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Eosinophilia in Migrants. Differential diagnosis

22nd of March 2019Filip Moerman

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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)