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  • Recebido em 10.10.2001. / Received in October, 10 t h of 2001.Aprovado pelo Conselho Consultivo e aceito para publicao em 21.05.2002. / A p p roved by the Consultive Council and accepted for publication in May, 2 1s t of 2002.* Trabalho realizado no Hospital de Guarnio de Florianpolis, Santa Catarina. / Work done at "Hospital de Guarnio de Florianpolis", Santa Catarina.

    1 Mdico Dermatologista, Scio efetivo da Sociedade Brasileira de Dermatologia, Florianpolis/SC / M.D. Dermatologist, member of the Brazilian Society of Dermatology, Florianpolis - SC.2 Residente de Pediatria do Hospital Infantil Joana de Gusmo. / Resident in Pediatrics of Hospital Infantil Joana de Gusmo.

    2 0 0 3 by Anais Brasileiros de Dermatologia

    Larva migrans visceral: relato de caso*

    Visceral larva migrans: case report*

    Alexandre Bortoli Machado1 Marice Emanuela El Achkar2

    R e s u m o : La rva migrans visceral doena infecciosa, adquirida por ingesto de ovos provenientes dos ver-mes Toxocara canis e/ou Toxocara cati que infestam ces e gatos; as larvas penetram a parede intestinal emigram atravs dos tecidos levando a alteraes diversas, conseqentes a uma resposta inflamatria imune.1

    Os autores descrevem um caso clnico de l a rva migrans visceral com apresentao clnica atpica.Palavras-chave: l a rva migrans visceral; Toxocara canis; To x o c a r a.

    Summary: Visceral larva migrans is an infectious human disease that occurs following ingestion ofeggs from the environment originating from roundworms which commonly infect dogs and cats,Toxocara canis and Toxocara cati. The larvae penetrate the gut wall and migrate through the tissuescausing disorders consequent to an inflammatory immune response1. The authors describe a clinicalcase of visceral larva migrans with an unusual clinical presentation and also its clinical aspects,diagnosis and treatment are reviewed.Key words: larva migrans visceral; Toxocara canis; Toxocara.

    Machado & A c h k a r 2 1 5

    An bras Dermatol, Rio de Janeiro, 78(2):215-219, mar. / a b r. 2003.

    Caso Clnico / Case Report

    INTRODUOA larva migrans visceral doena causada por hel-

    mintos, Toxocara canis, Toxocara leonina e Toxocara cati,cujos vermes adultos vivem nos tratos intestinais de seushospedeiros, ces e gatos, que liberam grande nmero deovos nas fezes.

    As infeces humanas so espordicas e ocorremem todo o mundo, atingindo principalmente crianas abai-xo de 10 anos de idade, com pico entre um e quatro anos,que, em contato com a sujeira do solo ou areia contamina-da por fezes de animais, ingerem ovos desses parasitas.2

    RELATO DE CASOPaciente de 25 anos, branco, do sexo masculino,

    advogado, natural e procedente de Florianpolis.Paciente previamente hgido, iniciou com leses

    da pele pruriginosas na regio periumbilical, com pro-gresso rpida em poucos dias. Evoluiu com comprome-timento do trax, abdmen e regio deltidea, sendo pre-

    INTRODUCTION Visceral larva migrans is a disease caused by the

    Toxocara canis, Toxocara leonina and Toxocara catihelminths, whose adult worms live in the intestinal tract oftheir hosts, principally dogs and cats, which liberate greatnumber of eggs in their feces.

    Human infections are sporadic and occur all overthe world, affecting mainly children under 10 years of age,with a peak frequency between one and four years old, whoingest eggs of these parasites following contact with soil orsand contaminated by animal feces.2

    CASE REPORT P a t i e n t 25 years of age, white, male, lawyer, natural

    and resident in Florianpolis. The previously healthy patient, reported onset of

    pruriginous skin lesions in the periumbilical region andfast progression within a few days. It coursed with involve -ment of the thorax, abdomen and deltoid area, though with -

  • Figura 1: Dorso dopacienteexibindoextenso comprometi-mento.Figure 1: Back ofpatient, pre -sentingextensiveinvolvement

    216 Machado & A c h k a r

    An bras Dermatol, Rio de Janeiro, 78(2):215-219, mar. / a b r. 2003.

    servados membros, dobras flexurais, regio anogenital,face, mucosas e anexos. Negava qualquer intercorrnciaprvia, bem como uso de medicaes e/ou outros sinais esintomas.

