Unusual presentation of some parasitic diseases.

1. Unusual presentation of some parasitic diseases. By: Dr: Nadia Aly El-Dib Professor of Parasitology.

2. The majority of symptoms attributable to parasitosis are not specifically diagnostic”. • Parasites may not produce clinically demonstrable symptoms and may alter the metabolic balance of the host causing unusual response”. • Scientific knowledge & clinical experience will be the key to reach a suitable diagnosis”. Introduction:

3. The following are few interesting cases referred to the Parasitology department. Medical sense and laboratory skills were necessary for diagnosis

4. A case of melena in a 2 months baby. • The duodenal aspirate of a 2 months baby was taken by upper endoscopy & sent to the Parasitology Department for examination. • There were 2 cylindrical worms (1-1.5cm long) in the aspirate. • The patient presented with:diarrhea, melena & anemia.

5. The worms were identified in the Parasitology Department as female: Ancylostomaduodenale. • Eggs of Ancylostoma duodenale were identified microscopically from the bottom of the tube.

6. Larvae require about 6-8 weeks from skin penetration to develop into adults. • Eggs begin to appear in feces about 8-12 weeks after infection. The problem was: To explain the occurrence of infection in a 2 months baby !!

7. It is not logic that the baby could catch infection immediately at birth. • The only logic explanation: The baby got infection transplacentally from an infected mother.

8. A 50 years old female patient, presented with a single firm, freely mobile subcutaneous nodule, just above the tarsus of the left eyelid & below the eyebrow. • No inflammatory signs in the skin. A mass in the upper eyelid:

9. CT scan showed no evidence of orbital or intracranial extensions. • Blood picture didn’t show eosinophilia or micrifilarimia. • The nodule was excised surgically. • From one end of this nodule, a living motile nematode worm came out.

10. It measured 13 cm. in length × 2mm. in breadth.

11. The nodule showed fibrous tissue capsule with inflammatory cells & the core was mainly formed of hyaline substance with no other worms.

12. Cross section of the worm, showed double uterine tubes & a smaller digestive duct in the haemocele. • Diagnosed as: Dirofilaria conjunctivae (repens).

13. An example of the zoonotic parasitic diseases is this rare case infected with: Dirofilaria conjunctivae (repens). A parasite of dogs and cats. Mosquitoes act as vectors for its transmission

14. Case report: • A38 years old male patient from the rural suburbs of Taif, Saudi Arabia, complained of continuous epistaxis and nasal obstruction, for about 10 days (in spite of routine treatment of epistaxis). • Careful clinical examination, revealed the presence of a dark object in the nosopharynx. • Topical anesthetic spray was used and the object was pulled with a clamp. A case of epistaxis:

15. O.S. P. S. The cause of epistaxis was identified as: leech (Hirudo spp.) Mode of infection: drinking or Wadding into contaminated water

16. A case of cutaneous lesion diagnosed as leishmaniasis

17. A 43 years old male patient, complained of a skin lesion in the upper part of the chest. • He gave history of visiting KSA since 2-3 months. • There was intermittent mild fever with slight loss of weight. • His lesion was previously diagnosed as cutaneous leishmaniasis and the patient was given (Pentostam) by I.m & intra lesional routes. • No improvement, with appearance of new smaller lesions & what seemed to be an abscess behind the lesion.

18. Aspiration of the abscess did not show pus

19. Microscopic examination: • No amastigotes were detected in the scrappings from the lesion. • PCR for Leshmania DNA was negative (samples were taken under complete aseptic conditions in the surgical department from different areas of the lesions) • Histopathological examination diagnosed: • Proliferative lymphoma of the skin.

20. The patient was given chemo & and radiotherapy and showed good response.

21. Apatient passing small pieces of an unknown tape worm out of his anus: Case report: A 40 years old male Yemeni living in Madinah, Saudi Arabia, attended the general hospital complaining of occasional passage of fleshy structures out of his anus since about three years. This complaint was very irritating for him especially his condition was not diagnosed or treated. The patient brought 2 samples at 2 different occasions to the laboratory.

