Loeffler's Syndrome Research Articles

Cardiac Tuberculosis: A Case Series from Ethiopia, Italy, and Uganda and a Literature Review.

Extrapulmonary tuberculosis (TB) is estimated to account for up to 20% of active cases of TB disease, but its prevalence is difficult to ascertain because of the difficulty of diagnosis. Involvement of the heart is uncommon, with constrictive pericarditis being the most common cardiac manifestation. Diagnostic research for cardiac disease is frequently lacking, resulting in a high mortality rate. In addition to direct cardiac involvement, instances of cardiac events during antitubercular therapy are described. This case series describes five cases of TB affecting the heart (cardiac TB) from Italy and high-burden, low-income countries (Ethiopia and Uganda), including a case of Loeffler syndrome manifesting as myocarditis in a patient receiving antitubercular therapy. Our study emphasizes how cardiac TB, rare but important in high-burden areas, is a leading cause of pericardial effusion or pericarditis. Timely diagnosis and a comprehensive approach, including imaging and microbiological tools, are crucial. Implementing high-sensitivity methods and investigating alternative samples, such as detection of tuberculosis lipoarabinomannan or use of the GeneXpert assay with stool, is recommended in TB control programs.

Clinical case of Loeffler’s endomyocarditis

Eosinophilic endomyocarditis is caused by direct infiltration of heart tissue by eosinophils with the development of specific inflammation. The main etiological factor of the disease is a significant increase in the level of eosinophils in peripheral blood. Loeffler syndrome can be caused by such factors and pathological conditions as idiopathic hypereosinophilic syndrome, allergic diseases, parasitic infections, autoimmune processes, cancer. A clinical case of Loeffler syndrome in an 84-year-old patient with heart, lung, liver, kidney and pancreatic lesions is presented. Difficulties of differential diagnostics of this syndrome because of individual clinical picture and signs of the course are discussed in the article. Timely diagnosis of such a condition will prevent the rapid development of severe complications and carry out appropriate therapy, which will significantly prolong the life of patients with Loeffler syndrome. However, in the presence of nonspecific symptoms, the diagnosis of this disease may be diagnostically difficult for the physician.

Approaches to the diagnosis of the Churg-Strauss syndrome

Churg-Strauss syndrome or eosinophilic granulomatosis with polyangiitis is a rare congenital autoimmune disease characterized by pathologies in the development of various organs. It develops either as a result of a genetic mutation (mutation of the CHD7 gene), or under the influence of external factors. The disease was first described in 1951 by Jacob Churg and Lotte Strauss as «allergic granulomatosis ». As a separate disease, the syndrome was isolated in 1990. The frequency of the disease ranges from 2 to 8 cases per 1 million people. There are no gender differences in the incidence of men and women. The disease begins to appear around the age of 38–49 years. The development of the syndrome goes through three stages. At the initial stage, allergic manifestations develop: rhinitis, sinusitis, hay fever, bronchial asthma, and drug intolerance. At the second stage, a hypereosinophilic syndrome, clinically manifested in Loeffler's syndrome, eosinophilic pneumonia, and eosinophilic gastroenteritis, develops. At the third stage, signs of systemic vasculitis appear.

Helminth Infections in Children.

Helminth Infections in Children.

Multimodality Imaging Clues for Restrictive Cardiomyopathy

Restrictive cardiomyopathy is an entity that can be mistaken for several mimicking conditions, including hypertrophic cardiomyopathy. These patients present with heart failure, which is essentially due to left ventricular diastolic dysfunction, with preserved left ventricular ejection fraction. Conditions associated with hypereosinophilia and diastolic dysfunction with restrictive heart disease are called Loeffler's syndrome. There is also associated left ventricular thrombus formation and fibrosis. Here, we present a case of restrictive cardiomyopathy associated with rheumatoid arthritis presenting clinically with heart failure. The clues pointing toward hypereosinophilic endocarditis were a high absolute eosinophil count and a large left ventricular thrombus. We discuss the multimodality imaging findings to differentiate the different types of restrictive cardiomyopathy.

