Albendazole therapy for loiasis refractory to diethylcarbamazine treatment.

Although diethylcarbamazine is curative in approximately 60% of patients who acquire loiasis as long-term visitors to an endemic area, some individuals continue to have signs and symptoms of infection despite multiple courses of diethylcarbamazine. On the basis of a study of albendazole treatment of loiasis in microfilaremic patients that suggested a macrofilaricidal effect of the drug, we treated three patients who had symptomatic loiasis refractory to more than four courses of diethylcarbamazine with albendazole. At the time of treatment, all patients had persistent symptoms despite decreasing titers of antifilarial antibodies and normal eosinophil counts. Symptoms resolved in all three patients following albendazole therapy. In one patient, nonspecific symptoms recurred 2 years later, but unlike her symptoms before albendazole therapy, they were not accompanied by the appearance of subcutaneous nodules containing adult worms. The other two patients have been symptom-free in the 8 years after albendazole treatment. In summary, albendazole may be useful for the treatment of loiasis when diethylcarbamazine is ineffective or cannot be used.     

IgG4 serology of loiasis in three villages in an endemic area of south-eastern Gabon

Human filariasis due to Loa loa differs from other filariasis in that the majority of infected subjects are without circulating microfilariae (occult loiasis). In search for alternative diagnostic methods, which do not depend on circulating microfilariae or the (rather infrequent) eye-passage of adult worms, it was shown earlier that IgG4 antibodies directed against Loa loa adult worm antigen are apparently a good marker of occult loiasis and specific with regard to the sympatrically occurring Mansonella perstans . In this study we evaluated an IgG4 antibody-based ELISA using crude extract of Loa loa microfilariae (which is easier to obtain than adult worm) to estimate the prevalence of loiasis in 3 villages in South-East Gabon. Of 222 examined individuals (80 children < 16 years, 142 adults) 44 (20%) carried Loa loa microfilariae and 170 (77%) M. perstans . Using the mean OD-value + 1 standard deviation of 9 sera from patients solely infected with M. perstans (from the Gambia, where Loa loa is not endemic) as a cut-off, 35 of the 44 microfilaraemic Loa loa patients and 2 of the 9 Gambian controls were positive. This shows that our method had a sensitivity of 80% and a specificity of 78%. Among the remaining 178 subjects who had no microfilariae of Loa loa , as many as 97 (55%) had significant levels of specific IgG4 antibodies against Loa loa , suggesting that they carried occult loiasis. The mean IgG4 level in these putatively occult loiasis patients was slightly but significantly lower than in microfilaraemic subjects ( P < 0.03). In conclusion, despite the limited sensitivity and specificity of our method, IgG4- ELISA at present is a very useful tool in estimating the real prevalence of loiasis in epidemiological surveys and at the individual level can confirm the diagnosis of L. loa amicrofilaraemic subjects with clinical signs suggesting loiasis.     

Loiasis in endemic and nonendemic populations: immunologically mediated differences in clinical presentation

To define the clinical spectrum of loiasis more precisely and to begin to assess the immunologic basis for the difference in clinical manifestations between visitors to endemic areas and natives of these areas, 51 West African patients with loiasis were evaluated and compared with 42 infected expatriates. Microfilaremia was present in 90% and Calabar swellings in only 16% of the endemic patients. Conversely, only 10% of the expatriates were microfilaremic while 95% complained of Calabar swellings. The endemic population showed significantly decreased levels of peripheral blood eosinophils, parasite-specific IgG, and lymphocyte proliferation to parasite antigens compared with the nonendemic population. These findings support the hypothesis that differences in the modulation of the immune response to parasite antigen are responsible for the observed differences in clinical presentation between expatriate and endemic populations with loiasis.     

Loa loa infection in temporary residents of endemic regions: recognition of a hyperresponsive syndrome with characteristic clinical manifestations

Loiasis in residents of endemic areas is generally manifested by microfilaremia, episodic angioedema, periocular migration of adult worms, modest eosinophilia, and variable antibody levels. In 20 temporary residents who acquired loiasis in West Africa, however, the clinical presentations were markedly different. Only three of the 20 had detectable microfilaremia. Furthermore, these patients often showed a state of marked immunological hyperresponsiveness manifested by very high titers of antibody to filariae, increased levels of serum IgE, and profound hypereosinophilia--to levels greater than 3,000/mm3 in 18 of the 20. These patients were also notable for the increased severity, frequency, and pruritic nature of their angioedema. Also, significant complications occurred in seven of the 20; one patient developed endomyocardial fibrosis and six, renal disease after treatment with diethylcarbamazine. Thirteen of the 20 developed subcutaneous nodules; adult parasites were recovered from three of five of these patients who underwent biopsy. All of the patients responded to therapy with diminution of their clinical symptoms and decreases in levels of eosinophils, IgE, and antibody to filariae.     

