r e v b r a s r e u m a t o l .2 0 1 6;5 6(2):185–187
w w w . r e u m a t o l o g i a . c o m . b r
REVISTA BRASILEIRA DE
REUMATOLOGIA
Case report
Chronic polyarthritis as isolated manifestation of
toxocariasis
Gabriela R. Viola
a, Maria Fernanda A. Giacomin
a, Camila M.P. Franc¸a
a,
Adriana M.E. Sallum
a, Cristina M.A. Jacob
b, Clovis A. Silva
a,c,∗a PediatricRheumatologyUnit,PediatricDepartment,SchoolofMedicine,Universidade de SãoPaulo,SãoPaulo,SP,Brazil b PediatricAllergyandImmunologyUnit,PediatricDepartment,SchoolofMedicine,Universidade de SãoPaulo,SãoPaulo,SP,
Brazilc DivisionofRheumatology,SchoolofMedicine,Universidade de SãoPaulo,SãoPaulo,SP,Brazil
a r t i c l e
i n f o
Article history:
Received 20 December 2013 Accepted 28 July 2014
Available online 20 February 2015
Keywords:
Chronic arthritis Eosinophilia Toxocariasis Children
Juvenile idiopathic arthritis Leukemia
a b s t r a c t
Human toxocariasis is a parasitic zoonosis mainly caused byToxocara canisorToxocara cati
and is acquired by ingestion of the parasite’s embryonated eggs. Arthralgia and/or arthri-tis were reported in up to 17% of the cases, generally with acute duration (less than 6 weeks). However, to our knowledge, chronic polyarthritis, as the isolated presentation of
Toxocarainfection, was not reported. One of the 5809 patients that was followed up at our service (0.017%) had chronic polyarthritis as the single manifestation of toxocariasis and was described herein. A 3-year-old girl was referred to our service with severe painful chronic polyarthritis for a period longer than 10 weeks and morning stiffness of 30 min. Dog contact exposure history in the recreational areas of neighborhood was reported. Her exams showed high levels of eosinophils in peripheral blood (29%), bone marrow aspirate revealed marked eosinophilia (32%) andToxocaraenzyme-linked immunosorbent assay (Elisa) was positive (1:1280). She was treated with paracetamol (40 mg/kg/day) and thiabendazole (25 mg/kg/day) for 10 days, and all manifestations reduced. After eight months of follow-up, she was on clinical and laboratorial remission. In conclusion, we described a case of chronic polyarthri-tis, as isolated manifestation of toxocariasis, mimicking juvenile idiopathic arthritis and leukemia. Importantly, this zoonosis should be considered in patients with arthritis and eosinophilia.
© 2014 Elsevier Editora Ltda. All rights reserved.
Poliartrite crônica como manifestac¸ão isolada da toxocaríase
Palavras-chave:
Artrite crônica
r e s u m o
A toxocaríase é uma zoonose parasitária causada principalmente peloToxocara canisou pelo T. cati. É adquirida pela ingestão de ovos embrionados do parasita. A artralgia e/ou artrite foram relatadas em até 17% dos casos, geralmente com durac¸ão aguda (menos de seis
∗ Corresponding author.
E-mail:[email protected](C.A. Silva). http://dx.doi.org/10.1016/j.rbre.2014.07.005
186
rev bras reumatol.2016;56(2):185–187Eosinofilia Toxocaríase Crianc¸as
Artriteidiopáticajuvenil Leucemia
semanas).Noentanto,quesetemconhecimento,apoliartritecrônicacomomanifestac¸ão isoladadainfecc¸ãoporToxocaraaindanãofoidescritanaliteratura.Umdos5.809pacientes acompanhados emnossoservic¸o(0,017%) exibiupoliartritecrônicacomo manifestac¸ão únicadatoxocaríaseefoidescritonesteestudo.Umameninadetrêsanosfoi encamin-hadaaonossoservic¸ocompoliartritecrônicadolorosagraveporumperíodosuperiora10 semanaserigidezmatinaldiáriade30minutos.Foirelatadahistóriadeexposic¸ãoacontato comcãonasáreasdelazerdobairro.Seusexamesrevelaramníveiselevadosdeeosinófilos nosangueperiférico(29%),oaspiradodemedulaósseareveloueosinofiliaacentuada(32%) eoensaioimunoenzimáticoligadoaenzima(Elisa)paraToxocarafoipositivo(1:1.280).A crianc¸afoitratadacomparacetamol(40mg/kg/dia)etiabendazol(25mg/kg/dia)durante10 diasehouveregressãodetodasasmanifestac¸ões.Depoisdeoitomesesdeseguimento, apequenapacienteestavaemremissãoclínicaelaboratorial.Emconclusão,descreve-se umcasodepoliartritecrônicacomomanifestac¸ãoisoladadatoxocaríase,quemimetizou umaartriteidiopáticajuvenileleucemia.Éimportanteressaltarqueessazoonosedeveser consideradaempacientescomartriteeeosinofilia.
©2014ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Humantoxocariasisisaparasiticzoonosiscausedmainlyby
ToxocaracanisorToxocaracatiandisacquiredbyingestionof theembryonatedeggsoftheparasite.1,2Theclinicalformsare systemic(viscerallarvamigrans),localized(ocularand neuro-logical),asymptomaticandcovert.2–4
Ofnote,thecovertformpresentsnon-specificsymptoms, suchaslymphadenopathy,dermatologicaldisorders,asthma andjointmanifestations.2–4 Arthralgiaand/orarthritiswere reported in up to 17% of the cases,2 generally with acute duration(lessthan6weeks).InBrazil,theprevalenceof toxo-cariasisinurbanareasrangedfrom3.6%to24.7%.5,6However, toour knowledge,severe andpainful chronicpolyarthritis, as the isolated presentation ofToxocara infection, was not reported.