Occult strongyloides stercoralis infection masquerading as a drug reaction with eosinophilic pneumonia

Background: Pseudomelanosis or melanosis duodeni is seen in association with drugs, microorganisms or occasional bleeding, usually from peptic ulceration. We present a case of Strongyloides stercoralis presenting as pseudomelanosis duodeni during anemia workup after patient’s initial presentation as eosinophilic pneumonia. Case presentation: The patient is a 77 year-old female with a history of diastolic congestive heart failure, chronic kidney disease, diabetes mellitus, and hypertension who presented for evaluation of black stool. Two months earlier, in her prior admission for acute eosinophilic pneumonitis, the patient’s hematocrit was 26%. In her current admission with heme-positive dark stool on exam, the hematocrit dropped to 19%. The patient underwent esophagogastroduodenoscopy to identify the source of bleeding. The upper endoscopy revealed three non-bleeding ulcers in the gastric antrum and discoloration of the duodenal bulb and second portion of the duodenum. By histology, the duodenal biopsies showed areas of hemosiderin-laden macrophages in the lamina propria, focal helminth eggs and larvae in the crypt lumen with sizes ranging from 35-65 microns x ~20 microns. Polymerase chain reaction of the paraffin embedded tissue with 28S primer set detected Strongyloides stercoralis DNA, confirming the histologic findings. Given the confirmation of Strongyloides stercoralis, the patient’s initial presentation of eosinophilic pneumonia (Loeffler syndrome) may be a result of the parasitic infection or the successful response to steroid treatment for acute eosinophilic pneumonia caused Strongyloidiasis hyperinfection. The patient’s symptoms were improved with Ivermectin and hematocrit level increased to 28%. Conclusions: This case highlights the importance in recognition of helminth infection in the evaluation of eosinophilic pneumonia and pseudomelanosis duodeni. Keywords: Pseudomelanosis duodeni; Strongyloides stercoralis; Eosinophilic pneumonia; polymerase chain reaction.

Loeffler Syndrome: Uncommon or Poorly Diagnosed?

Loeffler Syndrome: Uncommon or Poorly Diagnosed?

Echocardiographic features and behavior of cardiac structural abnormalities in mucopolysaccharidosis

Abstract Funding Acknowledgements Type of funding sources: None. Mucopolysaccharidosis (MPS) is a rare genetic lysosomal storage disorder with a wide variability of phenotype. A systematic descriptive study dealing with the echocardiographic (E) features of valvular involvement and their evolution over the time in adolescent and adult patients, whose number is growing up in adult echocardiographic laboratory, is lacking in the medical literature. Purpose To detect the E features of valvular involvement and their evolution in adolescent and adult patients. Method Study design: observational descriptive retrospective. Study group: 142 E studies in 17 adolescent and adult patients with diagnosis of MPS from 2001 until 2020. Mitral (M), aortic (A), tricuspid (T) valves (V) E features (thickness, mobility, calcification, and function), their evolution over the time and the behaviour with Enzyme replacement therapy (ERT) or bone marrow transplant (BMT) were assessed. Result 52% male, mean age 21 yrs ranges 16 to 48 yrs. 5% of the patient had MPS type I, 11% MPS type II, 29% MPS type IV, and 52% MPS type VI. 70% received ERT and 11% BMT. In the severe case all the valves were involved (panel A, B, C; white arrows point to valve leaflets; yellow arrows MV apparatus) the whole MV apparatus was involved since the earlier stage and in the latest stage the calcification was massive (panel C). The predominant valvular dysfunction was the regurgitation followed by mixed disorder while the most frequent severe lesion was the stenosis; the echocardiographic pattern differs from the classical hockey stick appearance of the early phase of rheumatic MV and the thickening is different from the myxomatous MV for the reduced mobility and the presence of calcification. The reduced mobility of the TV (panel C) also differs from the Loeffler syndrome because of the restriction of the leaflets and the association with thickening and calcification. Under treatment, the MV thickening was found to have a slow progression of less than 1 mm yearly in 61% cases. Conclusion Our results showed that all the valves are affected mainly the MV; the echocardiographic pattern of MPS, different from other valvular diseases of adolescent and adult age, can help in avoiding misdiagnose. Our observations also suggest that the cardiac involvement show slow rate of progression after the initiation of the therapy. Further studies are required to confirm our results. Type of valve % of valve thickness % of reduced mobility % calcification diffuse % valve lesion Mitral valve 88% 65% 47% 75% Aortic valve 76% 23% 41% 57% Tricuspid valve 82% 47% 17% 52% Abstract Figure. Echocardiographic features

Humans as Accidental and Natural Hosts for Worms.

