Eosinophilia & meningitis in tropics

Question 1

What is an abnormal eosinophil count?

Answer 1

> 5-10%
450-500mm3

Question 2

What causes raised eosinophils?

Answer 2

Helminths plus
Aspergillus
Cocci
Scabies, myiasis
Cystoiospora (plus sarcocystis)
Congenital toxo
HIV - allergies, eosinophilic folliculitis
Drug reactions
Asthma
Dermatitis
IBD
Malignancy
Hypereosinophilic syndrome
Psoriasis
Vasculitis

Question 3

What are the common causes of eosinophilia caused by helminth?

Answer 3

Acute schistosomiasis
Strongyloides
Filarias (Loa, Oncho, Mansonella, lymphatic)
Hookworms (including CLM)
Acute ascariasis
Trichinosis
Larva migrans syndromes (Toxocara, Baylisascaris, Angiostrongylus, Anisakis,
Gnathostomiasis, Fascioliasis, other flukes)

Question 4

When to suspect a helminth based eosinophil count?

Answer 4

> 1500 absolute count - likely to be a worm

Question 5

Acute katayama fever causing raised eosinophils. ∆ made how?

Answer 5

Serology (can be -ve)
Most will have negative stool

Question 6

Why does katayama fever occur in schistosomiasis? Most common symptom?

Answer 6

Egg laying begins
Not detectable in stool or urine

Fever, cough

Question 7

Fever, respiratory symptoms and swimming in Africa with eosinophils. ∆ to exclude?

Answer 7

Schisto (all other helminths mostly present GI symptoms)

Question 8

Rash, GI and respiratory symptoms in immigrant from Asia, most likely ∆?

Answer 8

Strongyloides

Most patients are asymptomatic

Question 9

Patient from Amazonia area, presenting with gram -ve meningitis and bacteraemia, always rule out what?

Answer 9

Strongyloides

Question 10

Army soldier presenting with eosinophilia but no rash. ∆?

Answer 10

Hookworm - no rash human hookworm

Question 11

Migratory swellings with eosinophilia from DRC? Confirmatory tests?

Answer 11

Loa Loa (migratory - calibar swellings)

Blood smear for microfilaria

Question 12

5 yr old girl been playing with dogs in Thailand, presents with fever, abdo pain and diarrhoea with a rash and eosinophilia. Always think of?

Answer 12

Toxocara canis - visceral larva migraña

Question 13

Larva migrans syndromes - causes?

Answer 13

Toxocara
Baylisascaris
Angiostrongylus
Gnathostomiasis
Acute Ascaris
Paragonimus
Acute Fascioliasis

TBAG - zoonotic helminths causing LM

Question 14

Migratory nodules with eosinophilia?

Answer 14

Gnatho
Paragon
Fasciola
Sparagonis

ALL MOVE

Fixed nodules - cystercircosis and onchocercosis

Question 15

pulmonary infiltrates and eosinophils?

Answer 15

1) Fleeting infiltrates (Loeffler’s):
Larva migrans (Schisto, Strongyloides,
Toxocara, Ascaris, Hookworm)
NASA for nematodes + schisto and toxocara

2) Localized infiltrates: Paragonimus,
Echinococcus

3) Diffuse infiltrates: Tropical Pulmonary
Eosinophilia due to Filariasis

Question 16

Eosinophilia in tropics crucial part of hx re: symptoms?

Answer 16

GI symptoms
Resp symptoms
Skin symptoms

Question 17

Neurological symptoms in returning traveller with eosinophilia. Which organisms are you worried about?

Answer 17

Acute schistosomiasis, Angiostrongylus, gnatho, neurocysticercosis

Question 18

Tests in a patient returning from tropics with eosinophilia?

Answer 18

Confirm eosinophilia, check urinalysis
Stool for Ova and Parasites x 3
Urine, blood smear
Serology: schistosomiasis, filariariasis,
strongyloidiasis, toxocariasis
Consider IgE level, CXR

Question 19

Common causes of eosinophilia caused by helminth

Answer 19

1) Trematode - schisto
2) Nematode human - hookworm, strongy
3) Zoonotic nematode - CLM (dog hookworm), toxocara, gnathostoma
4) Filarial parasites (only in central and West Africa)

Question 20

What are the most common causes of meningitis?

Answer 20

Strep pneumo, Meningococcus,
Hemophilus Influenza

Question 21

4 symtoms/signs of meningits?

Answer 21

Headache, fever, neck stiffness, decreased GCS

Question 22

Classic LP findings for aseptic/bacterial/chronic meningits?

Answer 22

Question 23

When would you not do an LP before a CT head in a resource poor setting?

