Subconjunctival Loa Loa Worm: a First Native Case Report in a Moroccan Child

Article Information

Abdessamad Lalaoui1, Houda Nassih1, Rabiy El Qadiry1, Nahid Mahir1, Aicha Bourahouat1, Imane Ait Sab1, Soufiane Berradi2, Redouane Moutaj3

1Pediatric Ward, Department of Pediatrics, Child and Mother Hospital, Mohammed VI University Hospital Center, Marrakesh Medical and Pharmacy Faculty, Caddy Ayad university, Marrakesh, Morocco

2Ophthalmological Ward, Ouarzazate Provincial Hospital Center, Morocco

3Parasitology Department, Avicenne Military Hospital, Marrakesh Medical and Pharmacy Faculty, Caddy Ayad University, Marrakesh, Morocco

*Corresponding Author: Abdessamad Lalaoui, B Pediatric Ward, Department of Pediatrics, Child and Mother Hospital, Mohammed VI University Hospital Center, Marrakesh Medical and Pharmacy Faculty, Caddy Ayad university, Marrakesh, Morocco

Received: 28 July 2020; Accepted: 12 August 2020; Published: 16 September 2020

Citation: Abdessamad Lalaoui, Houda Nassih, Rabiy El Qadiry, Nahid Mahir, Aicha Bourahouat, Imane Ait Sab, Soufiane Berradi, Redouane Moutaj. Subconjunctival Loa Loa worm: a First Native Case Report in a Moroccan Child. Archives of Clinical and Medical Case Reports 4 (2020): 898-902.

View / Download Pdf Share at Facebook

Abstract

The loiasis is limited to, Western and Central Africa. Characteristic clinical features include Calabar swellings and subconjunctival migration of the adult parasite. Severe complications of infection, including cardiomyopathy, nephropathy, and fatal encephalitis, are rare, but do occur. So far, all Moroccan cases are seen in adult travelers. We report the first case of autochthone loiasis in a Moroccan child.

 

Keywords

First native loiasis; Morocco; Child; Ivermectin

First native loiasis articles, Morocco articles, Child articles, Ivermectin articles

First native loiasis articles First native loiasis Research articles First native loiasis review articles First native loiasis PubMed articles First native loiasis PubMed Central articles First native loiasis 2023 articles First native loiasis 2024 articles First native loiasis Scopus articles First native loiasis impact factor journals First native loiasis Scopus journals First native loiasis PubMed journals First native loiasis medical journals First native loiasis free journals First native loiasis best journals First native loiasis top journals First native loiasis free medical journals First native loiasis famous journals First native loiasis Google Scholar indexed journals Ivermectin articles Ivermectin Research articles Ivermectin review articles Ivermectin PubMed articles Ivermectin PubMed Central articles Ivermectin 2023 articles Ivermectin 2024 articles Ivermectin Scopus articles Ivermectin impact factor journals Ivermectin Scopus journals Ivermectin PubMed journals Ivermectin medical journals Ivermectin free journals Ivermectin best journals Ivermectin top journals Ivermectin free medical journals Ivermectin famous journals Ivermectin Google Scholar indexed journals Child articles Child Research articles Child review articles Child PubMed articles Child PubMed Central articles Child 2023 articles Child 2024 articles Child Scopus articles Child impact factor journals Child Scopus journals Child PubMed journals Child medical journals Child free journals Child best journals Child top journals Child free medical journals Child famous journals Child Google Scholar indexed journals syndrome articles syndrome Research articles syndrome review articles syndrome PubMed articles syndrome PubMed Central articles syndrome 2023 articles syndrome 2024 articles syndrome Scopus articles syndrome impact factor journals syndrome Scopus journals syndrome PubMed journals syndrome medical journals syndrome free journals syndrome best journals syndrome top journals syndrome free medical journals syndrome famous journals syndrome Google Scholar indexed journals fatal encephalitis articles fatal encephalitis Research articles fatal encephalitis review articles fatal encephalitis PubMed articles fatal encephalitis PubMed Central articles fatal encephalitis 2023 articles fatal encephalitis 2024 articles fatal encephalitis Scopus articles fatal encephalitis impact factor journals fatal encephalitis Scopus journals fatal encephalitis PubMed journals fatal encephalitis medical journals fatal encephalitis free journals fatal encephalitis best journals fatal encephalitis top journals fatal encephalitis free medical journals fatal encephalitis famous journals fatal encephalitis Google Scholar indexed journals treatment articles treatment Research articles treatment review articles treatment PubMed articles treatment PubMed Central articles treatment 2023 articles treatment 2024 articles treatment Scopus articles treatment impact factor journals treatment Scopus journals treatment PubMed journals treatment medical journals treatment free journals treatment best journals treatment top journals treatment free medical journals treatment famous journals treatment Google Scholar indexed journals laparoscopy articles laparoscopy Research articles laparoscopy review articles laparoscopy PubMed articles laparoscopy PubMed Central articles laparoscopy 2023 articles laparoscopy 2024 articles laparoscopy Scopus articles laparoscopy impact factor journals laparoscopy Scopus journals laparoscopy PubMed journals laparoscopy medical journals laparoscopy free journals laparoscopy best journals laparoscopy top journals laparoscopy free medical journals laparoscopy famous journals laparoscopy Google Scholar indexed journals surgery articles surgery Research articles surgery review articles surgery PubMed articles surgery PubMed Central articles surgery 2023 articles surgery 2024 articles surgery Scopus articles surgery impact factor journals surgery Scopus journals surgery PubMed journals surgery medical journals surgery free journals surgery best journals surgery top journals surgery free medical journals surgery famous journals surgery Google Scholar indexed journals Venous compression articles Venous compression Research articles Venous compression review articles Venous compression PubMed articles Venous compression PubMed Central articles Venous compression 2023 articles Venous compression 2024 articles Venous compression Scopus articles Venous compression impact factor journals Venous compression Scopus journals Venous compression PubMed journals Venous compression medical journals Venous compression free journals Venous compression best journals Venous compression top journals Venous compression free medical journals Venous compression famous journals Venous compression Google Scholar indexed journals tomography articles tomography Research articles tomography review articles tomography PubMed articles tomography PubMed Central articles tomography 2023 articles tomography 2024 articles tomography Scopus articles tomography impact factor journals tomography Scopus journals tomography PubMed journals tomography medical journals tomography free journals tomography best journals tomography top journals tomography free medical journals tomography famous journals tomography Google Scholar indexed journals

