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Journal of Postgraduate Medicine, Vol. 55, No. 1, January-March, 2009, pp. 76-77 Letter Trichuris dysentery syndrome with eosinophilic leukemoid reaction mimicking inflammatory bowel disease Krishnamurthy S, Samanta D, Yadav S Department of Pediatrics, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi-110 002 Code Number: jp09020 Sir, A six-year- old girl presented with loose stools (with blood and mucus), progressively increasing pallor and poor growth for two years. There was no history of worm passage in stools, abdominal pain, vomiting, tenesmus, fever or cough. She was growing well two years back. Anthropometrical evaluation showed proportionate short stature; height 95 cm (Z score -4.28), weight 12 kg (Z score -5.05). Severe anemia and clubbing were noted. Hemoglobin was 3.5 g/dl, TLC 80 X 10 9 /L, eosinophils 50%, polymorphs 20%, and lymphocytes 28% with platelet count of 250 X 10 9 /L. She had microcytic hypochromic anemia and eosinophilic proliferation with shift to the left. Bone marrow aspiration showed increase in eosinophilic precursors, with no evidence of malignancy. Stool microscopy showed eggs of Trichuris trichiura and 10-15 red blood cells per high power field. Mantoux test and HIV-ELISA were negative. Immunoglobulin profile was normal. She was given blood transfusion, intravenous ceftriaxone and albendazole 400 mg single dose. Dysentery persisted, and a colonoscopy was planned to rule out ulcerative colitis. Colonoscopy demonstrated whipworms ( Trichuris trichiura ) on the edematous mucosa of the transverse colon and descending colon [Figure - 1], some of which were removed. Histopathological examination of the biopsy specimen showed nonspecific colitis. She was then given mebendazole 100 mg twice daily for three days. Dysentery subsided. Repeat blood tests after one week showed TLC 11x 10 9 /L, eosinophils 2%. She has been on follow-up for one year. She has gained weight (presently 15 kg, Z score -3.45) and height (presently 103 cm, Z score -3.7), and remains free of symptoms. Trichuris trichiura is found primarily in tropical climates characterized by poor sanitation. [1] Trichuris Dysentery Syndrome (TDS) associated with heavy worm infestation includes chronic dysentery, anemia, clubbing of fingers as well as developmental and cognitive deficits, and constitutes an important public health problem. Severe stunting and clubbing of fingers in TDS, as seen in our case, has been attributed to increases in Tumor Necrosis Factor-alpha and other cytokines in the lamina propria of the colonic mucosa and peripheral blood, decrease in plasma Insulin-like growth factor-1 and decreased collagen synthesis. [1] Eosinophilic leukemoid reaction is known with helminthic infestations, [2] especially ascariasis. Ascariasis may coexist with trichuriasis. However, neither stool microscopic examination nor colonoscopy findings in our case showed evidence of co-infestation with Ascaris lumbricoides . Only one case of trichuriasis with eosinophilic leukemoid reaction has been previously described. [3] In fact, significant eosinophilia is usually not seen in trichuriasis since the worm is intra-luminal, mucosal inflammation being rare. [3] The presence of eosinophilic leukemoid reaction in our case, which can be explained on basis of colitis, is a rare phenomenon. Eosinophilic leukemoid reaction is associated with malignancies [4] which necessitated bone marrow aspiration in our case. Due to clubbing, short stature, and eosinophilia with leukemoid reaction, we had considered ulcerative colitis, [5] which was ruled out by histopathological examination of the biopsy specimen. To conclude, Trichuris trichiura infection can lead to severe growth retardation, anemia and clubbing. Eosinophilic leukemoid reaction should be considered a hematological manifestation of TDS. References
Copyright 2009 - Journal of Postgraduate Medicine The following images related to this document are available:Photo images[jp09020f1.jpg] |
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