Paiboon Sithithaworn

Department of Parasitology Faculty of Medicine 5 June 2012

Inflammation/infection of lungs

Pneumonia

Bronchospasm

Pulmonary edema

Causative agents of parasitic pneumonia

 Habitat in Lungs

Paragonimus --- cyst in lung

Habitat outside lungs Protozoa : E.histolytica

malaria

Trematode : Schistosomes
Nematodes : Hookworms Ascaris Filaria

Strongyloides

Pulmonary amebiasis
Manifestations

Extension of amebic liver abscess fever, chest pain, cough Haemoptysis and anchovy sauce like pus

Diagnosis

Hepatomegaly Plural effusion Active trophozoite in sputum or pleural pus Serology for amebiasis Stool positive for ameba may not relevant

Pulmonary malaria
Pulmonary manifestations

Cough to severe and rapidly fatal pulmonary edema Acute respiratory distress syndrome can occur in vivax malaria.

Diagnosis

Conventional blood film examination

Severe falciparum malaria may cause pulmonary edema and pleural effusion

PCR detection of P. falciparum in human urine and saliva samples

Erythrocytic cycle

Cytoadherance in falciparum malaria

Sequestrated of blood vessel between parasite ligand expressed on surface of the infected RBC and the receptor on endothelial cell

Lung blood vessel

CLINICAL DISEASE OF STRONGYLOIDIASIS Pathology in strongyloidiasis varies in both in severity and areas of the body involved. Cutaneous manifestation Pulmonary symptoms Intestinal symptoms Hyperinfection syndrome Reactive arthritis Chronic strongyloidiasis : totally asymptomatic and the only abnormal clinical finding being a peripheral eosinophilia.

Pulmonary strongyloidiasis

Heavy infection or hyperinfection often develop cough, fever, and transient pulmonary infiltrates (Loeffler's Syndrome).

Larval migration through the lungs may stimulate symptoms, depending on host's immune response.

Some patients may be asymptomatic, while others may present with pneumonia.

Larvae can be found in the sputum.

Cutaneous strongyloidiasis
Initial skin penetration causes very little reaction : pruritus and erythema .

Skin migration or larva migrans : larva curren ("racing larvae") for cases of strongyloidiasis where one or more rapidly progressing linear

Urticarial tracks starting near the anus . These tracks may progress as fast as 10 cm/hour.

Onset is sudden and the lesions may disappear within 12 to 18 hours.

Intestinal strongyloidiasis
Mucosa may be severely damaged with sloughing of tissue, although this type of damage is unusual . Symptoms may mimic peptic ulcer with abdominal pain, which may be localized in the right upper quadrant.

In an immunocompetent patient, there is a leukocytosis with a peripheral eosinophilia of 50-75%, while in chronic cases the eosinophilia may be much lower.
Chronic infections have lasted over 30 years as a result of the autoinfective capability of the larvae.

Hyperinfection Syndrome:
Autoinfection is responsible for longterm infections that persist for years

Under immunosuppressed large numbers of larvae produced and found in every tissue of the body.

Associate with immunosuppressive and steroid therapy.

Patient may die from sepsis, primarily as a result of intestinal flora.

Other causes of death may include peritonitis, brain damage, or respiratory failure.

Antelminthis treatment with thiabendazole or ivermectin is required prior to corticostriod treatment

LABORATORY DIAGNOSIS
1. Stool examination for rhabditiform larvae. 2. If negative, examination of duodenal contents is recommended (duodenal aspirates, Entero-Test capsule). 3. Various concentrates (Baermann) and cultures (HaradaMori, petri dish, agar plate) can also be used for larval recovery. 4. Eggs are rarely seen in the stool, but may be recovered from duodenal contents. 5. In very heavy infections, eggs (less common), larvae (both types), and adult worms may be recovered in the stool. 6. Serology Antibody detection (ELISA, GAPT).