Article Details

1. Introduction

Loiasis, infection with the filarial nematode Loa loa, is limited to and highly endemic in Central and West Africa. Characteristic clinical manifestations include episodic angioedema and subconjunctival migration of adult worms. Microfilariae are detected in the peripheral blood during the day. Treatment with diethylcarbamazine, ivermectin or albendazole is curative in most cases. Unfortunately, these drugs are associated with severe side effects, especially in patients with high levels of microfilaremia. We report the first case of a native subconjunctival loiasis in a Moroccan child.

2. Case Report

A well-appearing 11-year-old boy, with no medical history, presented to the emergency department for complaints of foreign body sensations of the right eye evolving for three days. He was original from Ouarzazat, a city in southern Morocco. He never traveled abroad or contacted any foreigners or travelers before. The child reported several episodes of transient swelling of the lid, associated with painful eye redness, tearing, and photophobia for the last two months. He was seen by several ophthalmologists who treated his condition as severe allergic conjunctivitis without any improvement. No other previous cardiac, abdominal, or skin manifestations were reported. The boy was apyretic with a body temperature of 37.2°C. General examination showed no evidence of lymphedema or systemic involvement. Slit-lamp examination of the right eye found an upper subconjunctival granuloma containing a moving opalescent eyeworm with significant palpebral edema and hyperemic conjunctivitis (Figure 1). Visual acuity, eye tone, ocular fundus as well as the rest of the ophthalmological examination was unremarkable. Under topical anesthesia, an intact worm was extracted from the superior conjunctiva of the right eye (Figures 2 and 3). It was immediately sent to a specialized parasitological laboratory, which identified the specimen as an adult male Loa loa measuring approximately 3.6 cm × 0.4 mm. Simultaneously, the excisional biopsy of the upper right subconjunctival granuloma showed an inflammatory granuloma rich in eosinophils. Blood was drawn daily at noon for five consecutive days, and showed no Loa Loa microfilariae in thick blood smears stained with Giemsa stain. Meanwhile, laboratory workup found normal eosinophils count of 50/mm3 on complete blood count. Renal and hepatic functions were within the normal range (respectively urea nitrogen of 0.2 g/l, creatinine of 4 mg/l, AGPT of 13 u/l, SGPT of 16 u/l, PPT of 87%). After the diagnostic confirmation of loiasis, the child received ivermectin as a single dose of 3 mg per 6 months. Treatment was carried out successfully for twelve months, and no side effects were noted. Also, no other new cases were reported in the same area. After 18 months of follow-up, the boy remains asymptomatic and in good health.

fortune-biomass-feedstock

Figure 1: Subconjunctival granuloma of the right eye of an 11-year-old boy.

fortune-biomass-feedstock

Figure 2: Eyeworm extraction from the right eye.

fortune-biomass-feedstock

Figure 3: Loa Loa male worm after surgical removal.

