An outbreak of acute eosinophilic myositis attributed to human Sarcocystis parasitism.

Seven members of a 15-man U.S. military team that had operated in rural Malaysia developed an acute illness consisting of fever, myalgias, bronchospasm, fleeting pruritic rashes, transient lymphadenopathy, and subcutaneous nodules associated with eosinophilia, elevated erythrocyte sedimentation rate, and elevated levels of muscle creatinine kinase. Sarcocysts of an unidentified Sarcocystis species were found in skeletal muscle biopsies of the index case. Albendazole ameliorated symptoms in the index case; however, his symptoms persisted for more than 5 years. Symptoms in 5 other men were mild to moderate and self-limited, and 1 team member with laboratory abnormalities was asymptomatic. Of 8 team members tested for antibody to Sarcocystis, 6 were positive; of 4 with the eosinophilic myositis syndrome who were tested, all were positive. We attribute this outbreak of eosinophilic myositis to accidental tissue parasitism by Sarcocystis.

Unusual cutaneous infectious and parasitic diseases.

The cutaneous manifestations of thirteen unusual infections and parasitic diseases are described. Their geographic distribution, morphologic features of the causative organism, histopathologic changes, criteria for diagnosis, and treatment are included.

Unusual infections in humans.

Nine cases of unusual infections in humans are presented. In each case, we present the clinical history, histopathologic changes (if indicated), morphologic features of the causative organism, diagnosis, discussion, differential diagnosis, therapy, and current literature. All of the cases are illustrated with pertinent photographs. The nine cases are as follows: (i) acanthocephaliasis, the first acquired human infection by Moniliformis moniliformis in the United States; (ii) dipylidiasis, an uncommon infection caused by the dog tapeworm, Dipylidium caninum; (iii) granulomatous amebic encephalitis, caused by the recently identified leptomyxid group of amebae; (iv) schistosomiasis, a dual infection of the urinary bladder with the rare presentation of both adult worms and eggs of Schistosoma haematobium and Schistosoma mansoni in tissue sections; (v) syphilitic gastritis, an uncommon presentation of Treponema pallidum infection, in a patient with an additional incidental infection by Helicobacter pylori; (vi) microsporidiosis, the only infection caused by a Pleistophora sp. in humans; (vii) sporotrichosis, a rare disseminated infection caused by Sporothrix schenckii with numerous yeast cells in the scrotum; (viii) angiostrongyliasis, the first and only infection caused by Angiostrongylus costaricensis acquired in either Puerto Rico or the United States; and (ix) botryomycosis of the skin and subcutaneous tissue, caused by gram-positive cocci with an unusually large number of granules.

Enterobiasis: a histopathological study of 259 patients.

Enterobius worms or their eggs, or both, are present in preserved tissue sections or tissue specimens of 259 patients whose medical records are on file at the Armed Forces Institute of Pathology, Washington D.C., U.S.A. The most common site of infection (86.5%) was found to be the lumen of the appendix, where the worms provoke no reaction. Of the 259 patients 11 (4.2%) had worms and/or eggs in granulomas of the abdominal and pelvic peritoneum, and an equal number had granulomas on the peritoneum of the salphinx or on the surface of the ovary. There were also ectopic worms and/or eggs in granulomas on the peritoneum of the small and large intestines (2.7%). These Enterobius granulomas form around degenerating adult worms, around discrete eggs, around clusters of eggs, and, we believe, also around the tracks of migrating worms. Three patients (1.2%) had worms in perianal abscesses. A necrotic granuloma, removed from the lung of one patient, surrounded a degenerating adult worm. This suggests that the worm, carried to the lung as an embolus, impacted in a pulmonary arteriole. A stool specimen of one patient contains eggs of Enterobius, and that of another patient contains an adult Enterobius. This is the largest recorded histopathological study of enterobiasis in man.

Majocchi's granuloma.

Majocchi's granuloma (nodular granulomatous perifolliculitis) is a well recognized but uncommon infection of dermal and subcutaneous tissue by fungal organisms (dermatophytes) usually limited to the superficial epidermis. The organism usually associated with Majocchi's granuloma is Trichophyton rubrum; however, other dermatophytes including T. mentagrophytes (variety granulosum), T. epilans, T. violaceum, M. audouinii, M. gypseum, M. ferrugineum, and M. canis may be the causative agent. A review of 17 cases revealed not only the variety of possible organisms but also a marked variation from the usual hyphal forms. The morphologic variations including yeast forms, bizarre hyphae, mucinous coatings, and the Splendore-Hoeppeli phenomenon may be factors which allow the dermatophytes to persist and grow in an abnormal location. Also, there is evidence that Majocchi's granuloma may occur in two distinct groups of patients.