Diagnosing multiple parasitic infections: trypanosomiasis, loiasis and schistosomiasis in a single case.

A case is reported of a 32-year-old traveller with loiasis, schistosomiasis and African trypanosomiasis. The patient had been working in oil exploration in Nigeria and Gabon and presented with Calabar swellings and carpal tunnel syndrome. Serology for all 3 diseases was positive but microfilariae of Loa loa and ova of schistosomiasis were not found. Treatment with diethylcarbamazine and praziquantel was given for loiasis and schistosomiasis respectively. Trypanosomes were isolated from a lymph node aspirate only after repetition of the procedure 2 months later and the patient was treated with suramin. He developed a drug induced nephritis and was then treated successfully with alpha-difluoromethylornithine. There is a discussion of the difficulties encountered making these diagnoses in Europeans particularly where there are atypical clinical features. The risks of rural work in West Africa are noted and the importance of considering all parasitic diseases relevant to the travel/occupational history is emphasised.     

Enterobiasis: a histopathological study of 259 patients.

Enterobius worms or their eggs, or both, are present in preserved tissue sections or tissue specimens of 259 patients whose medical records are on file at the Armed Forces Institute of Pathology, Washington D.C., U.S.A. The most common site of infection (86.5%) was found to be the lumen of the appendix, where the worms provoke no reaction. Of the 259 patients 11 (4.2%) had worms and/or eggs in granulomas of the abdominal and pelvic peritoneum, and an equal number had granulomas on the peritoneum of the salphinx or on the surface of the ovary. There were also ectopic worms and/or eggs in granulomas on the peritoneum of the small and large intestines (2.7%). These Enterobius granulomas form around degenerating adult worms, around discrete eggs, around clusters of eggs, and, we believe, also around the tracks of migrating worms. Three patients (1.2%) had worms in perianal abscesses. A necrotic granuloma, removed from the lung of one patient, surrounded a degenerating adult worm. This suggests that the worm, carried to the lung as an embolus, impacted in a pulmonary arteriole. A stool specimen of one patient contains eggs of Enterobius, and that of another patient contains an adult Enterobius. This is the largest recorded histopathological study of enterobiasis in man.     

Loiasis--a neglected and under-estimated affliction: endemicity, morbidity and perceptions in eastern Cameroon

Loiasis is a neglected disease that may have great social and economic impact in some endemic areas. This study was designed to update the geographical distribution of loiasis and assess the frequency and perceptions of the clinical signs of the disease in the Eastern province of Cameroon. The investigation covered 32 villages and involved 4146 respondents. Human infection with Loa loa was endemic in all the study villages but the prevalence of microfilaraemia generally decreased from south to north. All of the study villages had local names for eye worm and Calabar swellings that varied in meaning and among the various ethnic groups. The most common traditional treatment for eye worm was garlic or onion juice, which is dripped into the affected eye. The body sites that were most affected by Calabar swellings were the upper (30%) or lower (32%) limbs. The swellings were very painful (46%), mildly painful (28%) or painless (26%). Most respondents (94%) reported that the swellings itched. The prevalence of L. loa microfilaraemia in most of the study villages was >20%. These villages are clearly at risk of severe adverse events, with encephalopathy, following mass distribution of ivermectin. The prevalence of the main clinical manifestations of loiasis (i.e. eye worm and/or Calabar swellings) was twice that of detectable microfilaraemia.     

Case report: Loiasis with peripheral nerve involvement and spleen lesions

Loiasis, which is caused by the filarial nematode Loa loa, affects millions of persons living in the rainforest areas and savannah regions of central Africa. Typical manifestations are calabar swellings and the eyeworm. We report a case of loiasis with unusual clinical complications: a peripheral neuropathy and focal hypo-echogenic lesions of the spleen, which disappeared after treatment with albendazole and ivermectin. The literature reports that L. loa infection can be associated with various manifestations, some of them being serious. More information is needed to better characterize the protean manifestations of the disease in loiasis-endemic areas to evaluate the true incidence of loiasis.     

