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Eosinophilia in Migrants. Differential diagnosis
22nd of March 2019Filip Moerman
Modifiez le style des sous-titres du masque
Eosinophilia
(cosmopolitan)
Strongyloides
Katayama
Filariasis
Larva currens and serology
Paragonimiasis
Asthma
Clinical, thick BF,
skin snip
Drug reactions(DRESS,…)
Stools
Skin conditions
Liver flukes
Stools/urine
Tissue nematodes
Ascariasis
Allergies
Serology
Fever
Serology
History
Location (Asia)
ABPA
Lymphoma
Leukemia
IBD
Auto-immune
Helminths
Hypersensitivity
Malignancies
EAA
Eosinophilic oesophagitis
Solid tumors
Churg-Strauss
Hookworms
Stools, US
Stools, US
Reduced PEF
Contact fresh water
Coughdyspne
a
Rash
Normal CXR
Anemia
DD of very high Eosinophil counts• Loeffler• Strongyloides (!)• Fasciolasis• Filariasis• Schistosomiasis (!)• Trichinosis (…)
The Loeffler Syndrome
• Ascaris, hookworm (A. duodenale, N. americanus), Strongyloides
• Combination of cough, fever, RX lung infiltrates, high eosinophil count. Not rare!
• Epidemic context• Simple treatment by Mebendazole (Vermox©)
Pathogenesis of Loeffler
Ascaris lumbricoides : endoscopic aspect.
Strongyloides stercoralis infection
Areas with high incidence of Strongyloides stercoralis infection
Strongyloides stercoralis : larva currens
Stoma-patiënt, STEROID use : multiplication of Strongyloides stercoralis larvae
CAVE Immunosuppression!
Fasciola hepatica infection
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Trematodes : Fasciola hepatica
– snail ‘cresson’ or other plants will ‘encyst’ (metacercaria)– Tussue passage :
• pain• eosinophilia• hepatomegaly
– Gall bladder crises
– D/ via copro and serology– R/
• Fasinex : triclabendazole • bithionol • nitazoxanide
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Fasciola hepatica : adult worm in bile system
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History: 47 year old female with 2 weeks constant right upper quadrant pain. No fever or systemic symptoms. Referred because of a dilated common bile duct noted on ultrasound. 4 years ago she had a cholecystectomy for what was diagnosed as symptomatic gall bladder disease. Exact operative findings from that time were not available. Epidemiology: Housewife from Abancay, a town in a rural area high in the Andes. Typical diet for the area with large amounts of vegetables such as potatoes, corn, and green salads with very little meat or fish. Physical Examination: Afebrile. Tender abdomen predominantly in the epigastric area and right upper quadrant, but without peritoneal signs. Normal rectal exam. Labs/X-ray: Hemoglobin 11. WBC 8,000 with 75 segs, 17 lymphs and 5 eos. Transaminases and total bilirubin normal. Alk Phos not performed. An ERCP was performed and showed a filling defect compatible with CBD stones. A papillotomy was performed and the CBD directly visualized. The left (A) and right (B) images show the abnormality, indicated by the white arrows, at low and high magnification respectively.
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Fasciola hepatica : best treatment = Triclabendazole
Filarial disease
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Filarioses
• Lymphatic filarioses• Onchocercosis• Loasis• Mansonellosis• Dirofilariosis• ( Guinea Worm)
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Lymphatische filarioses
Wuchereria bancrofti
Brugia malayi
Video : zie http://www.liquidjigsaw.com/animation/anim1.htm
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Urine : normal, chyluria (fresh) and after centrifugation
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Loasis : Kliniek
• Eosinophilia++• Calabar swellings• Migration through subcutis• Eye passage…
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Infection with Schistosoma spp.
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Schistosomiasis
Theodor Maximillian Bilharz
1825-1862
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Schistosomiasis
• Schistosoma mansoni en S. haematobium : frequent
• Schistosoma intercalatum, S.japonicum en S.mekongi : less frequent
• Geography
– S. mansoni : Africa, Middle East, South-America
– S. haematobium : Africa, Middle East
– S. intercalatum : Central Africa
– S. japonicum : South-East Asia / Far East
– S. mekongi : Mekong delta
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SchistosomiasisTransmission-experiment S. japonicum : cows with boots and cows without…
Cartoon waterbuffel from Meguro Parasitological Museum, Tokyo
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Schistosomiasis
Life Cycle
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Miracidium
Cercaria Adult worm
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Schistosomiasis : vector• Sweet water snails
– Biomphalaria : S. mansoni– Bulinus : S. haematobium– Bulinus : S. intercalatum– Oncomelania : S. japonicum– Tricula : S. mekongi
Biomphalaria Bulinus
Oncomelania
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Still water close to Lake Victoria : snail biotope
Cfr Lake Malawi: BEAUTIFUL!! but…
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Schistosomiasis : clinical (early)
• Swimmer’s itch : cercarial dermatitis• Katayama syndrome : reaction on first eggs laid by the female worm(non-immune person)
– Fever ± 4-8 weeks after infection– Abdominal pain, nausea– Cough – asthma-like picture– Eosinophylia– Hepatosplenomegaly
Swimmer’s itch
CT-scan lung : Katayama
Serology and copro/urine initially negative
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Schistosomiasis : treatment• Before PZQ: metrifonaat (organofosfaat insecticide Dipterix) : S. haematobium• oxamniquine (Vansil) single-dose : only on S. mansoni (Brasil)
• 1972 : Praziquantel (Biltricide© : pyrazino-isoquinoline)– developed against cestodes– efficacious, broad-spectrum– little toxicity– oral single dose (600 mg/15 kg)– some authors do repeat
Trichinella spiralis infection
Trichinella of the high North are
not killed by freezing meat
Nematoden : Trichinella spiralis“disease of the fat heads)”
• T. s. spiralis : pigs
• T. s. nativa : northern hemisphere
• T. s. nelsoni : Africa, South-Europe
• NEVER free stage in nature! NO eggs!
• Adult worm in intestinal mucosa
• Metastasis of larvae to muscles and heart
• Intracellular
45-year-old man : 40°C, myalgia, headache. Bilateral proptosis with chemosis and eyelid edema. No diarrhea. No trismus or subungual splinter hemorrhages. Patient ate raw horse meat 10 days before symptoms occurred.
WBC = 17,500/mm3 with 14 % eosinophils. CK = 651 U/L (< 170 U/L). Trichinosis ELISA negative. CT orbits : bilateral proptosis and moderate ocular-muscle hypertrophyR/ corticosteroids + albendazole (10 mg per kilogram) for 10 days, and there was rapid improvement. Two months later, the serologic test for trichinosis became positive. By that time, the patient was asymptomatic.
NEJM, July 29, 2004
Nematoden : Trichinella
spiralis• Acute fever
• Periorbital edema
• Diarrhea – eosinophylia
• Myositis
• Neurologic complications
• Heart failure
• Kidney failure
• D/ muscle biopsy
• R/ Albendazole + prednisone
Conclusion / Summary• High eosinophilic count must urge MDs to look
for the above mentioned worms.• MUST be treated! (danger of Endomyocardfibrosis)
• Statistically one in four migrants from ‘the south’ will be positive for one of the above mentioned germs.
• Treatment in not difficult, but ‘staging’ might be necessary (Schisto, filaria, fasciola)