Infection DOI 10.1007/s15010-015-0766-x
CASE REPORT
Vasculitis secondary to anti‑C1q antibodies induced by Toxocariasis Hubert de Boysson1,3 · Nicolas Martin Silva1 · François Comoz2 · Jonathan Boutemy1 · Boris Bienvenu1
Received: 10 January 2015 / Accepted: 18 March 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract Introduction Vasculitides occurring during parasitic infection are rare and may imply different mechanisms. Methods A case report of cutaneous vasculitis and visceral damage during a larva migrans syndrome. Results We report the case of a 64-year-old man who developed a purpura along with fever, respiratory failure, abdominal pain and myalgia. Immunological screening showed a high titer of both antinuclear antibodies and antidouble-stranded DNA antibodies along with anti-C1q antibodies. Toxocara canis serology returned highly positive with a positive western-blot. The use of antiparasitic drugs in combination with corticosteroids resulted in a dramatic improvement in the patient’s condition. Conclusions Clinicians should be aware of the systemic complications that may occur during Toxocara canis infection, including vasculitis and immunological disorder. Keywords Toxocara cani(s) · Larva migrans · Vasculitis · c1q-antibody · Eosinophilia
Introduction Vasculitides can occur during viral, bacterial, fungal or parasitic infections. Vessel damage may be secondary to * Hubert de Boysson h.deboysson@ch‑lisieux.fr 1
Department of Internal Medicine, Caen University Hospital, Caen, France
2
Department of Pathology, Caen University Hospital, Caen, France
3
Service de Médecine Interne, CHU côte de Nacre, avenue de la côte de Nacre, BP 95182, 14033 Caen Cedex 9, France
immune-complex deposits on vessel walls, direct invasion of endothelial cells, the extension of a localized focus of infection involving blood vessels or a septic hematogenous embolization [1]. Our report concerns a patient with a cutaneous vasculitis associated with anti-C1q antibodies and high titer of both antinuclear antibodies and anti-doublestranded DNA antibodies which occurred during a severe visceral larva migrans syndrome.
Case report A 64-year-old man, who was a dog owner and had a past history of an aorto-mesenteric bypass and sleep apnea was admitted for hypoxemic respiratory failure, cough, fever, abdominal pain, purpura and myalgia. Four months earlier, he had presented with hypoxemic pneumonia which had been treated with third generation cephalosporin and with macrolide. At that stage, laboratory findings showed a hypereosinophilia at 1000/mm3, but no further investigations were conducted. Throughout the following 4 months, he complained of transient evening fever, abdominal pain and arthralgia. In our department, laboratory findings showed both increased inflammatory parameters (C-reactive protein at 80 mg/l) and hypereosinophilia (1000/mm3). The serum creatinine level was normal and neither proteinuria nor microscopic hematuria was observed. The protein electrophoresis indicated a polyclonal hypergammaglobulinemia at 18.4 g/l. Whilst antibiotics were administered as a result of a suspicion of pneumonia, the patient suffered with both headaches and a purpuric rash on his lower limbs. Laboratory findings showed a fluctuant increased hypereosinophilia between 10, 000 and 21, 000/mm3. Immunologic screening showed both high titer antinuclear antibodies (ANA, 1/1280) and anti-double-stranded DNA antibodies. His rheumatoid
13
H. de Boysson et al. Table 1 List of main paraclinical investigations performed in the patient Investigation
Results
Blood cultures HBV, HCV, HIV, CMV
Negative Negative Negative
Anguilluliasis, Trichina, Toxoplasma serologies, parasitological examination of faeces Lymphocytic phenotypage T cell clonality research FIP1L1-PDGFRA/B fusion gene screening Whole-body tomography
Negative
Cardiac MRI Upper and lower endoscopic examination Temporal artery biopsy × 2 Cutaneous biopsy (Fig. 1)
Thickening of the small intestine and the colon Pulmonary oedema Normal left ventricle function Pulmonary arterial hypertension Systolic pulmonary artery pressure at 45 mmHg Increased pulmonary artery occlusion pressure Inferobasal myocardial fibrosis Inflammatory colitis Eosinophilic infiltrate; no granulomatous or necrotizing vasculitis Leukocytoclastic vasculitis with IgA deposits
Colic biopsy
Non-specific colitis with eosinophilic infiltrate
Echocardiogram Cardiac catheterism
HBV hepatitis B virus, HCV hepatitis C virus, HIV human immunodeficiency virus, CMV cytomegalovirus, MRI magnetic resonance imagery
Fig. 1 Skin biopsy showing a leukocytoclastic vasculitis with vessel wall destruction, influx of neutrophils, karyorrhexis, fibrinoid necrosis, and extravasation of erythrocytes (HES staining, ×40)
factor was positive (625 units, normal range
