Pediatric Pulmonology 50:E35–E36 (2015)
Case Report
Toxocariasis: An Unusual Cause of Pleural Effusion Blandine Vallentin,* Ania Carsin, and Jean-Christophe Dubus Summary. Toxocara canis, one of the most frequent parasites worldwide, rarely triggers respiratory symptoms. We report the case of a 5-year-old girl hospitalized for a unilateral eosinophilic pleural effusion due to Toxocara canis. Besides the fact that she was living in a squat, no other medical condition was reported. There was no other site of infection caused by the parasite and she was successfully treated with albendazole. This case report is obviously unique as very few cases of pleural effusion due to Toxocara canis are reported in literature, all in adult patients. Pediatr Pulmonol. 2015;50:E35–E36. ß 2015 Wiley Periodicals, Inc. Key words: eosinophil; pleural effusion; pneumonia; toxocariasis.
INTRODUCTION
An eosinophilic pleural effusion is defined as a pleural effusion containing more than 10% of eosinophile infiltration. This type of pleural effusion represents 5% to 16% of all the pleural effusions.1 In adults, the causes are mainly malignancies (including lung or breast cancers and hematological diseases), and more rarely infections, post-surgical procedures, iatrogenic causes, or autoimmune diseases. In children, this situation is exceptional and other causes must be excluded, especially hematological malignancies or parasitic infections. CASE REPORT
A 5-year-old girl was referred to our pediatric emergency department for an abdominal pain. The history had begun the day before without any fever nor other clinical symptoms. The family and the child had been living in France for less than 3 weeks and had previously stayed in Romania. They lived in a squat with no declared animals. The respiratory exam found a respiratory rate of 35/minute, a pulsed oxymetry of 97%, with an abolition of breath sounds at the thoracic left side. The rest of the examination was within normal limits, except a deplorable state of dental health. Blood samples showed an increase in inflammatory markers (C reactive protein 48 mg/l, erythrocyte sedimentation rate 71 mm at the first hour), and in leukocytes (24 10^9 /l), with a marked hypereosinophilia (2.1 10^9/l, with a maximum few days later of 7.2 10^9/l). The chest X-ray showed an abundant left pleural effusion and a lower lobar ß 2015 Wiley Periodicals, Inc.
atelectasis. An empirical treatment with vancomycine and cefotaxime was first initiated. Because of the abundance of the pleural effusion, a pleural tube was placed. The analysis of the pleural fluid showed a large majority of eosinophils (more than 50% of the pleural cells in the 400 ml analyzed). The chest CT-scan confirmed the atelectasis and pleural effusion, and found no sign of malignancy. The bone marrow smears revealed only eosinophils, with no blast cells. Serological tests for toxocarosis, hydatidosis, trichinosis, toxoplasmosis, and anguillulosis were positive only for Toxocara canis (2.282 by Western Blot and Elisa techniques). Examination of the retina was strictly normal. Antibiotics were stopped and a treatment with albendazole 15 mg/kg/d was initiated for 15 days. The control of the chest X-ray Unite de pneumopediatrie et medecine infantile, CHUTimone-Enfants, 13385 Marseille Cedex 5, France. Conflicts of interest: none Funding source: none reported.
Correspondance to: Blandine Vallentin, Unite de pneumopediatrie, CHU Timone-Enfants, 13385 Marseille Cedex 5, France. E-mail: [email protected] Received 27 January 2015; Revised 2 March 2015; Accepted 12 March 2015. DOI 10.1002/ppul.23192 Published online 2 April 2015 in Wiley Online Library (wileyonlinelibrary.com).
E36
Vallentin et al.
