Ocular Toxocariasis: Beyond Typical Patterns through the New Imaging Technologies.

PURPOSE: To report five cases of ocular Toxocariasis (OT) in which ultrawide-field (UWF) imaging was helpful in diagnosis and assessment. OT is an underdiagnosed condition triggered by the ocular invasion of Toxocara larvae. Typical features are peripheral granuloma or endophthalmitis. METHODS: A retrospective case series of 10 outpatients were studied by complete ophthalmologic examination and complementary tests. UWF retinal imaging, fundus autofluorescence (FAF) and spectral-domain optical coherence tomography (SDOCT) were retrospectively analyzed. Five patients with suspected OT were included. RESULTS: UWF imaging and FAF was able to detect all retinal lesions in a single rapid capture. Two patients showed positive serology for Toxocara. An image suggesting the larva in the vitreous cavity was shown in one patient. Antihelmintic 15 treatment along with steroids was prescribed in two patients. CONCLUSION: UWF imaging and SDOCT provide a more efficient approach and follow-up in OT, raising final standards of care.

Imaging of toxocariasis.

Several imaging modalities have now been employed to visualize the manifestations of larval Toxocara infection in hepatic, neurologic, ocular, renal, and other anatomical sites. This report reviews the usefulness and value of these individual imaging methods in diagnosis and follow-up of the different cases causing eosinophilic (granulomatous) infiltrations the liver, lungs, brain, heart, and eyes. Imaging provides a means of assisting in diagnosis and management in this infection where diagnosis by biopsy is often unlikely to capture an actual larva for the purpose of making a definitive diagnosis on the basis of larval morphology or DNA detection.

[A Case Diagnosed Toxocariasis After the Intiation of Treatment with Steroids for Eosinophilic Granulomatosis with Polyangitis (EGPA)].

Toxocariasis causes a variety of symptoms. We experienced a case of toxocariasis which was initially treated with steroids for Eosinophilic Granulomatosis with Polyangitis (EGPA). A 53-year-old woman with the past medical history of bronchial asthma presented at the outpatient department in the middle of August. She complained of chest discomfort lasting for one week. Ischemic heart disease was initially suspected due to ST depression on ECG and positive Troponin I. However coronary angiography did not reveal any abnormality. Her symptoms continued and after one month she presented at the hospital again with an elevated eosionophil count. Chest computed tomography showed ground glass opacities on both lungs. She was diagnosed as having EGPA based on her clinical symptoms and the results of the blood test which were consistent with the diagnostic criteria of EGPA. After prednisolone was prescribed, her symptoms and eosinophilia dramatically improved. However, we found that the histology of the lung and kidney was not compatible with EGPA and the result of serum parasite antibodies turned out to be strongly positive for toxocariasis after initiating predonisolone. Based on this result, we concluded that our patient had a case of toxocariasis and prescribed albendazole in addition to prednisolone. The patient completed a 3-week course of albendazole and a 3-month course of prednisolone without any problems. In general, steroids are not commonly used as a treatment of toxocariasis, however it seems to have been effective in this case. Toxocariasis shows a variety of symptoms and can be misdiagnosed as other diseases such as EGPA.

Hepatic toxocariasis: a rare cause of right upper abdominal pain in the emergency department.

Toxocara canis and Toxocara cati are common helminths that reside in the intestinal tract of cats and dogs. Toxocariasis and, commonly, T. canis, is a disease commonly seen in children, which is characterised by hypereosinophilia, hepatomegaly, fever, transient pulmonary infiltration, and hypergammaglobulinaemia. Humans, who are not the actual host for these parasitic worms, are infected following oral intake of the infective eggs. Radiological differentiation of hepatic toxocariasis can be difficult, as liver lesions, which present as multiple hypoechoic lesions with regular borders, can look like a tumour, an infarction or an infection. We report on a case that presented to our emergency department (ED) with abdominal pain. During the initial review, the pathology in the liver was thought to be an infarction or an infection; however, the patient was diagnosed with hepatic toxocariasis following further evaluation.

[Ultrasonographic findings in ocular toxocariasis]. / Achados ultrassonográficos em toxocaríase ocular.

