Case Report Respiratory Failure Associated with Ascariasis ...downloads.hindawi.com/journals/criid/2016/4070561.pdf · suum infestation are those who have stayed in areas with suboptimal

Case ReportRespiratory Failure Associated with Ascariasis ina Patient with Immunodeficiency

Lanocha Aleksandra1 Zdziarska Barbara1 Lanocha-Arendarczyk Natalia2

Kosik-Bogacka Danuta2 Guzicka-Kazimierczak Renata1 and Marzec-Lewenstein Ewa3

1Department of Haematology and Transplantology Pomeranian Medical University Unii Lubelskiej 1 71-252 Szczecin Poland2Department of Biology and Medical Parasitology Pomeranian Medical University Powstancow Wielkopolskich 7270-111 Szczecin Poland3Department of Anesthesiology and Intensive Care Pomeranian Medical University Unii Lubelskiej 1 71-252 Szczecin Poland

Correspondence should be addressed to Kosik-Bogacka Danuta kodanpumedupl

Received 22 February 2016 Accepted 26 April 2016

Academic Editor Sinesio Talhari

Copyright copy 2016 Lanocha Aleksandra et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

In industrialized countries risk groups for parasitic diseases include travelers recent immigrants and patients with immunode-ficiency following chemotherapy and radiotherapy and AIDS A 66-year-old Polish male was admitted in December 2012 to theDepartment of Haematology in a fairly good general condition On the basis of cytological cytochemical immunophenotypic andcytogenetic analysis of bonemarrow the patient was diagnosed with acute myeloblastic leukemia On the 7th day of hospitalizationin the Department of Haematology patient was moved to the Intensive Care Unit (ICU) due to acute respiratory and circulatoryfailure InMarch 2013 3months after the onset of respiratory failures amature form ofAscaris spp appeared in the patientrsquos mouthThis report highlights the importance of considering anAscaris infection in patients with low immunity presenting no eosinophiliabut pulmonary failure in the central countries of Europe

1 Introduction

Ascaris lumbricoides (Linnaeus 1758) is the most commonsoil-transmitted intestinal nematode affecting humans andcausing significant medical problems especially in devel-oping countries Globally estimated 8916 million peoplewere infected with A lumbricoides in 2010 [1] In Europeascariasis is a rare condition affecting mostly rural citizens(12) and people who are in regular contact with pigs forprofessional reasons In Poland the prevalence of A lumbri-coides in humans does not exceed 1 and concerns mainlychildren from rural areas [2] Ascariasis generally occursthrough hand-to-mouth ingestion of agricultural products orfood contaminated with parasite eggs Poor sanitation andinadequate sewage disposal play a key role in themaintenanceand propagation of ascariasis [3] Although not commonin developed countries ascariasis invasion is increasinglylikely to be encountered by clinicians because of the grow-ing rates of travel to developing countries and increased

migration Moreover in industrialized countries risk groupsfor parasitic diseases (eg A lumbricoides infection) includepatients with immunodeficiency following chemotherapyand radiotherapy and AIDS [4 5]

The pig roundworm Ascaris suum (Goeze 1758) has alsobeen reported to be able to infect humans and developinto the adult stage Both the morphology and developmentcycles of A lumbricoides and A suum are very similar andthe identification of these species in the environment isvery difficult [6] Most infections with A lumbricoides areasymptomatic Clinical manifestations are different at eachstage of the infection This helminth usually lives in thesmall intestine but can also cause intestinal obstruction orperforation peritonitis common in childhood [7] Further-more A lumbricoides can also migrate through ampulla ofVater to produce cholangitis pancreatitis cholecystitis andhepatic abscesses in rare cases [8] Second-stage larvae (L

2)

hatching from the invasive egg in the body pass throughthe intestinal wall and migrate via the portal vein system

Hindawi Publishing CorporationCase Reports in Infectious DiseasesVolume 2016 Article ID 4070561 5 pageshttpdxdoiorg10115520164070561