6 weeks later was normal. As our patient was living in a makeshift camp, a medical monitoring via humanitarian associations was initiated, but they left quickly their resort. DISCUSSION
Toxocariasis is a helminth infection, mainly caused by Toxocara canis and more rarely by Toxocara catis.2,3 Vertical transmission is linked to the ingestion of the Toxocara eggs present in the faeces of puppies or kitten. Upon ingestion of the eggs by humans, Toxocara larvae do not undergo further growth or maturation into adult worms, and larvae hatch in the intestine, enter into the systemic circulation and disseminate to various tissues leading to an intense inflammatory response and eosinophilia. The reproductive cycle of Toxocara is relatively complex, and depends on many factors (age of the host, environmental conditions, species ...) but mainly affects puppies less than 5 weeks. The prevalence of human toxocarosis is very high, estimated to 2–5% in healthy subjects of urban areas and to 14–35% in subjects of rural zones. Indeed, toxocarosis is one of the most important parasitic infections worldwide. In children, the more frequent presentation of toxocariasis is the Larva Migrans Visceral syndrome. Diagnosis can also be evoked on an isolated eosinophilia. In most of the pediatric cases, a soil ingestion or geophagy is described. In our case, we did not find the notion of contact with puppies or other animals but the child was living in poor living conditions, which may have favored the contact with some contaminated areas. To the best of our knowledge, only 12 cases of pulmonary toxocariasis have been reported in adults (age 20–75 years, sex ratio 2).4 The most common features associate pulmonary symptoms, such as cough and dyspnea, and bilateral pulmonary nodules on chest imaging. More exceptionally, the presence of an isolated
Pediatric Pulmonology
uni or bilateral eosinophilic pleural effusion related to toxocariasis has been described in five other adult cases (age from 30 to 68 years, sex ratio 1.5).5 Our case report of pleural effusion in a pediatric age seems unique. The treatment of toxocariasis associates a 5–20 day course of albendazole or mebendazole and prophylactic measures including good hygiene, prompt disposal of pet feces, and veterinarian care for pets, including deworming.3 CONCLUSION
Toxocariasis with pleural or pulmonary involvement should be discussed for children with hypereosinophila and respiratory or abdominal signs, especially if geophagy is noted or if the child is living in areas exposed to dog or cat feces, in rural areas or unhealthy conditions. ACKNOWLEDGMENTS
The author acknowledges Dr. E Bosdure and E Sauvaget for her clinical contribution, and to Dr S Ranque for his parasitic advices. REFERENCES 1. Krenke R, Nasilowski J, Korczynski P, Gorska K, Przybylowski T, Chazan R, Light RW. Incidence and aetiology of eosinophilic pleural effusion. Eur Respir J 2009;34:1111–1117. 2. Macpherson CN. The epidemiology and public health importance of toxocariasis: a zoonosis of global importance. Int J Parasitol 2013;43:999–1008. 3. Moreira GM, Telmo P de L, MendonSc a M, Moreira AN, McBride AJ, Scaini CJ, ConceiSc ~ao FR. Human toxocariasis: current advances in diagnostics, treatment, and interventions. Trends Parasitol 2014;30:456–564. 4. Ranasuriya G, Mian A, Boujaoude Z, Tsigrelis C. Pulmonary toxocariasis: a case report and literature review. Infection 2014;42:575–578. 5. Blanco-Perez JJ, Abal-Arca J, Rocha GF. Pleural effusion and toxocariasis (in Spanish). Med Clin (Barc) 2006;126:75.
Case Report
Toxocariasis: An Unusual Cause of Pleural Effusion Blandine Vallentin,* Ania Carsin, and Jean-Christophe Dubus Summary. Toxocara canis, one of the most frequent parasites worldwide, rarely triggers respiratory symptoms. We report the case of a 5-year-old girl hospitalized for a unilateral eosinophilic pleural effusion due to Toxocara canis. Besides the fact that she was living in a squat, no other medical condition was reported. There was no other site of infection caused by the parasite and she was successfully treated with albendazole. This case report is obviously unique as very few cases of pleural effusion due to Toxocara canis are reported in literature, all in adult patients. Pediatr Pulmonol. 2015;50:E35–E36. ß 2015 Wiley Periodicals, Inc. Key words: eosinophil; pleural effusion; pneumonia; toxocariasis.
INTRODUCTION
An eosinophilic pleural effusion is defined as a pleural effusion containing more than 10% of eosinophile infiltration. This type of pleural effusion represents 5% to 16% of all the pleural effusions.1 In adults, the causes are mainly malignancies (including lung or breast cancers and hematological diseases), and more rarely infections, post-surgical procedures, iatrogenic causes, or autoimmune diseases. In children, this situation is exceptional and other causes must be excluded, especially hematological malignancies or parasitic infections. CASE REPORT
A 5-year-old girl was referred to our pediatric emergency department for an abdominal pain. The history had begun the day before without any fever nor other clinical symptoms. The family and the child had been living in France for less than 3 weeks and had previously stayed in Romania. They lived in a squat with no declared animals. The respiratory exam found a respiratory rate of 35/minute, a pulsed oxymetry of 97%, with an abolition of breath sounds at the thoracic left side. The rest of the examination was within normal limits, except a deplorable state of dental health. Blood samples showed an increase in inflammatory markers (C reactive protein 48 mg/l, erythrocyte sedimentation rate 71 mm at the first hour), and in leukocytes (24 10^9 /l), with a marked hypereosinophilia (2.1 10^9/l, with a maximum few days later of 7.2 10^9/l). The chest X-ray showed an abundant left pleural effusion and a lower lobar ß 2015 Wiley Periodicals, Inc.