PURPOSE: To evaluate ophthalmic ultrasound findings in the three presentation forms of ocular toxocariasis (peripheral or posterior pole granulomas and chronic endophthalmitis), in patients with confirmed diagnosis of ocular toxocariasis. METHODS: 11 patients (11 eyes) with clinical and confirmed diagnosis of active ocular toxocariasis, presented positive ELISA test, were analyzed, prospectively, in the study. The patients were submitted to an ocular ultrasound examination (10-MHz transducer, contact technique). RESULTS: In the series of 11 patients, mean age was 7.9 years-old (range from 2 to 17 y), 73% male, referring previous contact with dogs (91%), and with the soil (50%), no referral of appetite perversion. In the analyses of compromised eyes (11 eyes), the ophthalmoscopic examination revealed the following distribution of the 3 forms of ocular toxocariasis: 7 cases (63.6%), posterior pole granuloma; 1 (9.1%), chronic endophthalmitis; 2 (18.2%), peripheral granuloma; and 1 (9.1%), posterior pole granuloma associated with chronic endophthalmitis. Visual acuity impairment: no light perception (3 eyes, 27.3%); hand motion (4 eyes, 36.4%); counting fingers at 10 cm (1 eye, 9.1%); 20/200 (1 eye, 9.1%); 20/70 (1 eye, 9.1%); undefined (1 eye, 9.1%). Serology was positive to Toxocara canis (ELISA test) in 100% of the cases. Ophthalmoscopy was difficult or impossible in 64% of the cases due to the media opacity. Ultrasound findings noted were vitreous membranes with retinal attachment (100%); parietal lesions (granulomas) with high (80%) or medium (20%) reflectivity. CONCLUSION: The most consistent ultrasound finding in the eye with toxocariasis was a high-reflectivity retinal mass, located in posterior pole or periphery, which may be calcified, and which has as main characteristic the adherence of vitreous membranes. In addition to clinical history, systemic evaluation and serology, the ultrasound can help in the diagnosis of ocular toxocariasis, especially in media opacities.

Nodulos parasitrrios cutáneos: estudio ultrasongrafico de tres casos poco freccuentes en la edad pedáátrica / Cutaneous parasitic nodules: ultrasonographic study of three infrequent cases in the pediatric age

The parasitic nodules are part of the cutaneous manifestations of the parasitic diseases, fundamentally affect children. We report the clinic history, study by images and parasitological results of three infrequent parasitic cases in the pediatric age, which were studied with images, specially ultrasound, and this contributed somehow to the diagnosis. The final parasitological diagnoses were dirofilaria, toxocara and myiasis. The epidemiology, clinical and dermatológica! manifestations are discussed of each one.

Los nodulos parasitarios forman parte de las manifestaciones cutáneas de las enfermedades parasitarias, las cuales afectan fundamentalmente a niños. Se da a conocer la historia clínica, el estudio por imágenes y los resultados histopatológicos y parasitarios de tres casos poco frecuentes en la edad pediátrica, los cuales fueron estudiados con ultrasonido que contribuyó de alguna manera al diagnóstico. Los parásitos encontrados fueron dirofilaria, toxocara y una larva de mosca. Se discute la epidemiología, manifestaciones clínicas y dermatológicas de cada una de estas parasitosis.

Optical coherence tomography in presumed subretinal Toxocara granuloma: case report.

Our aim was to study optical coherence tomographic findings in a case of Toxocara granuloma. A patient with a cicatricial macular lesion, diagnosed as ocular toxocariasis, was examined with optical coherence tomography. In optical coherence tomography images, the macular granuloma appeared as a highly reflective round mass protruding above the retinal pigment epithelium with two other surrounding masses. Optical coherence tomography may increase understanding of the pathophysiology of the retinal Toxocara granuloma and help in the clinical diagnosis and management of its macular complications.

Hepatic involvement in larva migrans of Toxocara canis: report of a case with pathological and radiological findings.

Patients with the clinical syndrome of visceral larva migrans as a result of Toxocara species, have typical lesions in the liver consisting of granulomas that contain numerous eosinophils and often Charcot-Leyden crystals. This syndrome is rarely taken into account in patients with cholestatic syndrome, especially when hypereosinophilic reaction is absent. We report the case of a 47-year-old immunocompetent woman who presented with abdominal pain, in whom multiple focal liver lesions were discovered. She had come in contact with dogs. Diagnosis of toxocariasi was done. A good clinical response has been obtained by treating with thiabendazole. We present the findings of various imaging studies of the patient. This report shows that visceral larva migrans may be the cause of a chronic liver disease and should be suspected also in patients without fever and hypereosinophilia with cryptogenic cholestatic and focal liver lesions.

Hepatic toxocariasis: US, CT and MRI findings.