Free-living adult : female Agar plate culture method

Free-living adults

Filariform larva (L3)

Rhabditiform larva (L1)

Egg (rarely seen)

TREATMENT Thiabendazole repeated or extended (one week) therapy may be necessary, and the cure rates range from 55 to 100%.

Albendazole is a broad-spectrum anthelmintic variable therapeutic efficacy (cure rate 4555% in strongyloidiasis). Oral dose is 400 mg doses given twice daily for 3 days for uncomplicated strongyloidiasis and for 710 days for hyperinfection.

Ivermectin : become widely used at 200 g/kg/day as a current drug of choice for strongyloidiasis.

Evaluation of curative treatment is problematic for parasitological diagnosis

Decline in enzyme-linked immunosorbent assay optical density over time from baseline to final post-treatment serologic testing in 40 patients who had received two doses of ivermectin. Indirect evidence of cure

Case study 1
A 47 year old male presented with complaints of severe midepigastric pain, become worse over a period of about a week. He had received prednisone over the course of several years and the dose had been increased two months before. Previous diagnostic testing included an O&P examination, which was reported as "No Parasites Seen." He was treated with supportive care for epigastric pain and developing pneumonia, but failed to improve. He became comatose and died three days later.

Autopsy findings : worms in colon High eosinophilia may or may not be present. In this case, no eosinophils were noted
(eosinopenia can occur in the hyperinfection syndrome = poor prognostic sign)

Strongyloides stercoralis rhabditiform larva in crypt of colon. Fatal disseminated strongyloidiasis

Case study 2
53 pemphigus vulgaris 1 . intravenous dexamethasone 4 . 8 azathioprine 100 / 3 hypotension ICU acute respiratory distress syndrome ventilatory support. X-ray extensive bilateral bronchopneumonia.

pemphigus vulgaris

Ziehl-Neelsen stain of bronchial secretions Strongyloides stercoralis

hyperinfection syndrome disseminated

strongyloidiasis. albendazole+ivermectin

Intestinal ascariasis
Mechanical damage in the intestine. Malabsorption of nutrients Intestinal blockage / obstruction.

Pulmonary ascariasis
Ascaris migrates to the lungs via the bloodstream larvae in the lung tissue cause pulmonary eosinophilia, Adult worms release metabolic causing allergic reactions. Asthma, eye pain, and rashes can result from allergic response. Ascaris liberating vasoactive amines and causing the degranulation of intestinal mast cells.

Heart-lung migration of larval stage

Ascaris larvae in the lung tissue.

AL- prominent alae, IN-intestine, EC- excretoty ducts 400x magnification

Ascaris adult worm in duodenum

Tropical pulmonary Eosinophilia (TPE)

Definition

Hyperresponse to filarial infection. The syndrome includes High eosinophil count Pulmonary symptoms : dyspnea Radiological changes, Fever, and weight loss

Geographic Distribution

Common in southern India, Sri Lanka, Malaysia, and Southeast Asia, Aso occurs in the Caribbean, South America, Africa

Clinical manifestation of TPE

Predominance in males (4:1 male: female) Age group of 20-40 years. Caused by both Brugia and

Wuchereria

Associated with occult filariasis (amicrofilaremia) and positive serology test. Hypereosinophilia of 3,000 to 50,000 cells/mm and high serum IgE

A rapid response to diethylcarbamazine

TPE Can also caused by Toxocara canis, Ankylostoma, and Strongyloides

Lung biopsy showing a pulmonary granuloma with intense eosinophilic inflammatory reaction.

Conclusions
Pneumonia by Protozoa - systemic infection & blood borne caused by infection of visceral organ including lung Pneumonia by Helminths

Strongyloides : Hyperinfection / disseminated infection

the presence of filariform larva in bronchial lavage or sputum

Ascaris : Larval migration through lung cause

eosinophilic infiltration Adult in intestine allergic reaction to worm protein (coelomic fluid)

Filaria : Tropical pulmonary eosinophilia caused by allergic reaction to microfilariae