23. The case was diagnosed as due to infection with: Bertiella spp. Family : Anoplocephalidae Tapeworm of the nonhuman primates e.g. orangutan and different species of bonnet monkeys as well as dogs.

24. The adult parasite B. studeriis 30 cm. B. mucronata is up to 45 cm in length. It’s scolex is subglobose with four muscular suckers and a rudimentary unarmed rostellum. All segments are shorter than broad, maximum breadth reaches about 10mm. Segments: shed in chains of about 20 segments (in stools or spontaneously)

25. Man acquires infection by the accidental ingestion of: mites containing cysticercoid larvae. At least 29 human cases infected with B.studeri and B. mucronatahas been reported.

26. The patient was treated with: praziquantel, 20 mg/ kg. /body weight on 2 successive days. Follow up of the patient after two weeks showed complete absence of complaints. It was not clear if the patient has acquired infection in Yemen or in Saudi Arabia.

27. Case report: • This case was referred to the Parasitology Department after surgical removal of a nodule from the scalp of a 12 years girl from a village near Hwamdia, Giza, Egypt. • The girl has this nodule in the back of the scalp since about 6 years. • The overlaying skin was normal with hairs. • The only complaint was itching and pain. A case of 12 years child with a scalp nodule:

28. The nodule was previously diagnosed as lipoma (firm, non-cystic) • The mass was excised then opened in the surgical theatre and the following structures came out of the lesion. • There were sluggish wavy movements of the strange fleshy contents.

30. The only possible diagnosis is: Sparganum proliferum. • There are only very few cases previously reported in man. • The parasite showed branching and budding. • However, there is no extension to other areas?? • The adult parasite is unknown ???

31. The mode of infection: is also suggestive ??? • Drinking contaminated water (with infected cyclops), or eating improperly cooked infected flesh of a bird or an animal.

32. A 45 Years old male patient from Kom Hamada, Behaira, presented with dyspnea on mild effort & mild occasional bouts of cough. • Dyspnea started 6 months ago & was increasing in severity. • Pt. has swollen legs. A case with respiratory symptoms (dyspnea):

33. Swelling of the left leg began since 10 years. • It was diagnosed as DVT for which he received 6 months of anticoagulant therapy without regression of the leg swelling • Doppler study was –ve for venous occlusion . • Two years back, swelling of the other leg began. • 6 months ago the Pt. started to feel heaviness in the chest – shortness of breath & occasional cough during muscular effort , he had no expectoration

35. Chest x-ray showed mild plueral effusion on the Rt. Side.

36. In spite of the free Doppler study on both lower limbs. His condition was diagnosed as possible P.E. (pulmonary embolism). • Again he was given anticoagulant therapy.

37. CBC:- Showed marked esinophilia 12% of the WBcs count. • Lung functions:- were of restrictive pattern his vital capacity was 52% of predictive value & FVC WAS 32 % of predicted value.

38. Study of different data was –ve for pulmonary embolism • C X R P.A: • Showed :- • Obliteration of the RT . Costophrenic angle • Free lung apices • Normal sized heart. • Serological test for bancroftian filariasis was strongly positive

39. In the view of swollen legs – restrictive pulmonary functions – High eosinophil count – the strongly +ve serological test for filariasis the most likely diagnosis was T.P.E. • Tropical Pulmonary Eosinophilia • The pt. was treated with (D.E.C.- diethylcarbmazine ) and Alzental. • plus: corticosteroides.

40. T.P.E • Characterized by pulmonary infiltrates , dyspnea , occasional wheeze and marked peripheral esinophilia. • Only a small percentage < 0.5% of pts. Infected with filariasis develop this reaction.

41. The diagnostic criteria for T.P.E . Include: • History supportive of exposure to lymphatic filariasis • Pulmonary symptoms in the form of dyspnea –wheeze and restrictive lung functions. • High peripheral eosinophilia • E levated IGE • High titer for antifilarial antibodies • Peripheral blood –ve for microfilaria • Clinical response to D.E.C.

42. These are only very few of many cases in which the role of a Parasitologist was very crucial in their diagnosis and management.

43. Thank you.