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a r c h s o c e s p o f t a l m o l . 2 0 1 4; 8 9(1 0) :411–413 ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www .elsevier.es/oftalmologia Short communication Ocular loiasis in a patient with chronic hypereosinophilia A. Burgués-Ceballos , M.A. Marcos, G.A. March, J.R. Juberías Servicio de Oftalmología, Hospital Clínico Universitario, Valladolid, Spain a r t i c l e i n f o Article history: Received 17 December 2012 Accepted 24 January 2013 Available online 22 October 2014 Keywords: Loa loa Loiasis Ocular filariasis Eosinophilia Conjunctiva a b s t r a c t Case report: We present a case of ocular loiasis with a subconjunctival filaria, 5.5 cm long, and a severe microfilaremia, 1 microfilaria/ml, on a previously asymptomatic woman from Equatorial Guinea, with a past medical history of hypereosinophilia of unknown origin. Discussion: Ocular loiasis is an imported infestation with a very low rate in our country. Nevertheless, chronic infestation in immigrants coming from endemic areas of Africa may increase the rate of this disease in our country. © 2012 Sociedad Espa ˜ nola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved. Loiasis ocular en paciente con hipereosinofilia crónica Palabras clave: Loa loa Loiasis Filariasis ocular Eosinofilia Conjuntiva r e s u m e n Caso clínico: Se presenta un caso de loiasis ocular con una filaria subconjuntival de 5,5 cm de longitud y una microfilaremia grave de una microfilaria/ml, en una paciente previamente asintomática, procedente de Guinea Ecuatorial, con antecedente de hipereosinofilia crónica en estudio. Discusión: La loiasis ocular es una infestación importada y poco frecuente en nuestro medio. No obstante, las parasitaciones crónicas procedentes de inmigrantes de zonas endémicas de África, pueden convertir la loiasis en una enfermedad emergente en nuestro medio. © 2012 Sociedad Espa ˜ nola de Oftalmología. Publicado por Elsevier España, S.L.U. Todos los derechos reservados. Introduction Loa loa is a nematode from equatorial Africa that causes cutaneous filariasis. 1 Approximately 3–13,000,000 people are Please cite this article as: Burgués-Ceballos A, Marcos MA, March GA, Juberías JR. Loiasis ocular en paciente con hipereosinofilia crónica. Arch Soc Esp Oftalmol. 2014;89:411-413. Corresponding author. E-mail address: [email protected] (A. Burgués-Ceballos). affected all over the world. 2 In endemic regions, the loiasis rate is of about 40%. Sporadic cases have been described out- side Africa in African immigrants and travelers. In Spain, in the past 5 years no cases with ocular involvement have been reported. 2173-5794/$ see front matter © 2012 Sociedad Espa ˜ nola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.

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Page 1: Ocular loiasis in a patient with chronic hypereosinophilia

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a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(1 0):411–413

ARCHIVOS DE LA SOCIEDADESPAÑOLA DE OFTALMOLOGÍA

www .e lsev ier .es /o f ta lmologia

hort communication

cular loiasis in a patient with chronic hypereosinophilia�

. Burgués-Ceballos ∗, M.A. Marcos, G.A. March, J.R. Juberías

ervicio de Oftalmología, Hospital Clínico Universitario, Valladolid, Spain

r t i c l e i n f o

rticle history:

eceived 17 December 2012

ccepted 24 January 2013

vailable online 22 October 2014

eywords:

oa loa

oiasis

cular filariasis

osinophilia

onjunctiva

a b s t r a c t

Case report: We present a case of ocular loiasis with a subconjunctival filaria, 5.5 cm long,

and a severe microfilaremia, 1 microfilaria/ml, on a previously asymptomatic woman from

Equatorial Guinea, with a past medical history of hypereosinophilia of unknown origin.

Discussion: Ocular loiasis is an imported infestation with a very low rate in our country.

Nevertheless, chronic infestation in immigrants coming from endemic areas of Africa may

increase the rate of this disease in our country.