Mucosal leishmaniasis in Brazil.

The clinical diagnosis and laboratory identification of Leishmania braziliensis braziliensis, a parasitic disease affecting the upper aerodigestive tract, is difficult. A retrospective computer-assisted analysis of patient records was done after examination of 58 patients with mucosal leishmaniasis in an endemic area of L. braziliensis braziliensis in Bahia, Brazil during January 1987. Biopsies of clinically active and clinically inactive mucosal patients were examined for parasites using routine hematoxylin and eosin histopathology and a new technique for rapid detection of Leishmania amastigotes using a genus-specific indirect immunofluorescent assay. No amastigotes were found in specimens from seven patients with clinically inactive mucosal disease using immunofluorescent monoclonal assay techniques, whereas specimens from seven out of 14 patients with clinically active mucosal disease were positive. These results suggest that the immunofluorescent antibody technique is markedly superior in identifying the intracellular amastigote in tissue sections of mucosal biopsies when compared to histopathology techniques or with other standard tests done in rural areas of Brazil. Various clinical and laboratory test data of the entire group of patients were examined and the efficacy of treatment evaluated. The median interval of time noted between cutaneous and mucosal disease was 4.5 years. Relapse was noted in 31% of patients treated with a low dose of meglumine antimoniate (10 mg per kg of body weight). Patients treated with a high dose of meglumine antimoniate (20 mg per kg of body weight) had a relapse rate of 27.3%. A chi-square statistical analysis revealed no significant difference (chi 2 = 0.049) between the two groups. Patients were considered cured if mucosal granulations were clinically absent after 4.6 years.

South American brugian filariasis: report of a human infection acquired in Peru.

A 27-year-old white woman from New York City acquired an infection by a Brugia species while she camped in the Amazon basin of Peru. She was infected by at least one adult male worm and one gravid female worm. Both worms were intact and in a lymphatic vessel of a right cervical lymph node. The lymph node and surrounding fibroadipose tissue contained many microfilariae. The male worm was 50 micron wide and the female, 100 micron. Both worms had thin (1 micron) cuticles with fine transverse striations. There were 3 to 4 somatic muscle cells per quadrant. Microfilariae had tails characteristic of the genus Brugia. Although specific identification was not possible from the available material, the worm closely resembled Brugia guyanensis, a parasite of the coatimundi (Nasua nasua) and the only species of Brugia known in South America.

Nodules in the conjunctiva, bung-eye, and bulge-eye in Africa caused by Mansonella perstans.

Eight patients from Uganda, Sudan, Nigeria, and Zaire presented with swelling of the eyelids, proptosis, or conjunctival granulomas. In 5 patients the cause was Mansonella perstans; in 1, it was a Wuchereria bancrofti-like worm; and in 2, an unidentifiable worm. The morphologic features and histopathologic changes in the conjunctiva and periorbital fat are described and illustrated.

Dicroceliasis (lancet fluke disease) in an HIV seropositive man.

Dicroceliasis is an unusual zoonotic trematode infection caused by the lancet liver fluke, Dicrocoelium dendriticum. Grazing herbivores (usually sheep or cattle) are the definitive hosts. The life cycle proceeds through two intermediate hosts: the land snail and the field ant. Human infection is acquired by consuming the field ant. This case report describes a human immunodeficiency virus-seropositive patient who presumably acquired this parasite from bottled water contaminated with ants. A brief discussion of the parasitology, pathology, clinical findings and treatment is presented.

Adult Mansonella perstans in the abdominal cavity in nine Africans.

Adult Mansonella perstans infected the abdominal cavity of nine patients seen at Karawa Hospital in the Ubangi territory of Zaire. In four patients the worms were removed at laparotomy, and in the other five they were removed at autopsy. Twelve adult worms were identified in the nine patients. None of the worms caused symptoms or contributed to the patient's death. Worms were in the hernial sac in three patients, and one each was in connective tissue beside a reactive mesenteric lymph node, in peripancreatic connective tissue, in perirenal connective tissue, in hepatic portal connective tissue, on the serosal surface of the small intestine, and in connective tissue adjacent to rectum. The diameter of male worms was 45 microns to 60 microns and of female worms, 80 microns to 125 microns. One female worm was removed intact. It was 6 cm long and had a bifurcated tail characteristic of M. perstans.