2 Case Reports in Infectious Diseases

to the liver and then proceed to the lungs where they mayproduce pneumonia Symptoms include wheezing dyspneanonproductive coughing hemoptysis and fever The res-piratory distress experienced during pulmonary ascariasisreferred to as Lofflerrsquos syndrome occurs 4 to 16 days afteringesting embryonated roundworm eggs [9] Skin urticarialrash may also accompany these symptoms Chest X-raysreveal rounded infiltrates with peripheral eosinophilia [10]Occasionally A lumbricoides may pass from the nose or themouth during vomiting [11] In this study we present anunusual ascariasis and respiratory failure in a patient withacute myeloblastic leukemia (AML)

2 Case Presentation

A 66-year-old male was admitted in December 2012 tothe Department of Haematology in a fairly good generalcondition In an interview during admission the patientreported coughing a recurrent low-grade fever night sweatsmalaise and weakness Physical examination revealed bilat-eral lymphadenopathy cervical (up to 2 cm) axillary to15 cm numerous inguinal nodes (up to 2ndash25 cm) singlecrackles at the base of both lungs no hepatomegaly and mildsplenomegaly 1 cm below costal margin Laboratory studiesshowed increased inflammatory parameters serum lactatedehydrogenase (LDH) anemia and thrombocytopenia blastsin the blood smear and negative bacteriological resultsconcerning the presence of aerobic and anaerobic bacteriaMicroscopic examination of stool was negative for helminthicova and examination of feces was recommended to beconducted several times No helminth eggs were found ChestX-ray revealed no indication of infiltrates in the lungs orpneumothorax On abdominal ultrasonography the liver wasnot palpable while the spleen was uniform but enlarged inthe long axis it measured 133mmOn the basis of cytologicalcytochemical immunophenotypic and cytogenetic analysisof bone marrow in December 2012 the patient was diag-nosed with acute myeloblastic leukemia On the 7th day ofhospitalization in the Department of Haematology patientwas moved to the Intensive Care Unit (ICU) due to acuterespiratory and circulatory failure The patient displayedviolent dyspnea and a cherry-colored scalp and neck alongwith high anxiety and respiratory effort tachypnea 43minand auscultation of the lungs individual crackles at the baseof the lungs including single crackles towards the angles ofthe blades and increased vesicular murmur over the wholelung HR is 130min RR is 150110mmHg and oxygensaturation is 92ndash94 on an oxygen mask with a reservoirat a flow rate of 15 Lmin Before admission to the ICUmorphine steroids and diuretics were administered Thisresulted in little improvement and tachypnea 20ndash25minBlood gases did not correlate with the clinical conditionof the patient the clinical picture suggestive of pulmonaryembolism In the following minutes an increased severityof changes was noticed during the auscultation of the lungsshortness of breath remained with an extended expiratoryphaseThe patient was intubated and treated in the ICU Aftera slight improvement in general condition the patient was

Figure 1 Adult male of Ascaris lumbricoides

transferred to the Department of Haematology but was stillin a general poor condition In a short time the patient wasreturned to the ICU A build-up of heart failure was observedand clinical symptoms of pulmonary edema were observedthese were treated in a conventional manner and a transientimprovement was obtained However in a short time onceagain respiratory problems returned with a decrease to 76oxygen saturation despite constant oxygen flow to the oxygenmask with a reservoir (15 Lmin) and the occurrence ofnumerous changes was recorded during the auscultation ofthe lungs Respiratory failures were accompanied by lossesof consciousness Chest X-rays showed bilateral multiplescattered airless changes most likely associated with inflam-mations

After improvement in general condition in January 2013the patient was transferred to the Department of Haematol-ogy to measure bone marrow cytology 836 myeloblastsThe patient was qualified for palliative therapy with hydrox-yurea because of poor general condition and respiratoryand heart failure Two months after the onset of pulmonaryfailures chest X-ray inspections showed no infiltrates in thelungs wherein in the bottom of the left lung and the topsof both the lungs discreet cicatricial changes and echocar-diography EF (ejection fraction) was 55 (previously 35)nonenlarged heart The patient was qualified for intensivechemotherapy remission induction therapy DA (daunoru-bicin with cytarabine) 2nd group stratification was at gt60years of age according to the PALG protocol Chemotherapywas complicated by sepsis probably catheter-related with anetiology of Staphylococcus epidermidis

