Toxocariasis After Slug Ingestion Characterized by Severe Neurologic, Ocular, and Pulmonary Involvement

Fellrath, Jean-Marc; Magnaval, Jean-François

A previously healthy 71-year-old male patient was referred to the Department of Pneumology in Neuchâtel hospital due to a fever accompanied with cough, which was nonresponsive to azithromycin therapy. This syndrome was associated with headaches, confusion, memory and balance impairment, and scalp hyperesthesia. Blood eosinophilia was present and was abnormally elevated on the 1st day after admission (Table 1) . Abdominal ultrasonography did not identify any enlargement of the liver or spleen; however, a contrast computed tomography (CT) scan demonstrated multiple low-density areas disseminated through the whole organ. A chest CT scan revealed diffuse micronodular opacities. Bronchoalveolar lavage and transbronchial biopsies identified a sterile and nonhemorrhagic eosinophilic alveolitis along with a substantial endoalveolar and interstitial eosinophilic accumulation. A brain magnetic resonance imaging (MRI) revealed subcortical ischemic lesions, and a cerebrospinal fluid (CSF) examination revealed a granulocytic pleocytosis. Parasitological examination of stools did not retrieve parasite propagula, and results from a large panel of bacteriology cultivations were negative. Polymerase chain reaction assays on blood for cytomegalovirus, and on fluid from bronchoalveolar lavage for Chlamydia pneumoniae, Mycoplasma pneumoniae, adenoviruses, bocaviruses, coronavirus 229E, enteroviruses, influenza A , B and C viruses, metapneumovirus A and B, parainfluenza 1, 2, 3, 4a and 4b viruses, rhinoviruses, and respiratory syncytial A and B viruses tested negative. Serology did not find any blood-specific antibodies against C pneumoniae, Chlamydia trachomatis, Chlamydia psitacci, Coxiella burnetii, Legionella pneumophila (serogroups 1-6), M pneumoniae, and human immunodeficiency virus. Immunodiagnoses for autochthonous helminthiases (alveolar and cystic echinococcoses, strongyloidiasis, and toxocariasis) only tested positive for toxocariasis (Table 1) . Although pathology examination of a left temporal artery biopsy was unremarkable, as were the results of laboratory tests for antineutrophil cytoplasmic, anti-myeloperoxidase, antinuclear antibodies and rheumatoid factor, a hypothesis of vasculitis of unknown etiology that would have elicited severe neurologic disorders was raised. An oral corticosteroid therapy was therefore started and yielded a minor improvement of the clinical picture. One month later, a reassessment of the case history revealed a long-standing daily intake of 2 or 3 raw local slugs for alternative therapy of gastroesophageal reflux; this information prompted us to perform further investigations. A liver MRI did not identify any abnormality corresponding with the low-density areas previously observed by CT scan. Such transient hepatic lesions have been related to Toxocara spp migrating larvae [9] . This finding combined with the presence of abnormally elevated blood eosinophilia, high serum levels of total immunoglobulin E (Table 1) , and the positive result of the specific serodiagnosis by enzyme-linked immunosorbent assay (ELISA) therefore oriented the diagnosis towards a toxocaral etiology. The patient's serum displayed a typical 7-band pattern as assessed by Western blot analysis (Toxocara WB; LDBio, Lyon, France) [10] . In CSF, granulocytic pleocytosis was attributed to eosinophilia, and the toxocariasis immunodiagnosis via ELISA for intrathecal-specific antibody synthesis was positive (optical density: 0.330; cutoff value: 0.11