LETTERS

Author affiliations: University of Queensland, Delayed Diagnosis Cetirizine was prescribed again; ede- Brisbane, Queensland, Australia (J. Dun- ma subsided after 4 days of treatment combe, C. Lau, A. Clements); University of of Dirofilariasis and but relapsed in the following 3–4 days. South Australia, Adelaide, South Australia, Complex Ocular At least 4 subsequent relapses oc- Australia (P. Weinstein), Queensland Uni- Surgery, Russia curred; thus, a computed tomographic versity of Technology, Brisbane (J. Aaskov); scan of the paranasal sinuses and or- and Australian Army Malaria Institute, Bris- To the Editor: Dirofilaria repens bits was performed, 4 months after bane (M. Rourke, R. Grant) is a vector-borne, zoonotic, filarial signs and symptoms began (Figure,

DOI: http://dx.doi.org/10.3201/eid1902.120464 nematode that infects dogs, cats, and panel A). The scan detected a soft tis- humans. In humans, D. repens worms sue structure, 12 × 13 × 14 mm, be- References cause subcutaneous dirofilariasis, char- hind the left eyeball, adjacent to and acterized by the development of benign medially dislodging the optic nerve. 1. Singh N, Kiedrzynski T, Lepers C, Ben- subcutaneous nodules that mimic skin No other abnormalities were found yon EK. Dengue in the Pacific: an update carcinomas (1), and ocular dirofilaria- in the visible area of the brain and of the current situation. Pac Health Dia- log. 2005;12:111–9. sis in orbital, eyelid, conjunctival, ret- sinuses. Magnetic resonance imag- 2. Arima Y, Matsui T. Epidemiologic update roocular, and intraocular locations (2). ing (MRI) performed 1 month later on the dengue situation in the western Intraocular and retroocular dirofila- (Figure, panel B) corroborated the Pacific region, 2010. Western Pacific Sur- riasis causes considerable damage and presence of a cyst-like structure with veillance and Response Journal. 2011;2: doi: 10.5365/wpsar.2011.2.2.005. discomfort in patients from the pres- an irregular, rounded shape and clear, 3. Lau CL, Dobson AJ, Smythe LD, Fearn- ence of the worms and from their surgi- smooth borders closely adhered to the ley EJ, Skelly C, Clements AC, et al. cal removal (3). Here, we report a ret- eyeball and optic nerve. T2-weighted Leptospirosis in American Samoa 2010: roocular D. repens nematode infection images showed that the lesion had a epidemiology, environmental drivers and the management of emergence. Am J Trop in a patient in Russia that illustrates high-density core but the surrounding Med Hyg. 2012;86:309–19. http://dx.doi. the difficulties in clinical management tissue was low density. Adjacent to org/10.4269/ajtmh.2012.11-0398 and the inherent risks of surgical proce- the lesion, the retrobulbar tissue was 4. Lau CL, Clements AC, Skelly C, Dobson dures to remove the worms. slightly swollen, the optic nerve was AJ, Symthe LD, Weinstein P. Leptosiro- sis in American Samoa: estimating and A 20-year-old