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Toxocariasis: a Rare Cause of Multiple Cerebral Infarction Hyun Hee Kwon Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea

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Toxocariasis: a Rare Cause of Multiple Cerebral Infarction Hyun Hee Kwon Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea Case Report Infection & http://dx.doi.org/10.3947/ic.2015.47.2.137 Infect Chemother 2015;47(2):137-141 Chemotherapy ISSN 2093-2340 (Print) · ISSN 2092-6448 (Online) Toxocariasis: A Rare Cause of Multiple Cerebral Infarction Hyun Hee Kwon Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea Toxocariasis is a parasitic infection caused by the roundworms Toxocara canis or Toxocara cati, mostly due to accidental in- gestion of embryonated eggs. Clinical manifestations vary and are classified as visceral larva migrans or ocular larva migrans according to the organs affected. Central nervous system involvement is an unusual complication. Here, we report a case of multiple cerebral infarction and concurrent multi-organ involvement due to T. canis infestation of a previous healthy 39-year- old male who was admitted for right leg weakness. After treatment with albendazole, the patient’s clinical and laboratory results improved markedly. Key Words: Toxocara canis; Cerebral infarction; Larva migrans, visceral Introduction commonly involved organs [4]. Central nervous system (CNS) involvement is relatively rare in toxocariasis, especially CNS Toxocariasis is a parasitic infection caused by infection with presenting as multiple cerebral infarction. We report a case of the roundworm species Toxocara canis or less frequently multiple cerebral infarction with lung and liver involvement Toxocara cati whose hosts are dogs and cats, respectively [1]. due to T. canis infection in a previously healthy patient who Humans become infected accidentally by ingestion of embry- was admitted for right leg weakness. onated eggs from contaminated soil or dirty hands, or by in- gestion of raw organs containing encapsulated larvae [2]. Keeping dogs and ingestion of raw cow liver are associated Case Report with increased risk of toxoriasis. A cross-sectional study of Ko- rean patients reported that a recent history of eating raw cow A 39-year-old right-handed man with no significant past liver was associated with an increased risk of toxocariasis [3]. medical history was admitted to the hospital with a 3-day his- Clinical manifestation range from asymptomatic infection to tory of right leg weakness. He had undergone discectomy for fulminant disease, and the lungs, livers, and eyes are the most herniated nucleus pulposus at the L5-S1 level 8 years prior Received: April 21, 2015 Revised: May 29, 2015 Accepted: June 5, 2015 Corresponding Author : Hyun Hee Kwon, MD Department of Internal Medicine, Daegu Catholic University Medical Center, 33 Duryugongwon-ro 17-gil Nam-gu, Daegu 705-718, Korea Tel: +82-53-650-4708, Fax: +82-53-621-4106 E-mail: [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and repro- duction in any medium, provided the original work is properly cited. Copyrights © 2015 by The Korean Society of Infectious Diseases | Korean Society for Chemotherapy www.icjournal.org 138 Kwon HH • Toxocariasis and cerebral infarction www.icjournal.org A B Figure 1. Diffusion-weighted brain magnetic resonance imaging showing multifocal small acute infarctions in the internal border zone of both the cerebral hemisphere (A) and left cerebellar hemisphere (B). and had not experienced any complications. He smoked a temporooccipital lobes of both PCA territory, and left cerebel- pack of cigarettes per day for 20 years. He habitually ate un- lar hemisphere (Fig. 1). Chest CT showed multiple peripheral dercooked meat, including 2 weeks prior to admission. He ground glass opacities in both lungs that were considered eo- had no recent history of contact with pet animals and no past sinophilic pneumonia (Fig. 2). Abdominal CT on portal phase medical history of allergy. showed small ill-defined hypodense lesions in both lobes of the On admission, his blood pressure was 120/80 mmHg, his liver that were considered eosinophilic infiltrations (Fig. 3). His pulse was regular at 88 beats per minute, and his temperature CSF contained 0/mm3 WBC, 63 mg/dL protein, and 49 mg/dL was 36.8℃. There were neither audible carotid bruits nor car- sugar; no bacteria or viruses were detected. diac murmurs. Neurological examination revealed alert men- Because he had marked eosinophilia and multiple eosino- tal status and grade 3 weakness of the right leg. Deep tendon philic infiltrations in both lungs and liver, serologic testing for reflexes were increased in his right leg. Fundoscopy results parasitic infections was performed. Serologic test result (per- were normal. formed at Seoul Clnical Laboratory (SCL), Seoul, Korea) for