Visceral Larva Migrans (VLM) syndrome is commonly caused by larvae of roundworms
- Visceral Larva Migrans syndrome
- lung and liver granulomas
VLM syndrome is a parasitic infestation caused by larvae of the dog roundworm
The clinical signs and symptoms in patients with toxocarosis are a direct consequence of the damage caused by migrating larvae and the host’s subsequent inflammatory response. Inflammation presents as eosinophilic granulomas (Arrango, 1998). Common signs and symptoms of toxocarosis include fever, abdominal pain, hepatomegaly, splenomegaly, and lower respiratory tract findings such as cough, dyspnea or bronchospasm (Despommier, 2003). Due to the difficulty in finding the causative parasites, the diagnosis of VLM syndrome is generally based on compatible clinical manifestations, epidemic history, marked eosinophilia, histological examination, immunological test, radiography and computerized tomography (CT), in addition to the disappearance of symptoms after antihelmintic treatment (Turrientes
A 14-year-old boy living in Assiut, Egypt, was referred and admitted to Chest Department, Assiut University Hospital. The patient came from a rural area. His medical history was clear according to his parents, until 2 weeks before admission, when he developed severe dry cough without dyspnea, mild chest pain, generalized fatigue and abdominal pain. At the time of admission, the vital signs of the patient were as follows: body temperature, 36.9 °C; heart rate, 70 beats/min (regular rhythm); respiratory rate, 18 breaths/ min; and blood pressure, 120/75 mmHg. Lung auscultation revealed abnormal crackles and heart sounds were normal. On abdominal examination, mild tenderness to palpation in the right upper quadrant, there was no lower extremity edema. Neurologic examination did not reveal focal deficits. There was no cervical, axillary or inguinal lymphadenopathy. On admission, hematological examination of peripheral blood showed iron deficiency anemia (Hemoglobin 7.5 g/dl), leukocytosis (40,000 cells/mm3) accompanied by marked eosinophilia (25,000 cells/mm3).
Chest X-ray showed an infiltrative shadow in both middle and lower lung fields mainly in the right lung (Fig. 1A). Using Post-Contrast Spiral CT Chest (Fig.1B and C), the chest was scanned in 10mm continuous slices from the rout of the neck caudally to the suprarenal glands. Lung CT showed bilateral multiple sharply defined, smoothly marginated, rounded pulmonary nodules measuring less than 1 cm in diameter with centrilobular pattern and characteristic tree in bud sign. The most predominant two pulmonary nodules demonstrated mainly in the anterior segment of upper lobe and lateral segment of lower lobe of right lung field respectively (indicated by arrows). Chest CT showed clearly patent airways down to the segmental bronchi i.e no endoluminal lesion or extrinsic compression. There is no pleural thickening or effusion and no hilar or mediastinal lymphadenopathy.
The upper abdominal CT revealed multiple discrete hypodense hepatic focal lesions appeared in both hepatic lobes, more pronounced at right lobe, some of them displaying peripheral ring wall enhancement (indicated by arrows) (Fig. 2). To evaluate the liver findings further, an ultrasound guided liver biopsy was performed. Histopathological analysis of the biopsy showed alteration of the normal architecture of the liver with fatty degeneration of liver cells (Fig. 3A). The biopsy demonstrates multiple inflammatory granulomas with eosinophilic infiltrations in liver tissues (Fig. 3B). The center of the granuloma showed multiple larvae (Fig. 3C and D). Despite symptomatic treatment in the form of antibiotics and antitussive, the patient continued to have severe dry cough. The patient file was referred to Parasitology Department, Assiut University seeking for medical advice. From the clinical manifestation, the detection of anti-
VLM is a syndrome caused by the migrating larvae of
VLM syndrome has a worldwide prevalence, although there is a strong prediction for the tropical countries (Chang
VLM syndrome is a systemic manifestation of toxocarosis. It is usually an asymptomatic or vaguely symptomatic condition, which is caused by migrating larvae of
This case confirmed the findings of chest radiography and computed tomography demonstrated in the earlier publications (Inoue
Histopathological analysis of the prior reports were in a good agreement with our case, as the typical liver biopsy showed central necrosis surrounded by a mixed inflammatory infiltrate with numerous eosinophils and variable numbers of neutrophils, lymphocytes and Charcot-Leyden crystals (Kaplan
The clinical symptoms of our patient resolved completely after recommended anthelmintic treatment, the eosinophil count decreased and the infiltrative shadow disappeared completely. No recurrence was observed after discharge of the patient.
According to the available literature, it seems that the present case reported for the first time in Egypt a hepatopulmonary VLM syndrome.
The symptomatology of VLM syndrome is similar to the definable parasitic and nonparasitic diseases so that the physicians and the patients alike usually ignore the milder symptoms of VLM syndrome. We present a case that was discovered accidently; we made a diagnosis of VLM syndrome by clinical manifestation, remarkable eosinophilia, chest radiography, and pulmonary and hepatic computerized tomography. Furthermore, the detection of anti-