    Ao exame percebiam-se diversas ppulas eritemato-sas, confluentes em alguns pontos, formando placas papulo-sas eritematosas de bordas bem delimitadas (Figuras 1, 2 e 3).

    Os exames laboratoriais de sangue (glicemia, bio-qumica heptica e renal, VHS e sorologias para colageno-ses), parcial de urina e parasitolgico de fezes (trs amos-tras em dias alternados) mostraram-se inalterados, comexceo do hemograma e IgE. O hemograma apresentoueosinofilia relativa com 1092 eosinfilos/mm3 (12%), e osttulos de IgE 836KU/L (normal < 100). Os exames radio-lgicos de trax e a ultra-sonografia abdominal no eviden-ciaram alteraes. A histopatologia da pele demonstrou der-matite perivascular superficial com predomnio de eosinfi-los, bem como espongiose com formao de vesculas con-tendo linfcitos e eosinfilos (Figuras 4 e 5).

    Os diagnsticos iniciais formulados foram: dermati-te de contato alrgica, penfigide bolhoso inicial, vasculiteurticariforme, angete alrgica de Churg-Strauss e sndromehipereosinoflica. Tendo em vista que em nosso meio a prin-cipal etiologia de eosinofilia a infeco parasitria intesti-nal com (potencial) ciclo evolutivo invasivo, procedeu-secom pesquisa sorolgica, por meio de enzima imunoensaio(Elisa) para Echinococus granulosus, Trichinella spiralis,Toxocara canis e Toxocara cati. Evidenciaram-se ttulosreagentes elevados para T. canis de 2,45 (positivo > 1,10) -Laboratrio Balage, Espanha, caracterizando quadro delarva migrans visceral, todavia apenas com repercussescutneas e hematolgicas.

    out affecting the members, flexural folds, anogenital region,face, mucous membranes and annexes. He denied any pre -vious intercurrent disease, use of medications or other signsand symptoms.

    Physical exam showed several erythematous papules,which were confluent in some points, forming papular ery t h e -matous plaque with well-delimited borders (Figures 1, 2 and 3).

    Laboratory exams of blood (glycemia, hepatic andrenal biochemistry, ESR and serology for collagen dis -eases), partial urine and parasitology of feces (three sam -ples from alternate days) were unaffected, except for bloodcount and IgE. The blood count presented re l a t i v eeosinophilia with 1092 eosinophils/mm3 (12%), and IgEtiters of 836KU/L (normal 1.10) -Laboratrio Balage, Spain, characterizing a picture of vis -ceral larva migrans, though with only cutaneous and hema -tological repercussions.

    Figura 2:Presena dediversasleses papu-lo-eritem-atosas, agrupadas econfluentesem regioanterior dotronco. Figure 2:Presence ofdiverse papu -lar-erythema -tous lesionsin groupsand conflu -ent in theanteriorregion of thetrunk

  • Machado & A c h k a r 2 1 7

    An bras Dermatol, Rio de Janeiro, 78(2):215-219, mar. / a b r. 2003.

    Systemic treatment was initi -ated with ivermectin 12mg/day(200g/kg/day) for three consecutivedays with immediate improvement ofthe eosinophilia, as well as totalinvolution of the cutaneous lesions.S e rologic control was requested 30days after treatment, which detectedreduced titers of 0.25 that were con -s i d e red negative (negative 1.10) - Laboratrio Balage, Spain.

    DISCUSSIONThe case concerns a patient

    with visceral larva migrans, who only presented cutaneouslesions and eosinophilia as clinical elements to guide thediagnosis.

