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[Visceral larva migrans. Successful treatment with fenbendazole

(author's transl)]

 

[Article in German]

 

Wolff C.

 

Visceral Larva migrans (VLM) is a parasite, which produces a

disease by nematode species. Specific hosts are certain mammals. After

penetrating the human organism, these parasites never mature to adult

worms but can produce a lot of various symptoms which are dependent on

the kind of manifestation. Perilous illnesses are described. The

incidence is undoubtedly more than is realized. A new

microprecipitation test has proved to be highly specific for the

diagnosis. An effective nontoxic treatment in human medicine--exept

for mebendazole--was not known until now. We report about the illness

of a patient with all typical laboratory findings and clinical signs.

The application of Fenbendazole for the first time in humans showed to

be highly effective against this ubiquitous illness.

 

Publication Types:

 

* Case Reports

 

 

PMID: 7095820 [PubMed - indexed for MEDLINE]

 

 

 

 

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Visceral Larva Migrans

Last Updated: January 18, 2006

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Synonyms and related keywords: visceral larva migrans, toxocariasis,

Toxocara canis, Toxocara cati, VLM, parasitic infection, roundworm

parasites, chronic eosinophilic pneumonia, myocarditis,

Henoch-Schönlein purpura, eating dirt

 

AUTHOR INFORMATION Section 1 of 10 Click here to go to the next

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Author: Raymond D Pitetti, MD, MPH, Assistant Professor, Department of

Pediatrics, Division of Pediatric Emergency Medicine, University of

Pittsburgh School of Medicine; Consulting Staff, University of

Pittsburgh Physicians

 

Raymond D Pitetti, MD, MPH, is a member of the following medical

societies: Allegheny County Medical Society, American Academy of

Pediatrics, American Medical Association, and Pennsylvania Medical Society

 

Editor(s): Robert W Tolan, Jr, MD, Chief of Allergy, Immunology and

Infectious Diseases, The Children's Hospital at St Peter's University

Hospital, Clinical Associate Professor of Pediatrics, Drexel

University College of Medicine; Mary L Windle, PharmD, Adjunct

Assistant Professor, University of Nebraska Medical Center College of

Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Leslie L Barton, MD,

Professor, Program Director, Department of Pediatrics, University of

Arizona School of Medicine; Daniel Rauch, MD, FAAP, Director,

Pediatric Hospitalist Program, Associate Professor, Department of

Pediatrics, New York University School of Medicine; and Russell W

Steele, MD, Professor and Vice Chairman, Department of Pediatrics,

Head, Division of Infectious Diseases, Louisiana State University

Health Sciences Center

 

Disclosure

 

 

INTRODUCTION Section 2 of 10 Click here to go to the previous

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Background: Several roundworm parasites of domestic animals can infect

humans. It is usually the larval stages of these parasites that are

found in human tissues and provoke the clinical condition referred to

as larva migrans. Toxocara species, the ascarid of dogs and cats, most

commonly is associated with larva migrans. Classic visceral larva

migrans (VLM) typically occurs in preschool-aged children with a

history of eating dirt. Children can present with severe infection and

suffer from seizures, myocarditis, and encephalitis. Death also has

been reported in some cases.

 

Pathophysiology: Children contract Toxocara infections by ingesting

embryonated eggs. The larvae hatch in the small intestine, invade the

mucosa, and enter the portal system. The liver traps some larvae, but

other larvae proceed to the lungs and the circulatory system where

they can disseminate to virtually every organ. The parasite, however,

cannot complete its life cycle in humans. Larvae persist in tissues,

provoking a granulomatous reaction and eventually dying. Clinical

manifestations depend upon the tissue damage caused by the invading

larvae and the associated immune-mediated inflammatory response.

 

Frequency:

 

* In the US: The seroprevalence of Toxocara infection in children

varies from 2-10%.

 

* Internationally: Although most reported cases occur in the

United States, international incidence is likely similar or slightly

higher.

 

Mortality/Morbidity: Death is rare. Long-term morbidity is present

with ocular larva migrans (ie, loss of vision in the affected eye) but

not usually with VLM. Chronic eosinophilic pneumonia, myocarditis, and

Henoch-Schönlein purpura have been associated with VLM.

 

Race: Infection rates are higher among African Americans and Hispanic

Americans, likely because of greater exposure to the parasite.