Answer 23

Focal neurology
New onset seizures
GCS <!0
Severe immunocompromise

Question 24

Antibiotic of choice in most cases of bacterial meningitis?

Answer 24

Ceftriaxone (plus ampicillin in listeria/strep agalacticae)

Question 25

Specific antibiotic for bacterial meningitis for the following pathogens? - Strep pneumonia - Hib - meningococcal - Listeria - Ecoli - Salmonella

Answer 25

Question 26

Organism responsible for meningitis in elderly man in south east Asia, classically in areas of pig raising, open wound, hx of alcohol and T2DM?

Answer 26

Streptococcus suis

Question 27

Bacterial causes of meningitis to think about in tropics?

Answer 27

TB Rickettsia, Orientia Lepto B pseudomallei All present aseptic meningitis

Question 28

Picture of CSF analysis in TB meningitis?

Answer 28

High protein Low glucose Mildly raised WCC 100-500 with mainly mononuclear (lymphocytes)

Question 29

Who is at risk of listeria meningitis?

Answer 29

Compromised - newborns, elderly, chronic disease, Assoc contaminated milk products/Associated with processed meat

Question 30

What are the common presenting symptoms of subacute meningitis?

Answer 30

Gradual onset (days to months) Symptoms HA, nausea, confusion, cranial nerve palsies Fevers, sweats, wt loss variable

Question 31

Causes of subacute onset meningitis?

Answer 31

Tuberculosis Cryptococcal disease Spirochetes - Syphilis, Lyme Other fungi -e.g. Histo, Cocci Other bacteria - Brucella, Melioidosis, Scrub typhus, Parasites (T solium)

Question 32

How quick to give Antibiotics in any suspicion of bacterial meningitis?

Answer 32

2 hrs

Question 33

Subacute meningitis CSF analysis?

Answer 33

20-500 WCC Mononuclear Glucose <45 Protein 50-500

Question 34

Haemoptysis, cough, SOB, conjunctiva insuffusion, fever and jaundice. Very high bilirubin. Diagnosis?

Answer 34

Leptospirosis

Question 35

Fever, cough, weight loss, oral lesions. Bilateral infiltrates, central and perihilar shadowing on CXR. Diagnosis?

Answer 35

Paracocci

Question 36

Non HIV patient presenting with cryptococcus, lung presentation most likely?

Answer 36

Pulmonary nodule

Question 37

HIV infected patient from high jungle with 2 months hx of fever, dry cough, very low CD4. Miliary pattern on CXR/CT chest with very high LDH and pancytopenia. Diagnosis?

Answer 37

Histoplasmosis - high LDH and pancytopenia High LDH caused by histo and lymphoma PCP does not cause LDH rise or pancytopenia

Question 38

42 year old male with cough and haemoptysis for 2 years from the highlands of Peru. Peripheral sub pleural nodule in lower lung field on CT chest with eosinophilia. Diagnosis?

Answer 38

Paragonimus

Question 39

Fungal causes of TB mimickers re: pulmonary presentation?

Answer 39

Histo Crypto Paracocci PCP

Question 40

32 year old male with SOB, cough, haemoptysis, lives in rural highlands. Rapidly progressive over 2 days, shocked. Lobar consolidation on CXR, gram neg bacilli on gram stain. ∆?

Answer 40

Yersinia Pestis Primary or sec from a bubo Rx: ciprofloxacin, aminoglycoside

Question 41

45 yr old fever, cough, pleuritic chest pain. Lives in French Guyana. Transaminases high, blood culture negative, platelets 100. Consolidation of lower lobe on CXR.

Answer 41

Coxiella Burnetii- Q fever Contaminated livestock Acute and chronic presentation (osteomyelitis, endocarditis) Lung involvement: lobar segmental pneumonia, round or wedge shaped opacities Diagnosed with serology Rx: doxy

Question 42

65 yr old male from Texas with no symptoms found to have a nodule on CXR.

Answer 42

Dirofilaria immitus Vector borne - aedes and anopheles Asymptomatic but with eosinophilia Single well demarcated pulmonary nodule Diagnosis- excision, no Rx.

Question 43

55 yr old female with chills, headache, SOB, progressive over 2 days. 2 relatives died of lymhoma. Gram -ve sepsis - grown in CSF and Blood. Diagnosis?

Answer 43

Stongyloides, from HTLV and hyper infection with gram negative sepsis. Miliary pattern, ground glass, nodular lesions of stongy hyper infection. Intestinal mucosal thickning.

Question 44

28 year old male from Honduras, works bare foot, presents with SOB, wheezing. CXR some bilateral infiltrates. Eosinophilia. ∆

Answer 44

Hookworm and Loefflers syndrome