    Cases of visceral larva migrans are fre q u e n t l ycaused by Toxocara canis and Toxocara cati, followingingestion of eggs from the environment. These parasitesusually infect dogs and cats, respectively. In man, wheningested eggs reach the intestine, they give rise to larvaethat can result in a potential tissular invasion.10,11

    Most of the carriers do not present signs or symp -toms of infection. The clinical picture (vide Box 1) is veryvariable and can present cough, fever, abdominal pain,hepatomegaly and skin lesions. Severe infections cancause serious re s p i r a t o ry, cardiovascular and neuro l o g i -cal impairment. While an ocular infection can result ina m a u ro s i s .6 , 8

    Realizou-se tratamento sist-mico com ivermectina 12mg/dia(200mg/kg/dia) durante trs diasconsecutivos com melhora imediatada eosinofilia, bem como involuototal das leses cutneas. Solicitou-se sorologia de controle 30 dias apso tratamento, que exibiu ttulos redu-zidos de 0,25, considerados negativo(negativo < 1,00 / borderline 1,00 -1,10 / positivo > 1,10) - LaboratrioBalage, Espanha.

    DISCUSSOTrata-se de paciente portador

    de larva migrans visceral, que apresentou apenas lesescutneas e eosinofilia como elementos clnicos auxiliaresno diagnstico.

    Os casos de larva migrans visceral so ocasionadosfreqentemente por Toxocara canis e Toxocara cati, poringesto de ovos embrionados do ambiente. Tais parasitasinfectam normalmente ces e gatos, respectivamente. Nohomem, os ovos ingeridos, ao alcanarem o intestino, origi-nam larvas que apresentam potencial de invaso tecidual.10,11

    A maioria dos portadores no apresenta sinais e sin-tomas de infeco. O quadro clnico (vide Quadro 1), muitovarivel, pode manifestar-se com tosse, febre, dor abdomi-nal, hepatomegalia e leses da pele. Infeces gravespodem ocasionar grave comprometimento respiratrio, car-diovascular e neurolgico. A infeco ocular pode resultarem amaurose.6,8

    Figura 3: Maior detalhe das leses na

    regio axilar.

    Figure 3: : Close-up of thelesions in the axillaryregion

    Figura 4: Histopatologia (HE 40x) demonstrando quadro infla-matrio inespecfico. / Figure 4: Histopathology (HE 40x) demon -

    strating nonspecific inflammatory picture

    Figura 5: Histopatologia (HE 100x) destacando infiltrado eosinoflico. / Figure 5: Histopathology (HE 100x) highlighting

    eosinophilic infiltrateo.

  • 218 Machado & A c h k a r

    An bras Dermatol, Rio de Janeiro, 78(2):215-219, mar. / a b r. 2003.

    As leses cutneas geralmente esto ausentes.Quando presentes, so inespecficas e polimrficas, predo-minando leses urticadas, papulosas e papulovesiculosas,decorrentes de hipersensibilidade aos parasitas. Tal fato evi-dencia-se pela ausncia de larvas nas leses e predomniode infiltrado eosinoflico histopatologia.3

    O diagnstico de larva migrans visceral pode serestabelecido por sorologia.4,9 O exame histopatolgico apre-senta alteraes inespecficas, freqentemente dermatiteperivascular superficial com predomnio de eosinfilos. Emalguns casos, pode-se observar ainda exocitose de eosinfi-los, bem como vesculas espongiticas.12

    O tratamento geralmente bem-sucedido quando dodiagnstico precoce e emprego correto das drogas anti-hel-mnticas. No h consenso quanto droga de escolha, sendorelatados albendazol e ivermectina com bons resultadosteraputicos.7

    As causas de eosinofilia so muito variveis (videQuadro 2), destacando-se infeces parasitrias, reaes adrogas e reaes alrgicas. Em nosso meio, enfatiza-se opapel das infeces por helmintos, principalmente ascari-dase, estrongiloidase, triquinose e toxocarase. Helmintosque permanecem na luz intestinal e no invadem a mucosacausam pouca ou nenhuma eosinofilia.4,5

    Critrios importantes a serem considerados para odiagnstico de l a rva migrans visceral fundamentam-se emdados epidemiolgicos, quadro clnico polimorfo e eosino-filia perifrica. Ressalta-se, tambm, que grande parte dospacientes apresenta-se previamente hgida, iniciandoabruptamente o quadro, cuja evoluo procede de modovarivel. A sorologia ratifica o diagnstico de l a rv amigrans v i sc eral, havendo entretanto necessidade, algumasvezes de iniciar-se a teraputica de modo emprico, dada agravidade do caso em questo, bem como os altos ndicesde suspeita clnica.

