 cells/lL (white blood cell count of 19,800 cells/lL with 60 % eosinophils). Computed tomography (CT) of the chest showed multiple nodular opacities throughout both lungs (Fig. 1). Bronchoscopy and bronchoalveolar lavage (BAL) was done, however a biopsy was not done due to patient receiving recent anticoagulant therapy. BAL fluid analysis showed 285

Introduction Toxocariasis is a parasitic disease that is caused by the ingestion of infective eggs of Toxocara canis or T. cati, whose definitive hosts are dogs and cats, respectively [1]. Upon ingestion of the eggs by humans, larvae hatch in the

G. Ranasuriya (&)  Z. Boujaoude Division of Pulmonary Medicine, Department of Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, 3 Cooper Plaza, Suite 312, Camden, NJ 08103, USA e-mail: [email protected] A. Mian  C. Tsigrelis Division of Infectious Diseases, Department of Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, USA

Case report and review

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Fig. 1 Initial computed tomography of the chest showing multiple nodular opacities throughout both lungs

Fig. 2 Computed tomography of the chest 2 weeks following completion of albendazole therapy, demonstrating marked improvement of the bilateral pulmonary nodules

nucleated cells with 5 % eosinophils. Cytology was negative for malignant cells, and routine, mycobacterial, and fungal cultures were negative. Trans-thoracic echocardiogram did not reveal any valvular vegetations. Blood cultures were negative. Stool ova and parasite examinations could not be obtained. Anti-neutrophil cytoplasmic antibody testing was negative. Testing for Strongyloides immunoglobulin G antibody via enzyme-linked immunosorbent assay (ELISA) was negative. Testing for Toxocara antibody via ELISA subsequently returned positive at a titer of 4.19 (reference range \1.00) and a diagnosis of suspected Toxocara infection and visceral larva migrans with bilateral pulmonary nodular lesions was made. The patient was given albendazole 400 mg twice daily for a total duration of 5 days. She did not receive any corticosteroids. At a follow-up visit 2 weeks following the completion of albendazole therapy, she did not have any further dyspnea. A repeat CT scan of the chest was performed at that time which demonstrated marked improvement of the bilateral pulmonary nodules (Fig. 2), and a

123

complete blood count with differential was done which showed an absolute eosinophil count that was decreased at 635 cells/lL (white blood cell count of 12,700 cells/lL with 5 % eosinophils). To provide an updated review of previously published pulmonary toxocariasis cases, a PubMed search of the English language literature was performed from the beginning of the database through November 13, 2013, and included the following individual search terms: ‘‘pulmonary toxocariasis,’’ ‘‘toxocara and lung,’’ ‘‘toxocara and pulmonary,’’ and ‘‘pulmonary visceral larva migrans.’’ We also reviewed the reference sections of each pulmonary toxocariasis case report or series that was found to search for additional cases. Inclusion criteria that were applied to each article included all of the following: (1) Toxocara infection diagnosed by serological testing or biopsy; (2) pulmonary parenchymal abnormality on chest imaging; (3) increased absolute eosinophil blood count; (4) sufficient clinical details regarding individual cases were available in the article. We identified 11 previously reported cases of pulmonary toxocariasis in our literature review (Table 1) [2–11]. Several reports were excluded from further assessment, including one report of a case with only pleural effusion and no pulmonary infiltrates [12]. Reports that did not include sufficient clinical details regarding individual cases were also excluded from this review [13–15]. Of the 12 patients with pulmonary toxocariasis included in our review (including our own case), the mean age was 44 (range 20–75) years (Table 1). There were five cases reported from Japan, three from the USA, and one each from Turkey, Serbia, Greece, and Spain. Various risk factors for Toxocara acquisition were noted, including dog and cat exposure and the consumption of raw foods including chicken liver, beef liver, chitlins, raw pork, and raw snails. Initial absolute eosinophil blood counts were very high in most patients, and most patients that had BAL sampled had an elevated BAL eosinophil percentage. Presenting symptoms included cough in six patients, dyspnea in five patients, and wheezing in one patient. CT chest most commonly revealed multiple bilateral lung nodules. Most patients were treated with albendazole and/ or corticosteroids and their condition improved.