Visceral larva migrans (VLM) most commonly occurs as a febrile disease of childhood particularly affecting children between 1 and 7 years of age. Pulmonary, dermatological, hepatic, lymphatic, cardiac, rheumatological and neurological manifestations may occur. VLM seems to be a rare disease in adults. We report the imaging findings of a woman with hepatic toxocariasis. Ultrasonography showed a solitary hepatic lesion measuring 4 x 3 cm, displaying a hypoechoic-heterogeneous pattern with ill-defined borders and distal acoustic enhancement, located in the right sub-diaphragmatic area. Two enlarged periportal lymph nodes and moderately dilated intrahepatic biliary ducts were also noted. The probability of toxocariasis was discussed, based on sonographic and biopsy findings, and the final diagnosis was confirmed by a specific ELISA test. In summary, a clinical picture of cholestasis initially resembling hepatitis or malignancy should be further evaluated by imaging techniques, and the ultrasound examiner should be familiar with the possible findings of hepatic toxocariasis, which consist of focal ill-defined hepatic lesions, hepato-splenomegaly, biliary dilatation, sludge and periportal lymph node enlargement.

Ultrasound biomicroscopy findings in peripheral vitreoretinal toxocariasis.

PURPOSE: To describe the morphologic alterations in ultrasound biomicroscopy (UBM) present in peripheral vitreoretinal toxocariasis. METHODS: An observational prospective study of case series. Fifteen eyes of 15 patients with clinical and laboratory diagnosis of peripheral vitreoretinal toxocariasis were enrolled. The patients were submitted to UBM examination of the region corresponding to the pars plana of the affected eye. RESULTS: The most common morphologic alterations found by UBM in patients with peripheral vitreoretinal toxocariasis were as follows: vitreal membranes (13 cases), toxocara granuloma (11 cases), and pseudocysts (8 cases). Other less frequent findings were thickening of the ciliary body (6 cases), cystic formation (2 cases), peripheral retinal detachment (2 cases), rectification of the iris root (1 case), and posterior synechiae (1 case). CONCLUSIONS: UBM allows detection of well-defined morphologic alterations associated with peripheral vitreoretinal toxocariasis, being useful to reinforce the clinical diagnosis.

[Hypereosinophilia with myocardial involvement due to toxocariasis. Diagnosis of regional myocardial perfusion abnormalities by pulsed tissue Doppler echocardiography]. / Myokardiale Beteiligung des Eosinophilie-Syndroms bei einer Fadenwurminfektion. Nachweis regionaler Myokardrestriktion mittels Pulswellen-Gewebe-Doppler-Echokardiographie.

CASE REPORT: The case of a 57-year-old woman is reported who was admitted for peripheral hypereosinophilia. DIAGNOSIS: Detailed investigations revealed first of all a hypereosinophilic syndrome with infiltration of bone marrow and lung. The patient suffered more and more from angina pectoris with signs of heart failure. Coronary angiography was therefore carried out which showed normal coronary arteries. With suspicion of myocardial involvement endomyocardial biopsies were performed which revealed the presence of Löfflers endocarditis parietalis fibroplastica. Finally, serological studies for parasites disclosed a positive ELISA test for Toxocara, confirmed later to be rising. CONCLUSION: Myocardial involvement of hypereosinophilia, caused by Toxocara is not described until now. Further diagnostic by means of pulsed wave tissue Doppler echocardiography provided regional differentiation of a restrictive filling pattern which documented the importance of this new diagnostic tool in myocardial illness.

Ultrasound findings in children with toxocariasis: report on 18 cases.

PURPOSE: To evaluate abdominal ultrasound (US) findings in children infected with Toxocara canis. MATERIALS AND METHODS: Eighteen children, 18 months to 7 years of age, with serological diagnosis of T.canis infection underwent abdominal US. Eosinophil counts, hemoglobin levels and immunoglobulin E titers were measured for all patients. RESULTS: Abdominal ultrasound revealed multiple hypoechoic areas in the livers of 15 patients (83.3%). Hepatohilar lymph-node enlargement was present in 14 patients (77.7%), 2 of whom also showed peripancreatic lymph-node enlargement. Hepatomegaly was present in 13 patients (72.7%) and splenomegaly in 9 (50%). CONCLUSION: The most prevalent findings of abdominal ultrasound examination of children with T.canis infection are hepatic granulomas and abdominal lymph-node enlargement. This infection should be considered in the differential diagnosis of any children who exhibit these findings on abdominal US examination, especially for those with eosinophilia.

Differential diagnosis of leukokoria: radiologic-pathologic correlation.