FromJanuary1983toNovember2013,werevisedthecharts ofpatients followedup atthe PediatricRheumatologyUnit oftheChildren’sInstituteofHospitaldasClínicasda Facul-dadedeMedicinaUniversidadedeSãoPaulo.Onlyoneofthe 5809patients(0.017%)hadchronicpolyarthritisasthesingle manifestationoftoxocariasisandwasdescribedherein.
Case
report
A 3-year-old girl was referred to our service with chronic polyarthritis in knees, wrists, shoulders, elbows and hips, withpainful joint effusions inknees and wrists. Thetotal durationofpolyarthritiswas10weeks.Atthatmoment,she refusedtowalkduetoseverepain.Shehad30minof morn-ingstiffnessandlossofappetite.Dogcontacthistoryinthe recreationalareasofneighborhoodwasreported.Laboratory examinationsshowedhemoglobin10.1g/dL,hematocrit32%, white blood cell (WBC) 17,800mm3 (neutrophils 42%, lym-phocytes25%,eosinophils29%,andmonocytes4%),platelets 464,000mm3,erythrocytesedimentationrate(ESR)55mm/1st hour,C-reactive protein(CRP)42.8mg/dL,andlactate dehy-drogenase(LDH)879mg/dL(normalrange117–213).Serologic testforhepatitisA,BandC,humanimmunodeficiencyvirus
(HIV),cytomegalovirus,rubella,Epstein–Barrvirus, toxoplas-mosisandantistreptolysinOwerenegative.Threeconsecutive stoolexaminationsdidnotidentifyanyparasiteinfestation. ImmunoglobulinEwas272g/L(normal<60g/L).Herbone
marrow aspirate revealed marked eosinophilia (32%; nor-malrange0.5–7%)withoutneoplasticcells.Therheumatoid factor also was negative, and ophthalmological examina-tion was normal. Toxocara enzyme-linked immunosorbent assay (ELISA) was 1:1280. She was treated with paraceta-mol(40mg/kg/day)and thiabendazole(25mg/kg/day)for10 days, and all manifestations reduced.After 2 months, the ESRwas14mm/1sthour,CRP0.93mg/dLandWBC8200mm3 (neutrophils 35%, lymphocytes 53%, eosinophils 6% and monocytes6%),platelets224,000mm3,andimmunoglobulin Ewas162g/L.Aftereightmonthsoffollow-up,shewason
clinicalandlaboratorialremission.
Discussion
Chronic polyarthritis, mimicking neoplasia and juvenile idiopathicarthritis(JIA), asthemainmanifestationof toxo-cariasis,haverarelybeenobservedinourtertiaryUniversity Hospital inthelast 30 years.Thepresenceofconcomitant arthritisandeosinophiliasuggeststhediagnosis.
Toxocariasis isavery commonparasitosisinBrazil,and its prevalencerangedfrom3.6%to24.7%.5,6 Thisinfection, asa causeofisolated eosinophilicarthritis, isveryseldom seen in the literature.7 Indeed, it was rarely described in arthritisofHenoch-Schönleinpurpura.8–10 Thediagnosisof toxocariasis issuspectedinpatientsthat presented house-holdcontactwithdogs11,12anditisconfirmedbythepresence ofspecificantibodies,detectedbyELISAmethod,with sensi-tivityof90–92%andspecificityof90–95%.1,4 Thehighlevels ofeosinophilsinperipheralbloodwasalsoobservedinmore than60%ofthepatients,1,4,12andIgEtitershadhighlevelsin childrenupto3yearsold,2,4asobservedherein.
rev bras reumatol.2016;56(2):185–187
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Howevertoourknowledge,chronicarthritisinchildrenwas notpreviouslyreportedwiththisinfection.
Importantly,themaindifferentialdiagnosesinourpatient wereacutelymphoblasticleukemia(ALL)andJIA.The pres-enceofconcomitantseverearticularpainandhighLDHlevels, evenwithout other systemicmanifestations, indicate bone marrowaspirationtoexcludethisneoplasia,asinourcase. Moreover,JIAisthemostimportantcauseofchronicarthritis withmorningstiffness;however,theexclusionofinfections isnecessarytoconfirmthisdiagnosis.13
Thetreatmentoftoxocariasisisnecessaryforsymptomatic patientstoreducethenumberofpotentiallymigratorylarvae.9 Theuse ofthiabendazole(25mg/kg/day) forashort period therapyisindicatedtocovertforms,asinthepresentcase.4
Inconclusion,wedescribed acaseofchronic polyarthri-tis,asisolatedmanifestationoftoxocariasis,mimickingJIA andALL.Thiszoonosisshouldbeconsideredinpatientswith arthritisandeosinophilia.
Fundings
ThisstudywassupportedbyFundac¸ãodeAmparoàPesquisa do Estado de São Paulo (FAPESP – grants 2008/58238-4 to CAS and 2011/12471-2 to CAS), by Conselho Nacional do Desenvolvimento Científico e Tecnológico (CNPQ – grant 302724/2011-7toCAS),byFedericoFoundationtoCASandby NúcleodeApoioàPesquisa“SaúdedaCrianc¸aedo Adoles-cente”daUSP(NAP-CriAd).
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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