Cardiopulmonary alterations by ultrasound in a patient with uncomplicated mixed malaria infection: a case report from the Amazon Basin.

BACKGROUND: Information on cardiopulmonary complications in clinical malaria is sparse and diagnosis may be difficult in resource-limited areas due to lack of proper diagnostic tools and access to medical care. A case of pericardial effusion and pulmonary alterations assessed by ultrasound in a patient with uncomplicated mixed malaria infection is described. CASE PRESENTATION: A previously healthy 23-year-old male from the Amazon Basin was diagnosed with mixed infection of Plasmodium vivax and Plasmodium falciparum by peripheral blood smear. The patient presented with mild malaria symptoms without signs of severe malaria, but reported moderate chest pain and shortness of breath. Laboratory analyses revealed thrombocytopenia and anemia. The electrocardiogram had PR depressions and bedside ultrasound of the cardiopulmonary system showed pericardial effusion (18 mm) accompanied by multiple B-lines in the lungs, identified as vertical artifacts extending from the pleural line. Cardiac biomarkers were normal. The patient was treated according to national guidelines for malaria and suspected pericarditis, respectively. At follow-up on day 5, the pericardial effusion (9mm) and B-lines had markedly decreased. By day 21 the patient was asymptomatic, had completed the treatment, and the electrocardiogram and ultrasound findings had normalized. CONCLUSIONS: This case report highlight the usefulness of bedside ultrasound to identify cardiopulmonary involvement in patients with uncomplicated malaria and relevant symptoms.

Inflammasome-Independent Role for NLRP3 in Controlling Innate Antihelminth Immunity and Tissue Repair in the Lung.

Alternatively activated macrophages are essential effector cells during type 2 immunity and tissue repair following helminth infections. We previously showed that Ym1, an alternative activation marker, can drive innate IL-1R-dependent neutrophil recruitment during infection with the lung-migrating nematode, Nippostrongylus brasiliensis, suggesting a potential role for the inflammasome in the IL-1-mediated innate response to infection. Although inflammasome proteins such as NLRP3 have important proinflammatory functions in macrophages, their role during type 2 responses and repair are less defined. We therefore infected Nlrp3 -/- mice with N. brasiliensis Unexpectedly, compared with wild-type (WT) mice, infected Nlrp3 -/- mice had increased neutrophilia and eosinophilia, correlating with enhanced worm killing but at the expense of increased tissue damage and delayed lung repair. Transcriptional profiling showed that infected Nlrp3 -/- mice exhibited elevated type 2 gene expression compared with WT mice. Notably, inflammasome activation was not evident early postinfection with N. brasiliensis, and in contrast to Nlrp3 -/- mice, antihelminth responses were unaffected in caspase-1/11-deficient or WT mice treated with the NLRP3-specific inhibitor MCC950. Together these data suggest that NLRP3 has a role in constraining lung neutrophilia, helminth killing, and type 2 immune responses in an inflammasome-independent manner.

Evidence for Asthma in the Lungs of Mice Inoculated with Different Doses of Toxocara canis.

Toxocara canis, a common roundworm that mainly causes toxocariasis, is a zoonotic parasite found worldwide. Humans, an accidental host, can acquire T. canis infection through accidental ingestion of T. canis-embryonated egg-contaminated food, water, and soil, and by encapsulated larvae in a paratenic host's viscera or meat. Long-term residence of T. canis larvae in a paratenic host's lungs may induce pulmonary inflammation that contributes to lung injury, airway inflammatory hyperresponsiveness, and collagen deposition in mice and clinical patients. This study intended to investigate the relationship between T. canis infection and allergic asthma in BALB/c mice inoculated with high, moderate, and low doses of T. canis eggs for a 13-week investigation. The airway hyperresponsiveness (AHR) to methacholine, collagen deposition, cytokine levels, and pathological changes in lung tissues was assessed in infected mice at weeks 1, 5, and 13 postinfection. The cell composition in bronchoalveolar lavage fluid of infected mice was assessed at weeks 5 and 13 postinfection. Compared with uninfected control mice, all groups of T. canis-infected mice exhibited significant AHR, a dose-dependent increase in eosinophilic infiltration leading to multifocal interstitial and alveolar inflammation with abundant mucus secretion, and collagen deposition in which the lesion size increased with the infective dose. Infected mice groups also showed significant expressions of eotaxin and type 2 T-helper-dominant cytokines such as interleukin (IL)-4, IL-5, and IL-13. Overall, these results suggest that T. canis larval invasion of the lungs may potentially cause pulmonary inflammatory injury and could subsequently contribute to the development of allergic manifestations such as asthma.

