parasitic pulmonary disease (rev)2

8/3/2019 Parasitic Pulmonary Disease (Rev)2

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RESPIRATORY TRACT

PARASITIC INFECTION

(PARASITIC PNEUMONIA)

Teguh Wahju Sardjono

SudjariAswin Djoko Baskoro2010-2011


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Learning Objectives

After getting this lecture, student has ability to :

- Describe the kind, biology and life cycle ofparasites which infect respiratory tract

- Explain the pathogenesis, clinical manifestation,treatment, prevention and rehabilitation ofpulmonary diseases caused by parasites


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Introduction

The Anatomy of Lung


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Parasitic Pneumonia

Definition

Parasitic pneumonia is an infection of the lungs by parasites.It is a rare cause of pneumonia, occurring almost exclusivelyin immuno-compromised persons.

This is a respiratory infection that may or may not be serious.

Classification ( topics which will be discussed right here)

Helminthic Pneumonia (egg, larval and adult stage) Nematodes

Loeffler Syndrome

Occult Filariasis Cestodes (Hydatid cyst). Trematodes (Bronchopulmonary bilharziasis i.e. Schistosomiasis,

paragonimiasis). - Protozoal Pneumonia

Amoebic Lung Absces

Pneumocystic Pneumonia

Toxoplasmic Pneumonia


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Helminthic Pneumonia

1. Nematodes : Larvae Loefflers syndrome Occult filariasis

2. Cestodes : Hydatid cyst

3. Trematodes : rare cases

Egg : Schistosoma/ Bilharziasis

Pathogenesis : Verminous pneumonitis i.e. focal pneumonia caused by the

worms of bilharziasis when reaching the lungs.

Bilharzial granuloma or bilharzial tubercles that represent adistinctive reaction around the ovum after it penetrates the vesselwall

Adult : Paragonimiasis


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Loefflers Syndrome

(Lffler's syndrome)

Is a disease in which a certain type of white blood cell

(eosinophil) accumulates in the lung in response to a

parasitic infection.

It was first described in 1932 by Wilhelm Lffler

in casesof eosinophilic pneumonia caused by the parasites

Ascaris lumbricoides,

Strongyloides stercoralis

Hookworms : Ancylostoma duodenaleand Necator americanus.

Many authors give the term "Lffler's syndrome" to any

form of acute onset pulmonary eosinophilia no matter

what the underlying cause.


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commonname :

human round

worm

the largest of the intestinal nematodes parasitizing humans.

worldwide in distribution

most prevalent through out the tropics, sub-tropics

more prevalent in the countryside than in the city Infection initiated by swalowing infective stage of eggs

hatch in the intestine blood stream lung migration

pathologic effects

Ascaris lumbricoides


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Hookworms

There are 2 species that infecthuman :

1. Ancylostoma duodenale

2. Necator americanus

Adult stage parasitizesintestinal tract produce eggs

Eggs hatched on the soil to berhabditiform filariform larva

Larvae penetrate the skin

blood stream migrates

through lungs (lung migration) pathologic effects


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Strongyloides stercoralis Adult: Parasitizes intestinal tract

produces eggs, hatched to be larvae

Larvae : Penetrates skin Migratesthrough lungs

Asymptomatic - most

Acute infection Migrating larvae in lungs

(Loefflers)

Migration through intestinal tract abdominal pain and diarrhea

Heavy infection malabsorption,

steatorrhea, weight loss andedema

Eosinophilia - not constant finding


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The blood-lung migration phase of

the larvae Lffler's syndrome

During the migration through the lungs

- the larvae may cause a pneumonia.

- The symptoms/Clinical manifestation of the pneumonia are:

- low fever,- cough,

- blood-tinged sputum,

- asthma.

- Large numbers of worms may give rise to allergic symptoms.- Eosinophilia is generally present.

.


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Occult Filariasis

Occult Filariasis is commonly used to designate filarial infections inwhich microfilaria (mf) are not found in the peripheral blood althoughthey may be seen in tissues. However, it has now been shown that insome cases with occult filariasis, mf may actually be found after morecareful blood examination despite their low density.

Occult filariasis is believed to result from a hypersensitivity reactionto filarial antigens derived from microfilariae. Only a very smallproportion of individuals in a community where filariasis is endemicdevelop occult forms of the disease.

Caused by the larvae of :

- Wuchereria bancrofti

- Brugia malayi

- Brugia timori


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The clinical manifestations of Occult

filariasis

Tropical Pulmonary Eosinophilia(TPE)

Glomerulopathies(Granulonephritis)

Endomyocardial fibrosis

Filarial Arthritis

Filarial granulomas in the breast


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Tropical Pulmonary Eosinophilia(TPE)

was first described by Frimodty Moller and Barton in 1940. Its main clinical symptoms are:

Severe Cough and wheezing (specially at night)

Frequent weight loss and fatigue but with minimal or no fever.

Restrictive or obstructive lung abnormalities.