In March 2013 3 months after the onset of respiratoryfailures a mature form of Ascaris spp appeared in thepatientrsquos mouth (Figure 1) Stereomacroscopic examinationshowed that it was amale roundworm 15 cm long and 25mmdiameter Pyrantel was administered orally The patientresponded well to the antiparasitic treatment and showed nogastrointestinal symptoms In an interview with the patient

Case Reports in Infectious Diseases 3

he denied eating unwashed fruits and vegetables but twoweeks prior to the onset of respiratory failure (December2012) he had removed the feces of pigs at a farm

3 Discussion

This report highlights the importance of considering anAscaris infection in patients with low immunity presentingno eosinophilia but pulmonary failure in the central countriesof Europe Populations at risk for A lumbricoides and Asuum infestation are those who have stayed in areas withsuboptimal sanitation practiced poor personal hygiene andhave a poor educational background especially in developingcountries Ascariasis in humans can cause gastrointestinaland respiratory symptoms and severe complications requir-ing surgical intervention [12] In the human host the wormcan establish residence in the gastrointestinal region fromthe stomach to the ileocecal valve but up to 99 of thecases reported have worms localized to the jejunum andproximal ileum [13 14] Furthermore there are some reportsof erythema nodosum and severe sepsis after a spontaneousabortion in a patient with coexisting ascariasis [15 16]

Clinical manifestations are different at each stage of theinfection Parasites migrate from the small intestine to thepulmonary circulation where they mature and destroy capil-laries and alveolar walls [17] Larval pulmonary migration isgenerally asymptomatic However symptomatic pulmonaryascariasis is characterized by a dry cough low fever dyspneabronchial asthma and wheezing The respiratory distressexperienced during pulmonary ascariasis is referred to asLofflerrsquos syndrome and occurs 4 to 16 days after ingestingembryonated roundworm eggs [18]

In many cases pulmonary ascariasis in chest X-raysshows fleeting infiltrates that may develop peripheral conflu-ence and intra-alveolar hemorrhage and exudate may also bepresent (associated with larvae migration) [9 19 20]

In our patient arterial-blood gas analysis did not correlatewith the clinical condition of the patient and the clinicalpicture suggested pulmonary embolism Two months afterthe pulmonary failure a chest X-ray showed no infiltratesin the lungs and pneumothorax However discreet cicatricialchanges were observed in the lower left lung and the topsof both lungs It cannot be excluded that the presented caseof respiratory failure in a patient with AML was probablyprovoked by the infestation with roundworm

Two cases of pulmonary ascariasis in Austrian malesin 2010 have been reported Both patients demonstrateddyspnea a nonproductive cough fever and eosinophilia (19and 26) One of the patients was in remission of b-cell non-Hodgkin lymphoma Serology for Ascaris was positive twicein both patients while microscopic examination of stool wasnegative for helminthic ova [9] Ascaris worms may enternasogastric and endotracheal tubes and block their lumen[13] There are case reports in the literature of fatal outcomesfrom blockages of endotracheal tubes by roundworms [2122]

Two to three months are required between ingestionof the infective eggs and moulting to the adult male or

female Females may produce 250000 eggs per day whichare excreted in the feces of the host A lumbricoides and Asuum are geohelminths (transmitted soil nematodes) eggsbecome invasive after 3-week residence in the soil undersuitable environmental conditions [23] They are resistantto environmental factors thanks to their chitinous sheathUnembryonated ova enter the environment via feces andcan remain viable in the soil for up to 15 years [18] Asin our patient in many cases usually there is a lack ofeggs in stool samples in both roundworm species until 2to 3 months after the pulmonary symptoms occur unlessthe patient was already harboring a patent infection Wheninfections occur with only male worms no eggs are formedDiagnosis is most commonly made by finding eggs in thestool occasionally an adult worm is passed in the stoolAdults of Ascaris spp worms expelled from the anus or themouth could be identified using the classical characteristics ofthewormDuring the early transpulmonarymigratory phaselarvae can be found in sputum or gastric aspirates [18] Inthis case this diagnosis was considered when an adult maleworm was found in the patients mouth Esophagus ascariasisis extremely rare because the esophagus is not a normalhabitat of Ascaris spp as it prefers an alkaline environmentand rarely travels from the jejunum and duodenum to thestomach (an acid environment) and then to esophagus [24]