Restaging Pulmonary Schistosomiasis.

Schistosomiasis is traditionally classified into an acute and a chronic phase, although a precise temporal distinction between the two phases has not been established. Lung involvement can be observed in both phases. We previously reported seven cases of pulmonary lesions due to chronic schistosomiasis in African immigrants. All cases were documented with CT scans and demonstrated complete resolution after treatment with praziquantel. Moreover, another case showed spontaneous disappearance of the nodule before treatment with praziquantel. These findings are similar to those observed in the acute phase of schistosomiasis, with well-defined or ground glass nodules that resolve spontaneously. According to these findings, we postulate the presence of an "intermediate" phase of schistosomiasis involving the lungs that can be defined as an "early chronic phase," and presents analogies to the acute phase. We also hypothesize that in the "early chronic phase," the female worms transit through the lungs where they may lay eggs. These passages not only cause transient, but also radiologically visible alterations. The pathophysiology of lung lesions in the late chronic phase is probably different: the adult worms settled in the mesenteric plexuses produce eggs for years. The eggs repeatedly migrate to the perialveolar capillary beds via portal-caval shunting. Thus, in this case it is the eggs and not the adult worms that reach the lungs in a scattered way. Based on our findings, we suggest the alternative hypothesis that the pulmonary involvement is a phase of the natural evolution of the infection, both from Schistosoma mansoni and Schistosoma haematobium.

Bronchodilator Reversibility Occurring during the Acute Phase of Paragonimiasis westermani Infection.

A 43-year-old woman was referred to our hospital with peripheral blood hypereosinophilia and abnormal chest X-ray findings. Her pleural effusion revealed hypereosinophilia and a low glucose level. She was diagnosed with pulmonary paragonimiasis based on an elevated antibody level of Paragonimiasis westermani. Although she had no medical history of allergic disorders, a pulmonary function test revealed bronchodilator reversibility. After praziquantel therapy, her symptoms, hypereosinophilia in peripheral blood, and pleural effusion were improved. A repeated pulmonary function test after praziquantel therapy showed a negative bronchodilator response. Pulmonary paragonimiasis may induce bronchodilator reversibility during the acute phase of infection.

Strongyloides hyperinfection syndrome complicating (ectopic) Cushing syndrome.

Strongyloidiasis can present with a wide variety of symptoms and can lead to a potentially fatal hyperinfection. Although any factors that suppress the host defense mechanisms can potentially trigger hyperinfection, prolonged steroid use has been quite well described. A patient with disseminated small cell lung cancer suffered a Strongyloides stercoralis hyperinfection syndrome complicating ectopic adrenocorticotropic hormone (Cushing syndrome). Evaluation revealed lymphopenia, elevated levels of adrenocorticotropic hormone in the setting of elevated cortisol levels, a normal pituitary, and metastatic malignancy. S. stercoralis larval forms were seen in the stool and sputum. At autopsy, S. stercoralis larval forms were seen in the lung along with evidence of metastatic small cell lung carcinoma.

Prevalence and intensity of Paragonimus uterobilateralis infection among school children in Oban village, South Eastern, Nigeria.

A survey of Paragonimus infection among primary school children aged 6-10 years in Oban village, Akamkpa Local Government Area of Cross River State, Nigeria, was conducted. A total of 198 children were examined:112 (56.6%) were boys while 86 (43.4%) were girls. Eleven of the subjects were sputum positive for paragonimus eggs, giving an overall prevalence rate of 5.5%. The findings show that paragonimiasis is a significant health problem in South Eastern Nigeria; the risk of infection could be minimized by the proper cooking of fresh water crabs and crayfish before consumption.