T. His white blood cell count was 11,900/mm3 with 26.7% eo- canis IgG antibody via enzyme-linked immunosorbent assay sinophils (2,600/mm3). Laboratory data were as follows: he- (ELISA, Bordier Affinity Products SA, Crissier, Switzerland) moglobin, 14.5 g/dL; platelets, 160,000/mm3; aspartate ami- was positive with an antibody titer of 3.12 (reference range notransferase, 37 IU/L; alanine aminotransferase, 20 IU/L; <1.00). This method has 91% sensitivity and 86% specificity [5]. alkaline phosphatase, 61 IU/L; creatinine 0.7 mg/dL; C-reac- Results of serologic tests for other helminthes (cysticercus, tive protein, 32.8 mg/L; and erythrocyte sedimentation rate, Paragonimus westermani, Clonorchis sinensis sparaganum, 38 mm/h. Renal function and electrolytes were normal. The Entamoeba histolytica) were all negative. Any larva was not Venereal Disease Research Laboratory (VDRL) test and hu- found in the CSF and CSF ELISA assay for T. canis IgG anti- man immunodeficiency virus (HIV) antibody test in serum body was negative. were negative. Electrocardiogram showed normal sinus While biopsy could be performed to find Toxocara larva in rhythm and transthoracic echocardiogram showed no evi- the affected tissue and confirm the diagnosis, toxocariasis is dence of mural thrombi or vegetations. Diffusion-weighted usually diagnosed based on a combination of clinical symp- brain MRI revealed multifocal small embolic acute infarctions toms, exposure history, marked eosinophilia, characteristic in the internal border zone of both cerebral hemispheres, imaging findings and positive toxocariasis ELISA results. Thus, www.icjournal.org http://dx.doi.org/10.3947/ic.2015.47.2.137 • Infect Chemother 2015;47(2):137-141 139 Figure 2. Chest computed tomography shows multiple peripheral ground opacities in both lungs. Figure 3. Abdomen computed tomography on portal phase shows small ill-defined hypodense lesions (arrows) in both lobes of the liver. the patient was diagnosed with multiple cerebral infarction cluding CT scan and brain MRI were planned but the patient and concurrent multi-organ involvement due to T. canis in- didn’t visit our hospital. fection without tissue biopsy. He was treated with albendazole (400 mg twice daily for 2 weeks) and steroid (prednisolone 30mg twice daily for 7 days). Prednisolone was gradually ta- Discussion pered for one month. On day 14 of albendazole administra- tion, his leukocytosis was 14,300 /mm3 with 2.7% eosinophils. Toxocariasis is a zoonotic parasitic infection contracted In subsequent weeks, the patient’s leg weakness improved to from dogs and cats. This disease occurs in developed coun- grade 4. Two months after treatment, the follow-up tests in- tries as well as in the tropics and sub-tropics where dog treat- 140 Kwon HH • Toxocariasis and cerebral infarction www.icjournal.org ment and population control are limited [3]. Human infection toxocariasis due to the rarity of the disease. Albendazole is the occurs by ingestion of embryonated eggs in contaminated soil most commonly used drug as it can penetrate the cerebrospi- or on unwashed hands, therefore high exposure to dogs and nal fluid and has acceptable toxicity. Other antihelmintics in- cats and contaminated soil are associated with toxocariasis clude thiabendazole, mebendazole, oxibendazole, and [2]. Occasionally, toxocariasis is caused by consumption of flubendazole. Concurrent administration of corticosteroids raw liver and meat contaminated with larvae of T. canis. In has been used to suppress intense allergic responses [1, 9]. In South Korea, chops of raw cow liver and meat are popular some studies, corticosteroids were effective at relieving seri- dishes and are thought to have health benefits; toxocariasis, ous neurologic symptoms brought on by an intensive inflam- including subclinical toxocariasis, is therefore prevalent in matory response [17] and increased plasma levels of albenda- South Korea [3, 6]. We report here a case of toxocariasis pre- zole by approximately 50% [18]. senting as multiple embolic infarction with concurrent viscer- Because ingestion of uncooked cow liver and meat in South al migrans involving the lungs and liver. The patient frequently Korea is common, toxocariasis is prevalent. This infection has consumed raw cow liver and meat, and this was likely the various clinical manifestations including asymptomatic eosin- source of infection. ophilia and eosinophilic infiltration of the lungs, liver, and Toxocara can infect any organ, but is commonly recognized eyes. Central nervous system (CNS) involvement is relatively in the lungs, liver, and eyes [4]. Although T. canis can cross the rare in toxocariasis, especially CNS presenting as multiple ce- blood-brain barrier, CNS infection is rarely reported, but epi- rebral infarction. However, physicians
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