atelectasis. An empirical treatment with vancomycine and cefotaxime was first initiated. Because of the abundance of the pleural effusion, a pleural tube was placed. The analysis of the pleural fluid showed a large majority of eosinophils (more than 50% of the pleural cells in the 400 ml analyzed). The chest CT-scan confirmed the atelectasis and pleural effusion, and found no sign of malignancy. The bone marrow smears revealed only eosinophils, with no blast cells. Serological tests for toxocarosis, hydatidosis, trichinosis, toxoplasmosis, and anguillulosis were positive only for Toxocara canis (2.282 by Western Blot and Elisa techniques). Examination of the retina was strictly normal. Antibiotics were stopped and a treatment with albendazole 15 mg/kg/d was initiated for 15 days. The control of the chest X-ray Unite de pneumopediatrie et medecine infantile, CHUTimone-Enfants, 13385 Marseille Cedex 5, France. Conflicts of interest: none Funding source: none reported.
Correspondance to: Blandine Vallentin, Unite de pneumopediatrie, CHU Timone-Enfants, 13385 Marseille Cedex 5, France. E-mail: [email protected] Received 27 January 2015; Revised 2 March 2015; Accepted 12 March 2015. DOI 10.1002/ppul.23192 Published online 2 April 2015 in Wiley Online Library (wileyonlinelibrary.com).
E36
Vallentin et al.
6 weeks later was normal. As our patient was living in a makeshift camp, a medical monitoring via humanitarian associations was initiated, but they left quickly their resort. DISCUSSION
Toxocariasis is a helminth infection, mainly caused by Toxocara canis and more rarely by Toxocara catis.2,3 Vertical transmission is linked to the ingestion of the Toxocara eggs present in the faeces of puppies or kitten. Upon ingestion of the eggs by humans, Toxocara larvae do not undergo further growth or maturation into adult worms, and larvae hatch in the intestine, enter into the systemic circulation and disseminate to various tissues leading to an intense inflammatory response and eosinophilia. The reproductive cycle of Toxocara is relatively complex, and depends on many factors (age of the host, environmental conditions, species ...) but mainly affects puppies less than 5 weeks. The prevalence of human toxocarosis is very high, estimated to 2–5% in healthy subjects of urban areas and to 14–35% in subjects of rural zones. Indeed, toxocarosis is one of the most important parasitic infections worldwide. In children, the more frequent presentation of toxocariasis is the Larva Migrans Visceral syndrome. Diagnosis can also be evoked on an isolated eosinophilia. In most of the pediatric cases, a soil ingestion or geophagy is described. In our case, we did not find the notion of contact with puppies or other animals but the child was living in poor living conditions, which may have favored the contact with some contaminated areas. To the best of our knowledge, only 12 cases of pulmonary toxocariasis have been reported in adults (age 20–75 years, sex ratio 2).4 The most common features associate pulmonary symptoms, such as cough and dyspnea, and bilateral pulmonary nodules on chest imaging. More exceptionally, the presence of an isolated
Pediatric Pulmonology
uni or bilateral eosinophilic pleural effusion related to toxocariasis has been described in five other adult cases (age from 30 to 68 years, sex ratio 1.5).5 Our case report of pleural effusion in a pediatric age seems unique. The treatment of toxocariasis associates a 5–20 day course of albendazole or mebendazole and prophylactic measures including good hygiene, prompt disposal of pet feces, and veterinarian care for pets, including deworming.3 CONCLUSION
Toxocariasis with pleural or pulmonary involvement should be discussed for children with hypereosinophila and respiratory or abdominal signs, especially if geophagy is noted or if the child is living in areas exposed to dog or cat feces, in rural areas or unhealthy conditions. ACKNOWLEDGMENTS
The author acknowledges Dr. E Bosdure and E Sauvaget for her clinical contribution, and to Dr S Ranque for his parasitic advices. REFERENCES 1. Krenke R, Nasilowski J, Korczynski P, Gorska K, Przybylowski T, Chazan R, Light RW. Incidence and aetiology of eosinophilic pleural effusion. Eur Respir J 2009;34:1111–1117. 2. Macpherson CN. The epidemiology and public health importance of toxocariasis: a zoonosis of global importance. Int J Parasitol 2013;43:999–1008. 3. Moreira GM, Telmo P de L, MendonSc a M, Moreira AN, McBride AJ, Scaini CJ, ConceiSc ~ao FR. Human toxocariasis: current advances in diagnostics, treatment, and interventions. Trends Parasitol 2014;30:456–564. 4. Ranasuriya G, Mian A, Boujaoude Z, Tsigrelis C. Pulmonary toxocariasis: a case report and literature review. Infection 2014;42:575–578. 5. Blanco-Perez JJ, Abal-Arca J, Rocha GF. Pleural effusion and toxocariasis (in Spanish). Med Clin (Barc) 2006;126:75.
