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Letter
Eosinophilic Pleural Effusion
in Gnathostomiasis
Philippe Parola,*
Gerard Bordmann,† Philippe Brouqui,* and Jean Delmont*
*Hopital Nord, Marseille, France; and †Swiss Tropical Institute, Basel,
Switzerland
Suggested
citation for this article
To the Editor: Moore et al. reported a case series of patients
infected with imported gnathostomiasis who had typical intermittent, migratory
skin manifestations or peripheral blood eosinophilia or both, as well
as undiagnosed eosinophilia with nonspecific symptoms (1).
We would like to add some comments based on a recent patient treated in
Marseille, France.
In April 2003, a 66-year-old man living in Marseille indicated a history
of fever for 8 days. He had returned from Vietnam 1 month earlier, where
he had stayed for 4 weeks in the Ho Chi Minh City area and 2 days in the
Mekong Delta area. He was well during his trip, and reported no arthropod
bites except from mosquitoes. He had no direct skin contact with river
water. Dietary intake included local dishes with rice, fish, pork, shrimp,
and chicken. His symptoms started 3 weeks after he returned to Marseille
and included fever (temperature 38°C), asthenia, chills (1 day), moderate
dyspnea during exercise, transient bilateral pain of the testes, and an
episode of hemospermia. He was referred by his family doctor to the Infectious
and Tropical Diseases Unit, North Hospital.
On admission, the patient's temperature was 38°C. Physical examination
of the patient, including the testes, was normal except for a systolic
heart murmur (preexisting and known to the patient), and clinical signs
of left pleural effusion. The effusion was subsequently confirmed by chest
x-ray, which also showed a discrete diffuse bilateral lung infiltrate.
Results of routine laboratory tests conducted on blood samples were normal
except for an elevated eosinophil count of 5.2 109/L. Blood
smears for plasmodia and microfilaremia were negative. Urologic examination,
including echography and prostate-specific antigen, showed no abnormalities
except a prostatic adenoma (preexisting and known to the patient). No
eggs or parasites were detected by microscopic examination in stools or
in urine, although both sedimented and centrifuged urine specimens were
studied and filtration techniques were used. After transthoracic aspiration
of 100 mL of pleural effusion, cytologic examination showed an eosinophil
count of 5,800/L without parasites. Bacterial culture, including mycobacteria,
was negative. On day 4, the patient was afebrile and was discharged. On
admission, results of a first set of examinations involving reactivities
to schistosomiasis, paragonimiasis, strongyloidiasis, cysticercosis, trichinosis,
gnathostomiasis, filariasis, and toxocariasis were negative.
One month later, the eosinophil count of our patient had decreased to
1.8 x 109/L. He was afebrile, and his only complaint was asthenia.
A new set of serologic examinations was conducted. The Western blot assay
for gnathostomiasis conducted at the Swiss Tropical Institute (Socinstrasse
57, CH-4002, Basel, Switzerland) was positive, showing immunoglobulin
G reactivity to four specific bands including the 24-kDa band, considered
pathognomonic for the diagnosis of Gnathostoma infection (1).
The seroconversion confirmed the diagnosis of gnathostomiasis. All other
serologic tests remained negative, except an increase of antibodies against
Acanthocheilonema vitae used as antigen for unspecific serologic
screening for filariasis (Laboratoire Marcel Merieux, Lyon, France). After
a 21-day course of albendazole and a single dose of ivermectin, the eosinophil
count of our patient decreased to 0.8 x 109/L.
Three aspects of gnathostomiasis as an emerging imported disease can
complement the findings of Moore et al. (1). First, the
clinical findings in our case are very unusual. Hemospermia is often benign
with predominant causes including prostatic and seminal vesicle disease.
Infections, including mainly schistosomiasis and tuberculosis, have been
associated with these symptoms (2). Although our patient
had a prostatic adenoma, this is the first time that hemospermia has been
associated with gnathostomiasis. Because of the anxiety hemospermia caused,
this symptom was the main reason that our patient consulted our center.
Secondly, eosinophilic pleural effusion is also unusual in gnathosthosmiasis.
Although reported as a potential cause in reference books (3),
a MEDLINE search (key words: gnathostomiasis and eosinophilia and pleural
effusion or pleuritis or lung) disclosed only two references to pleural
effusion as the main symptom of gnathostomiasis (4,5).
The eosinophilic pleural and pulmonary response may be elicited by the
larvae of helminths carried hematogenously into lungs and pleura in an
aberrant fashion (3). The last point we stress is that,
as shown by Moore et al. (1), patients returning from
disease-endemic areas, mainly Southeast Asia and Central and South America,
should be tested systematically for gnathostomiasis. Although some patients
show a typical cutaneous form of gnathostomiasis associated with eosinophilia
(6,7), most atypical forms are probably underdiagnosed,
and severe neurologic involvement may occur if treatment is not given
(1). However, until recently specific serologic tests
for gnathostomiasis were available only in Asia, mainly in Thailand and
Japan. Some laboratories in Europe currently provide testing for gnathostomiasis,
which would be a valuable aid in evaluating patients returning from the
tropics.
References
- Moore DA, McCroddan J, Chiodini PL. Gnathostomiasis:
an emerging imported disease. Emerg Infect Dis. 2003;9:647–50.
- Mulhall JP, Albertsen PC. Hemospermia:
diagnosis and management. Urology. 1995;46:463–7.
- Wilson ME, Weller PF. Eosinophilia. Tropical infectious diseases.
In: Guerrant RL, Walker DH, Weller PF, editors. Principles, pathogens,
and practice. Philadelphia: Churchill Livingstone; 1999. p. 1400–19.
- Dow C, Chiodini PL, Haines AJ, Michelson SM. Human
gnathostomiasis. J Infect. 1988;17:147–9.
- Nagler A, Pollack S, Hassoun G, Kerner H, Barzilai D, Lengy J. Human
pleuropulmonary gnathostomiasis: a case report from Israel. Isr
J Med Sci. 1983;19:834–7.
- Menard A, Dos Santos G, Dekumyoy P, Ranque S, Delmont J, Danis M,
et al. Imported
cutaneous gnathostomiasis: report of five cases. Trans R Soc Trop
Med Hyg. 2003;97:200–2.
- Parola P. Gnathostomiasis.
Lancet. 2001;358:332.
Suggested citation
for this article:
Parola P, Bordmann
G, Brouqui P, Delmont J. Eosinophilic pleural effusion in gnathostomiasis
[letter]. Emerg Infect Dis [serial on the Internet]. 2004 Sep [date
cited]. Available from: http://www.cdc.gov/ncidod/EID/vol10no9/03-0671.htm
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