Patients with some type of immunocompromised condi-tion and those submitted to immunosuppressive therapy havean increased probability of acquiring parasitic infectionsgenerally with a high degree of severity [25] The variedclinical picture of the parasitic infection in people with lowimmunity results in a number of cases that are not recognizedParasitic infestations in states of immune deficiencymay posea serious threat to health and even life with sudden scatteredsymptoms affecting many organs Nonopportunistic intesti-nal parasites such as hookworms Opisthorchis viverrini andA lumbricoides were common in HIV-infected patients afterchemotherapy regardless of immune status [26] This casestudy is nontypical because with no increase in eosinophilcount we did not suspect ascariasis Eosinophilia often occursin verminuous diseases in particular tissue in which suchparasites are readily available to the eosinophils migratingwithin tissues In the early stages of invasion of the respiratorytract high eosinophilia is common (10ndash30 sdot 109L) andthe larvae of Ascaris spp occur occasionally in the sputumHigh eosinophilia is associated mainly with the wanderinglarvae Over time it falls below 10 sdot 109L and is not apathognomonic symptom in ascariasis induced by matureparasites [27] Peripheral blood eosinophilia was absentin this study on admission and the diagnosis was partlymisled by immunodeficiency in the patient because of acutemyeloblastic leukemia

Ascaris lumbricoides and A suum in humans are trans-mitted through ingestion of agricultural products or foodcontaminated with parasite eggs In Poland human infectionwith A suum and pig infection with A lumbricoides arepossible and both these species are considered together inthe epidemiological evaluation of the environment [28] Theprevalence of A suum in pigs has declined over the last


decades as well infections in humans may now be morecommon in the western world as contact with pig feces (asmanure spread) may occur frequently [9]

Ascaris lumbricoides and A suum may constitute twodifferent but closely related species or may represent host-associated subpopulations or races of the same species [2930] Leles et al [6] suggested that the origin of Ascaris spp isstill not well understood Studies obtained from experimentalinfections and molecular methods have been inconclusiveand to 2016 none of the published studies answered thequestion of whether A lumbricoides and A suum are trulydistinct species Researchers including Alves et al [31] andBetson and Stothard [32] discussed that the use of mitochon-drial markers or DNA barcoding approaches to infer speciesrelationships and transmission dynamics for Ascaris is con-troversial There are in the literature publications about pig-associated haplotypes among Ascaris worms collected fromhumans who live in areas without pigs suggesting retentionof ancestral haplotypes In contrast based on microsatellitesthese parasites looked like human-associated Ascaris [33]

4 Conclusion

This case of respiratory failure in a patient with AMLprobably induced by human Ascaris infestation is ratherrarely discussed It should be noted that an exact diagnosis ofthe patient and a search for nonspecific common etiologicalfactors (including ascariasis) is required to achieve goodoutcomes and improve the patientrsquos condition while notexcluding cases of patients with low immunity In conclusionphysicians should paymore attention to the possibility of thisdisease and reduce the risk of misdiagnosis in this regard

Abbreviations

AML Acute myeloblastic leukemiaDA Daunorubicin with cytarabineEF Ejection fractionHR Heart rateICU Intensive Care UnitLDH Lactate dehydrogenaseL2 Second-stage larvae

PALG Polish Adult Leukemia GroupRR Respiration rate

Competing Interests

The authors declare that they have no competing interests

Authorsrsquo Contributions

Lanocha Aleksandra Zdziarska Barbara Guzicka-Kazim-ierczak Renata and Marzec-Lewenstein Ewa analyzed andinterpreted the patient data Lanocha-Arendarczyk Nataliaand Kosik-Bogacka Danuta carried out the parasitologicalstudies All the authors read and approved the final paper

Acknowledgments

The Pomeranian Medical University in Szczecin providedfinancial support (WLBiML-431-04S14)

References

[1] R L Pullan J L Smith R Jasrasaria and S J Brooker ldquoGlobalnumbers of infection and disease burden of soil transmittedhelminth infections in 2010rdquo Parasites and Vectors vol 7 article37 2014

[2] P Nowak M Jochymek and A Pietrzyk ldquoOccurrence ofhuman intestinal parasites in selected populations of Cracowregion in the years 2000ndash2006 on the basis of parasitologicalstool examinations performed in the Laboratory of Parasitologyof the District Sanitary-Epidemiological Centerrdquo WiadomosciParazytologiczne vol 53 no 4 pp 285ndash293 2007