Abnormal chest radiographs that frequently show diffusemottled pulmonary interstitial infiltrate.

Peripheral blood eosinophilia > 3000 cell/l

Extreme elevation of immunoglobin (IgE)

Extreme elevation of anti-filarial antibodies

caused by an immune hyperresponsiveness to microfilariae

trapped in the lungs

typically seen in young males.


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Tropical Pulmonary Eosinophilia

(TPE)

Detection:Using IFAT(Indirect Flourescent Antibody Test)filarial antibodies are detected.

Treatment:Dramatic clinical improvement in response tospecific anti-filarial chemotherapy with DEC


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GLOMERULOPATHIES (GLOMERULONEPHRITIS)

Glomerulonephritis is associated with lymphatic filariasis.

Filarial antibodies have been detected in 2 of 5 children withfilariasis and acute glomerulonephritis.

Renal biopsy showed diffuse messangial proliferativeglomerulonephritis with C3 deposition on the basement

membrane. The condition responds well to DEC therapy.


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Filarial granulomas in the breast

particularly prevalent in India and Srilanka whereW.bancroftiis the predominant species.

Filarial granulomas present as hard breast lumps

attached to the overlying skin

difficult to distinguish from malignant tumours.

Histological examination an eosinophilic

granulomatous reation around the filarial parasites

which are in varying stages of degeneration.

Both adult worms and mf have been found in the

granulomas. Filarial antibodies have been demonstrated in

these patients and the condition responds to DEC

therapy which, in many instances, can lead to

complete disappearance of the lump.


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Pulmonary Hydatid cyst

Hydatid disease is a parasitic infestation by a tapeworm of the genusEchinococcus

Human echinococcosis is a zoonotic infection caused by thetapeworm of the genus Echinococcus.

Of the 4 known species ofEchinococcus, 3 are of medical importance

in humans: Echinococcus granulosus, causing cystic echinococcosis (CE);

Echinococcus multilocularis, causing alveolar echinococcosis (AE);

Echinococcus vogeli.

E granulosus is the most common of the three. E multilocularis is rarebut is the most virulent

Pulmonary hydatid diseases are less prevalent rather than hepatichydatid disease


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Life cycle and pathogenesis

Definitive host: dogs and other canidae adult worm = EchinococcosisIntermediate host : (sheep, goat, swine and also human) got infection byingestion of embryonated eggs larvae invade and live inside severalorgans eg. Liver (the most prevalent) lung, brain heart etc)


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Hydatid cyst

Clinical picture of the ruptured cyst:

30% of pulmonary cysts rupture, especially those with a diametergreater than 7 cm. Rupture may occur spontaneously or as aresult of coughing, sneezing, muscular effort, trauma to the chestor infection.

A communication with the bronchial tree allows air to leak intothe potential space between the pericyst and the laminar layer.The air localizes at the superior aspect of the cyst, giving rise tothe meniscus radiological sign (air cap or operculum) i.e. haloappearance.

Rupture of a cyst produces an abrupt cough with expectorationand fever; hemoptysis is common.


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Diagnosis:

A high index of suspicion is invaluable, rural residenceand contact with dogs are suggestive.

Diagnosis is established radiologically andserologically.

The complement fixation test (Casoni test). It ispositive in 66% cases.

The indirect hemagglutinin test. It is positive in about70% of cases.

Treatment :Surgical excision is the best.


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Radiological Diagnosis

A 5 6 cm circular lesionlocated in the apex of theright lung at X-ray.

A round partially filled cysticopacity of >8cm diameter in

right lower zone.A case with bilateral hydatidcysts at lower zone of thorax.

Microscopic features ofhydatid cyst.


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C. Adult form : Paragonimiasis

caused by Paragonimus westermani

Geographic Distribution:Mostly in Far East, some speciesalso found in Southeast Asia(Thailand, Cambodya etc)

Habitat of adult worm Can migrate to other organ esp

brain and striataed muscle

Infection in human may as long as20 years.

Cat, dog and pig can be the host


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Clinical symptoms

Acute phase (invasion and migration):

Pulmonary disturbance, diare, abdominal pain, fever, cough,urticaria, hepatosplenomegaly.

Chronic phase, lung symptoms eg cough, hemoptisis (bloody cough) abnormal radiological appearance

Lesion in other organsmore severe (eg : brain)

Laboratory Diagnosis By finding the eggs in stool or sputum examination

(2-3 months after infection)

Treatment- Praziquantel (drug of choice).

- Bithionol

Oval shape, brown colour,(85 m x 53 m) with operculum

On one side and thickening of the wallAt the opposite of the operculum


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Broncho-Pulmonary Bilharziasis

(Schistosomiasis)

This includes:

Verminous pneumonitis i.e. focal pneumonia caused by theworms of bilharziasis when reaching the lungs.

Bilharzial granuloma or bilharzial tubercles that represent adistinctive reaction around the ovum after it penetrates the

vessel wall. Pleural effusion is reported secondary to hypoproteinemia or

after administration of anti-bilharzial treatment.

