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Eosinophilia in Migrants. Differential diagnosis
22nd of March 2019 Filip Moerman
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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
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DD of very high Eosinophil counts
Loeffler Strongyloides (!) Fasciolasis Filariasis Schistosomiasis (!) Trichinosis (…)
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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©)
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Pathogenesis of Loeffler
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Ascaris lumbricoides : endoscopic aspect.
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Strongyloides stercoralis infection
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Areas with high incidence of Strongyloides stercoralis infection
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Strongyloides stercoralis : larva currens
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CAVE Immunosuppression!
Stoma-patiënt, STEROID use : multiplication of Strongyloides stercoralis larvae CAVE Immunosuppression!
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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
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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
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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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Theodor Maximillian Bilharz
Schistosomiasis Theodor Maximillian Bilharz
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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
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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
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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 Oncomelania Biomphalaria Bulinus
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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 Eosinophyila Hepatosplenomegaly Serology and copro/urine initially negative Swimmer’s itch CT-scan lung : Katayama
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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
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Trichinella spiralis infection
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Trichinella of the high North are not killed by freezing meat
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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
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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
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Nematoden : Trichinella spiralis
Acute fever Periorbital edema Diarrhea – eosinophylia Myositis Neurologic complications Heart failure Kidney failure D/ muscle biopsy R/ Albendazole + prednisone
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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)
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Contacter dect infectio si nécessaire
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