1. Eosinophilia in Migrants. Differential diagnosis
22nd of March 2019
Filip Moerman

2. Eosinophilia Rash Cough dyspnea Fever (cosmopolitan) Filariasis
Helminths
Filariasis
Katayama
Clinical, thick BF,
skin snip
Stools/urine
Contact fresh water
Tissue nematodes
Rash
Serology
Paragonimiasis
Liver flukes
Serology
Normal CXR
Cough
dyspnea
Stools, US
Location (Asia)
Fever
Auto-immune
Strongyloides
Eosinophilia
(cosmopolitan)
Larva currens and serology
Churg-Strauss
IBD
Hookworms
Stools
Anemia
Malignancies
Ascariasis
Solid tumors
Stools, US
Leukemia
Drug reactions
(DRESS,…)
Lymphoma
History
Skin conditions
Asthma
Reduced PEF
Eosinophilic oesophagitis
Hypersensitivity
Allergies
ABPA
EAA

3. DD of very high Eosinophil counts
Loeffler
Strongyloides (!)
Fasciolasis
Filariasis
Schistosomiasis (!)
Trichinosis (…)

4. 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©)

5. Pathogenesis of Loeffler

6. Ascaris lumbricoides : endoscopic aspect.

7. Strongyloides stercoralis infection

8. Areas with high incidence of Strongyloides stercoralis infection

9. Strongyloides stercoralis : larva currens

10. CAVE Immunosuppression!
Stoma-patiënt, STEROID use : multiplication of Strongyloides stercoralis larvae
CAVE Immunosuppression!

11. Fasciola hepatica infection

12. 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

14. Fasciola hepatica : adult worm in bile system

16. 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.

17. Fasciola hepatica : best treatment = Triclabendazole

18. Filarial disease

19. Filarioses Lymphatic filarioses Onchocercosis Loasis Mansonellosis
Dirofilariosis
( Guinea Worm)

20. Lymphatische filarioses
Wuchereria bancrofti
Brugia malayi
Video : zie

21. Urine : normal, chyluria (fresh) and after centrifugation

28. Loasis : Kliniek Eosinophilia++ Calabar swellings
Migration through subcutis
Eye passage…

31. Infection with Schistosoma spp.

32. Theodor Maximillian Bilharz
Schistosomiasis
Theodor Maximillian Bilharz

33. Schistosomiasis Geography
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

35. Cartoon waterbuffel from Meguro Parasitological Museum, Tokyo
Schistosomiasis
Transmission-experiment S. japonicum : cows with boots and cows without…
Cartoon waterbuffel from Meguro Parasitological Museum, Tokyo

36. Schistosomiasis
Life Cycle

37. Miracidium
Cercaria
Adult worm

38. Schistosomiasis : vector
Sweet water snails
Biomphalaria : S. mansoni
Bulinus : S. haematobium
Bulinus : S. intercalatum
Oncomelania : S. japonicum
Tricula : S. mekongi
Oncomelania
Biomphalaria
Bulinus

39. Still water close to Lake Victoria : snail biotope
Cfr Lake Malawi: BEAUTIFUL!! but…

40. 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
Eosinophyila
Hepatosplenomegaly
Serology and copro/urine initially negative 
Swimmer’s itch
CT-scan lung : Katayama 

42. 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

43. Trichinella spiralis infection

44. Trichinella of the high North are not killed by freezing meat

45. 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

46. 45-year-old man : 40°C, myalgia, headache
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 hypertrophy
R/ 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

47. Nematoden : Trichinella spiralis
Acute fever
Periorbital edema
Diarrhea – eosinophylia
Myositis
Neurologic complications
Heart failure
Kidney failure
D/ muscle biopsy
R/ Albendazole + prednisone

48. 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)

49. Contacter dect infectio si nécessaire