Diagnosis of oesophageal mucormycosis managed with medical therapy alone.

Mucormycosis is an invasive mould that can cause aggressive infection, particularly in immunocompromised patients. Though oesophageal mucormycosis is relatively rare, it remains an elusive and devastating manifestation of this disease. The management is also challenging, due to surgical morbidity and contraindications such as thrombocytopenia in immunocompromised hosts. In this report, we present the case of a 60-year-old Lebanese man with newly diagnosed acute myeloid leukaemia who developed oesophageal mucormycosis after induction chemotherapy with idarubicin/cytarabine (7+3). The diagnosis was made when the patient developed febrile neutropenia and odynophagia. CT scan of the chest revealed a thickened oesophagus. Oesophagogastroduodenoscopy with biopsy, histopathology and PCR were performed, resulting in the diagnosis of Rhizopus microsporus The patient was successfully treated with liposomal amphotericin B and salvage posaconazole therapy without surgical intervention. We reviewed the clinical characteristics of the six published oesophageal mucormycosis reports from the literature.

[Human Gongylonema pulchrum infection in esophagus: a case report].

This paper reports a female patient with Gongylonema pulchrum parasitizing in the esophagus, with aims to call for the attention to the role of parasite detection in the diagnosis of human diseases.

Detection and quantification of Spirocerca lupi by HRM qPCR in fecal samples from dogs with spirocercosis.

BACKGROUND: Spirocerca lupi, the dog oesophageal nematode, causes a potentially fatal disease in domestic dogs, and is currently clinically diagnosed by coproscopy and oesophagoscopy. To date, a single molecular method, a semi-nested PCR, targeting the cox1 gene, has been developed to aid in the diagnosis of spirocercosis. The present study describes three novel high-resolution melt (HRM) quantitative PCR (qPCR) assays targeting fragments of the ITS1, 18S and cytb loci of S. lupi. The performance of these molecular assays in feces was compared to fecal flotation and to the previously described cox1 gene semi-nested PCR in 18 fecal samples from dogs with clinical oesophageal spirocercosis diagnosed by oesophagoscopy. RESULTS: The HRM qPCR for ITS1 and 18S were both able to detect 0.2 S. lupi eggs per gram (epg), while the HRM qPCR for the cytb and the semi-nested PCR for the cox1 detected 6 epg and 526 epg, respectively. Spirocerca lupi was detected in 61.1%, 44.4%, 27.8%, 11.1% and 5.6% of the fecal samples of dogs diagnosed with spirocercosis by using the ITS1 and 18S HRM qPCR assays, fecal flotation, cytb HRM qPCR and cox1 semi-nested PCR, respectively. All dogs positive by fecal flotation were also positive by ITS1 and 18S HRM qPCRs. Quantification of S. lupi eggs was successfully achieved in the HRM qPCRs and compared to the fecal flotation with no significant difference in the calculated concentrations between the HRM qPCRs that detected the 18S and ITS1 loci and the fecal flotation. The HRM qPCR for the 18S cross-amplified DNA from Toxocara canis and Toxascaris leonina. In contrast, the HRM qPCR for ITS1 did not cross-amplify DNA from other canine gastrointestinal parasites. CONCLUSIONS: This study presents two new molecular assays with significantly increased sensitivity for confirming and quantifying fecal S. lupi eggs. Of these, the HRM qPCR for ITS1 showed the best performance in terms of the limit of detection and absence of cross-amplification with other parasites. These assays will be useful in detecting infection and for follow-up during therapy.

Human Gongylonema pulchrum Infection: Esophageal Symptoms and Need for Prolonged Albendazole Therapy.

AbstractWe describe a case of human infection with Gongylonema pulchrum acquired in southeast Georgia. The patient presented with intermittent yet persistent nausea and vomiting for months. This case describes the need for extraction of worms on two occasions each followed by courses of albendazole treatment. Gongylonema pulchrum infections with high worm burden may relapse after extraction of the worm and a 3-day short course of albendazole therapy. Longer courses of albendazole may be indicated in selected circumstances.

Serological cross-reactivity of three commercial in-house immunoassays for detection of Dirofilaria immitis antigens with Spirocerca lupi in dogs with benign esophageal spirocercosis.

The nematode Spirocerca lupi infects dogs and is endemic in Israel. It leads to formation of esophageal nodules and neoplasia. Infection is diagnosed by coproscopy, endoscopy and radiography. Dirofilaria immitis causes heartworm disease in dogs, and has a world-wide distribution, but autochthonous infection has never been detected in Israel. Infection is confirmed based on identifying D. immitis microfilariae, in concentrated blood specimens by microscopy (Knott's test or other tests) and serological tests specifically detecting circulating adult worm antigens. In the first part of this study, sera from dogs definitively diagnosed with esophageal spirocercosis by endoscopy were examined using three in-house immunoassays for detecting D. immitis antigen, and were positive in 2/19 (10.5%), 5/35 (14.3%) and 14/48 (29.2%) dogs, in assays 1 to 3, respectively, with no statistical difference between assays (P=0.08). Next, sera from 32 additional dogs with confirmed esophageal spirocercosis, which were confirmed to be negative for D. immitis and Dirofilaria repens DNA using a sensitive high-resolution melt PCR were tested using assay 3 and 8/32 (25%) were positive. These results demonstrate serological cross-reactivity between D. immitis and S. lupi in blood samples of dogs. In areas where the distributions of both nematodes overlap, this cross-reactivity should be considered when dog are screened for heartworm disease.