© 2012 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights

reserved.

Loiasis ocular en paciente con hipereosinofilia crónica

alabras clave:

oa loa

oiasis

ilariasis ocular

r e s u m e n

Caso clínico: Se presenta un caso de loiasis ocular con una filaria subconjuntival de 5,5 cm de

longitud y una microfilaremia grave de una microfilaria/ml, en una paciente previamente

asintomática, procedente de Guinea Ecuatorial, con antecedente de hipereosinofilia crónica

en estudio.

osinofilia

onjuntivaDiscusión: La loiasis ocular es una infestación importada y poco frecuente en nuestro medio.

No obstante, las parasitaciones crónicas procedentes de inmigrantes de zonas endémicas

de África, pueden convertir la loiasis en una enfermedad emergente en nuestro medio.

© 2012 Sociedad Espanola de Oftalmología. Publicado por Elsevier España, S.L.U. Todos

ntroduction

oa loa is a nematode from equatorial Africa that causesutaneous filariasis.1 Approximately 3–13,000,000 people are

� Please cite this article as: Burgués-Ceballos A, Marcos MA, March GA,rch Soc Esp Oftalmol. 2014;89:411-413.∗ Corresponding author.

E-mail address: [email protected] (A. Burgués-Ceballos).

173-5794/$ – see front matter © 2012 Sociedad Espanola de Oftalmolog

los derechos reservados.

affected all over the world.2 In endemic regions, the loiasisrate is of about 40%. Sporadic cases have been described out-

Juberías JR. Loiasis ocular en paciente con hipereosinofilia crónica.

side Africa in African immigrants and travelers. In Spain, inthe past 5 years no cases with ocular involvement have beenreported.

ía. Published by Elsevier España, S.L.U. All rights reserved.

Page 2: Ocular loiasis in a patient with chronic hypereosinophilia

412 a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(1 0):411–413

Fig. 2 – Photograph of the filaria (5.5 cm length) after being

with diethylcarbamazine was established at increasing dosageto reach 200 mg/8 h maintained during 2 weeks, methylpred-nisolone 16 mg/24 h during 6 days and hydroxyzine 25 mg/12 h.

Fig. 1 – Photograph of the subconjunctival filaria.

Females of the Chrysops tabanid flies sting during the dayand absorb blood with microfilariae of infected subjects. Thelarvae become infecting agents within the tabanid, penetratehealthy people through the cutaneous sting and migrate to thesubcutaneous tissue, where they become adult nematodes.Mating is performed in the skin and pregnant females releasemicrofilariae which access peripheral blood.1,3

This paper presents the case of a female with chronichypereosinophilia of unknown cause prior to the appearanceof subconjunctival loiasis.

Clinic case

A female, 22 years, from Equatorial Guinea and residing inSpain, visited the Emergency Service after experiencing amoving foreign body in the left eye. She referred feeling thesame symptoms the day before although it disappeared spon-taneously. In addition, she reported seeing “a worm” in saideye.

In what concerns general antecedents, she referred visitingEquatorial Guinea 4 months before, slight hypereosinophilia(1000/�l) with 3 years evolution under study and edemaepisodes in lower limbs together with subcutaneous movingforeign body during childhood.

Left eye anterior segment biomicroscopic explorationrevealed a nasal subconjunctival worm-shaped parasite whichdescribed a reptilian movement away from the incoming light(Fig. 1). The rest of the ophthalmological examination wasnormal for both eyes.

Subsequently, the parasite was extracted after instilling5% topical lidocaine, using tweezers through a conjunctival

incision which did not require stitching. Tobramycin and dexa-methasone eyedrops were prescribed, 4 times a day during7 days.

extracted from the subconjunctival space.

