Eosinophilia & meningitis in tropics Flashcards
What is an abnormal eosinophil count?
> 5-10%
450-500mm3
What causes raised eosinophils?
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
What are the common causes of eosinophilia caused by helminth?
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)
When to suspect a helminth based eosinophil count?
> 1500 absolute count - likely to be a worm
Acute katayama fever causing raised eosinophils. ∆ made how?
Serology (can be -ve)
Most will have negative stool
Why does katayama fever occur in schistosomiasis? Most common symptom?
Egg laying begins
Not detectable in stool or urine
Fever, cough
Fever, respiratory symptoms and swimming in Africa with eosinophils. ∆ to exclude?
Schisto (all other helminths mostly present GI symptoms)
Rash, GI and respiratory symptoms in immigrant from Asia, most likely ∆?
Strongyloides
Most patients are asymptomatic
Patient from Amazonia area, presenting with gram -ve meningitis and bacteraemia, always rule out what?
Strongyloides
Army soldier presenting with eosinophilia but no rash. ∆?
Hookworm - no rash human hookworm
Migratory swellings with eosinophilia from DRC? Confirmatory tests?
Loa Loa (migratory - calibar swellings)
Blood smear for microfilaria
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?
Toxocara canis - visceral larva migraña
Larva migrans syndromes - causes?
Toxocara
Baylisascaris
Angiostrongylus
Gnathostomiasis
Acute Ascaris
Paragonimus
Acute Fascioliasis
TBAG - zoonotic helminths causing LM
Migratory nodules with eosinophilia?
Gnatho
Paragon
Fasciola
Sparagonis
ALL MOVE
Fixed nodules - cystercircosis and onchocercosis
pulmonary infiltrates and eosinophils?
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
Eosinophilia in tropics crucial part of hx re: symptoms?
GI symptoms
Resp symptoms
Skin symptoms
Neurological symptoms in returning traveller with eosinophilia. Which organisms are you worried about?
Acute schistosomiasis, Angiostrongylus, gnatho, neurocysticercosis
Tests in a patient returning from tropics with eosinophilia?
Confirm eosinophilia, check urinalysis
Stool for Ova and Parasites x 3
Urine, blood smear
Serology: schistosomiasis, filariariasis,
strongyloidiasis, toxocariasis
Consider IgE level, CXR
Common causes of eosinophilia caused by helminth
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)
What are the most common causes of meningitis?
Strep pneumo, Meningococcus,
Hemophilus Influenza
4 symtoms/signs of meningits?
Headache, fever, neck stiffness, decreased GCS
Classic LP findings for aseptic/bacterial/chronic meningits?
When would you not do an LP before a CT head in a resource poor setting?
Focal neurology
New onset seizures
GCS <!0
Severe immunocompromise
Antibiotic of choice in most cases of bacterial meningitis?
Ceftriaxone (plus ampicillin in listeria/strep agalacticae)
Specific antibiotic for bacterial meningitis for the following pathogens?
- Strep pneumonia
- Hib
- meningococcal
- Listeria
- Ecoli
- Salmonella
Organism responsible for meningitis in elderly man in south east Asia, classically in areas of pig raising, open wound, hx of alcohol and T2DM?
Streptococcus suis
Bacterial causes of meningitis to think about in tropics?
TB
Rickettsia,
Orientia
Lepto
B pseudomallei
All present aseptic meningitis
Picture of CSF analysis in TB meningitis?
High protein
Low glucose
Mildly raised WCC 100-500 with mainly mononuclear (lymphocytes)
Who is at risk of listeria meningitis?
Compromised - newborns, elderly, chronic disease, Assoc contaminated milk products/Associated with processed meat
What are the common presenting symptoms of subacute meningitis?
Gradual onset (days to months)
Symptoms HA, nausea, confusion,
cranial nerve palsies
Fevers, sweats, wt loss variable
Causes of subacute onset meningitis?
Tuberculosis
Cryptococcal disease
Spirochetes - Syphilis, Lyme
Other fungi -e.g. Histo, Cocci
Other bacteria - Brucella,
Melioidosis, Scrub typhus,
Parasites (T solium)
How quick to give Antibiotics in any suspicion of bacterial meningitis?
2 hrs
Subacute meningitis CSF analysis?
20-500 WCC Mononuclear
Glucose <45
Protein 50-500
Haemoptysis, cough, SOB, conjunctiva insuffusion, fever and jaundice. Very high bilirubin. Diagnosis?
Leptospirosis
Fever, cough, weight loss, oral lesions. Bilateral infiltrates, central and perihilar shadowing on CXR. Diagnosis?
Paracocci
Non HIV patient presenting with cryptococcus, lung presentation most likely?
Pulmonary nodule
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?
Histoplasmosis - high LDH and pancytopenia
High LDH caused by histo and lymphoma
PCP does not cause LDH rise or pancytopenia
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?
Paragonimus
Fungal causes of TB mimickers re: pulmonary presentation?
Histo
Crypto
Paracocci
PCP
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. ∆?
Yersinia Pestis
Primary or sec from a bubo
Rx: ciprofloxacin, aminoglycoside
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.
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
65 yr old male from Texas with no symptoms found to have a nodule on CXR.
Dirofilaria immitus
Vector borne - aedes and anopheles
Asymptomatic but with eosinophilia
Single well demarcated pulmonary nodule
Diagnosis- excision, no Rx.
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?
Stongyloides, from HTLV and hyper infection with gram negative sepsis.
Miliary pattern, ground glass, nodular lesions of stongy hyper infection.
Intestinal mucosal thickning.
28 year old male from Honduras, works bare foot, presents with SOB, wheezing. CXR some bilateral infiltrates. Eosinophilia. ∆
Hookworm and Loefflers syndrome