Discussion We report here a case of pulmonary toxocariasis and provide a current review of 11 additional previously published cases of pulmonary toxocariasis. Toxocara can involve almost any organ, and pulmonary symptoms that have been commonly reported include coughing or wheezing [16], which is consistent with the cases we described in our

75, Female

52, Male

42, Male

71, Male

46, Male

20, Female

38, Male

38, Female

26, Female

37, Male

48, Male

34, Male

1

2

3

4

5

6

7

8

9

10

11

12

Spain/1992

USA/1992

USA/1997

Japan/1999

Japan/2002

Greece/2005

Serbia/2006

Japan/2006

Japan/2006

Japan/2006

Turkey/2012

USA/2012

Country/yeara

Raw snail; dogs

Dogs; cats

Puppy; chitlins; raw pork

Raw beef liver

None

Dog trainer

Puppy

N/A

Chicken liver; dogs

Chicken liver; dogs

None

Kitten; dog; pet diapers

Risk factors for Toxocara

15,565

9,800

10,388

10,248

8,482

16,500

954

‘‘Mild eosinophilia’’

16,317

5,400

3,160

11,880

Absolute eosinophil count bloodb

64 %

N/A

N/A

N/A

96 %

N/A

24 %

N/A

30 %

11 %

42 %

5%

Eosinophil percent BAL

Multiple bilateral lung nodules

‘‘Right lower-zone infiltrate’’

Multiple bilateral lung nodules

Multiple bilateral lung nodules

‘‘Consolidation and ground glass opacities left upper and middle fields’’

‘‘Non-cavitating pulmonary lesions’’

Multiple bilateral lung nodules

Multiple lung nodules and wedge-shaped ground-glass opacities

Multiple bilateral lung nodules

Multiple bilateral lung nodules

Infiltrate in right upper lobe and both lower lobes

Multiple bilateral lung nodules

CT chest findings

No therapy

Steroids (N/A)

No therapy

MEB and TIAB (N/A)

ALB 600 mg/d (56 day)

Steroids (N/A)

ALB 15 mg/kg/d (30 day)

ALB (N/A)

ALB 600 mg/day (33 d) ? PRE 60 mg/day (22 d)

DEC 300 mg/day (12 d)

ALB 15 mg/kg/d (N/A) ? PRE 0.75 mg/ kg/day (N/A)

ALB 400 mg BID (5 days)

Treatment (duration)

2,100

N/A

‘‘Patient recovered’’

N/A

366

‘‘Abated’’

‘‘Normal’’

‘‘Normal’’

‘‘Decreased’’

‘‘Normal’’

340

635

Repeat blood eosinophil after therapyc

11

10

9

8

7

6

5

4

3

3

2

Current case

Reference number

c

b

a

Repeat absolute peripheral blood eosinophil count (cells/lL) after anti-parasitic therapy

Initial absolute peripheral blood eosinophil count (cells/lL)

Year of publication of case report

BAL, Bronchoalveolar lavage fluid; CT, computed tomography; N/A, not available; ALB, albendazole; BID, twice daily; MEB, mebendazole; TIAB, tiabendazole; PRE, prednisolone; DEC, diethylcarbamazine

Age (years)/sex

Patient

Table 1 Characteristics of patients with pulmonary toxocariasis, including our patient and those identified in the literature review

Pulmonary toxocariasis

123

G. Ranasuriya et al.

review. Dyspnea was also a commonly reported symptom in our review. Pulmonary infiltrates may be seen in onethird of patients [16], and of the 12 cases described in this report, the most common findings on CT imaging of the chest was multiple bilateral lung nodules. Although a 5-day course of albendazole or mebendazole is commonly recommended for toxocariasis [1, 16], some physicians treat for longer courses, for up to 20 days [16] or even longer. The mean duration of anti-parasitic therapy was 27 days in our review (Table 1), although information on the duration of anti-parasitic therapy was not available for all patients. Further studies are needed to assess the most appropriate duration of anti-parasitic therapy for pulmonary toxocariasis. Corticosteroids were used in several cases in our report (Table 1). Although corticosteroids are commonly used for ocular toxocariasis, their role in the treatment of pulmonary toxocariasis is not clear, but might be warranted for severe pulmonary involvement [1, 16]. Although several of the cases reported consumption of raw foods (e.g., chicken liver, etc.) as a risk factor for Toxocara infection (Table 1) [3, 8, 13, 14], this method of transmission is uncommon, and direct contact with areas exposed to dog or cat feces is the most commonly reported method of transmission. Therefore, the most important measures to prevent Toxocara infection include good hygiene, education of pet owners, including prompt disposal of pet feces to minimize environmental contamination, and veterinarian care for pets, including deworming. Conflict of interest

None.