[3] C J Das J Kumar J Debnath and A Chaudhry ldquoImaging ofascariasisrdquo Australasian Radiology vol 51 no 6 pp 500ndash5062007

[4] M K Mathur A K Verma G E Makwana and M SinhaldquoStudy of opportunistic intestinal parasitic infections in humanimmunodeficiency virusacquired immunodeficiency syndromepatientsrdquo Journal of Global Infectious Diseases vol 5 no 4 pp164ndash167 2013

[5] D I Kosik-Bogacka N Łanocha A Łanocha et al ldquoDemodexfolliculorum and Demodex brevis in healthy and immunocom-promised patientsrdquoOphthalmic Epidemiology vol 20 no 3 pp159ndash163 2013

[6] D Leles S L Gardner K Reinhard A Iiguez and A AraujoldquoAre Ascaris lumbricoides and Ascaris suum a single speciesrdquoParasites and Vectors vol 5 no 1 article 42 2012

[7] A Coskun N Ozean A C Durak I Tolu M Gulec and CTuran ldquoIntestinal ascariasis as a cause of bowel obstructionin two patients sonographic diagnosisrdquo Journal of ClinicalUltrasound vol 24 no 6 pp 326ndash328 1996

[8] H H Nag and R Ji ldquoAscariasis presenting as acute abdomen-acase reportrdquo Indian Journal of Surgery vol 75 no 1 pp 128ndash1302013

[9] M Hoenigl T Valentin I Zollner-Schwetz et al ldquoPulmonaryascariasis two cases in Austria and review of the literaturerdquoWiener Klinische Wochenschrift vol 122 no 3 pp 94ndash96 2010

[10] K Kanneganti J SMakker and P Remy ldquoAscaris lumbricoidesto expect the unexpected during a routine colonoscopyrdquo CaseReports in Medicine vol 2013 Article ID 579464 4 pages 2013

[11] J Margery and A Niang ldquoAdult ascaris worm passing from themouthrdquoTheAmerican Journal of TropicalMedicine andHygienevol 85 no 3 p 395 2011

[12] M ZM Abdellatif U S Belal E H Abdel-Hafeez AM Atiyaand K Norose ldquoAscaris lumbricoides causing acute abdomen acase reportrdquo Eastern Mediterranean Health Journal vol 19 no12 pp 1035ndash1037 2013

[13] P OrsquoLorcain and C V Holland ldquoThe public health importanceofAscaris lumbricoidesrdquo Parasitology vol 121 pp S51ndashS71 2000

[14] B Kowalewska M Rudzinska D Zarudzka and A KotłowskildquoAn evaluation of the intensity of intestinal parasitic infec-tions among patients of Out-patient Division of Maritime andTropical Medicine in Gdynia over last 30 yearsrdquo DiagnostykaLaboratoryjna vol 49 no 1 pp 9ndash15 2013

[15] B Bergler-Czop A Lis-Swity G Kaminska-Winciorek and LBrzezinska-Wcisło ldquoErythema nodosum caused by ascariasis


and Chlamydophila pneumoniae pulmonary infectionmdasha casereportrdquo FEMS Immunology and Medical Microbiology vol 57no 3 pp 236ndash238 2009

[16] D Nosalska J Paluszkiewicz I Kijuk and K PrzesmyckildquoSevere sepsis after spontaneous abortion in a patientwith coex-isting ascariasis Case reportrdquo Anestzga Reanimacja IntensywnaTerapia vol 1 pp 43ndash45 2007

[17] S Martınez C S Restrepo J A Carrillo et al ldquoThoracic man-ifestations of tropical parasitic infections a pictorial reviewrdquoRadiographics vol 25 no 1 pp 135ndash155 2005

[18] T Batyraliev B Eryonucu Z Karben et al ldquoPulmonary edemaassociated with Ascaris lumbricoides in a patient with mildmitral stenosis a case reportrdquo European Journal of GeneralMedicine vol 1 pp 43ndash45 2004