Abdominal angiostrongylosis in an African man: case study.

A nodule removed from the cecum of a 25-year-old Zairian man contained a degenerated adult nematode. The surrounding tissue contained larvae and eggs in various stages of cleavage. Eggs and larvae were indistinguishable from those of Angiostrongylus costaricensis. These morphological features are described. The diameter and cuticle, and the anatomic location of the adult worm is consistent with A. costaricensis. The tissue reaction was chronic with granulomatous inflammation and numerous eosinophils. This is the first report of abdominal angiostrongylosis of a human in Africa.

Liesegang rings in tissue. How to distinguish Liesegang rings from the giant kidney worm, Dioctophyma renale.

Liesegang rings (LRs) are periodic precipitation zones from supersaturated solutions in colloidal systems. They are formed by a process that involves an interplay of diffusion, nucleation, flocculation or precipitation, and supersaturation. Examples include LRs of calcium carbonate in oölitic limestone (in nature), LRs of silver chromate in gelatin (in vitro), and LRs of glycoprotein in pulmonary corpora amylacea (in vivo). Here we describe LRs in lesions from 29 patients--mostly lesions of the kidney, synovium, conjunctiva, and eyelid. The LRs formed in cysts, or in fibrotic, inflamed, or necrotic tissue. The LRs in this study varied greatly in shape and size, measuring 7-800 microns. Special stains and energy-dispersive radiographic analysis or scanning electron microscopy revealed that some LRs contained calcium, iron (hemosiderin), silicon, and sulfur. Some pathologists have mistaken LRs for eggs, larvae, or adults of the giant kidney worm, Dioctophyma renale. D. renale is a large blood-red nematode that infects a variety of fish-eating mammals, especially mink. Fourteen documented infections of humans have been recorded, usually with adult worms expelled from the urethra. The adult worms are probably the largest helminth to parasitize humans. Eggs of D. renale are constant in size (60-80 microns X 39-47 microns), contain an embryo, and have characteristic sculpturing of the shell. Liesegang rings should not be mistaken for eggs, larvae, or adults of D. renale, or for any other helminth.

Cutaneous botryomycosis in a patient with acquired immunodeficiency syndrome.

A patient with acquired immunodeficiency syndrome presented with multiple pruritic papules and nodules over the trunk and extremities. Biopsy specimens from two of these lesions contained granules within abscesses of the papillary dermis. There were numerous gram-positive cocci within the granules. Culture of one lesion failed to produce growth. A mouse inoculated with tissue from a lesion revealed no evidence of sepsis or organ involvement. The skin lesions showed no obvious response to systemic antimicrobial therapy but gradually resolved after treatment had been discontinued. Such lesions should be clinically distinguished from other cutaneous manifestations of acquired immunodeficiency syndrome, such as Kaposi's sarcoma.

Loiasis: "Calabar" swellings and involvement of deep organs.

The authors report clinical and histopathologic changes in six patients with symptomatic loiasis. One patient had cutaneous swellings, three patients presented with hydrocele, one patient developed bowel obstruction, and one had generalized fatal loiasis. The first five patients had localized lesions provoked by adult worms; all were surgically removed. The sixth patient died of disseminated loiasis that included a severe loal encephalitis. The authors discuss the mechanism of "Calabar" swellings, the reaction to adult Loa loa worms and loal encephalitis.

Lymphadenitis caused by Loa loa.

The World Health Organization's Collaborating Centre for the Histopathology of Filarial Diseases of Man contains specimens of lymph node from 13 patients infected by the filarial nematode Loa loa. Ten of these nodes have distinctive microscopic features characterized by distended sinuses that contain histiocytes and eosinophils and by atrophy of lymphoid follicles. Less striking features include fibrosis of capsule and trabeculae, dilated lymphatic vessels of capsule and medulla, and inflammatory cell infiltrates. We believe that these changes, although in themselves nonspecific, are characteristic of lymphadenitis caused by Loa loa. These 10 lymph nodes were removed from the inguinal region--one from each of 10 native Zairians . At the time of herniorrhaphy the nodes in eight patients were found to be enlarged and were removed for diagnosis. Seven of the 10 patients were infected with Dipetalonema perstans as well as Loa loa, and one of these seven had three filarial infections--L. loa, D. perstans and D. streptocerca . Lymph nodes from other patients infected by other filariae that were available for study at the AFIP did not have these histopathologic features.