References 1. Lassmann B, Tsigrelis C, Virk A. 33-year-old woman with marked eosinophilia. Mayo Clin Proc. 2007;82:103–6. 2. Demirci M, Unlu¨ M, Fidan F, Kaya S. Eosinophilic pneumonia due to toxocariasis: an adult case report. Turkiye Parazitol Derg. 2012;36:258–9.

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3. Morimatsu Y, Akao N, Akiyoshi H, Kawazu T, Okabe Y, Aizawa H. A familial case of visceral larva migrans after ingestion of raw chicken livers: appearance of specific antibody in bronchoalveolar lavage fluid of the patients. Am J Trop Med Hyg. 2006;75:303–6. 4. Sakai S, Shida Y, Takahashi N, Yabuuchi H, Soeda H, Okafuji T, Hatakenaka M, Honda H. Pulmonary lesions associated with visceral larva migrans due to Ascaris suum or Toxocara canis: imaging of six cases. AJR Am J Roentgenol. 2006;186:1697–702. 5. Povazan D, Djuric´ M, Uzurov-Dinic´ V, Lalosevic´ D, Lalosevic´ V, Secen S, Povazan A. Adult human case of toxocariasis with pulmonary migratory infiltrate and eosinophilia. Vojnosanit Pregl. 2011;68:881–5. 6. Haralambidou S, Vlachaki E, Ioannidou E, Milioni V, Haralambidis S, Klonizakis I. Pulmonary and myocardial manifestations due to Toxocara canis infection. Eur J Intern Med. 2005;16:601–2. 7. Inoue K, Inoue Y, Arai T, Nawa Y, Kashiwa Y, Yamamoto S, Sakatani M. Chronic eosinophilic pneumonia due to visceral larva migrans. Intern Med. 2002;41:478–82. 8. Aragane K, Akao N, Matsuyama T, Sugita M, Natsuaki M, Kitada O. Fever, cough, and nodules on ankles. Lancet. 1999;354:1872. 9. Sane AC, Barber BA. Pulmonary nodules due to Toxocara canis infection in an immunocompetent adult. South Med J. 1997;90:78–9. 10. Feldman GJ, Parker HW. Visceral larva migrans associated with the hypereosinophilic syndrome and the onset of severe asthma. Ann Intern Med. 1992;116:838–40. 11. Roig J, Romeu J, Riera C, Texido A, Domingo C, Morera J. Acute eosinophilic pneumonia due to toxocariasis with bronchoalveolar lavage findings. Chest. 1992;102:294–6. 12. Jeanfaivre T, Cimon B, Tolstuchow N, de Gentile L, Chabasse D, Tuchais E. Pleural effusion and toxocariasis. Thorax. 1996;51:106–7. 13. Yoon YS, Lee CH, Kang YA, Kwon SY, Yoon HI, Lee JH, Lee CT. Impact of toxocariasis in patients with unexplained patchy pulmonary infiltrate in Korea. J Korean Med Sci. 2009;24:40–5. 14. Kang YR, Kim SA, Jeon K, Koh WJ, Suh GY, Chung MP, Kim H, Kwon OJ, Kang ES, Um SW. Toxocariasis as a cause of new pulmonary infiltrates. Int J Tuberc Lung Dis. 2013;17:412–7. 15. Ribeiro JD, Fischer GB. Eosinophilic lung diseases. Paediatr Respir Rev. 2002;3:278–84. 16. Woodhall DM. Toxocariasis. In: Magill AJ, Ryan ET, Hill DR, Solomon T, editors. Hunter’s tropical medicine and emerging infectious diseases. 9th ed. Philadelphia: Saunders Elsevier; 2013. p. 850–2.

Pulmonary toxocariasis: a case report and literature review.

Toxocariasis is a parasitic disease caused by Toxocara canis or T. cati. We report a patient with toxocariasis who presented with dyspnea, high-grade ...
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