Impaired pulmonary gas exchange in ewes naturally infected by small lungworms.

Respiratory rate and blood gases were studied in 2 groups of ewes: the ewes in group 1 (9 ewes) acted as uninfected controls and those in group 2 (6 ewes) were infected with small lungworms (Muellerius, Cystocaulus, Protostrongylus and < 1% Neostrongylus). The respiratory rate was higher in infected (49 +/- 19 breath min-1) than in uninfected ewes. (20 +/- 3 breath min-1); it was strongly reduced after treatment (49 vs 22) in infected ewes. The partial carbon dioxide arterial tension (PCO2), total CO2 and HCO3- were higher (respectively 77 vs 39 mmHg, 38 vs 23 mmol-1 and 35 vs 23 mmol-1) in infected compared with uninfected ewes, whereas arterial pH (7.2 vs 7.4) and partial oxygen tension PO2 were lower (41 vs 81 mmHg) in infected ewes. Group 2 was treated with fenbendazole (at 15 mg kg-1 bodyweight) to eliminate small lungworms, and the respiratory rate and blood gases were measured 3 weeks after treatment. The values after treatment were similar to those in uninfected ewes. It is concluded that heavy infections by small lungworms in ewes impairs gas exchange, but that gas exchange improves rapidly after treatment.

Relationship between cytologic changes in bronchoalveolar lavage fluid and weight gain in calves with gastrointestinal nematodes and lungworms.

Two of three groups of 10 calves each were infected with either 100,000 infective larvae (L3) of Ostertagia spp. and 100,000 L3 of Cooperia spp. or with 4000 L3 of Dictyocaulus viviparus, respectively, at the age of 14 weeks. The third group was not infected. After treatment with an anthelminthic five calves from each group were challenged with either 100,000 L3 of Ostertagia spp. and 100,000 L3 of Cooperia spp. or 4000 L3 of Dictyocaulus at the age of 20 weeks. The calves were 25 weeks old when slaughtered. Total and differential cell counts were determined in bronchoalveolar lavage fluid and showed that neutrophils were the most frequent and eosinophils the least frequent cell present. There was a significant negative relationship between eosinophil levels and weight gain of the calves.

Blood gas analysis in dogs with pulmonary heartworm disease.

Blood gases were analyzed in dogs with pulmonary heartworm (HW) disease. The arterial oxygen tension (PaO2) in dogs with mild signs of dirofilariasis (mildly affected group, n = 48, 85.7 +/- 8.2 mmHg) and in dogs with signs of right heart failure (severely affected group, n = 13, 76.4 +/- 11.6 mmHg) was lower (p < 0.01) than in dogs without HW infection (HW-free group, n = 19, 91.5 +/- 7.3 mmHg). Only 2 dogs in the severely affected group had a PaO2 less than 60 mmHg. The arterial carbon dioxide tension (PaCO2, p < 0.01) and mixed venous O2 (p < 0.01) and CO2 (p < 0.01) tensions were lower, and alveolar-arterial oxygen difference (AaDO2, p < 0.01) was greater in the severely affected group than in the HW-free and mildly affected groups. Arterial pH and bicarbonate (HCO3-) concentrations were lower (p < 0.01) in both affected groups than in the HW-free groups. The anion gap level was not different among the 3 groups. Serum lactic acid level in the severely affected group was higher (p < 0.01) than in the HW-free and mildly affected groups. However, a slightly higher serum lactic acid concentration was found only in 2 dogs of the severely affected group (3.84 mmol/l and 3.82 mmol/l). The PaO2 (r = -0.62) and AaDO2 (r = 0.66) correlated significantly (p < 0.01) with mean pulmonary arterial pressure. One week after HW removal, blood gases, pH and HCO3- concentration remained unchanged in the mildly affected group. In the severely affected group, blood gas values were the same, but pH and HCO3- concentration improved slightly.

Longitudinal study of the effects of lungworm infection on bovine pulmonary function.

