Rapidly progressive respiratory failure after helminth larvae ingestion.

BACKGROUND: Self-administration of helminths has gained attention among patients as a potential but unproven therapy for autoimmune disease. We present a case of rapidly progressive respiratory failure in a patient with systemic sclerosis (SSc) and pulmonary arterial hypertension (PAH) as a result of self-administration of parasitic organisms. CASE: A 45-year-old woman with a history of interstitial lung disease and PAH due to limited cutaneous SSc presented to pulmonary clinic with worsening dyspnea, cough, and new onset hypoxemia. Three months prior to presentation she started oral helminth therapy with Necator americanus as an alternative treatment for SSc. Laboratory evaluation revelaed eosinophilia and elevated IgE levels. IgG antibodies to Strongyloides were detected. High resolution computed tomography of the chest revealed progressive ILD and new diffuse ground glass opacities. Transthoracic echocardiogram and right heart catheterization illustrated worsening PAH and right heart failure. The patient was admitted to the hospital and emergently evaluated for lung transplantation but was not a candidate for transplantation due to comorbidities. Despite aggressive treatment for PAH and right heart failure, her respiratory status deteriorated, and the patient transitioned to comfort-focused care. CONCLUSION: Although ingestion of helminths poses a risk of infection, helminth therapy has been investigated as a potential treatment for autoimmune diseases. In this case, self-prescribed helminth ingestion precipitated fatal acute worsening of lung inflammation, hypoxemia, and right heart dysfunction, highlighting the risk of experimental helminth therapy in patients, especially those with underlying respiratory disease.

Discovery and validation of biomarkers to guide clinical management of pneumonia in African children.

BACKGROUND: Pneumonia is the leading cause of death in children globally. Clinical algorithms remain suboptimal for distinguishing severe pneumonia from other causes of respiratory distress such as malaria or distinguishing bacterial pneumonia and pneumonia from others causes, such as viruses. Molecular tools could improve diagnosis and management. METHODS: We conducted a mass spectrometry-based proteomic study to identify and validate markers of severity in 390 Gambian children with pneumonia (n = 204) and age-, sex-, and neighborhood-matched controls (n = 186). Independent validation was conducted in 293 Kenyan children with respiratory distress (238 with pneumonia, 41 with Plasmodium falciparum malaria, and 14 with both). Predictive value was estimated by the area under the receiver operating characteristic curve (AUC). RESULTS: Lipocalin 2 (Lpc-2) was the best protein biomarker of severe pneumonia (AUC, 0.71 [95% confidence interval, .64-.79]) and highly predictive of bacteremia (78% [64%-92%]), pneumococcal bacteremia (84% [71%-98%]), and "probable bacterial etiology" (91% [84%-98%]). These results were validated in Kenyan children with severe malaria and respiratory distress who also met the World Health Organization definition of pneumonia. The combination of Lpc-2 and haptoglobin distinguished bacterial versus malaria origin of respiratory distress with high sensitivity and specificity in Gambian children (AUC, 99% [95% confidence interval, 99%-100%]) and Kenyan children (82% [74%-91%]). CONCLUSIONS: Lpc-2 and haptoglobin can help discriminate the etiology of clinically defined pneumonia and could be used to improve clinical management. These biomarkers should be further evaluated in prospective clinical studies.

Trichomonas empyema with respiratory failure.

Pulmonary trichomoniasis is rare, and few cases of trichomonas empyema have been reported in the literature. We describe a rare case of a non-immunocompromised 55-year-old man with Trichomonas empyema presenting with bilateral pleural effusion leading to respiratory failure. Examination of the pleural effusion showed numerous motile organisms by fresh wet preparation that were identified as Trichomonas species by Liu stain. The patient was successfully treated with metronidazole, ampicillin/clavunalate, fibrinolytic therapy, and thoracotomy decortication.

A Fatal Strongyloides Stercoralis Hyperinfection Syndrome in a Patient With Chronic kidney Disease: A Case Report and Literature Review.

Strongyloides stercoralis hyperinfection syndrome is a rare but fatal disease, which occurs commonly in immunocompromised patients. Strongyloidiasis among patients with chronic kidney disease is rarely reported.A 55-year-old Chinese male presented to hospital with diarrhea and abdominal pain. He developed acute respiratory failure and progressed to diffuse alveolar hemorrhage owing to disseminated strongyloidiasis immediately. The bronchoalveolar lavage revealed filariform larvae of Strongyloides stercoralis.This patient was diagnosed with Strongyloides hyperinfection syndrome. Although albendazole, mechanical ventilator support, fluid resuscitation, vasopressor support, extracorporeal membrane oxygenation, hydrocortisone, and broadspectrum antimicrobials were actively used, the patient eventually died.Similar cases in patients with chronic kidney disease in the literature are also reviewed. Through literature review, we recommend that strongyloidiasis should be routinely investigated in patients with chronic kidney disease who will undergo immunosuppressive therapy.

