Chronic polyarthritis as isolated manifestation of toxocariasis

ABSTRACT

Human toxocariasis is a parasitic zoonosis mainly caused by Toxocara canis or Toxocara catiand is acquired by ingestion of the parasite’s embryonated eggs. Arthralgia and/or arthri-tis were reported in up to 17% of the cases, generally with acute duration (less than 6weeks). However, to our knowledge, chronic polyarthritis, as the isolated presentation ofToxocara infection, was not reported. One of the 5809 patients that was followed up at ourservice (0.017%) had chronic polyarthritis as the single manifestation of toxocariasis and wasdescribed herein. A 3-year-old girl was referred to our service with severe painful chronicpolyarthritis for a period longer than 10 weeks and morning stiffness of 30 min. Dog contactexposure history in the recreational areas of neighborhood was reported. Her exams showedhigh levels of eosinophils in peripheral blood (29%), bone marrow aspirate revealed markedeosinophilia (32%) and Toxocara enzyme-linked immunosorbent assay (Elisa) was positive(1:1280). She was treated with paracetamol (40 mg/kg/day) and thiabendazole (25 mg/kg/day)for 10 days, and all manifestations reduced. After eight months of follow-up, she was onclinical and laboratorial remission. In conclusion, we described a case of chronic polyarthri-tis, as isolated manifestation of toxocariasis, mimicking juvenile idiopathic arthritis andleukemia. Importantly, this zoonosis should be considered in patients with arthritis andeosinophilia.

Keywords:
Systemic lupus erythematosus; Acute acalculous cholecystitis; Abdominal computed tomography; Abdominal computed tomographyInitial

RESUMO

A toxocaríase é uma zoonose parasitária causada principalmente pelo Toxocara canis ou peloT. cati. É adquirida pela ingestão de ovos embrionados do parasita. A artralgia e/ou artriteforam relatadas em até 17% dos casos, geralmente com duração aguda (menos de seis sema-nas). No entanto, que se tem conhecimento, a poliartrite crônica como manifestação isoladada infecção por Toxocara ainda não foi descrita na literatura. Um dos 5.809 pacientes acom-panhados em nosso serviço (0,017%) exibiu poliartrite crônica como manifestação únicada toxocaríase e foi descrito neste estudo. Uma menina de três anos foi encaminhada aonosso serviço com poliartrite crônica dolorosa grave por um período superior a 10 semanase rigidez matinal diária de 30 minutos. Foi relatada história de exposição a contato comcão nas áreas de lazer do bairro. Seus exames revelaram níveis elevados de eosinófilos nosangue periférico (29%), o aspirado de medula óssea revelou eosinofilia acentuada (32%)e o ensaio imunoenzimático ligado a enzima (ELISA) para Toxocara foi positivo (1:1.280). Acriança foi tratada com paracetamol (40 mg/kg/dia) e tiabendazol (25 mg/kg/dia) durante10 dias e houve regressão de todas as manifestações. Depois de oito meses de seguimento,a pequena paciente estava em remissão clínica e laboratorial. Em conclusão, descreve-seum caso de poliartrite crônica como manifestação isolada da toxocaríase, que mimetizouuma artrite idiopática juvenil e leucemia. É importante ressaltar que essa zoonose deve serconsiderada em pacientes com artrite e eosinofilia.

Palavras-chave:
Artrite crônica; Eosinofilia; Toxocaríase; Crianças; Artrite idiopática juvenil; Leucemiar

Introduction

Human toxocariasis is a parasitic zoonosis caused mainly by Toxocara canis or Toxocara cati and is acquired by ingestion of the embryonated eggs of the parasite.1^,2 The clinical forms are systemic (visceral larva migrans), localized (ocular and neurological), asymptomatic and covert.2^-4

Of note, the covert form presents non-specific symptoms, such as lymphadenopathy, dermatological disorders, asthma and joint manifestations.2^-4 Arthralgia and/or arthritis were reported in up to 17% of the cases,2 generally with acute duration (less than 6 weeks). In Brazil, the prevalence of toxocariasis in urban areas ranged from 3.6% to 24.7%.5^,6 However, to our knowledge, severe and painful chronic polyarthritis, as the isolated presentation of Toxocara infection, was not reported.

From January 1983 to November 2013, we revised the charts of patients followed up at the Pediatric Rheumatology Unit of the Children's Institute of Hospital das Clínicas da Faculdade de Medicina Universidade de São Paulo. Only one of the 5809 patients (0.017%) had chronic polyarthritis as the single manifestation of toxocariasis and was described herein.