woman living in displaced medially and downward, mapping risk using environmental data. Rostov-na-Donu in southwestern Rus- and the adjacent upper muscle was PLoS Negl Trop Dis. 2012;6:e1669. Epub sia who had never traveled outside the displaced medially and upward. The 2012 May 29. city sought ophthalmologic consul- diagnosis was evidence of a retroocu- 5. McBride WJ, Mullner H, LaBrooy JT, Wronsky J. The 1993 dengue 2 epidemic tation for pain and skin redness and lar cystic lesion in the left orbit with a in North Queensland: a serosurvey and swelling in the inner corner of the well-defined capsule and high-density comparison of hemagglutination inhibi- upper left eyelid. Swelling migrated but heterogeneous core structure. tion with an ELISA. Am J Trop Med Hyg. successively to the temporal area, the High-resolution ultrasound ex- 1998;59:457–61. 6. Ooi E, Gubler DJ, Nam VS. Dengue re- lower eyelid, and the inner corner of amination (Figure, panel C) revealed search needs related to surveillance and the lower eyelid. The patient had no a well-defined, 3-mm, cyst-like wall emergency response [cited 2012 Oct 2]. other ocular signs or symptoms, and containing fluid and dense, coiled- www.tropika.net/svc/review/061001- her general condition was otherwise twisted linear internal structures that Dengue_Surveillance_and_emergency_ response good. Results of ophthalmologic ex- appeared to be actively moving (Vid- 7. Duncombe J, Clements A, Hu W, Wein- amination and routine laboratory tests eo 1, Appendix, wwwnc.cdc.gov/EID/ stein P, Ritchie S, Espino FE. Geo- were within normal limits. Four days article/19/2/12-1388-V1.htm). Color graphical information systems for den- of treatment with cefotaxime resulted Doppler examination (Figure, panel gue surveillance. Am J Trop Med Hyg. 2012;86:753–5. http://dx.doi.org/10.4269/ in the remission of signs and symp- D; Video 2, Appendix, wwwnc.cdc. ajtmh.2012.11-0650 toms. Approximately 2 months later, gov/EID/article/19/2/12-1388-V2. 8. Kay B, Nam VS. New strategy against swelling in the inner corner of the htm) revealed blood vessels in the Aedes aegypti in Vietnam. Lancet. upper eyelid appeared again, affect- wall but not inside the cystic structure. 2005;365:613–7. ing the whole upper eyelid, without These additional examinations led to Address for correspondence: Jennifer Duncombe, itching or tenderness. Allergies were a diagnosis of a retroocular parasitic School of Population Health, University of diagnosed; cetirizine was adminis- cyst in the left orbit, most likely a Di- Queensland, Herston Rd, Herston, Queensland tered for 4 days, and the signs remit- rofilaria spp. parasite. The parasitic 4006, Australia; email: [email protected] ted at the third day of treatment. One cystic nodule was removed during month later, marked upper left eyelid a transpalpebral orbitotomy. A live, swelling occurred, resulting in ptosis. adult roundworm, 87 × 0.6 mm, was