 

Sex: No sex predilection exists.

 

Age: Infection primarily affects children aged 1-4 years, but it can

occur at any age.

 

CLINICAL Section 3 of 10 Click here to go to the previous

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History:

 

* Children with visceral larva migrans (VLM) may complain of loss

of appetite, fever, cough, wheezing, or abdominal pain.

 

* Ask the parents about the presence of household pets and if

their child is known to eat dirt.

 

* Ascertain a careful history regarding occupational and household

chemical exposures, drug exposures, asthma, atopic dermatitis, travel

to tropical areas, or the consumption of raw meat.

 

Physical:

 

* Children may have marked hepatomegaly and splenomegaly,

wheezing, and rales.

 

* Children also may have a pruritic rash or urticaria.

 

* Periorbital edema and strabismus also have been seen in some

children with VLM.

 

Causes:

 

* Toxocara canis is the most common cause of VLM. Mature T canis

worms live in the small intestine of the dog, their natural host.

Heavily infected dogs can pass millions of eggs each day in their feces.

 

* Toxocara cati also causes VLM.

 

DIFFERENTIALS Section 4 of 10 Click here to go to the previous

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Ancylostoma Infection

Ascariasis

Asthma

Bancroftian Filariasis

Crohn Disease

Cutaneous Larva Migrans

Cysticercosis

Diphyllobothrium Latum Infection

Dirofilariasis

Dracunculiasis

Echinococcosis

Filariasis

Gnathostomiasis

Hookworm Infection

Hymenolepiasis

Hypereosinophilic Syndrome

Hypersensitivity Pneumonitis

Loffler Syndrome

Myocarditis, Nonviral

Paragonimiasis

Schistosomiasis

Strongyloidiasis

Taenia Infection

Trichinosis

Urticaria

Vasculitis and Thrombophlebitis

Whipworm

 

 

Other Problems to be Considered:

 

Allergies

Eosinophilia-myalgia syndrome

Neoplasia

Other parasitic infections

 

 

Quick Find

Author Information

Introduction

Clinical

Differentials

Workup

Treatment

Medication

Follow-up

Miscellaneous

Bibliography

 

Click for related images.

 

Related Articles

Ancylostoma Infection

 

Ascariasis

 

Asthma

 

Bancroftian Filariasis

 

Crohn Disease

 

Cutaneous Larva Migrans

 

Cysticercosis

 

Diphyllobothrium Latum Infection

 

Dirofilariasis

 

Dracunculiasis

 

Echinococcosis

 

Filariasis

 

Gnathostomiasis

 

Hookworm Infection

 

Hymenolepiasis

 

Hypereosinophilic Syndrome

 

Hypersensitivity Pneumonitis

 

Loffler Syndrome

 

Myocarditis, Nonviral

 

Paragonimiasis

 

Schistosomiasis

 

Strongyloidiasis

 

Taenia Infection

 

Trichinosis

 

Urticaria

 

Vasculitis and Thrombophlebitis

 

Whipworm

 

 

Continuing Education

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Patient Education

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Lab Studies:

 

* A complete blood count will often reveal a leukocytosis and

eosinophilia, but eosinophilia may not always be present. Children may

be anemic.

 

* Obtain stool cultures to rule out other parasitic infections.

 

* Elevated titers of isohemagglutinins to the A and B blood group

antigens support the diagnosis of visceral larva migrans (VLM).

 

* Enzyme-linked immunosorbent assay (ELISA) is the most commonly

used serologic test physicians use to diagnose VLM, with a reported

sensitivity of 78.3% and specificity of 92.3%.

 

* Hypergammaglobulinemia may be present.

 

Imaging Studies:

 

* Children with VLM may exhibit an abnormal liver parenchymal

pattern on both abdominal ultrasound and computed tomography.

 

* Magnetic resonance imaging may reveal multiple cerebral lesions

in patients with central nervous system VLM.

 

* Pulmonary infiltrates due to VLM will generally manifest as a

transient form of Löffler syndrome or simple eosinophilic pneumonia on

a chest radiograph.

 

Procedures:

 

* In unusual circumstances, liver biopsy may aid in diagnosing

VLM; however, microscopic identification of larvae from biopsies

occurs infrequently. A negative liver biopsy does not exclude VLM.