    O caso em questo exibia apenas leses pruriginosaspredominantemente no tronco e eosinofilia. A histria clni-ca permitiu excluir possveis causas como reaes a drogase correlatos. A pesquisa de parasitas nas fezes mostrou-se

    Cutaneous lesions are usually absent. Howeverwhen present they are nonspecific and polymorphic, withp revalently urticarial, papular and papular vesicularlesions, as a result of hypersensitivity to the parasites. Thisaspect is demonstrated by the absence of larvae in thelesions and prevalence of eosinophilic infiltrate onhistopathology.3

    The diagnosis of visceral larva migrans can beestablished by sero l o g y.4 , 9 The histopathological examp resents nonspecific alterations, frequently superficialperivascular dermatitis with a prevalence of eosinophils. Insome cases, exocytosis of eosinophils can also be observed,as well as spongiform vesicles.12

    Treatment is usually successful after precociousdiagnosis and correct use of anthelminthic drugs. There isno consensus regarding the choice drug, though albenda -zole and ivermectin have been reported to offer good thera -peutic results.7

    The causes of eosinophilia are very variable (vide Box2), but are notably due to parasitic infections, reactions tod rugs and allergic reactions. Among our patients, the role ofinfections by helminths is emphasized, especially ascaridiasis,s t rongyloidiasis, trichinosis and toxocariasis. Helminths thatremain in the intestinal tract and do not invade the mucousmembrane cause little to no eosinophilia.4 , 5

    Important criteria to be considered for the diagnosisof visceral larva migrans are based on epidemic data, poly -morphic clinical picture and peripheral eosinophilia. It isalso underscored that the majority of patients were healthybefore an abrupt onset of the picture and their clinicalcourse proceeds in a variable form. Serology confirms thediagnosis of visceral larva migrans, though there is some -times a need to begin empiric treatment, given the gravity ofthe case, as well as a high index of clinical suspicion.

    The case in question only presented pruriginouslesions, predominantly in the trunk and eosinophilia. Theclinical history allowed the exclusion of possible causessuch as reactions to drugs or similar substances. Tests forparasites in the feces proved to be negative. Faced with the

    Quadro1: Quadro clnico de larva migrans visceral / Box 1: Clinical picture of visceral larva migrans

    Sintomas gerais / General symptoms

    Gastroenteorolgico / Gastroenterological

    Neurolgico / Neurological

    Cardiovascular / Cardiovascular

    Pneumolgico / Pneumological

    Dermatolgico / Dermatological

    Oftalmolgico / Ophthalmological

    Hematolgicos / Hematological

    Febre, astenia, sudorese / Fever, asthenia, sudoresis

    Dor abdominal, hepatoesplenomegalia / Abdominal pain, hepatosplenomegaly

    Cefalia, meningite, convulses / Cephalea, meningitis, convulsions

    Tamponamento cardaco / Cardiac tamponade

    Pneumonite / Pneumonitis

    Exantemas com diversas configuraes, freqentemente pruriginososExanthemas with diverse configurations, frequently pruriginous

    Amaurose / Amaurosis

    Eosinofilia, hipogamaglobulinemia / Eosinophilia, hypogammaglobulinemia

  • Machado & A c h k a r 2 1 9

    An bras Dermatol, Rio de Janeiro, 78(2):215-219, mar. / a b r. 2003.

    REFERNCIAS / REFERENCES1. Herry I. Acute life-threatening toxocaral tamponade. Chest1997 Dec; 112(6): 1692-3.2. Tierney Jr LM, McPhee SJ, Papadakis MA. Larva MigransVisceral (Toxocarase). LANGE...

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