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but has been used only sporadically for human dirofilariasis (9,10), which is habitually diagnosed postopera- tively, after the surgical removal of the nodules or worms (1).

Boris Ilyasov, Vladimir Kartashev, Nikolay Bastrikov, Rodrigo Morchón, Javier González-Miguel, and Fernando Simón Author affiliations: Rostov Oblast Diagnos- tic Centre, Rostov-na-Donu, Russia (B. Ilyasov); Rostov State Medical University, Rostov-na-Donu (V. Kartashev); Hospital of the North Caucasus Branch of the Russian Railway, Rostov-na-Donu (N. Bastrikov); and University of Salamanca, Salamanca, Spain (R. Morchón, J. González-Miguel, F. Simón)

DOI: http://dx.doi.org/10.3201/eid1902.121388

References

1. Pampiglione S, Canestri Trotti G, Rivasi Figure. Retroocular nodule of a Dirofilaria repens worm detected in a 20-year-old woman, F. Human dirofilariasis due to Dirofilaria Rostov-na-Donu, Russia. The cyst (arrows) is shown by computed tomography scan (A) (Nochtiella) repens: a review of world lit- and magnetic resonance imaging (B). Ultrasonography image (C) shows a worm-like erature. Parassitologia. 1995;37:149–93. structure inside the cyst (arrow), and Doppler imaging (D) shows marginal vascularization 2. Simón F, Siles-Lucas M, Morchón R, of the lesion (arrow). A color version of this figure is available online (wwwnc.cdc.gov/EID/ González-Miguel J, Mellado I, Carretón article/19/2/12-1388-F1.htm). E, et al. Human and animal dirofilariasis. The emergence of a zoonotic mosaic. Clin Microbiol Rev. 2012;25:471–506. http:// discharged from the cyst. Conven- D. repens nematodes are spread- dx.doi.org/10.1128/CMR.00012-12 tional PCR identified the roundworm ing in Europe from the south toward 3. Genchi C, Kramer LH, Rivasi F. Dirofilar- as D. repens (data not shown). the north and east (5–7) as a conse- ial infection in Europe. Vector Borne Zoo- notic Dis. 2011;11:1307–17. http://dx.doi. Although human subcutaneous quence of global warming, and predic- org/10.1089/vbz.2010.0247 Dirofilaria spp. nodules are benign, tion models have suggested incidence 4. Simón F, Morchón R, González-Miguel J, their detection may raise suspicion for is increasing among animal and hu- Marcos-Atxutegi C, Siles-Lucas M. What a malignant tumor; thus, differential man hosts (3). Consequently, human is new about animal and human dirofi- lariosis? Trends Parasitol. 2009;25:404–9. diagnosis is the key point in the man- ocular dirofilariasis will probably be http://dx.doi.org/10.1016/j.pt.2009.06.003 agement of human dirofilariasis (4). found with increasing frequency in the 5. Genchi C, Rinaldi L, Cascone C, Mor- The case we described illustrates the future. Our experience illustrates that tarino M, Cringoli G. Is heartworm dis- difficulties of diagnosis when worms dirofilariasis should be included in the ease really spreading in Europe? Vet Parasitol. 2005;133:137–48. http://dx.doi. are in deep locations and patients ex- differential diagnosis of any nodule, org/10.1016/j.vetpar.2005.04.009 perience unspecific and even unusual independent of its anatomic location 6. Kramer LH, Kartashev VV, Grandi G, signs. These confounders resulted in and the signs and symptoms shown Morchón R, Nagornii SA, Karanis P, et a lengthy diagnostic procedure, with by the patient. Moreover, ultrasonog- al. Human subcutaneous dirofilariasis, Russia. Emerg Infect Dis. 2007;13:150–2. consequent detrimental physical and raphy represents a noninvasive tech- http://dx.doi.org/10.3201/eid1301.060920 psychological effects on the patient. nique that enables rapid preoperative 7. Kartashev V, Batashova I, Kartashov Even though the final diagnosis de- identification of the parasitic origin of S, Ermakov A, Mironova A, Kuleshova termined that the nodule was nonma- the nodules, thus avoiding unneces- Y, et al. Canine and human dirofilari- osis in the Rostov region (southern Rus- lignant, its anatomic location required sary diagnostic delays. This technique sia). Veterinary Medicine International. aggressive surgical intervention to re- is used for the diagnosis of cardiopul- 2011; article ID 685713. http://dx.doi. move it. monary dirofilariasis in animals (8) org/10.4061/2011/685713