Worms and creepy crawly creatures are often associated with an “ick factor.” In this time of novel coronavirus 2019 (COVID-19), increased sanitation, handwashing, and social distancing can prepare us for other natural causes of infestations, secondary infections, and sometimes serious sequelae. North Americans enjoy beaches, lakes, and outdoor activities in the summer. As we have recently learned, being aware and prepared can be life saving. After social distancing and many weeks of sheltering at home from COVID-19, being outdoors again will necessarily need to be balanced with caution around other potential (although unusual) infestations and infections. This month’s CE/CME article, Exploring Tropical Infections: A Focus on Cutaneous Larva Migrans (CLM), documents two cases of travelers (to Chile and Jamaica, respectively) who were infected with CLM after walking barefoot on warm, moist surfaces contaminated by dog or cat feces. The egg hatching (first stage) and survival of the developing rhabdiform larvae (second stage) require an additional intermediate host (molluscs) to form filiform larvae (third stage) that can accidently infect human skin.1,2 Feet or lower legs can become infected with the parasite, which leaves the characteristic, migrating, serpiginous trails for several weeks before the larvae die or are destroyed with physical (liquid nitrogen) or chemical (topical or systemic) agents. Infection with CLM may be complicated by secondary bacterial infections, eczematization, local or general allergic reactions, or (in more severe cases) Loeffler syndrome (eosinophilia and transient pulmonary infiltrates). Systemic treatment (as in this month’s CE/CME cases) is not always necessary but ivermectin or albendazole are most effective.3 Although CLM is mostly diagnosed in travelers returning home to North America, we have our own endemic parasitic diseases. These diagnoses are often delayed or initially missed, resulting in severe pruritus, secondary infections, or other complications. For example, pinworms (thin, white roundworms that cause enterobiasis) lay eggs in the perianal areas of humans–most commonly in young children. Look for them 3 hours after the victim falls asleep, take tape samples on three consecutive mornings for eggs, or examine the skin under the nails for eggs with a dermatoscope. Over-the-counter or prescription medication can successfully treat this infestation.4 That said, hemorrhoids, contact dermatitis, and other causes of perianal itch also exist. Another infection that can affect individuals of any age, often after swimming in freshwater lakes or saltwater oceans, is cercarial dermatitis. Called swimmer’s itch, parasites released by infected snails burrow into the skin, causing an allergic reaction. Austrobilharzia variglandis require a primary host (often birds–especially geese) or other mammal species to complete their life cycle. Related lesions under bathing garments can be numerous, especially around the buttocks, and are self-limiting but may require topical steroids and oral antihistamines.5 Keep the cream in the refrigerator for a greater cooling effect! One of the authors (Dr Sibbald) encountered a life-changing case as a final year medical student. A previously healthy young patient went on a camping and canoeing trip with a friend. After his return, he was admitted to a tertiary hospital ICU and placed on a ventilator for respiratory failure. His skin developed hemorrhagic lesions and he had diffuse pulmonary infiltrates. A lung biopsy revealed mesocercariae of the trematode Alaria americana. It was later determined that this parasite was contracted from inadequately cooked frogs’ legs the patient ate less than 2 weeks before he succumbed to his illness. Many thousands of organisms were found within most of his internal organs.6 Although we may not like to think about it, parasites and their associated clinical syndromes are ubiquitous. Just like the precautions for COVID-19, we need to consider good hygiene and public health precautions around time spent in natural settings, swimming, or in contact with wildlife and domestic animals. This July, as always, please be smart, be safe, and enjoy the environment by giving it the respect it deserves! R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN

Loeffler's syndrome: A type of eosinophilic pneumonia mimicking community-acquired pneumonia and asthma that arises from Ascaris lumbricoides in a child.

Loeffler's syndrome: A type of eosinophilic pneumonia mimicking community-acquired pneumonia and asthma that arises from Ascaris lumbricoides in a child.