血清低钠低氯对病毒性脑炎的诊断价值

目的观察病毒性脑炎急性期血清钠、氟浓度的改变及其临床意义。方法选择我院收治的病毒性脑炎患者120例,另选同期健康人120例,对两组观察对象血清钾、钠、氯浓度进行动态监测。结果病毒性脑炎组血清钾正常,88例（73％）患者血清钠、氯水平明显下降,32例（27％）患者血清电解质正常。病毒性脑炎重症组与轻症组钠、氯水平间差异有统计学意义（P〈0．05）。结论成人病毒性脑炎急性期大部分存在低钠、低氯血症,低钠、低氯与患者病情轻重相关,动态监测血清钾钠氯有助于病毒性脑炎的诊断和鉴别诊断以及病情轻重和预后估计。     

Clinical Features of Imported Loiasis: A Case Series from the Hospital for Tropical Diseases,London

We retrospectively analyzed the background, clinical features, and treatment response of 50 cases of imported loiasis who presented between 2000 and 2014 to the Hospital for Tropical Diseases (HTD), London, United Kingdom. Of them, 29 were migrants from, and 21 were visitors to, countries where the disease is endemic. Clinical features differed between these groups. Migrants experienced fewer Calabar swellings (odds ratio [OR] = 0.12), more eye worm (OR = 3.4), more microfilaremia (OR = 3.5), lower filarial antibody levels, and lower eosinophil counts (P < 0.05 for all tests). Among 46 patients who were started on treatment at HTD, 33 (72%) received diethylcarbamazine (DEC) monotherapy as first-line treatment, and among 26 patients who were followed up after treatment, seven (27%) needed a second course of treatment. There were 46 courses of treatment with DEC, and 20 (43%) of them had reactions. All patients with microfilaremia > 3,000 microfilariae/mL and all those with an elevated C-reactive protein (CRP) (≥ 5 mg/L) before treatment had reactions (P = 0.10 and P = 0.01, respectively). These data suggest that monotherapy with DEC may not be the optimal treatment for patients with loiasis, particularly for those with a high microfilarial load.     

The number and generative capacity of human B lymphocyte progenitors, measured in vitro and in vivo, is higher in umbilical cord blood than in adult or pediatric bone marrow

We retrospectively identified opportunistic CNS infections in 655 patients who had undergone allogeneic, syngeneic or autologous BMT or PBSCT between 1990 and 1997. Twenty-seven patients (4%) developed CNS infections. All CNS infections occurred in allogeneic BMT or PBSCT patients. The most common CNS infections were toxoplasma encephalitis (74%) and cerebral aspergillosis (18%). Furthermore, we identified one patient with candida encephalitis and one patient with viral encephalitis. Overall mortality of patients with opportunistic CNS infection was 67%. There were two different groups of toxoplasma encephalitis with a different appearance on MR imaging. The first group showed edema, but no gadolinium enhancement, whereas the second group exhibited typical MRI appearances with the exception of frequent hemorrhagic transformation. The first group had a significant shorter latency between BMT and onset of CNS infection (mean 45 days vs 180 days, P = 0.02), a significant higher daily dose of corticosteroids as treatment for graft-versus-host disease (GVHD) (P = 0.01), more severe GVHD and a higher mortality (71% vs 36%). This study shows that the most common CNS infections in our patient population are toxoplasma encephalitis and cerebral aspergillosis, that there are two distinct subgroups of toxoplasma encephalitis and that CNS infections occur after allogeneic BMT only.     

Status epilepticus in central nervous system infections: an experience from a developing country

Objective

There is a paucity of comprehensive study in status epilepticus in central nervous system infections. This observational study evaluated the response to antiepileptic drugs in patients with status epilepticus and central nervous system infection.

Methods

The study took place at a tertiary care teaching hospital in India. A total of 37 of 93 adult patients (39.8%) with status epilepticus had central nervous system infection, and they underwent clinical evaluation, including status type and duration. Magnetic resonance imaging and cerebrospinal fluid analyses were performed. Patients were categorized into encephalitis, meningitis, and granuloma groups. The response to antiepileptic drugs was noted, and the status was considered refractory if seizures continued after the second antiepileptic drug. Refractory status epilepticus and mortality were correlated with the type of infection and various clinical and magnetic resonance imaging findings.