The microbiological study identified the extracted subcon-junctival parasite as a 5.5 cm long female Loa loa (Fig. 2).Bodily inspection enabled the identification of a subcutaneousfilaria in the left thigh. Blood analysis revealed relative andabsolute hypereosinophilia (23.9% eosinophiles and overalleosinophiles 2000/�l). Blood sample revealed one microfilariaper milliliter (Fig. 3).

The diagnosis of left conjunctival filariasis was done and,after consulting with the Internal Medicine Service, treatment

Fig. 3 – Photograph of a microfilaria present in peripheralblood stained with: (A) giemsa 400× and (B)hematoxylin–eosine 200×.

Page 3: Ocular loiasis in a patient with chronic hypereosinophilia

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a r c h s o c e s p o f t a l m

iscussion

oiasis is infestation by Loa loa, a nematode belonging to thepirurida order, superfamily Filarioidea. This group includes

species that can cause ocular involvement: Loa loa, Onchocercaolvulus and Mansonella perstans. Differential diagnosis can beade through clinic and epidemiology, although it requiresicrobiological confirmation.1

Onchocerca volvulus (onchocerciasis) can cause progressiveclerosing keratitis, chronic uveitis, chorioretinitis or opticeuropathy, without the adult subconjunctival larvae beingbservable. Mansonella perstans produces clinic which is veryimilar to that of Loa loa, while both can present the lar-ae in the subconjunctival space, anterior chamber, vitreous,horoids and even the retina.1,2,4 Retinopathy due to microfi-aremia caused by embolization of parasites toward choroidalnd retinal vessels has been described.4 The case presentederein only exhibited subconjunctival involvement.

Natives who become infested in endemic regions usuallyo not exhibit symptoms, as in the present case, probablyue to the development of tolerance to sustained parasitismespite exhibiting high levels of microfilaremia. In theseatients, the presence of subconjunctival larvae could be thenly clinical expression, as in the present case. In contrast,

nfested visitors exhibit significant allergic symptomatologyitching and angioedema in limbs).2,4,5

Loa loa can remain up to 15 years in the host beforeigrating2,5 and must spend between 6 and 12 months before

emales can reproduce.4 It can be said that the patient ofhis case, who is from Equatorial Guinea, a country with

loiasis prevalence of 27.1%,3 was already infested beforeer last visit to the endemic region, confirmed with aigher rate of microfilaremia (1 microfilaria per ml) and her

5

0 1 4;8 9(1 0):411–413 413

history of moving nodules and edema in lower limbs duringchildhood.

The surgical extraction of filaria from the subconjunctivalspace must be combined with systemic treatment for eradi-cating microfilaremia and possible loci of filariae such as thatexhibited by the patient as well as for reducing infectivity.Concomitant use of oral corticoids diminishes the probabil-ity of allergic reaction and encephalopathy induced by therapid mortality of microfilaria in the blood in cases with highmicrofilaremia,3,5 as in the present case.

Finally, it should be pointed out that chronic parasitiza-tion in immigrant populations could make loiasis an emergingdisease in our environment.5

Conflict of interests

No conflict of interests has been declared by the authors.

e f e r e n c e s

. Puente S, Subirats M, Lago M, Martinez ML, Gonzalez J,Gonzalez-Lahoz JM. Imagen calcificada en conjuntiva ocularen mujer ecuatoguineana. Enferm Infecc Microbiol Clin.1995;13:61–2.

. Alello F, Palma S, Varesi C, Cerulli A, Valente R, Alello L. A rarecase report of Loa loa ocular filariasis. Eur J Ophtalmol.2010;20:237–9.

. Padgett JJ, Jacobsen KH. Loiasis: African eye worm. Trans R SocTrop Med Hyg. 2008;102:983–9.

. Jolly BT, Foley KA. Loiasis: a case of an unusual ocular foreign

body. Ann Emerg Med. 1992;21:1153–6.

. Herrero-Morin JD, Fernández MN, González F, García E, Díaz M.Filariasis ocular por Loa Loa. ¿Parasitosis tropical emergenteen Europa? An Pediatr. 2006;65:166–74.