[19] R K Chitkara and G Krishna ldquoParasitic pulmonary eosino-philiardquo Seminars in Respiratory and Critical Care Medicine vol27 no 2 pp 171ndash184 2006

[20] P Akuthota and P F Weller ldquoEosinophilic pneumoniasrdquo Clini-cal Microbiology Reviews vol 25 no 4 pp 649ndash660 2012

[21] L E Imbeloni ldquoFatal obstruction of an endotracheal tube byan intestinal roundwormrdquo Respiratory Care vol 29 no 4 pp368ndash370 1984

[22] J P Nicholson K Kreiger B Hartman W Isom and J HLaragh ldquoCardiac arrest postoperatively in a patient infectedwith ascaris the roundwormrdquo Chest vol 96 no 4 pp 922ndash9231989

[23] S C Ojha C Jaide N Jinawath P Rotjanapan and P BaralldquoGeohelminths public health significancerdquo Journal of Infectionin Developing Countries vol 8 no 1 pp 5ndash16 2014

[24] P-P Zheng B-Y Wang F Wang R Ao and Y WangldquoEsophageal space-occupying lesion caused by Ascaris lumbri-coidesrdquo World Journal of Gastroenterology vol 18 no 13 pp1552ndash1554 2012

[25] J H Botero A Castano M N Montoya N E Ocampo M IHurtado and M M Lopera ldquoA preliminary study of the preva-lence of intestinal parasites in immunocompromised patientswith and without gastrointestinal manifestationsrdquo Revista doInstituto de Medicina Tropical de Sao Paulo vol 45 no 4 pp197ndash200 2003

[26] V Wiwanitkit ldquoIntestinal parasitic infections in Thai HIV-infected patients with different immunity statusrdquo BMC Gas-troenterology vol 1 article 3 2001

[27] S Pawlowski and J Stefaniak Clinical Parasitology in Terms ofMultidisciplinary Wydaw Lekarskie PZWL 2004

[28] T Kłapec and A Cholewa ldquoHealth risk asociated with the useof organic and organic-mineral fertilizersrdquo Medycyna Ogolna iNauki o Zdrowiu vol 18 pp 131ndash136 2012

[29] G Dover ldquoMolecular drive a cohesive mode of species evolu-tionrdquo Nature vol 299 no 5879 pp 111ndash117 1982

[30] P Nejsum E D Parker Jr J Frydenberg et al ldquoAscariasis is azoonosis in Denmarkrdquo Journal of Clinical Microbiology vol 43no 3 pp 1142ndash1148 2005

[31] E B AlvesM J Conceicao andD Leles ldquoAscaris lumbricoidesAscaris suum or ldquoAscaris lumbrisuumrdquordquo The Journal of Infec-tious Diseases vol 213 no 8 p 1355 2016

[32] M Betson and J R Stothard ldquoAscaris lumbricoides or Ascarissuum what1015840s in a namerdquo Journal of Infectious Diseases vol 213no 8 pp 1355ndash1356 2016

[33] M Betson F D Halstead P Nejsum et al ldquoA molecularepidemiological analysis of Ascaris on Unguja Zanzibar usingisoenzyme analysis DNA barcoding and microsatellite DNA

profilingrdquo Transactions of the Royal Society of Tropical Medicineand Hygiene vol 105 pp 370ndash379 2011

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

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EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


to the liver and then proceed to the lungs where they mayproduce pneumonia Symptoms include wheezing dyspneanonproductive coughing hemoptysis and fever The res-piratory distress experienced during pulmonary ascariasisreferred to as Lofflerrsquos syndrome occurs 4 to 16 days afteringesting embryonated roundworm eggs [9] Skin urticarialrash may also accompany these symptoms Chest X-raysreveal rounded infiltrates with peripheral eosinophilia [10]Occasionally A lumbricoides may pass from the nose or themouth during vomiting [11] In this study we present anunusual ascariasis and respiratory failure in a patient withacute myeloblastic leukemia (AML)