Clinical and physiologic investigations were done weekly in 5 nonsedated Friesian calves before, during, and after an induced infection with Dictyocaulus viviparus infective larvae. Clinical, hematologic, serologic, and parasitologic findings were all compatible with the classic picture of moderate subacute verminous bronchitis. Most pulmonary function values revealed significant (P less than or equal to 0.05) changes in the 2nd or 3rd week after inoculation and maximal changes at 5 weeks after inoculation. Most marked changes included a decrease in tidal volume, dynamic lung compliance, and arterial oxygen tension, and an increase in minute ventilation, minute viscous work of breathing, and alveolar-arterial oxygen difference. Minute ventilation, dynamic lung compliance, minute viscous work of breathing, and PaO2 revealed the most homogeneous change. Conversely, maximal change of intrapleural pressure, total pulmonary resistance, and viscous work of breathing had higher variability from week to week.

[Pulmonary involvement in malaria (review)]. / Comprometimento pulmonar na malária (revisão).

Pulmonary involvement occurs in 3 to 10% of the cases of Plasmodium falciparum malaria and represents the most serious complication of this infection, with a lethality of about 70%. The understanding of its pathogenesis is still very fragmentary, however it is recognized that activation of the immune system by antigens released by the parasite plays an important role in the induction and worsening of lung damage. Capillary endothelial cells, which control the flux of fluids to the interstitial space, appear to be the most involved structure. These cells are activated by cytokines, produced by lymphocytes and macrophages during the immune response, and express receptors and molecules of adhesion, allowing for sequestration of parasitized erythrocytes and adherence of cells, which will produce locally inflammatory mediators. The inflammatory reaction and lesion of endothelial cells that ensue, together with the hemodynamic alterations induced by the capillary blockade due to the sequestration of parasitized erythrocytes and leukocytes, cause alterations of the vascular permeability and transfer of liquid to intertitial space and alveoles. Severe cases are clinically expressed by a picture of Adult Respiratory Distress Syndrome. The clinical manifestations of pulmonary involvement may start suddenly at any time during the course of malaria, even after disappearance of circulating parasites. The inducing factors are unknown. Hyperparasitemia, renal failure and pregnancy are predisposing factors. The prognosis will depend on how fast the diagnosis is established and convenient treatment initiated. If parasites are present they shall be treated with schizonticidal drugs, hemodynamic parameters continuously evaluated, preferably through a Swam-Ganz catheter. Appropriate oxygen supply and fluid balance have to be warranted. Other complications of malaria, frequently associated to the pulmonary involvement, need special attention and proper treatment. A better understanding of the pathogenesis of lung damage associated to malaria will certainly help to improve treatment and reduce morbidity and mortality.

A lung nematode in Canadian Arctic muskoxen. Standard radiographic and computed tomographic imaging.

Medical imaging was used before death to follow the development of U. pallikuukensis infection in muskoxen and postmortem to investigate the distribution and characteristics of parasite-associated pulmonary cysts. In two experimentally infected animals, lesions were not visible radiographically until days 178 and 191 PI, 3 months after the parasites became patent. Serial radiographs taken throughout the period of patency of one animal showed an initial increase in lesion size by day 415 PI, but by day 789 PI, lesions had stabilized or decreased in size. Although all lesions detected postmortem were not visible radiographically during life, the radiographs did provide an indication of the relative severity of infection. In contrast to other parasitic pneumonias, there was no evidence of pulmonary disease outside of the discrete parasitic cysts. Radiographs of lungs postmortem proved to be an effective tool for locating parasitic cysts in a lightly infected muskox and demonstrated a bronchovascular cyst distribution. Postmortem CT provided a more rapid and detailed assessment of the number, size, and distribution of cysts in the lungs of one muskox.

[Evaluation of exercise tolerance in patients treated with praziquantel for chronic schistosomiasis with no signs of cardiopulmonary impairment]. / Evaluación de la tolerancia al ejercicio en pacientes con shistosomiasis crónica sin evidencias clínicas de compromiso cardiopulmonar tratados con praziquantel.

