Background
Ascariasis is the most frequent parasitic disease in the world. It is caused by Ascaris lumbricoides, the human roundworm which can reach a length of up to 45 cm with a diameter of 5 mm. In the course of ascariasis the reactive eosinophilia is usually present. Cardiac disease is the major cause of death in the course of sustained eosinophilia, whether reactive or clonal. Eosinophilic myocarditis is a rare, potentially fatal disease. Cardiac involvement does not correlate with the level of blood eosinophilia. In the heart the eosinophilic infiltration can produce myocarditis, intramural thrombus formation, constrictive pericarditis and fibroblastic endocarditis.
Case presentation
We present 24- year-old Caucasian woman suffering from the eosinophilic myocarditis in the course of Ascariasis. She was allergic to hair of dog, cat, grass pollen, dust from early childhood and psoriasis.
In February and March of 2012 the woman was complaining about severe pain and swelling in the both knees and ankles joints more intensify at night.
In March and April of 2012 the woman has observed swelling and bruising of the her right upper extremity. The ultrasonography study of right upper limb has revealed hyperechogenic thrombus with observed minimum blood flow in the vein. The patient was diagnosed with the axillary vein and the right subclavian vein thrombosis. The blood test study revealed limphocytosis 12,3×10*9/l with eosinophil granulocytes count 11×10*9/l.
In May of 2012 woman was admitted to Department of Rheumatology due to pain occurring in the musculoskeletal system. The patient was diagnosed due to suspicion of psoriatic arthritis. The blood test has revealed leuocytosis, elevated of erythrocyte sedimentation rate, C-Reactive Protein and Troponin I level as well as the antinuclear antibodies ANA-1 presence. The X-ray study of hand and foot bones did not reveal any abnormalieties. The EGC study has revealed sinus regular rhythm with 100 bpm, and negative T wave in leads II, III, aVF, V2-V6. Due to elevated hsT level the woman was moved at the cardiology department.
The blood test was repeated: it has confirmed leukocytosis with the high absolute eosinophil granulocytes level [4190/ul]. The echocardiography has shown a hyperechogenic thrombus in the heart apex, diastolic enlargement up to 12 mm with intensified contractility, clamping of apical heart segments and dynamic gradient up to 16 mmHg. The pericardial thickening and minimal pericardial liquid up to 2 mm were present. The ECG study has revealed sinus, regular rhythm with 90 bpm, negative T wave in II, III, aVF, V3-V6 leads. The performed chest x-ray exam, abdominal ultrasonography and 24-hour ECG study was within norme. The patient was diagnosed with eosinophilic pericarditis and myocarditis.
In June of 2012 the patient was admitted at the Allergology and Immunology Department due to suspition of hypereosynophilic syndrome (HES). The physical examination has revealed two small nodles over the right eyebrow and no more abnormalities. The performed blood test has revealed leukocytosis up to 14 000/uL with normal eosinophil granulocytes count. The inflammatory factors level was within norm. The parasitological study has revealed a lot of Ascarsis lumbricoides eggs in the feces. The mebendazol to the treatment was introduced. The echocardiography has shown smaller than earlier hyperechogenic thrombus in the heart apex up to 7 mm, left ventricule 40/24 mm in a diameter with preserved systolic function. MR has revealed a hyperechogenic thrombus in the heart apex, diastolic enlargement up to 12 mm with intensified contractility, clamping of apical heart segments pericardial thickening and minimal pericardial liquid up to 2 mm, a diverculum 8/ 4 mm in diameter in the middle heart segment without communication to right ventricule. Last time the patient was hospitalized due to hacking cough from 4 weeks, infiltration changes revealed by Chest X-ray study and systolic murmur heard best at “Erb’s point”. The blood test has revealed elevated CRP level, leukocytosis and eosinophilic granulocytes count 2640/uL, the feces exam do not show parasites eggs. In ECG study negative T wave was presented in I, II, aVL, aVF and V2-V6 leads.
Nowadays the patient is asymptomatic. Is she a candidate for a myocardial biopsy or other study?
Expert’s comments:(Written authorization required from each expert)
1. Prof. A. Rudziński
Ascariasis is very difficult to cure. The patient should be under the constant care of a specialist of infectious diseases. Currently, myocardial biopsy is not recommended. Typical heart failure treatment according to the latest ESC recommendation is advisable.
2. Prof. K. Rytlewski
The patient as a young woman should be informed that they can not get pregnant for a full explanation of the causes of the disease. She should use a contraception. I suggest the use of intrauterine spiral. Due to the episode of an embolism she don’t should use oral contraception.
3. Prof. P. Podolec
Patients should be under the permanent control a cardiologist and a specialist of infectious diseases. Should regularly undergo echocardiography and additional research, blood test too. Testing for parasites must be regularly repeated. Family of the patient have be treated with anthelmintic drugs.
Authors:
D. Kudliński MD, G. Kopeć MD, PhD, Sylwia Wiśniowska-Śmiałek MD, M. Urbańczyk MD, M. Krupiński MD, P. Rubiś MD, PhD, A. Leśniak-Sobelga MD, PhD, Prof. M. Kostkiewicz MD, PhD, Prof. P. Podolec MD, PhD
Experts:
Prof. P. Podolec MD, PhD, Prof. K. Rytlewski MD, PhD, Prof. L. Szydłowski MD, PhD