 

Histologic Findings: Multiple eosinophilic abscesses and allergic-type

granulomas often are found in affected tissues.

 

TREATMENT Section 6 of 10 Click here to go to the previous

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Medical Care:

 

* Therapy is aimed at relieving symptoms and is intended to

diminish the host inflammatory response to the parasite.

Corticosteroids and antihistamines are often used for this purpose.

Patients with myocarditis or central nervous system disease should

always be treated with corticosteroids.

 

* Antiparasite agents, such as mebendazole, may help reduce

symptoms; however, systemic treatment with antihelminthics can result

in hypersensitivity reactions. Clinical trials have raised questions

about their efficacy.

 

* Attempt to identify the source of infection. Infected puppies

and kittens should be treated with appropriate anthelminthic agents.

 

Consultations:

 

* Consider infectious diseases consultation in unusual or

difficult cases.

 

* Consider other consultations depending on the organ system involved.

 

Diet:

 

* No special diet is necessary for acute treatment.

 

* If children have a history of pica (eg, eating dirt, paint

chips), attempts should be made to alter the behavior.

 

Activity: No activity restrictions are required beyond that required

for the treatment of the acute infection or its sequelae.

MEDICATION Section 7 of 10 Click here to go to the previous

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Children can be treated with an anthelmintic agent. Severe infections

should be treated with systemic corticosteroids.

 

Drug Category: Anthelmintics -- Historically, the treatment of

visceral larva migrans (VLM), in either adults or children, was

primarily symptomatic. However, the identification of the

anthelmintics (eg, thiabendazole, diethylcarbamazine) in the 1960s

offered an effective therapeutic choice. Anthelmintics act against the

migrating larvae.

 

Parasite biochemical pathways are different from the human host; thus,

toxicity is directed to the parasite, egg, or larvae. Mechanism of

action varies within the drug class. Antiparasitic actions may include

the following:

 

* Inhibition of microtubules causes irreversible block of glucose

uptake

 

* Tubulin polymerization inhibition

 

* Depolarizing neuromuscular blockade

 

* Cholinesterase inhibition

 

* Increased cell membrane permeability, resulting in intracellular

calcium loss

 

* Vacuolization of the schistosome tegument

 

* Increased cell membrane permeability to chloride ions via

chloride channels alteration

 

Drug Name

Mebendazole (Vermox) -- Selectively and irreversibly blocks the

uptake of glucose and other nutrients in susceptible

intestine-dwelling helminths.

Adult Dose 100-200 mg PO bid pc for 5 d

Pediatric Dose <2 years: Not established

>2 years: 100 mg PO bid pc for 3 d

Contraindications Documented hypersensitivity

Interactions Carbamazepine and phenytoin may decrease effects of

mebendazole; cimetidine may increase mebendazole levels; increased

absorption with food

Pregnancy C - Safety for use during pregnancy has not been established.

Precautions Adjust dose in hepatic impairment

Drug Name

Thiabendazole (Mintezol) -- Inhibits mitochondrial formate reductase,

which is specific for helminth.

Adult Dose 0.25-1.5 g PO bid pc for 7 d

Pediatric Dose 50 mg/kg/d PO divided bid pc for 7 d

Contraindications Documented hypersensitivity; caution in children

weighing <30 lb

Interactions May elevate serum levels of theophylline increasing

toxicity (monitor serum levels and reduce dose prn)

Pregnancy C - Safety for use during pregnancy has not been established.

Precautions Closely monitor in hepatic or renal dysfunction; before

initiating therapy, supportive therapy is necessary for anemic,

dehydrated, or malnourished patients; use in confirmed worm

infestation (not prophylactically); may cause nausea, vomiting, and

mild CNS depression

Drug Name

Albendazole (Albenza) -- Acts primarily by inhibiting tubulin

polymerization, resulting in the loss of cytoplasmic microtubules.

Tends to be most effective against larval forms.

Adult Dose 400 mg PO bid pc for 3-5 d

Pediatric Dose <2 years: 200 mg PO bid pc for 3-5 d

>2 years: Administer as in adults

Contraindications Documented hypersensitivity

Interactions Coadministration with carbamazepine may decrease

efficacy; dexamethasone, cimetidine, and praziquantel may increase

toxicity

Pregnancy C - Safety for use during pregnancy has not been established.