A life-threatening brainstem compression by cerebral Echinococcus granulosus.

Cystic echinococcosis (CE) is a zoonotic disease caused by Echinococcus granulosus. It is of worldwide importance, and is widespread in the Mediterranean region and Middle East. This tapeworm shows great intraspecific variation in relation to host specificity, epidemiology and morphology. This variability led in previous years to the identification of ten (G1-G10) different genotypes of the parasite. Cerebral localization of E. granulosus is not common: it especially affects children and is more frequently located in the supratentorial region. It can be life-threatening due to its localization in eloquent areas especially in the posterior fossa. Despite the benign nature of hydatid cyst, invasion of critical areas may cause significant mortality and morbidity in some patients. Urgent surgical decompression and adjuvant medical treatment must be employed as soon as possible in these patients. We present a clinical case of life-threatening brainstem compression in a child due to a rare form of CE which was confirmed with biomolecular techniques. She presented with respiratory distress and progressive quadriparesis. All cysts were removed by microsurgical technique and albendazole was given postoperatively for one year with regular follow-ups.

[Massive haemoptysis associated with pulmonary Strongyloides stercoralis hyperinfestation]. / Hémoptysie massive associée à une hyperinfestation pulmonaire à Strongyloides stercoralis.

INTRODUCTION: Pulmonary infestation with Strongyloides stercoralis is an exceptionally rare cause of haemoptysis, the diagnosis being difficult and often delayed. CASE REPORT: We report the case of a retired coal miner suffering from pneumoconiosis who presented with acute respiratory insufficiency and massive haemoptysis, with a fatal outcome, associated with pulmonary stongyloidosis. The only identified source of infestation with Strongyloides stercoralis was his period in the coal mine and the only risk factors for the hyperinfestation were a short course of systemic corticosteroid therapy and the presence of a peritoneal-auricular valve. CONCLUSION: This observation illustrates the importance of a systematic search for anguillosis in ex coal miners prior to any immunosuppressant treatment in order to avoid the serious and frequently fatal form of hyperinfestation with Strongyloides stercoralis.

Fatal Toxoplasma gondii infection in the giant panda.

Toxoplasma gondii can infect nearly all warm-blooded animals. We report an acute fatal T. gondii infection in the endangered giant panda (Ailuropoda melanoleuca) in a zoo in China, characterized by acute gastroenteritis and respiratory symptoms. T. gondii infection was confirmed by immunological and molecular methods. Multilocus nested PCR-RFLP revealed clonal type I at the SAG1 and c29-2 loci, clonal type II at the SAG2, BTUB, GRA6, c22-8, and L358 loci, and clonal type III at the alternative SAG2 and SAG3 loci, thus, a potential new genotype of T. gondii in the giant panda. Other possible pathogens were not detected. To our knowledge, this is the first report of clinical toxoplasmosis in a giant panda.

Diffuse alveolar haemorrhage and severe hypoxemia from Strongyloides stercoralis hyperinfection syndrome.

Strongyloides stercoralis hyperinfection syndrome is a rare, yet highly fatal disorder. It occurs most commonly in immunocompromised patients. We report a case of a 36-year-old Ethiopian female who presented with abdominal pain and hypotension. Shortly thereafter, she developed acute respiratory failure and progressed to acute respiratory distress syndrome and septic shock. She was found to have diffuse alveolar hemorrhage due to disseminated strongyloidiasis. We discuss the clinical condition of Strongyloides hyperinfection syndrome presenting with severe hypoxemia and complicated by severe diffuse alveolar hemorrhage leading to death. Similar cases in the literature are also describe.

Deep breathing in children with severe malaria: indicator of metabolic acidosis and poor outcome.

Despite the frequent association of respiratory symptoms and signs with malarial morbidity and mortality in sub-Saharan Africa, the value of individual symptoms and signs has rarely been assessed. We have prospectively examined the association of individual clinical findings with the summary diagnosis of respiratory distress, outcome, and the presence of metabolic acidosis in children admitted with severe malaria to a Kenyan district hospital. Respiratory distress was present in 119 of the 350 children included in the study and in 23 of the 30 deaths (relative risk = 6.5, 95% confidence interval = 2.8-14.4). The features of a history of dyspnea, nasal flaring, and indrawing or deep breathing (Kussmaul's respiration) were individually most closely associated with the summary diagnosis of respiratory distress. Of these, deep breathing, which was sensitive (91%) and specific (83%) for the presence of severe metabolic acidosis (base excess < or = -12), is the best candidate sign to represent the prognostically important syndrome of malarial respiratory distress. Therefore, it warrants further prospective evaluation in different clinical settings and areas of different malaria endemicity.

