www.elsevier.com/locate/jpedsurg

Visceral larva migrans presenting as acute abdomenin a child

Mustafa Inana,*, Nermin Sakrub, Ulfet Vatanseverc, Selcuk Bilgid

aDepartment of Pediatric Surgery, Faculty of Medicine, University of Trakya, 22030 Edirne, TurkeybDepartment of Microbiology and Clinical Biology, Faculty of Medicine, University of Trakya, 22030 Edirne, TurkeycDepartment of Paediatrics, Faculty of Medicine, University of Trakya, 22030 Edirne, TurkeydDepartment of Pathology, Faculty of Medicine, University of Trakya, 22030 Edirne, Turkey

0022-3468/$ – see front matter D 2006

doi:10.1016/j.jpedsurg.2005.11.081

* Corresponding author. Trakya U

Cerrahisi AD, 22030, Edirne-Turkey. Te

+90 505 527 13 89; fax: +90 284 235 7

E-mail address: mustafainan@trakya

Index words:Visceral larva migrans;

Toxocariasis;

Acute abdomen;

Toxocara canis

Abstract An unusual presentation of visceral larva migrans observed in a patient is reported. A 5-year-

old boy suffering fever, abdominal pain, tenderness, and rigidity in the right lower and upper quadrant of

the abdomen was operated on, with the false diagnosis of acute abdomen, and exploratory surgery was

carried out. The pathological examination of the liver biopsy revealed eosinophil-rich necrotizing

granulomatous inflammation with Toxocara spp larva. The diagnosis was also confirmed by serologic

results. Clinicians should remember that toxocaral visceral larva migrans may rarely mimic an acute

abdomen and cause unnecessary operations.

D 2006 Elsevier Inc. All rights reserved.

Toxocara canis and T cati are distributed worldwide, and

the degree of host damage and the concomitant elicitation of

signs and symptoms vary with regard to which tissue has

been invaded: the liver, lungs, or central nervous system [1].

Human toxocariasis is manifested as 3 distinct entities. The

first is visceral larva migrans (VLM), with typical presen-

tation of fever, pulmonary manifestations, and hepatomeg-

aly. The second one is ocular toxocariasis, and the last one is

covert toxocariasis [2].

To our knowledge, acute abdomen table during the

toxocaral VLM syndrome has not been published in the

English literature [1-7]. We would like to report a patient

who had toxocaral VLM mimicking acute appendicitis and

discuss its clinical features.

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niversitesi Tip Fakqltesi, Cocuk

l.: +90 284 235 7641 1094, GSM:

6 52.

.edu.tr (M. Inan).

1. Case report

A 5-year-old boy presented to the emergency department

(ED) with a primary complaint of abdominal pain and fever

for a 2-day duration. Initially, the pain was dull, constant,

and perceived in the midepigastrium. The pain did not

respond to a dose of acetaminophen taken 2 days earlier at

the onset of his pain. Over the course of 24 hours, the pain

became sharp and colicky and had localized to the right

lower quadrant. The worsening pain was associated with 2

episodes of nonbloody, nonmucous diarrhea and anorexia.

His history was significant for upper airway infection over

the last week. He had been given antibiotic (unknown name)

and metimazol (antipyretic) and had experienced urticaria

after 4 days. He was admitted to another hospital and was

diagnosed to have lower airway infection and urticaria due

to metimizol. He had been given acetaminophen, claritro-

mycin, corticosteroids, and antihistaminics, which partially

improved his symptoms. He was transported to our ED

Journal of Pediatric Surgery (2006) 41, E7–E9

M. Inan et al.E8

because of high white blood cell count, fever, and

abdominal pain indicating acute abdomen. There was no

surgical history. There was no history of pica, association

with cats or dogs, and recent traveling. The family history

was not significant.

At the first examination, the blood pressure was 90/60

mm Hg, the pulse was 132 beats per minute, and the

temperature was 398C axillary (40.58C rectally). The

abdominal examination was significant for mild midepigas-

tric tenderness, and profound tenderness in the vicinity of

McBurney point and right upper quadrant. The patient had

moderate rebound and guarding exclusively in the right

lower quadrant. The examinations of other systems were

normal. Laboratory evaluation disclosed a white blood cell

count of 42,000 cells per mm3 with 50% neutrophils, 10%

lymphocytes, and 40% eosinophils. The hemoglobin level

was 12.3 g/dL. The results of electrolyte studies, liver

function tests, and serum lipase measurements were all

normal. Erythrocyte sedimentation rate was 36 mm/h

(1-12 mm/h) and C-reactive protein was 4.6 mg/dL

(1-10 mg/dL). The urinalysis demonstrated a specific

gravity of 1.025 and was positive for acetone. Radiography

of the chest was normal, but abdominal radiographs showed

paucity intestinal gas and mass effect on the upper and

lower right side of the abdomen with 2 little air-fluid levels

on the right fossa ilaca. The ultrasound examination of the

abdomen revealed hepatomegaly and locular fluid collection

neighboring to the right psoas muscle and kidney.