Precautions Discontinue use if LFTs increase significantly (resume

when levels decrease to pretest values); abdominal pain, nausea,

vomiting, diarrhea, dizziness, vertigo, fever, increased intracranial

pressure, and alopecia may occur; caution in patients receiving drugs

with a narrow therapeutic index (monitor carefully)

FOLLOW-UP Section 8 of 10 Click here to go to the previous

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Further Inpatient Care:

 

* Children rarely require hospitalization for visceral larva

migrans (VLM).

 

Transfer:

 

* Arrange transfer for children with disease that require services

or specialists not readily available (unusual occurrence).

 

Deterrence/Prevention:

 

* Avoid contaminated areas when possible.

 

Complications:

 

* Pneumonia

 

* Seizures

 

* Myocarditis

 

* Encephalitis

 

* Decreased visual acuity and blindness

 

* Death

 

Prognosis:

 

* VLM is generally benign and self-limiting. However, serious

sequelae can occur resulting in significant risk of morbidity and

mortality.

 

Patient Education:

 

* Instruct caregiver to worm household pets and to properly

dispose of pet feces.

 

* Encourage good personal hygiene, including washing hands after

playing with pets.

 

* Encourage caregivers to prevent children from playing in areas

that are soiled with pet or other animal feces.

 

* Teach older children that eating dirt may be dangerous.

 

MISCELLANEOUS Section 9 of 10 Click here to go to the previous

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Medical/Legal Pitfalls:

 

* Failure to recognize symptoms suggestive of visceral larva

migrans (VLM)

 

* Initiation of extensive or invasive evaluation without

considering this relatively common infection

 

BIBLIOGRAPHY Section 10 of 10 Click here to go to the previous

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visceral larva migrans due to Toxocara canis. Intern Med 2002 Sep;

41(9): 706-8[Medline].

* American Academy of Pediatrics: Toxocariasis (visceral larva

migrans, ocular larva migrans) In: 1997 Red Book: Report of the

Committee on Infectious Diseases. 1997: 530-1.

* Arango CA: Visceral larva migrans and the hypereosinophilia

syndrome. South Med J 1998 Sep; 91(9): 882-3[Medline].

* Bass JL, Mehta KA, Glickman LT, et al: Asymptomatic toxocariasis

in children. A prospective study and treatment trial. Clin Pediatr

(Phila) 1987 Sep; 26(9): 441-6[Medline].

* Chitkara RK, Sarinas PS: Dirofilaria, visceral larva migrans,

and tropical pulmonary eosinophilia. Semin Respir Infect 1997 Jun;

12(2): 138-48[Medline].

* Despommier D: Toxocariasis: clinical aspects, epidemiology,

medical ecology, and molecular aspects. Clin Microbiol Rev 2003 Apr;

16(2): 265-72[Medline].

* Dupas B, Barrier J, Barre P: Detection of Toxocara by computed

tomography. Br J Radiol 1986 May; 59(701): 518-9[Medline].

* Feldman GJ, Parker HW: Visceral larva migrans associated with

the hypereosinophilic syndrome and the onset of severe asthma. Ann

Intern Med 1992 May 15; 116(10): 838-40[Medline].

* Glickman LT, Magnaval JF: Zoonotic roundworm infections. Infect

Dis Clin North Am 1993 Sep; 7(3): 717-32[Medline].

* Herrmann N, Glickman LT, Schantz PM, et al: Seroprevalence of

zoonotic toxocariasis in the United States: 1971-1973. Am J Epidemiol

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* Inoue K, Inoue Y, Arai T, et al: Chronic eosinophilic pneumonia

due to visceral larva migrans. Intern Med 2002 Jun; 41(6):

478-82[Medline].

* Kabaalioglu A, Ceken K, Alimoglu E, et al: Hepatic toxocariasis:

US, CT and MRI findings. Ultraschall Med 2005 Aug; 26(4): 329-32[Medline].

* Kimmig P, Regnath T, Hassler D: [Toxocariasis: larva migrans

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with Toxocara canis infection. J Rheumatol 2000 Mar; 27(3):

818-9[Medline].

* Obwaller A, Jensen-Jarolim E, Auer H, et al: Toxocara

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* Sturchler D, Schubarth P, Gualzata M, et al: Thiabendazole vs.

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