Severe malaria in children in Papua New Guinea.

The clinical features of severe falciparum malaria and risk factors for mortality were studied in 489 children admitted with malaria to Madang Hospital, Papua New Guinea. The most common severe manifestations of malaria were severe anaemia (22%) and coma (16%). Children with severe anaemia were younger than those with coma (median age 2.2 vs. 3.7 years) and had been ill for longer before admission (median 7 vs. 4 days, respectively). Although the clinical features of coma in Madang children with malaria resembled closely those reported in African children, mortality was lower (8% vs. 17-25%, respectively). Overall, 17 (3.5%) children died, most within 12 h of admission. A high level of plasma lactate (> or = 5 mmol/l) was common (20%) and was the major predictor of death in multiple regression analysis. Raised plasma creatinine and decreased plasma bicarbonate were also independent predictors of mortality. Coma was not predictive of death, although a high proportion of children with profound coma died. Investigation of the causes of acidosis in children with malaria is a high research priority. In view of the short time interval between admission and death in many children, emphasis must be placed on the prevention or early recognition and treatment of acidosis in the district health clinic as well as the central hospital.

Complications and mortality patterns due to Plasmodium falciparum malaria in hospitalized adults and children, Rourkela, Orissa, India.

Of 1857 Plasmodium falciparum malaria patients hospitalized from 1995 to 1998, 608 had severe malaria and 83 died. Acute renal failure, jaundice and respiratory distress were common in adults whereas children frequently had severe anaemia. Cerebral malaria occurred equally in adults and children but recovery from coma was quicker in children. Multiple complications caused high mortality in adults.

Respiratory distress caused by parasites.

Parasitic etiologies of pulmonary symptoms generally represent some degree of immunocompromise or occur as uncommon presentations of common parasitic infections. In regions where HIV infection is more prominent, PCP probably will be the most common parasitic respiratory disease seen. In geographic regions where helminthic infections are more common, patients with respiratory symptoms and eosinophilia probably will be seen more often and require a search for a specific etiology. In more rare circumstances, travel to an endemic area may suggest a more exotic parasitic etiology for respiratory symptoms.

Disseminated cryptosporidiosis in Turkey: case report.

Cryptosporidium sp is a protozoan that displays an intracellular settlement primarily in the intestinal systems of humans and can result in diarrhoea. Undernourished children and persons with immunosuppression in developing countries are especially vulnerable to infection with this parasite. A 12-month-old female presented at Ege University, Faculty of Medicine, Department of Paediatrics with complaints of fever, diarrhoea, respiratory distress and growth-development retardation was diagnosed with CD40 deficiency (Hyper IgM Type 3). During the one year investigation process of the case with chronic diarrhoea and necrotic pneumonia, Cryptosporidium sp oocysts were found in nine of the 22 faecal examinations and also in transtracheal aspiration liquid examined using the Kinyoun Acid-fast staining method. In conclusion, it is thought that cryptosporidiosis should also be considered in the distinct diagnosis of immunodeficient infants who are presented with respiratory and gastrointestinal system complaints.

Guillain-Barre's syndrome associated with Plasmodium falciparum malaria: role of plasma exchange.

Guillain-Barre's syndrome (GBS) associated with malarial infection is a rare condition reported in the literature. We report a case of Plasmodium falciparum (PF) malarial infection with Guillain-Barre's syndrome complicated by respiratory failure and review of the literature. Our patient gradually improved after treatment with plasma exchange. Review of the literature showed 11 cases of GBS associated with malaria. Four of 8 patients with GBS associated with PF had respiratory failure, whereas, none of the patients with GBS associated with Plasmodium vivax (PV) developed respiratory failure. Three of four patients with respiratory failure died and one who survived was treated with intravenous immunoglobulin. Our patient was the second case to survive after treatment with plasma exchange. The role of plasma exchange, the pathogenesis of malaria in GBS and the mechanism that induced more severe GBS in PF than in PV were discussed.

[Acute respiratory insufficiency in parasitic eosinophilic pneumonia]. / Insuffisance respiratoire aiguë au cours d'une pneumopathie à éosinophiles parasitaire.

We report a case of bilateral eosinophilic pneumonia in a 33 year old man. This case developed rapidly into acute respiratory failure and required artificial ventilation. Intravenous corticosteroid therapy produced a rapid improvement in the clinical picture. There was hyper-eosinophilia in both the blood and the alveoli which leads to a search for a parasitic aetiology. The different parasitic serologies were negative except for Toxocaracanis. The ELISA index was strongly positive at 2,597. Treatment with thiabendazole was started.