Parasitic diseases (ascariasis, trichinosis, toxocariasis,

strongyloidiasis, and hook worm infections) or a drug

allergy was considered in this case because the eosinophil

count was markedly elevated and hepatomegaly was found.

However, the presumptive diagnosis of acute abdomen was

entertained based on the progression of the patient’s

symptoms, his abdominal examination, and elevated white

blood cell count. A stool specimen for ova and parasite

examination was also sent to the laboratory. The patient was

observed in the ED for a total of 12 hours. His pain did not

Fig. 1 Pathological examination of liver biopsy demonstrating

Toxocara spp larva (H&E; original magnification �100).

improve on serial abdominal examinations. There was also

no change in the laboratory results. With these findings, he

had undergone exploratory laparotomy. During the inter-

vention, 100 mL of serous-hemorrhagic fluids were found in

the right side of the abdomen, appendix vermiformis was

macroscopically normal, and Meckel’s diverticulum was not

found. During the progress of exploration, multiple small

grayish white nodules on the hepatic surface were observed.

The hepatic capsular integrity was destroyed in some areas

and necrotic material had spilled out of the peritoneum.

However, this necrotic material and the reactionary perito-

neal fluid were well isolated by the abdominal organs. The

abdominal cavity was cleaned, peritoneal fluid samples and

liver biopsy were taken, and an appendectomy was

performed. The patient’s postoperative course was unevent-

ful. Hypergammaglobulinemia, hyperisohemagglutinemia,

anemia, and hypoalbuminemia were not observed in the

patient. His stool examination for ova and parasites was

negative. Peritoneal fluid smears for acid-fast bacilli, and a

culture of the peritoneal fluid were negative. Serology for

T canis (enzyme-linked immunosorbent assay IgG with

secretory-excretory antigen) was highly positive (optical

density/optical density threshold 2813; positive N0.9). In the

pathological examination, eosinophil-rich necrotizing gran-

ulomatous inflammation with Toxocara spp larva in the

liver biopsy (Fig. 1) and normal appendix tissue were found.

After the diagnosis, oral albendazole (25 mg/kg twice daily

for 5 days) was started. The treatment was continued for

3 weeks, resulting in the decrease of eosinophil (8%) and

leukocyte (15,000 cells per mm3) counts.

2. Discussion

Visceral larva migrans is a disease usually observed in

children in which the larvae of animal parasites invade and

reside in human tissues for long periods. Although several

nematodes have been reported to produce VLM such as

Ascaris lumbricoides, A suum, and Capillaria hepatica,

Tcanis appears to be the primary causative agent [3]. Human

toxocariasis occurs after ingestion of infective eggs of Tcanis

and migration of larvae, particularly to liver, lungs, muscle,

and brain. Toxocaral VLM is characterized by malaise, fever,

pulmonary signs and symptoms, hepatomegaly, abdominal

pain, and occasionally, failure to thrive. Marked eosinophilia,

leukocytosis, hypergammaglobulinemia, hyperisohemagglu-

tinemia, anemia, and hypoalbuminemia are the principal

laboratory findings in VLM cases [2,4].

From this perspective, the distinctive features of our case

presented an acute abdomen in the ED, with the absence of

accompanying pulmonary signs and symptoms and absence

of hypergammaglobulinemia especially hyper IgE, hyper-

isohemagglutinemia, anemia, and hypoalbuminemia. During

the evaluation of this case, our first diagnosis was acute

appendicitis, possibly caused by A lumbricoides. However,

during the surgical intervention, the appendix was found to

Acute abdomen: visceral larva migrans E9

be normal; on further exploration, an eosinophil-rich

necrotizing granulomatous inflammation with Toxocara

spp larva was found on the liver surface. This result con-

firmed our definitive diagnosis of VLM due to toxocariasis.

The capsular tension of necrotic inflammation into the

liver tissue and reactionary peritoneal fluid may have caused

his abdominal clinical features. However, we thought that

our patient could be in parasitic infestation in the

preoperative period; his persistent pain in the right lower

abdominal quadrant and continued fever made surgery a

logical and necessary step.

Our case demonstrated that the diagnosis of toxocaral

VLM can be difficult without surgical intervention because

its clinical picture mimics an acute appendicitis, and if liver

abscesses are encountered during abdominal exploration in

such a patient, biopsy should be considered. In addition,

once the diagnosis is established, antihelmintics treatment

should be started as soon as possible [2,3,6]. The present

case report suggests that we are still not fully aware of the

potential gastrointestinal presentations and complications of

T canis infection.

Acknowledgments

The authors thank Metin Korkmaz, MD, and his

colleagues in the Department of Parasitology, Faculty of

Medicine, Ege University for serologic tests of the patient.

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