OBJECTIVE: The purpose of this study was to evaluate whether a progressive cycle ergometer test (PCET) can detect minimal functional abnormalities that might indicate compromise of the pulmonary vascular bed in patients treated with praziquantel for chronic schistosomiasis who have no clinical signs of cardiopulmonary impairment. PATIENTS AND METHOD: We studied 9 patients (whose mean (SD) age was 38 (18) years and 10 control subjects aged 32 (14) years. Both groups were evaluated by spirometry and a PCET to determine maximum oxygen consumption, heart rate, minute ventilation and gas exchange. Echocardiograms were used to rule out the presence of associated heart disease. RESULTS: Lung function was similar among patients and controls. Slight decreases in maximum oxygen consumption and heart rate reserve were observed with effort during the PCET, with normal respiratory response. No echocardiographic abnormalities that might indicate the presence of pulmonary vascular occlusive disease were observed. CONCLUSIONS: The results showed that the resting lung function is normal in these patients. However, there was a slight decrease in exercise tolerance, probably related to physical detraining. The data obtained during exercise indicated that pulmonary vascular occlusive disease is unlikely in these patients. Abnormalities may appear in later stages of the disease or in patients who do not receive early medical treatment.

Advances in pathophysiology of schistosomiasis japonica: a review.

Schistosomiasis is a chronic granulomatous disease caused by a delayed type of hypersensitivity reaction to eggs deposited or trapped in the tissues. Granuloma formation, depending on extent, if in the liver will lead to portal hypertension while if in the lungs, will lead to pulmonary hypertension and cor pulmonale.

[Pulmonary toxoplasmosis in patients with human immunodeficiency virus infection. 21 cases]. / Toxoplasmose pulmonaire chez les patients infectés par le virus de l'immunodéficience humaine. 21 observations.

OBJECTIVES: Assess expression of pulmonary toxoplasmosis, the second most frequent localization after brain, in patients infected with the human immunodeficiency virus (HIV). METHODS: Twenty-one HIV-infected patients (18M, 3F) were admitted for pulmonary toxoplasmosis between September 1987 and February 1995. Mode of HIV transmission was unprotected homosexual sexual activity (n = 16), intravenous drug abuse (n = 3) and transfusion (n = 2). RESULTS: Isolated pulmonary toxoplasmosis was found in 11 patients. In 10 patients pulmonary toxoplasmosis was associated with cerebral (n = 4), bone marrow (n = 2), ocular (n = 1) and multifocal (n = 3) localizations. Seven patients were admitted for acute pulmonary distress. Fever (reported for 20 patients) and nonproductive cough (reported for 16 patients) were the most common clinical symptoms. Chest roentgenogram revealed bilateral pulmonary infiltrates in 16 (76%) patients. Mean absolute CD4 count was 25 +/- 57 (range 0-110). Serologic evidence of past infection was observed in 18 patients. Serology tests were not done for two patients and negative for one. Two patients presented co-infection with Pneumocystis carinii. Fourteen patients had elevated serum lactic dehydrogenase (LDH) concentration. Among those, 4 patients whose LDH concentration was elevated more than ten fold died of respiratory distress. Patients received pyrimethamine and sulfadiazine (n = 13) or clindamycin (n = 8). Seven patients died during the first month after diagnosis was made. For the other patients, mean survival was 8 months. No relapse of toxoplasmosis was observed. All the patients took a secondary prophylaxis. CONCLUSION: No difference between patient with isolated pulmonary toxoplasmosis and patients with associated extra-pulmonary localization was noted for clinical, biological, radiological presentations and outcome.

[Parasitic invasions and bronchial obstruction]. / Parazitnye invazii i bronkhoobstruktivnyi sindrom.

The course and outcomes of bronchial obstruction were reviewed for clonorchiasis, metagonimosis, lambliasis. Bronchial obstruction is shown to run more aggressive course in Trematoda infestation with further transformation into bronchial asthma despite dehelminthization. In lambliasis current antiparasitic therapy is able to abolish the obstruction. In combination of lambliasis with bronchial asthma it is feasible to achieve a persistent remission of bronchial asthma.