M208 NEW-ONSET ASTHMA IN AN ADULT WITH PERIPHERAL EOSINOPHILIA AFTER HURRICANE MARIA IN PUERTO RICO

Loeffler syndrome, is a rare pulmonary manifestation of helminth infestation occurring during the pulmonary phase of the larval cycle. Respiratory symptoms, including cough, dyspnea, fever, and wheezing, in addition to skin, gastrointestinal and nonspecific symptoms can also be present. Helminths most commonly involved include Strongyloides, Ascaris, Ancylostoma and Necator.

Loeffler's Syndrome Secondary to Hyperinfection by Strongyloides stercoralis Associated with Methotrexate in a Patient with Rheumatoid Arthritis.

Loeffler's Syndrome Secondary to Hyperinfection by Strongyloides stercoralis Associated with Methotrexate in a Patient with Rheumatoid Arthritis.

Organ-sparing surgical treatment of Loeffler syndrome

Organ-sparing surgical treatment of Loeffler syndrome

Loeffler's Syndrome Following Cutaneous Larva Migrans: An Uncommon Sequel.

Cutaneous larva migrans (CLM) is characterized by the formation of distinctive, tortuous, and serpentine skin lesions occurring as a result of epidermal burrowing by certain helminthic larvae. Although this condition is usually uneventful, rarely it may result in patchy pulmonary infiltration with peripheral eosinophilia, also called Loeffler's syndrome. This association is fairly uncommon and is thus being reported.

Loeffler's Syndrome Induced by Ingestion of Urushiol Chicken.

Eosinophilic lung diseases are heterogeneous disorders characterized by varying degrees of pulmonary parenchyma or blood eosinophilia. Causes of eosinophilic lung diseases range from drug ingestion to parasitic or fungal infection as well as idiopathic. The exact pathogenesis of eosinophilic lung disease remains unknown. Urushiol chicken can frequently cause allergic reactions. Contact dermatitis (both local and systemic) represents the most-common side effect of urushiol chicken ingestion. However, there has been no previous report of lung involvement following urushiol chicken ingestion until now. A 66-year-old male was admitted to our hospital with exertional dyspnea. Serial chest X-ray revealed multiple migrating infiltrations in both lung fields, with eosinophilic infiltration revealed by lung biopsy. The patient had ingested urushiol chicken on two occasions within the 2 weeks immediately prior to disease onset. His symptoms and migrating lung lesions were resolved following administration of oral corticosteroids.

Eosinofilia tropical y síndrome de Loeffler. Estudio clínico, hematológico y funcional de nueve casos

Desde hace algún tiempo nos ha inquietado el problema de la Eosinofilia Tropical y el Síndrome de Loeffler, por tal razón decidimos abordar el tema en su aspecto clínico, hematológico y algo de la bioquímica en sangre. La primera etapa fué la de adquirir una técnica depurada en lo que se refiere a hematología; el objetivo fué alcanzado merced a la ocupación que desempeñamos en un laboratorio clínico. Luego se hizo el estudio seriado y sistemático de todos los enfermos que llegaron a nuestras manos en el período de un año. La base del estudio consistió en la investigación de 9 pacientes afectos de Eosinofilia Tropical en ese lapso. En este trabajo presentamos la interpretación clínica, hematológica y hallazgos bioquímicos en la sangre, realizados seriadamente.

Las formas febriles agudas de la fasciolosis hepática

Se ha presentado dos casos de hepatitis fasciolósica aguda (primeros casos en el Perú). El proceso, de carácter agudo, estuvo caracterizado por fiebre alta, hepatomegalia muy dolorosa y eosinofilia intensa. En uno de los casos pudo ser practicado biopsia de hígado por laparotomía, estando el paciente en la plenitud de los síntomas (probablemente el primer caso en el mundo). El examen histológico reveló absceso hepático múltiple con hepatitis reaccional. La infiltración celular estuvo caracterizada por ser muy rica en polinucleares eosinófilos. En el fragmento examinado no se encontró ningún elemento parasitario. Se hace un comentario clínico, etiológico, anatomopatológico y patogénico de esta interesante entidad. Se analiza su relación con el sindrome de Loeffler y con la Eosinofilia Tropical.