Demonstration of bilharzial ova in the sputum was also reported.

Bronchospasm simulating an asthmatic attack can also occur

early in the course of the disease or during anti-bilharzialtreatment.

Hemoptysis can occur during the larva through the lung.

Interstitial fibrosis can also occur.

Transient pulmonary infiltration with oesinophils.


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Diagnosis

Adults of Schistosomaspp. in lung tissue, stained with H&E.Images courtesy of Harvard Medical School, Cambridge, MA


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The protozoa causing humanamebiasis, Entamoebahistolytica, is not primarily arespiratory tract parasite.However, pleuropulmonary

involvement may arise as acomplication of amebic intestinalor extraintestinal disease.

infection of the lung by amebae;usually indicates extension ofEntamoeba histolytica infectionfrom abscess of liver, penetratingthrough the diaphragm into thelung.

Pulmonary amebiasis

Type of extra intestinal Amoebiasis


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Pulmonary amebiasis

Amebic pulmonary disease candevelop in several waysRupture of an amebic hepatic abscessthrough the diaphragm, which is themost commonLymphatic spread from the liverthrough the diaphragm

Hematogenous embolic spread fromthe liver or colon, an unusual disorderthat should be suspected when there ispulmonary amebiasis without hepaticdisease or noncontiguous pulmonaryand hepatic diseaseFever, enlarged tender liver, weightloss, pain in the lower chest andshoulder may be found. Leucocytosis,mild anemia and raised sedimentationrate are also present.


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Pleuropulmonary amebiasis is a very rare complication of

amebiasis infection Direct pulmonary involvement is exceptional.

The clinical diagnosis is difficult without any intestinalor extraintestinal manifestations.

Extension of infection through the diaphragm may resultin fibrinosis pleurisy, pleural effusion or basal pneumonia.

Radiologically, there may be elevation of the right hemi-diaphragm or obliteration of the costo-phrenic angle by

pleural effusion.


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Medical TreatmentAntibiotics in lung abscess

Anaerobic organisms: First choice - Clindamycin (Cleocin 3)

Alternative - Penicillin

Oral therapy - Clindamycin, metronidazole (Flagyl), amoxicillin (Amoxil)

Gram-negative organisms First choices - Cephalosporins, aminoglycosides, quinolones

Alternatives - Penicillins and cephalexin (Biocef)

Oral therapy - Trimethoprim/sulfamethoxazole (Septra)

Pseudomonal organisms: First choices include aminoglycosides, quinolones, and cephalosporin.

Gram-positive organisms

First choices - Oxacillin (Bactocill), clindamycin, cephalexin, nafcillin (Nafcil), andamoxicillin

Alternatives - Cefuroxime (Ceftin) and clindamycin

Oral therapy - Vancomycin (Lyphocin)


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Synthetic Emetine Dehydroemetine, a synthetic product, introduced into therapeutics

in 1961, replaces Emetine : six times more active than Emetine,half as toxic and of being eliminated twice as rapidly. Some timelater, it is produced in the form of sugar-coated pills, which simplifies

its administration.The derivatives of nitroimidazole

Metronidazole, had been used since 1966 revolutionizes thetreatment of all forms of Amoebiasis and leads gradually to thedisappearance of all the other medicines. It is easily administered,

well-tolerated and effective on the vegetative forms and cysts. Thismedicine is a complete amebicide.

Surgery : irigation abscess fluid using water sealed drainage (WSD)


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Pneumocystis Carinii

This organism appears as minute oval bodies or cysts 5-10 mm inlength and is probably related to the protozoa. It causes pneumoniain infants of a few months of age and in adults who areimmunosuppressed.

Breathlessness and tachypnea are the main features, other physicalsigns are rarely helpful.

Gas exchange becomes progressively impaired with progressive fallin the transfer factor and ultimately cyanosis.

The X-ray shows widespread mottling which is slowly progressive.

The diagnosis may be confirmed by lung biopsy (usually

transbronchial biopsy) or broncho-alveolar lavage.


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Pulmonary toxoplasmosis

Toxoplasmosis is an infection due to the parasite Toxoplasma gondii.

The disease can affect the brain, lung, heart, eyes, or liver, but mostprimary infections produce no symptoms. The time betweenexposure to the infection and symptom development is 1 - 2 weeks.

Pulmonary Toxoplasmosis should be considered in patients with HIVreceiving Aerosolized Pentamidine, who have fever and pulmonarydisease but do not respond to IV Pentamidine, especially if CPK, LDHand IgG to T. gondii are elevated.

The diagnosis of Pulmonary Toxoplasmosis in HIV disease may bedelayed or overlooked, leading to death from a treatable infection.

Medications to treat the infection include an antimalarial drug andantibiotics. AIDS patients should continue treatment for as long astheir immune system is weak to prevent the disease fromreactivating.

parasitic pulmonary disease (rev)2

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