3. Discussion

Infection with the filarial nematode Loa loa was first described by Mongin in 1770, when he extracted an adult worm from the eye of an African slave [1]. It has been estimated that Loa loa infects 3 to 13 million people in Central and West Africa [2]. Isolated cases have also been reported in Uganda, Malawi, Zambia, and Ethiopia, and in the region from Ghana to Guinea [2]. In Morocco, 26 imported adult cases were reported, with no autochthone or pediatric cases found to date [3]. Infection rates are usually higher in adults, particularly males, than in children, probably because of increased exposure to biting flies (Chrysops) [4].

Loa loa infection may be present as asymptomatic microfilaremia, with the infection being recognized only after subconjunctival migration of an adult worm. Other patients have episodic Calabar swellings. If the associated inflammation extends to the nearby joints or peripheral nerves, entrapment neu­ropathy or arthritis can develop. Nephropathy, encephalopathy, and cardiomyopathy can occur, but rarely [5]. Except for eye worm and renal abnormalities, clinical signs and symptoms are more common in visitors to Loa-endemic areas than in people native to these areas and reflect a heightened immune response to the parasite. Conversely, microfilariae are detectable in the peripheral blood of most endemic individuals with loiasis but are rare in infected visitors [6]. Definitive diagnosis can be made by extracting an adult worm from subcutaneous or subconjunctival spaces or identifying Loa loa microfilariae (or their DNA) in peripheral blood [6]. The removal of a subconjunctival worm requires topical or subconjunctival anesthesia, which may help to immobilize the worm. A suture is passed under the worm and tied tightly, and the worm is dissected out. Alternatively, cryo­therapy may help immobilize the worm or be used for removal [7]. Surgical removal of the adult worm from the subconjunctival space is always recommended. Still, systemic treatment should be considered for the eradication of remaining adult worms and microfilariae in order to reduce transmission [8]. Treatment with diethylcarbamazine (DEC), albendazole, or ivermectin is curative in most cases. However, these drugs are associated with severe side effects in patients with high levels of circulating microfilariae [2]. Clearance of forest around dwellings, screening houses, and the use of protective clothing can reduce personal exposure to Chrysops in endemic areas. DEC (300 mg weekly) is effective in preventing loiasis in long-term travelers to endemic areas [9].

4. Conclusion

Eyeworms can be due to native loiasis in southern Morocco. Management consists of surgical removal and antiparasitic drugs. Prognosis is good whenever multisystemic involvement is absent. Further epidemiological studies are required to assess the incidence of loiasis in north African countries.

References

  1. Observation on a worm found under conjunctiva in Maribou, Saint Domingue Island. J Med Chir Pharm Paris 32 (1770): 338-339.
  2. Klion AD. Loiasis. InHunter's Tropical Medicine and Emerging Infectious Disease (2013): 823-826.
  3. El Haouri M, Erragragui Y, Sbai M, et al. Cutaneous filariasis Loa loa: 26 moroccan cases of importation. InAnnales de Dermatologie et de Venereologie 128 (2001): 899.
  4. Klion AD, Nutman TB. Loiasis and Mansonella Infections. In: Tropical Infectious Diseases: Principles, Pathogens and Practice [Internet]. Elsevier (2011): 735-740.
  5. Nutman TB. Filarial Infections. In: The Travel and Tropical Medicine Manual [Internet]. Elsevier (2017): 574-587.
  6. Klion AD, Massougbodji A, Sadeler BC, et al. Loiasis in endemic and nonendemic populations: immunologically mediated differences in clinical presentation. Journal of Infectious Diseases 163 (1991): 1318-1325.
  7. Beare NAV, Bastawrous A. Ophthalmology in the Tropics and Sub-tropics. In: Manson’s Tropical Infectious Diseases [Internet]. Elsevier (2014): 952-994.
  8. Passos RM, Barbosa CP, Almeida JD, et al. Subconjunctival Loa loa worm: first case report in Brazil. Arquivos Brasileiros de Oftalmologia 75 (2012): 67-70.
  9. Nutman TB, Miller KD, Mulligan M, et al. Diethylcarbamazine prophylaxis for human loiasis. New England Journal of Medicine 319 (1988): 752-756.

© 2016-2024, Copyrights Fortune Journals. All Rights Reserved