Results

The median age of the patients was 37 years (16-78 years), and 17 patients were female; 35 patients had convulsive status epilepticus, and 2 patients had nonconvulsive status epilepticus. Twenty patients had encephalitis (Japanese 4, herpes simplex 3, nonspecific 12), including 1 patient with malaria, 9 patients with meningitis (tubercular 5, pyogenic 3, fungal 1), and 7 patients with granuloma (tubercular 5, neurocysticercosis 2). The mean duration of status epilepticus was 19.6 hours (0.25-72 hours). Magnetic resonance imaging results were abnormal in 66.7% of patients. In 67.6% of patients, status epilepticus was controlled after the first antiepileptic drug. Some 24.3% of patients were refractory to the second antiepileptic drug, and 10.8% of patients did not respond to the third antiepileptic drug. Patients with encephalitis had an insignificantly poor response. Eleven patients (29.7%) died, and mortality was higher in patients with refractory status epilepticus.

Conclusion

Of patients with status epilepticus and central nervous system infection, 24.3% had a refractory status that was associated with a high mortality. Their response to an antiepileptic drug in encephalitis was insignificantly poorer.     

Sinus node-atrioventricular node isolation: long-term results with the "corridor" operation for atrial fibrillation

The "corridor" operation is designed to restore sinus rhythm to patients with atrial fibrillation by electrically isolating the sinus node, a band of atrial tissue and the atrioventricular (AV) node from the remaining atrial tissue. Nine patients with drug-refractory atrial fibrillation underwent this operation; four patients had chronic atrial fibrillation and five had paroxysmal atrial fibrillation; the mean duration of symptoms was 12 +/- 8 years. Patient ages ranged from 25 to 68 years (mean 48 +/- 12). At preoperative electrophysiologic study, no patient had evidence of an accessory AV pathway or AV node reentry. Sinus node recovery time could not be determined in five patients because of recurrent atrial fibrillation during or before programmed stimulation. At operation the corridor of atrial tissue connecting the sinus and AV nodes was successfully isolated from the remaining left and right atrial tissue in all patients. One patient required early reoperation for recurrent atrial fibrillation before hospital discharge. At the predischarge electrophysiologic study, the corridor remained isolated in all patients except for one patient who had intermittent conduction between the corridor and excluded right atrium. One patient had nonsustained atrial fibrillation and one had atrial tachycardia evident in the corridor. Atypical AV node reentry of uncertain significance was induced in one other patient. Over a total follow-up of 191 patient months (mean 21 +/- 20), seven patients remained free of atrial fibrillation. Two patients had recurrent atrial fibrillation, which in one patient was effectively controlled by a single antiarrhythmic agent. A permanent pacemaker was implanted in four patients for sinus node dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Two cases of human Lagochilascaris infection in Colombia

Two human cases of infection with Lagochilascaris are described from Colombia. One patient was a 21 year-old woman who suffered from repeated attacks of tonsillitis and passage of worms from the nose. When a tonsillectomy was performed, numerous worms were found in the tissues. Treatment with thiabendazole and mebendazole was ineffective. She was cured after treatment with levamisole. The second patient was a 7 year-old girl who had a painful abscess on the neck that contained adult worms. She was also cured of this infection after treatment with levamisole. These are the first cases described from Colombia, and bring the total number of human cases recorded to twenty-three.     

Bancroftian lymphangitis in northeastern Brazil: a histopathological study of 17 cases.

The histological features in 17 patients (3 males and 14 females) with bancroftian lymphangitis, apparently not associated with lymphadenitis, are described. Degenerative alteration in the worms and a severe inflammatory process were observed in the great majority of the cases. The patterns of tissue reaction varied, including exudative, infiltrative and granulomatous lesions. Eosinophils were present, usually in great numbers. Thirteen out of 14 female subjects showed involvement of the breast lymphatics, and in two of these cases microfilariae were found in addition to adult worms. The breast parenchyma was in general spared. In men, lymphatics of the epididymis were affected; in one case, the patient was submitted for surgical castration for prostatic cancer and intact filarial worms without tissue reaction were incidentally detected in peritesticular lymphatics.     