Travel-associated pneumonias

Respiratory infections are responsible for up to 11% of febrile infections in travellers or immigrants from tropical and subtropical regions. The main pathogens are the same as in temperate climate zones: Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, influenza viruses, Legionella pneumophila. However, some pulmonary diseases can be attributed to bacterial, parasitic, viral or fungal pathogens that are endemic in tropical and subtropical regions. The most commonly imported infections are malaria, dengue, and tuberculosis. Pulmonary symptoms and eosinophilia in returning travellers and migrants may be caused by several parasitic infections such as Katayama syndrome, Loeffler syndrome, tropical pulmonary eosinophilia, amebiasis, paragonimiasis, echinococcosis, and toxocariasis. In Asia, Tsutsugamushi fever is transmitted by chiggers, spotted fever rickettsiae are transmitted by ticks. Transmission of zoonotic diseases occurs mainly via contact with infected animals or their excretions, human-to-human transmission is generally rare: MERS-CoA (dromedary camels), pulmonary hantavirus infection (rodents), tularemia (rabbits and hares), leptospirosis (rats), Q-fever (sheep and goats), very rarely anthrax (hides of ruminants) and pest (infected rats and wildlife). Inhalation of contaminated dust can cause infections with dimorphic fungi: histoplasmosis (bat guano) and coccidioidomycosis in America and parts of Africa, blastomycosis in America. Some infections can cause symptoms years after a stay in tropical or subtropical regions (melioidosis, tuberculosis, histoplasmosis, schistosomiasis-associated pulmonary hypertension). Noninfectious respiratory diseases caused by inhalation of high amounts of air pollution or toxic dusts may also be considered.

Loeffler’s Syndrome Mimicking Bronchial Asthma and Pneumonia in a Child: Case Report

A 14-year-old male child was hospitalized with complaints of a bronchial wheezing, cough, dyspnea, and sputum and a preliminary diagnosis of bronchial asthma and pneumonia. The patient was treated empirically for bronchial asthma and pneumonia, but gave neitherr clinical nor radiological response to treatment. On the high-resolution computerized tomography, a typical spiral image of Ascaris lumbricoides was identified inside a cavity in the upper lobe of the left lung with a diameter of 8x7 cm. Also,migratory pneumonic infiltrations progressing between the lower lobe and hilary region of the left lung were seen. Examination of the peripheral blood smear of the patient revealed eosinophilia (40%), while IgE was measured as 350 IU/mL. The patient was diagnosed as "Loeffler's syndrome" due to A. lumbricoides", and successfully treated with mebendazole 2x100 mg/day for three days. Loeffler's pneumonia should be considered when patients with bronchial asthma and pneumonia do not respond to specific treatment in developing countries. Radiological investigations may be available in the diagnosis of parasitic infections. In this case, early diagnosis by radiologic methods have prevented unnecessary drug use and related complications.

Hybrid Ascaris Suum/Lumbricoides (Ascarididae) Infestation in a Pig Farmer: a Rare Case of Zoonotic Ascariasis

We present a case of the 42-year-old pig farmer from the province of Cuneo in Northwest Italy who was infected by the soil-transmitted nematode Ascaris sp. In November 2010 the patient found one worm in his stool, subsequently identified as female specimen of Ascaris sp. After a first anthelmintic treatment, another worm was found in his stool, that was later identified as male Ascaris sp. Blood tests prescribed by the patient's family physician, as suggested by a parasitologist, found nothing abnormal. A chest x-ray was negative for Loeffler's syndrome and an ultrasound of the abdomen was normal with no evidence of hepatic problems. The nematode collected from the patient was genetically characterized using the ribosomal nuclear marker ITS. The PCR-RFLP analysis showed a hybrid genotype, intermediate between A. suum/lumbricoides. It was subsequently ascertained that some pigs on the patient's farm had A. suum infection; no other family member was infected. A cross-infestation from the pigs as source was the likely way of transmission. This conclusion is further warranted by the fact, that the patient is a confirmed nail-biter, a habit which facilitates oral-fecal transmission of parasites and pathogens.