Case report

A 3-year-old girl was referred to our service with chronic polyarthritis in knees, wrists, shoulders, elbows and hips, with painful joint effusions in knees and wrists. The total duration of polyarthritis was 10 weeks. At that moment, she refused to walk due to severe pain. She had 30 min of morning stiffness and loss of appetite. Dog contact history in the recreational areas of neighborhood was reported. Laboratory examinations showed hemoglobin 10.1 g/dL, hematocrit 32%, white blood cell (WBC) 17,800 mm³ (neutrophils 42%, lymphocytes 25%, eosinophils 29%, and monocytes 4%), platelets 464,000 mm³, erythrocyte sedimentation rate (ESR) 55 mm/1st hour, C-reactive protein (CRP) 42.8 mg/dL, and lactate dehydrogenase (LDH) 879 mg/dL (normal range 117-213). Serologic test for hepatitis A, B and C, human immunodeficiency virus (HIV), cytomegalovirus, rubella, Epstein-Barr virus, toxoplasmosis and antistreptolysin O were negative. Three consecutive stool examinations did not identify any parasite infestation. Immunoglobulin E was 272 µg/L (normal <60 µg/L). Her bone marrow aspirate revealed marked eosinophilia (32%; normal range 0.5-7%) without neoplastic cells. The rheumatoid factor also was negative, and ophthalmological examination was normal. Toxocara enzyme-linked immunosorbent assay (ELISA) was 1:1280. She was treated with paracetamol (40 mg/kg/day) and thiabendazole (25 mg/kg/day) for 10 days, and all manifestations reduced. After 2 months, the ESR was 14 mm/1st hour, CRP 0.93 mg/dL and WBC 8200 mm³ (neutrophils 35%, lymphocytes 53%, eosinophils 6% and monocytes 6%), platelets 224,000 mm³, and immunoglobulin E was 162 µg/L. After eight months of follow-up, she was on clinical and laboratorial remission.

Discussion

Chronic polyarthritis, mimicking neoplasia and juvenile idiopathic arthritis (JIA), as the main manifestation of toxocariasis, have rarely been observed in our tertiary University Hospital in the last 30 years. The presence of concomitant arthritis and eosinophilia suggests the diagnosis.

Toxocariasis is a very common parasitosis in Brazil, and its prevalence ranged from 3.6% to 24.7%.5^,6 This infection, as a cause of isolated eosinophilic arthritis, is very seldom seen in the literature.7 Indeed, it was rarely described in arthritis of Henoch-Schönlein purpura.8^-10 The diagnosis of toxocariasis is suspected in patients that presented household contact with dogs11^,12 and it is confirmed by the presence of specific antibodies, detected by ELISA method, with sensitivity of 90-92% and specificity of 90-95%.1^,4 The high levels of eosinophils in peripheral blood was also observed in more than 60% of the patients,1^,4^,12 and IgE titers had high levels in children up to 3 years old,2^,4 as observed herein.

Our patient had covert clinical form with chronic arthritis without other clinical manifestations.2^-4 Indeed, lymphadenopathy, dermatological disorders, wheezing, arthralgia and acute arthritis may be associated with this form.2^-4 However to our knowledge, chronic arthritis in children was not previously reported with this infection.

Importantly, the main differential diagnoses in our patient were acute lymphoblastic leukemia (ALL) and JIA. The presence of concomitant severe articular pain and high LDH levels, even without other systemic manifestations, indicate bone marrow aspiration to exclude this neoplasia, as in our case. Moreover, JIA is the most important cause of chronic arthritis with morning stiffness; however, the exclusion of infections is necessary to confirm this diagnosis.13

The treatment of toxocariasis is necessary for symptomatic patients to reduce the number of potentially migratory larvae.9 The use of thiabendazole (25 mg/kg/day) for a short period therapy is indicated to covert forms, as in the present case.4

In conclusion, we described a case of chronic polyarthritis, as isolated manifestation of toxocariasis, mimicking JIA and ALL. This zoonosis should be considered in patients with arthritis and eosinophilia.

• Fundings
  This study was supported by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP - grants 2008/58238-4 to CAS and 2011/12471-2 to CAS), by Conselho Nacional do Desenvolvimento Científico e Tecnológico (CNPQ - grant 302724/2011-7 to CAS), by Federico Foundation to CAS and by Núcleo de Apoio à Pesquisa “Saúde da Criança e do Adolescente” da USP (NAP-CriAd).

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Publication Dates

• Publication in this collection
  Mar-Apr 2016

History

• Received
  20 Dec 2013
• Accepted
  28 July 2014