CASE REPORT
Vasculitis secondary to anti‑C1q antibodies induced by Toxocariasis Hubert de Boysson1,3 · Nicolas Martin Silva1 · François Comoz2 · Jonathan Boutemy1 · Boris Bienvenu1
Received: 10 January 2015 / Accepted: 18 March 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract Introduction Vasculitides occurring during parasitic infection are rare and may imply different mechanisms. Methods A case report of cutaneous vasculitis and visceral damage during a larva migrans syndrome. Results We report the case of a 64-year-old man who developed a purpura along with fever, respiratory failure, abdominal pain and myalgia. Immunological screening showed a high titer of both antinuclear antibodies and antidouble-stranded DNA antibodies along with anti-C1q antibodies. Toxocara canis serology returned highly positive with a positive western-blot. The use of antiparasitic drugs in combination with corticosteroids resulted in a dramatic improvement in the patient’s condition. Conclusions Clinicians should be aware of the systemic complications that may occur during Toxocara canis infection, including vasculitis and immunological disorder. Keywords Toxocara cani(s) · Larva migrans · Vasculitis · c1q-antibody · Eosinophilia
Introduction Vasculitides can occur during viral, bacterial, fungal or parasitic infections. Vessel damage may be secondary to * Hubert de Boysson h.deboysson@ch‑lisieux.fr 1
Department of Internal Medicine, Caen University Hospital, Caen, France
2
Department of Pathology, Caen University Hospital, Caen, France
3
Service de Médecine Interne, CHU côte de Nacre, avenue de la côte de Nacre, BP 95182, 14033 Caen Cedex 9, France
immune-complex deposits on vessel walls, direct invasion of endothelial cells, the extension of a localized focus of infection involving blood vessels or a septic hematogenous embolization [1]. Our report concerns a patient with a cutaneous vasculitis associated with anti-C1q antibodies and high titer of both antinuclear antibodies and anti-doublestranded DNA antibodies which occurred during a severe visceral larva migrans syndrome.
Case report A 64-year-old man, who was a dog owner and had a past history of an aorto-mesenteric bypass and sleep apnea was admitted for hypoxemic respiratory failure, cough, fever, abdominal pain, purpura and myalgia. Four months earlier, he had presented with hypoxemic pneumonia which had been treated with third generation cephalosporin and with macrolide. At that stage, laboratory findings showed a hypereosinophilia at 1000/mm3, but no further investigations were conducted. Throughout the following 4 months, he complained of transient evening fever, abdominal pain and arthralgia. In our department, laboratory findings showed both increased inflammatory parameters (C-reactive protein at 80 mg/l) and hypereosinophilia (1000/mm3). The serum creatinine level was normal and neither proteinuria nor microscopic hematuria was observed. The protein electrophoresis indicated a polyclonal hypergammaglobulinemia at 18.4 g/l. Whilst antibiotics were administered as a result of a suspicion of pneumonia, the patient suffered with both headaches and a purpuric rash on his lower limbs. Laboratory findings showed a fluctuant increased hypereosinophilia between 10, 000 and 21, 000/mm3. Immunologic screening showed both high titer antinuclear antibodies (ANA, 1/1280) and anti-double-stranded DNA antibodies. His rheumatoid
13
H. de Boysson et al. Table 1 List of main paraclinical investigations performed in the patient Investigation
Results
Blood cultures HBV, HCV, HIV, CMV
Negative Negative Negative
Anguilluliasis, Trichina, Toxoplasma serologies, parasitological examination of faeces Lymphocytic phenotypage T cell clonality research FIP1L1-PDGFRA/B fusion gene screening Whole-body tomography
Negative
Cardiac MRI Upper and lower endoscopic examination Temporal artery biopsy × 2 Cutaneous biopsy (Fig. 1)
Thickening of the small intestine and the colon Pulmonary oedema Normal left ventricle function Pulmonary arterial hypertension Systolic pulmonary artery pressure at 45 mmHg Increased pulmonary artery occlusion pressure Inferobasal myocardial fibrosis Inflammatory colitis Eosinophilic infiltrate; no granulomatous or necrotizing vasculitis Leukocytoclastic vasculitis with IgA deposits
Colic biopsy
Non-specific colitis with eosinophilic infiltrate
Echocardiogram Cardiac catheterism
HBV hepatitis B virus, HCV hepatitis C virus, HIV human immunodeficiency virus, CMV cytomegalovirus, MRI magnetic resonance imagery
Fig. 1 Skin biopsy showing a leukocytoclastic vasculitis with vessel wall destruction, influx of neutrophils, karyorrhexis, fibrinoid necrosis, and extravasation of erythrocytes (HES staining, ×40)
factor was positive (625 units, normal range