2 Case Presentation

A 66-year-old male was admitted in December 2012 tothe Department of Haematology in a fairly good generalcondition In an interview during admission the patientreported coughing a recurrent low-grade fever night sweatsmalaise and weakness Physical examination revealed bilat-eral lymphadenopathy cervical (up to 2 cm) axillary to15 cm numerous inguinal nodes (up to 2ndash25 cm) singlecrackles at the base of both lungs no hepatomegaly and mildsplenomegaly 1 cm below costal margin Laboratory studiesshowed increased inflammatory parameters serum lactatedehydrogenase (LDH) anemia and thrombocytopenia blastsin the blood smear and negative bacteriological resultsconcerning the presence of aerobic and anaerobic bacteriaMicroscopic examination of stool was negative for helminthicova and examination of feces was recommended to beconducted several times No helminth eggs were found ChestX-ray revealed no indication of infiltrates in the lungs orpneumothorax On abdominal ultrasonography the liver wasnot palpable while the spleen was uniform but enlarged inthe long axis it measured 133mmOn the basis of cytologicalcytochemical immunophenotypic and cytogenetic analysisof bone marrow in December 2012 the patient was diag-nosed with acute myeloblastic leukemia On the 7th day ofhospitalization in the Department of Haematology patientwas moved to the Intensive Care Unit (ICU) due to acuterespiratory and circulatory failure The patient displayedviolent dyspnea and a cherry-colored scalp and neck alongwith high anxiety and respiratory effort tachypnea 43minand auscultation of the lungs individual crackles at the baseof the lungs including single crackles towards the angles ofthe blades and increased vesicular murmur over the wholelung HR is 130min RR is 150110mmHg and oxygensaturation is 92ndash94 on an oxygen mask with a reservoirat a flow rate of 15 Lmin Before admission to the ICUmorphine steroids and diuretics were administered Thisresulted in little improvement and tachypnea 20ndash25minBlood gases did not correlate with the clinical conditionof the patient the clinical picture suggestive of pulmonaryembolism In the following minutes an increased severityof changes was noticed during the auscultation of the lungsshortness of breath remained with an extended expiratoryphaseThe patient was intubated and treated in the ICU Aftera slight improvement in general condition the patient was

Figure 1 Adult male of Ascaris lumbricoides

transferred to the Department of Haematology but was stillin a general poor condition In a short time the patient wasreturned to the ICU A build-up of heart failure was observedand clinical symptoms of pulmonary edema were observedthese were treated in a conventional manner and a transientimprovement was obtained However in a short time onceagain respiratory problems returned with a decrease to 76oxygen saturation despite constant oxygen flow to the oxygenmask with a reservoir (15 Lmin) and the occurrence ofnumerous changes was recorded during the auscultation ofthe lungs Respiratory failures were accompanied by lossesof consciousness Chest X-rays showed bilateral multiplescattered airless changes most likely associated with inflam-mations

After improvement in general condition in January 2013the patient was transferred to the Department of Haematol-ogy to measure bone marrow cytology 836 myeloblastsThe patient was qualified for palliative therapy with hydrox-yurea because of poor general condition and respiratoryand heart failure Two months after the onset of pulmonaryfailures chest X-ray inspections showed no infiltrates in thelungs wherein in the bottom of the left lung and the topsof both the lungs discreet cicatricial changes and echocar-diography EF (ejection fraction) was 55 (previously 35)nonenlarged heart The patient was qualified for intensivechemotherapy remission induction therapy DA (daunoru-bicin with cytarabine) 2nd group stratification was at gt60years of age according to the PALG protocol Chemotherapywas complicated by sepsis probably catheter-related with anetiology of Staphylococcus epidermidis

In March 2013 3 months after the onset of respiratoryfailures a mature form of Ascaris spp appeared in thepatientrsquos mouth (Figure 1) Stereomacroscopic examinationshowed that it was amale roundworm 15 cm long and 25mmdiameter Pyrantel was administered orally The patientresponded well to the antiparasitic treatment and showed nogastrointestinal symptoms In an interview with the patient



3 Discussion













4 Conclusion


Abbreviations



Competing Interests




Acknowledgments


References










































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















3 Discussion













4 Conclusion


Abbreviations



Competing Interests




Acknowledgments


References










































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















4 Conclusion


Abbreviations



Competing Interests




Acknowledgments


References










































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of










































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















Documents

Case Report Respiratory Failure Associated with Ascariasis ...downloads.hindawi.com/journals/criid/2016/4070561.pdf · suum infestation are those who have stayed in areas with suboptimal