Successful resolution of esophageal granulomas in a dog infected with Spirocerca lupi.

A 13-year-old female Labrador Retriever presented with chronic regurgitation. Radiography and computed tomography (CT) revealed nodules in the caudal esophagus. Upper gastrointestinal endoscopy followed by histopathological examination revealed esophageal granulomas caused by Spirocerca lupi. The infection was treated with milbemycin oxime. The therapy was successful, and a remarkable reduction in granulomas was observed. This case report describes the diagnostic imaging findings and treatment outcome of a dog with S. lupi infection in Japan.

Successful resolution of oesophageal spirocercosis in 20 dogs following daily treatment with oral doramectin.

The purpose of this study was to evaluate the effect of a daily oral dose of doramectin in dogs with spirocercosis. Twenty naturally infected dogs were treated with 0.5 mg/kg doramectin administered orally once daily for 42 days. In 13 of the dogs there was resolution of the nodules after 42 days. Nodules were eliminated in five of the remaining seven dogs following treatment for an additional 42 days. In the remaining two dogs, treatment continued for a further 42 days (total 126 days), resulting in complete resolution. No adverse events associated with treatment were observed. This study concluded that doramectin at 0.5 mg/kg once a day is effective in the elimination of Spirocerca lupi nodules in dogs.

Characterization of Onthophagus sellatus as the major intermediate host of the dog esophageal worm Spirocerca lupi in Israel.

Spirocerca lupi is a parasitic nematode of dogs, that causes significant morbidity and mortality. Its intermediate hosts in Israel have never been described. The aim of this study was therefore to identify the intermediate hosts of S. lupi in Israel and to describe their abundance and annual infection rate with the nematode, in different microenvironments (i.e., the effects of irrigation and shade) in an endemic area. Dog dung pads were collected every 2 months from two different public parks for 1 year. Dung beetles were identified to the species level in infested dog feces and were examined for the presence of S. lupi larvae through dissection. The Scarabid beetle Onthophagus sellatus was the most abundant dung beetle species in dog dung pads and the only one infected with S. lupi larvae. The minimal period for development of the S. lupi L3 infective stage was 7 days. Significant differences were observed between the two different microenvironments and along the year. The highest risk for infection of dogs with the nematode was during the summer, in an irrigated, shady microenvironment.

An unusual cause of gastrointestinal bleeding and severe anemia in a child: leech infestation.

A 1-year-old boy with epistaxis, gastrointestinal bleeding and severe anemia that caused cardiorespiratory distress presented to our unit. The results of coagulation tests were normal. An erythrocyte suspension transfusion was given to the patient. On the second day of his hospitalization, a leech was removed from his nose. In developing countries, leech infestation should be considered in cases where epistaxis, hematemesis, gastrointestinal bleeding and severe anemia are of unknown origin.

[The mucosal changes and influencing factors in upper gastrointestinal anisakiasis: analysis of 141 cases].

BACKGROUND/AIMS: Anisakiasis is a well known parasitosis resulted from eating raw seafoods and there were many reports of cases. However, its endoscopic and clinical characteristics have not been reviewed well. The aim of this study was to clarify the gastric mucosal changes and influencing factors of upper gastrointestinal (UGI) anisakiasis. METHODS: We analyzed retrospectively the endoscopic and clinical characteristics of 141 cases with UGI anisakiasis diagnosed during UGI endoscopy, based on the review of medical records. The patients' data were collected consecutively from October 1999 through September 2006. RESULTS: In the 141 patients with UGI anisakiasis, the peak age was the 40s (44.7%). The female to male ratio was 1.82:1. The most prevailed season was winter (41.1%). The most frequent symptom was acute epigastric pain and 76.6% of the patients developed symptoms within 12 hours after the ingestion of raw seafoods. The greater curvature of body was the most preferred site of anisakid larvae. The median time from meal to symptom onset was shortest in esophageal location and longest in fundus location (3 vs. 18.7 hours). The various mucosal changes were observed and the most frequent mucosal change was edema (90.8%). Submucosal tumor was also found in 31.9% of the patients. The severity of mucosal change was related inversely with the time interval from meal to endoscopy (p=0.048). CONCLUSIONS: Anisakiasis presented various mucosal changes depending on the time interval from ingestion of raw seafood to endoscopy. Delayed endoscopy may lead chronic mucosal change and cause difficulty in the detection of anisakiasis. Therefore, the prompt endoscopic examination is required for the patients presenting acute gastrointestinal symptoms after taking raw fish.

