Ocular Larva Migrans, an underestimated disease Patricia Mihailescu1, Liliana Voinea2 , Ionica Ceaus1 , Claudia Istrate1 and Carmen Michaela Cretu3

1Parasitology, Eco-Para-Diagnostic, Bucharest, Romania 2University Emergency Hospital - Ophthalmology Department, Bucharest, Romania 3University of Medicine and Pharmacy”Carol Davila”, Bucharest, Romania

Toxocara spp. are roundworms (nematodes) of domestic dogs, cats and foxes. Humans normally become infected by ingestion of embryonated eggs, or improperly cooked liver of paratenic hosts. This helminthic infection is a major cause of blindness and may determine rheumatic, neurologic or asthmatic symptoms.

Toxocara canis – adults P.Mihailescu, C-M.Cretu

Toxocara spp._40x – embrionated egg P.Mihailescu, C-M.Cretu

Toxocara spp.

VLM

Visceral Larva

Migrans

CT

Covert toxocarisis

OLM

Ocular Larva Migrans

Asymptomatic

Toxocariasis

Objectives and methods: to improve the diagnosis of the OLM using the laboratory methods. For that purpose we used serological methods: ELISA for screening and commercial Western Blot (WB) for confirmation. The retrospective study is based on evaluation of clinical files of 54 patients with OLM admitted in Eco-Para-Diagnostic Medical Center from Bucharest, during 2008-2013 out of 96 suspicions of OLM. Results: Out of 96 suspicions of OLM, 54 patients were confirmed and studied using screening and confirmatory tests. The patients were 51.85% males and 48.15% females, aged between 5 and 76 years old. Patients from urban areas 75.92% and 24.08% from rural parts of Romania. Close contact with animals is present in46.29% of them. Associated diseases in 30 patients: VLM, Chlamydia infection , CMV infection and toxoplasmosis .

Toxocara syndromes

Retinalgranuloma

Anterior andposterior

uveitis

Optical nerveaffected

Iridocyclitis

37.04% 35.18%

1.86%

25.92%

Main locations

Investigations

Ophthalmological

exams

Visual acuity - VA

Ocular pressure - OP

Visual field - VF

Anterior segment –

biomicroscopy

Fundus ex:

number, size, activity of focis, retina integrity

Vitreal reaction

Laboratory exams

ELISA/WB test on SERUM and/or OF

WBC,GGT, AST,

ALT, LDH, CK

Proteins, Electrophoresis

Inflammatory syndrome

Total IgE

EO level

Ocular fluid: cytology, enzymes

Imaging diagnosis

Ocular US

CT

IRM

AFG

OCT

D.A. (9145) – RT-PCR Toxoplasma gondii OF - positive

Bibliography:

1. Ajay Singh et al - Detection and Treatment Of Ocular Toxocariasis – Review of Ophthalmology 1/30/2007. 2. Biglan AW et al – Serum and vitreous toxocara antibody in nematode endophtalmitis - Am J Ophthalmol., 1979(88), 898-901. 3. Dickson Despommier - Toxocariasis: Clinical Aspects, Epidemiology, Medical Ecology, and Molecular Aspects Clin. Microbiol. Rev. 2003, 16(2):265. DOI: 10.1128/CMR.16.2.265-272.2003. 4. Feelberg NT et al – Antibody to Toxocara canis in the aqueous humor - Arch.Ophthalmol.,1981 (99. 1563-1564. 5. Magnaval JF et al – Immunodiagnosis of ocular toxocariasis using Western-blot for detection of specific anti-Toxocara IgG and CAP for the measurement of specific anti-Toxocara IgE - J Helminthol 2002 Dec;76(4):335-9. 6. Molk R – Ocular toxocariasis. A review of the literature. Ann.Ophtalmol.,1983 (15), 216-231.

