Eur J Gen Med 2004; 1(2): 43-45 CASE REPORT PULMONARY EDEMA ASSOCIATED WITH ASCARIS LUMBRICOIDES IN A PATIENT WITH MILD MITRAL STENOSIS: A CASE REPORT Talantbek Batyraliev1, Beyhan Eryonucu2, Zarema Karben1, Hakan Sengul1, Niyazi Güler2, Orhan Dogru1, Alper Sercelik1 Sani Konukoglu Medical Center , Department of Cardiology1 Yüzüncü Yıl University, Department of Cardiology2 Ascaris lumbricoides remains the most common intestinal nematode in the world. Clinical manifestations of ascaris lumbricoides are different in each stage of the infection. We presented an unusual presentation of ascaris lumbricoides. Key words: Pulmonary oedema, mild mitral stenosis, Ascaris lumbricoides INTRODUCTION oedema due to mitral stenosis. Treatment of Ascaris lumbricoides (AL) remain the most diuretics was initiated. She was placed on common intestinal nematode in the world. oxygen by nasal cannula. Tachycardia was not Clinical manifestations of AL are different taken under control by treatment with digoxin in each stage of the infection. Infection with and verapamil. A reason for excessive nausea ascaris appears to be asymptomatic in the vast and vomiting was not determined and these majority of cases, but may produce serious semptoms were not responsive to antiemetic pulmonary disease or obstruction of biliary drugs. Despite intensive treatment, clinical or intestinal tract in a small proportion of improvement was not occured. Fortunately, at infected people. We presented an unusual the 3rd day, the patient was expelled ascaris presentation of AL and pulmonary edema lumbricoides (AL) (Figure). Once the AL was (1,2). removed the patient’s respiratory condition dramatically improved. The patient was CASE started on a 3-day course of mebendazole A 27-year-old woman was admitted to and discharged 4 days later in good general our hospital because of an episode of acute condition. severe dyspnea, nausea and vomiting. Her medical history revealed rheumatic mild DISCUSSION mitral stenosis. On admission, the patient was Severe pulmonary edema due to mild mitral in moderate respiratory distress and slightly stenosis is an unexpected finding. In this agitated. The vital signs were as follows: case, we suspected pulmonary edema due to blood pressure; 125/75mmHg, pulse; 138 mitral stenosis because of the medical history beats/min, respiratory rate; 40breaths/min, and of the patient at admission. Expiration of AL temperature; 37.3oC. Auscultation revealed helped diagnosis and treatment of this patient. loud S1, a grade 2/6 diastolic murmur. The Dramatic and rapid clinical improvement after lung fields had bilateral diffuse crackles. The expelling of AL with vomitting indicated remainder of the physical examination was that the reasons of pulmonary edema were normal. Laboratory values were within normal excessive tachycardia, shortened diastolic limits. An ECG showed sinus tachycardia. filling period and elevated left atrial and Cardiac enzymes were normal. Chest X ray pulmonary venous pressure associated with revealed pulmonary oedema and normal nausea and vomiting. To our knowledge cardiac size. Transthoracic echocardiography pulmonary edema associated with AL has not was performed to confirm valve function been reported. and showed mild mitral stenosis (valve area Ascariasis is caused by the parasite AL, 1.9cm2) and normal left ventricular function. the largest intestinal nematode found in The patient was treated as acute pulmonary humans. Ascariasis remains the most common intestinal nematode in the world. It is widely Correspondence: Dr. Beyhan Eryonucu distributed in tropical and subtropical regions Yüzüncü Yıl Universitesi Tıp Fakultesi Kardiyoloji AD where there is insufficient sanitation, hygiene, 65100 Van–Turkey and education regarding these parasites. Phone: +90 432 2157058 E-mail: [email protected] 44 Batyraliev et al. hemoptysis, dyspnea, and wheezing due to (1) Loffler’s syndrome, (2) the effects of larval tissue migration, (3) airway reactivity or bronchospasm, (4) infectious bacterial complications from parasitic migration and associated aspiration, and rarely (5) chronic eosinophilic pneumonia, transdiaphragmatic penetration, or symptoms of upper airway obstruction. Clinical evaluation shows 15cm pulmonary opacities on chest radiograph, peripheral blood eosinophilia, and larvae in respiratory or gastric secretions (1-3). Loeffler’s syndrome is another clinical manifestation of AL infection. It is most commonly seen in children and presents as cough; dyspnea; wheezing; sudden-onset fever; substernal chest discomfort; and less Figure. Ascaris lumbricoides commonly, hemoptysis. Symptoms develop 9–12 days after ingestion of the eggs and Ascariasis generally occurs through hand- last 2 to 3 weeks. The hallmark of Loeffler’s to-mouth ingestion of agricultural products or syndrome is fleeting pulmonary infiltrates on food contaminated with parasite eggs. chest X-ray, often accompanied by peripheral Rarely, transmission can occur via eosinophilia (3). inhalation of eggs or swallowing contaminated The most important tools for the respiratory secretions. The life cycle of AL diagnosis of AL infection are history, chest is complex and begins with the ingestion of X-ray, and ultrasonography. Diagnosis is eggs. The larvae penetrate the intestinal wall by microscopic detection of eggs in fecal and enter surrounding capillaries where they samples. Occasionally, patients present migrate through the lungs 1–2 weeks after after passing an adult worm in the stool or the initial ingestion. In the lungs, the larvae through the mouth or nose. During the early again penetrate the capillary walls, entering transpulmonary migratory phase, larvae can the alveolar space where they ascend the be found in sputum or gastric aspirates. AL tracheobronchial tree to the epiglottis, where may enter into nasogastric and endotracheal they are eventually swallowed. The larvae tubes and block their lumen (4-6). reach the small intestines, most commonly The classic treatment choices are the jejunum, where they mature into adult mebendazole orally twice a day for 3 days, worms. They live from 10 to 24 months and albendazole orally as a single dose, or are produce up to approximately 240,000 eggs pyrantel pamoate orally as a single dose not per day 2–3 months after the initial infection. to exceed 1 g. A stool ova and parasites test Adult forms may reach up to 40 cm in length should be repeated 2 weeks after treatment to and live for two years (1). ensure adequate eradication of the helminth Several clinical manifestations of because these medications typically do not this infection are reported. Typically, have an effect on the larvae. Pulmonary complications occur as a result of a large ascariasis is typically a self-limited disease obstructing mass of worms in the intestines, requiring only supportive therapy. However, the induction of stones by a single worm in if there is a superimposed bacterial infection, the hepatobiliary tree, or an inflammatory appropriate antimicrobial therapy is reaction with the migration of adult worms warranted. Antibiotics also may be indicated and larvae through tissue. 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