Leukokoria is an abnormal pupillary light reflection that usually results from an intraocular abnormality and is seen most often in children. One-half of the cases of childhood leukokoria are caused by retinoblastoma, a malignant tumor of immature retinoblasts that manifests in a normal-sized eye as a calcified mass, is often partially necrotic, and grows into the vitreous and through the choroid. Retinoblastoma enhances with contrast material and, unlike most tumors, may be darker than vitreous on T2-weighted images. When leukokoria is associated with microphthalmia, persistent hyperplastic primary vitreous (PHPV) (28% of cases) or retinopathy of prematurity (ROP) (5% of cases) should be considered. PHPV is a congenital, usually unilateral lesion that appears as a dense tubular mass extending from the lens to the retina along the course of the hyaloid canal. Hemorrhage from PHPV produces a subhyaloid (or subretinal) fluid collection, often with characteristic blood-fluid levels. ROP is bilateral and usually manifests in premature infants who received supplemental oxygen therapy. Coats disease (16% of leukokoria) is a sporadic unilateral idiopathic retinal telangiectasia that produces a lipoproteinaceous subretinal exudate leading to complete retinal detachment. The globe has normal size but increased attenuation and signal intensity from hemorrhage without calcification or enhancement. Toxocaral endophthalmitis (16% of leukokoria) is a granulomatous reaction to the parasite in the vitreous and uveoretinal coat. Retinal astrocytoma (3% of leukokoria), which manifests in a normal-sized globe, is an indolent benign neoplasm commonly associated with phakomatoses (usually tuberous sclerosis).

Case report: hepatic ultrasound findings in a case of toxocariasis.

Multiple hypoechoic areas within the liver may be caused by a large variety of disorders. We report a case of Toxocara infestation which produced such an appearance within the liver of an 18-month-old child. We believe that this is the first report of Toxocara granulomata detected by ultrasound, and suggest that ultrasound examination may provide a useful diagnostic clue to this disease.

Echographic characteristics of ocular toxocariasis.

Ocular toxocariasis most commonly presents as one of three distinct clinical syndromes: endophthalmitis, localized posterior granuloma, or peripheral granuloma. Using standardized echography, the authors studied 11 toxocariasis patients presenting with one of these syndromes. Common echographic findings were noted in ten of these patients, and included: (1) a solid, high-reflective peripheral mass, (2) a vitreous band or membranes extending between the posterior pole and the mass, and (3) a traction retinal detachment or fold from the posterior pole to the mass. These findings were present in patients presenting with leukocoria or endophthalmitis, as well as in patients in whom the peripheral nematode lesion could be visualized clinically. In combination with the history, clinical examination, and enzyme-linked immunosorbent assay (ELISA), standardized echography may be useful in establishing the diagnosis of ocular toxocariasis in cases of leukocoria in which nematode endophthalmitis is suspected.

Computed tomography of Toxocara canis endophthalmitis.

Many lesions, termed pseudogliomas, may mimic the appearance of retinoblastoma, both clinically and on computed tomography. The appearance of Toxocara canis endophthalmitis on computed tomography is presented. The role of computed tomography in the evaluation of patients presenting with leukokoria is discussed.

Ocular toxocariasis studied by CT scanning.

Ocular Toxocara canis infection causing larval granulomatosis and leading to chronic endophthalmitis and retinal detachment is a well-defined cause of unilateral leukokoria in children. The computed tomographic (CT) scan revealed a diffuse, nonenhancing, well-defined hyperdense lesion occupying most of the globe. The CT findings do not definitively differentiate the diffuse endophthalmitis of larval granulomatosis from retinoblastoma or other pseudogliomas.

Retinoblastoma. CT diagnosis.

Computed tomography (CT) scan is a valuable adjunct in the differential diagnosis and management of retinoblastoma. Thirty-one of 33 retinoblastoma patients studied with high resolution computed tomography had intraocular calcification demonstrable in at least one eye. Over 80% of tumors showed evidence of calcification on CT scan. The degree of calcification appeared to depend upon tumor size; only small tumors were devoid of calcification. The amount and distribution of calcification was similar on both histological and CT review. In patients under three years of age in whom a retinoblastoma is suspected, the presence of calcification on CT scan is virtually diagnostic of retinoblastoma; patients with leukocoria without calcification on CT probably have a simulating lesion.

[The significance of fluorescein angiogarphy in ocular toxocara granuloma (author's transl)]. / Fluoreszenzangiographie beim okulären Toxocara-Solitärgranulom.

Four serologically-proved cases of intraocular toxocara infections are demonstrated. Three different manifestations in the following way were found: 1. Solitary granuloma on the posterior pole (2 patients). 2. Anterior and posterior uveitis of both eyes with granuloma near the ora (1 patient). 3. Iridocyclitis of both eyes (1 patient). The fluorescein angiography examination in two cases with solitary granuloma have been repeated over a period of time and the relation of the satisfactory results to the further development of the disease is shown.