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8. Venco L, Vezzoni A. Heartworm (Dirofi- Inpatient and outpatient visit patients, 16 received the diagnosis in the laria immitis) disease in dogs and cats. In: data from fiscal years 2001–09 were Southwest or Southern Plains regions. Simón F, Genchi C, editors. Heartworm infection in humans and animals. Sala- obtained from the IHS National Fourteen available medical charts from manca (Spain): Ediciones Universidad de Patient Information Reporting System these 2 regions were reviewed, and Salamanca; 2001. p. 161–77. (2). For each fiscal year, records 4 patients were classified as having 9. O’Reilly MAR, O’Reilly PMR, Kace G. for AI/AN patients with at least 1 signs and symptoms consistent with Breast infection due to dirofilariasis. Eur Radiol. 2002;12:1097–9. http://dx.doi. inpatient or outpatient visit within the suspected LCMV infection (Table), org/10.1007/s003300101024 year that listed the ICD-9-CM code although no patients were confirmed 10. Boysson H, Duhamel C, Heuzé-Lecornu 049.0 (lymphocytic choriomeningitis by diagnostic testing as having LCMV L, Bonhomme J, de la Blanchardière A. and meningoencephalitis) were infection. All 4 suspected cases of Human dirofilariasis: a new French case report with Dirofilaria repens. Rev Med selected (3,4). A subset of medical LCMV infection were in women (age Interne. 2012;33:e19–21. records was reviewed for patients with range 16–43 years) who had a 1–2- the diagnosis code of interest in the day history of headache, nausea, and Address for correspondence: Fernando Simón, IHS Southwest and Southern Plains vomiting. Photophobia and neck or University of Salamanca, Parasitology, Faculty regions. Health care facilities were back pain were present in patients 1–3. of Pharmacy, Salamanca 37002, Spain; email: located in Arizona, New Mexico, and Cerebrospinal fluid from patients 2–4 [email protected] Oklahoma, USA. Suspected LCMV had increased leukocyte counts that infection was defined as a diagnosis were lymphocytic. of meningitis, choriomeningitis, The diagnoses of the 10 encephalitis, or meningoencephalitis remaining patients were classified not explained by another etiologic as miscodes because the written agent. A confirmed case of LCMV diagnoses in the charts did not Lymphocytic infection required laboratory detection mention lymphocytic meningitis. Choriomeningitis of antibodies, virus antigen, or virus. A Two patients had central nervous patient with no evidence of suspected system disease (Lyme encephalitis Virus Infections LCMV infection in his or her medical and tuberculosis meningitis) although among American record was not considered to have a an etiologic agent was confirmed that Indians case of LCMV infection. was not LCMV. Additional diagnoses Annual population denominators mistakenly coded are shown in To the Editor: Lymphocytic were determined by using annual IHS the Table. choriomeningitis virus (LCMV) Southwest and Southern Plains region Among the 4 patients identified is a rodent-borne pathogen that user populations, which includes all as having clinical signs and symptoms causes a spectrum of disease in registered AI/ANs who received IHS- of suspected LCMV infection in humans, ranging from self-limiting funded health care at least once during the Southwest and Southern Plains meningoencephalitis to congenital the previous 3 years (5). The annual regions during fiscal years 2001–09, birth defects to severe disseminated average incidence rate for diagnosed the average annual incidence rate was illness in organ transplant recipients cases of infection with LCMV was estimated to be 0.06 cases/100,000 (1). It is not known how frequently determined. Rates were also determined persons. In the same population, viral cases of LCMV infection are for viral meningitis not otherwise meningitis not otherwise specified was diagnosed in the United States. specified (ICD-9-CM code 047.9); reported for 971 patients (incidence rate We performed a retrospective case for unspecified causes of encephalitis, 13.69 cases/100,000 persons/year). analysis of American Indian and myelitis, or encephalomyelitis (323.9); Unspecified causes of encephalitis, Alaska Native (AI/AN) patients treated and for unspecified non-arthropod– myelitis, or encephalomyelitis were within the Indian Health Service borne viral diseases of the central diagnosed for 444 patients (incidence (IHS) health care system who had an nervous system or viral encephalitis rate 6.26 cases/100,000 persons), and LCMV-associated diagnosis defined not otherwise specified (049.9) (3). unspecified non-arthropod–borne by the International Classification Annual numbers were calculated on a viral diseases of the central nervous of Diseases, 9th Revision, Clinical patient basis, whereby the first time a system or viral encephalitis not Modification (ICD-9-CM). Our goal diagnosis was coded for a given patient otherwise specified were diagnosed was to estimate the incidence of during each fiscal year was counted. for 56 patients (incidence rate 0.78 LCMV-associated aseptic meningitis Twenty-six AI/AN patients cases/100,000 persons). and encephalitis diagnosed within a received the diagnosis code of 049.0 Using a population-based analysis well-defined population. during fiscal years 2001–09. Of these of diagnoses for patients who visited

328 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 2, February 2013