Immune responses during human Schistosomiasis mansoni. VIII. Differential in vitro cellular responsiveness to adult worm and schistosomular tegumental preparations

The proliferative responses of peripheral blood mononuclear cells from patients with Schistosoma mansoni infections were studied in response to heterogeneous schistosomal antigenic preparations derived from whole adult worms, cercariae or schistosomula, and soluble tegumental preparations from adult worms or schistosomula. The use of these preparations was standardized with a Brazilian patient population, and comparisons were made between previously used and newly, variously prepared antigenic preparations. Responses of cells from these intestinal/ambulatory patients were generally strong to whole adult worm antigens and low to moderate to whole cercarial or schistosomular materials. Although most patients responded well to whole worm extracts, they were not stimulated by the soluble adult tegumental preparation. In contrast, the responses to the soluble schistosomular tegumental material were vigorous. These responses were usually much higher than to whole schistosomula-derived materials. Thus it appears, using these particular preparations, that human schistosomal patient lymphocytes recognize and are stimulated by schistosomular tegumental antigens but they do not demonstrate good reactivity when exposed to an adult worm tegumental preparation.     

Adult Mansonella perstans in the abdominal cavity in nine Africans

Adult Mansonella perstans infected the abdominal cavity of nine patients seen at Karawa Hospital in the Ubangi territory of Zaire. In four patients the worms were removed at laparotomy, and in the other five they were removed at autopsy. Twelve adult worms were identified in the nine patients. None of the worms caused symptoms or contributed to the patient's death. Worms were in the hernial sac in three patients, and one each was in connective tissue beside a reactive mesenteric lymph node, in peripancreatic connective tissue, in perirenal connective tissue, in hepatic portal connective tissue, on the serosal surface of the small intestine, and in connective tissue adjacent to rectum. The diameter of male worms was 45 microns to 60 microns and of female worms, 80 microns to 125 microns. One female worm was removed intact. It was 6 cm long and had a bifurcated tail characteristic of M. perstans.     

Long term survival of 'damaged'Nippostrongylus brasiliensis adult worms in the testosterone-treated Indian soft-furred rat, Millardia meltada

When testosterone-treated female Millardia meltada were infected with Nippostrongylus brasiliensis , adult worms persisted for over seven weeks. The kinetics of faecal egg counts showed a biphasic pattern having a transient decline at around two weeks post infection (p.i.). Thus the status of   N. brasiliensis adult worms surviving in the small intestines of testosterone-treated M. meltada was examined. The fecundity and maturity of eggs in the uteri of female adult worms were examined at one, two, three and seven weeks p.i. Both the fecundity and maturity of eggs transiently decreased at two and three weeks p.i. and then completely recovered by seven weeks. Adoptive transfer of   N. brasiliensis adult worms into naive recipients can discriminate the status of worms. Those obtained from the stable phase of a primary infection ('normal' worm) can establish and survive in the recipients, whereas those obtained at the time of expulsion ('damaged' worm) are rapidly expelled. Therefore, 300 each of N. brasiliensis adult worms collected from the testosterone-treated female M. meltada at one, two and seven weeks p.i. were transferred intraduodenally into normal rats to determine their status. Those collected at one week p.i. persisted for eight days, indicating that they were still 'normal'. In contrast, worms collected at two and seven weeks p.i. were expelled within four days, indicating that they had already been 'damaged'. Moreover, when the 'damaged' worms obtained from rats were intraduodenally transferred into testosterone-treated female M. meltada , they were not expelled, suggesting that testosterone-treatment affected the final expulsive step, but not the damaging process, of the mucosal defence of M. meltada against N. brasiliensis adult worms .     

Total and "activated" peripheral blood T lymphocytes in patients with thyroid disorders.

The percentage of total and "activated" peripheral blood T lymphocytes was measured in patients with (i) hyperthyroid Graves' disease selected for absence of ophthalmopathy, (ii) treated Graves' disease, with ophthalmopathy, and (iii) other thyroid disorders including subacute thyroiditis, using sheep red blood cell rosette tests. No patient had significantly increased levels of either total or "activated" T lymphocytes. On the other hand, the percentage of total T cells was below normal in 8 of 18 patients with hyperthyroid Graves' disease and in 6 of 18 patients with ophthalmopathy compared with only one of 12 patients with nodular goitres. Similarly, low levels of "activated" T cells were demonstrated in 5 of 18 patients with hyperthyroid Graves' disease and in 10 of 18 patients with ophthalmopathy compared with only one of 12 patients with nodular goitres. Three of four patients with subacute thyroiditis tested had depressed levels of total T lymphocytes whilst only one had low levels of "activated" T lymphocytes. Levels returned to normal during the recovery phase in the two patients with positive tests who were retested. Depressed levels of T lymphocyte populations in patients with Graves' disease and subacute thyroiditis may be due to feedback suppression and/or "exhaustion" in association with the thyroidal and orbital immunological reactions.