The Mucosal Changes and Influencing Factors in Upper Gastrointestinal Anisakiasis: Analysis of 141 Cases / 대한소화기학회지

BACKGROUND/AIMS: Anisakiasis is a well known parasitosis resulted from eating raw seafoods and there were many reports of cases. However, its endoscopic and clinical characteristics have not been reviewed well. The aim of this study was to clarify the gastric mucosal changes and influencing factors of upper gastrointestinal (UGI) anisakiasis. METHODS: We analyzed retrospectively the endoscopic and clinical characteristics of 141 cases with UGI anisakiasis diagnosed during UGI endoscopy, based on the review of medical records. The patients' data were collected consecutively from October 1999 through September 2006. RESULTS: In the 141 patients with UGI anisakiasis, the peak age was the 40s (44.7%). The female to male ratio was 1.82:1. The most prevailed season was winter (41.1%). The most frequent symptom was acute epigastric pain and 76.6% of the patients developed symptoms within 12 hours after the ingestion of raw seafoods. The greater curvature of body was the most preferred site of anisakid larvae. The median time from meal to symptom onset was shortest in esophageal location and longest in fundus location (3 vs. 18.7 hours). The various mucosal changes were observed and the most frequent mucosal change was edema (90.8%). Submucosal tumor was also found in 31.9% of the patients. The severity of mucosal change was related inversely with the time interval from meal to endoscopy (p=0.048). CONCLUSIONS: Anisakiasis presented various mucosal changes depending on the time interval from ingestion of raw seafood to endoscopy. Delayed endoscopy may lead chronic mucosal change and cause difficulty in the detection of anisakiasis. Therefore, the prompt endoscopic examination is required for the patients presenting acute gastrointestinal symptoms after taking raw fish.

Treatment of esophageal spirocercosis with milbemycin oxime.

Six medium sized mixed breed dogs treated with milbemycin oxime (11.5mg on days 0, 7 and 28 and then monthly) stopped shedding Spirocerca lupi ova after 3-44 days. There was no evidence of subsequent shedding in repeated tests (about 5/dog) carried out from 31 to 133 days after initiation of treatment. Esophageal nodules disappeared in all dogs within 95-186 days and radiographic signs resolved within 85-127 days in the five dogs that were studied. This preliminary data shows milbemycin oxime deserves further evaluation for the treatment of spirocercosis.

Clinical differentiation between dogs with benign and malignant spirocercosis.

Spirocerca lupi is a nematode infesting the canine oesophagus, where it induces the formation of a nodule that may transform into a malignant sarcoma. The current, retrospective study compared the clinical presentation, haematology, serum albumin and globulin and radiology of benign cases (n=31) and malignant cases (n=31) of spirocercosis. Dogs with spirocercosis-induced sarcoma were significantly older (6.4+/-1.91 years) than benign cases (4.93+/-2.87). In the malignant cases there were significantly (p=0.03) more sterilized females (10/31) and fewer intact males (4/31) compared to 2/31 and 13/31, respectively, in the benign cases. Hypertrophic osteopathy was observed in 38.7% of malignant cases and in none of the benign cases (p=0.0002). Common clinical signs included weight loss, regurgitation, anorexia, pyrexia (T>or=39.5 degrees ), respiratory complications and salivation but did not differ in prevalence between groups. On haematology, the malignant group had significantly (p<0.05) lower haematocrit (0.34+/-0.08 vs. 0.41+/-0.07) and higher white cell count (31.6+/-27.83 vs. 17.71+/-13.18 x 10(3)microl(-1)), mature neutrophil count (26.06+/-26.08 vs. 12.23+/-9.96 x 10(3)microl(-1)) and thrombocyte count (493.15+/-151.61 vs. 313.27+/-128.54 x 10(9)microl(-1)). There were no differences in the mean corpuscular volume and immature neutrophil count. On radiology, the mass length was not significantly different, but the height and the width of the malignant masses were significantly larger (62.59+/-15.15 mm and 73.93+/-20.94 mm) compared to the benign group (46.43+/-23.62 and 49.29+/-25.56, respectively). Spondylitis was more prevalent in the malignant group (67.86% vs. 38.46%, p=0.03). Examining secondary pulmonary changes revealed significantly higher prevalence of bronchial displacement in the malignant group (52% vs. 17%, p=0.008). Hypertrophic osteopathy appeared to be a very specific but relatively rare (poor sensitivity) marker of malignancy. Female gender, anaemia, leukocytosis, thrombocytosis, spondylitis and bronchial displacement are significantly more common in malignant cases, but appear in benign cases as well. However, if found together in a specific case, they should increase the index of suspicion for malignancy in a diagnosed spirocercosis case.