Patricia Mihailescu: patriciamihailescu@yahoo.com

CASE 2. R.I.- 38 years old, male, worker; -Medical history: type II Diabetes, no insulin required February 2011 (local hospital) Symptoms: progressive decrease of vision, up to perception of fingers’s movements, headache RE - Total uveitis, possibly ocular toxocariasis/Secondary glaucoma -Ocular pressure 60 mmHg -Treatment: Corticosteroids , diuretics and anti-diabetes. Increased corticosteroids dosage +Albendazole 800mg/day 10 days → worsened. March 2011 (Bucharest) R E - Ocular pressure 44 mmHG -Fundus ex: vitreal inflammation, retinal folds, macular edema, retinal granuloma, retina detachment. -ELISA Toxocara canis IgG borderline -Avidity Index – low AI 0.46 (recent infection, less than 20 weeks) - WB Toxocara – positive -Treatment: progressively decreased corticosteroids plus Diethylcarbamazine May 2011 RE - Fundus ex: Vitreal inflamation, retinal folds, macular edema, retinal granuloma Central Retinal Vein Thrombosis -Toxocara serology – positive November 2011: R E disorganized eyebal -Fundus ex: Total optic nerve atrophy/Central Retinal Vein Thrombosis / Vitreous precipitates

SEQUELS R.I. (4620/04.11.2011) –

Western Blot Toxocara canis

Case 3. D.A. – male, 60 years old Medical history: Diabetes mellitus, high blood presure MAY 2012 LE - progressive decreasing of vision, headache, red eye, foreign body sensation, skin rash, pruritus, urticaria, migrating poliarthralgya - Fundus ex: hazy vitreous, difficult examination (few data) - ELISA Toxocara – negative - ELISA Toxoplasma gondii IgM - negative and IgG positive Diagnosis: ocular toxoplasmosis Treatment- alternatively 3 weeks with

Azithromycine/Rovamicyne/Clyndamycine +local corticosteroids → secondary glaucoma

DECEMBER 2012 Ocular Fluid: DNA Toxoplasma gondii positive (RT-PCR) WB Toxocara canis – positive Serum: WB Toxocara canis - positive Diagnosis: ocular toxoplasmosis + ocular toxocariasis Treatment: alternative courses -2 courses Diethilcarbamazine + corticosteroids deceased (permanent control of OP), than NSAI - Pyrimethamine + Azithromycine+ NSAI (local and general) - Clindamycine + NSAI (local and general) MARCH 2013 L E – perception of light (difficult examination) R E – cataract surgery – VA 1 AUGUST 2013 RE - VA normal LE - perception of light; secondary glaucoma and cataract) - surgery OCTOBER 2013 RE - VA normal LE – surgery - VA 1/20 (sequels)

D.A.(8781) – Western Blot Toxocara canis (serum)

D.A.(8868) – Western Blot Toxocara canis (ocular fluid)

CASE 1. P.L.- male, 26 years old No relevant medical history; animal contact - SEPTEMBER 2012: LE progressive blurred vision, scotoma Fundus ex: Papilla undefined borders, dilated veins, white yellowish active foci, between macula and papilla, about 1 PD, diffuse and extended sub retinal hemorrhages, Diagnosis: LE Suspicion OLM Laboratory: -Serology for Toxoplasma gondii IgM &IgG (ELISA) - negative - Serology for toxocariasis (ELISA) – borderline - WB Toxocara canis - positive - Low IgG Avidity Index Treatment: -Albendazole + corticosteroids (increased liver enzymes )– intolerance - Diethylcarbamazine - 2 courses Follow up: significant improvement – resorbtion of hemorrhages, no more active lesions

(Voinea & Cretu 2013)

P.L. ( 1229) – Western Blot Toxocara canis – positive

Conclusion: - OLM is a very important disease which causes major damages in the patients’ eyes. - That is the reason why clinicians should pay more attention to recognize the disease and improve the diagnosis, mostly in the areas with many stray dogs.

(Voinea & Cretu 2012)

(Voinea & Cretu 2012)

(Voinea & Cretu 2011)

Ocular MRI- RE retinal detachment

Ocular US- posterior uveitis, vitreal folds