Cough variant asthma induced by Lophomonas blattarum

Xu, Zhehao; Zhang, Shitong; Liang, Ruiyun

doi:10.1016/j.medcle.2023.09.024

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(B) Microscopic view of Lophomonas blattarum (×1000, staining): L. blattarum deforms into an ellipsoid and purplish-brown color after staining." ] ] ] "textoCompleto" => "Pulmonary infection with Lophomonas blattarum (L. blattarum) is hardly seen in clinical practice, often leading to misdiagnosis. The examination results usually demonstrate that the content of eosinophils in alveolar lavage fluid is significantly increased, or the content of eosinophils and immunoglobulin E on a routine blood test is increased. Nevertheless, the final correct diagnosis usually relies on the identification of the morphology. The first case of infection with it was reported in 1992 in China.<a class="elsevierStyleCrossRef" href="#bib0025">1</a> This article summarizes and analyzes the diagnosis and treatment of a case of pulmonary blattarum treated in our hospital to further enhance the understanding of the disease.A 34-year-old male patient has a 17-year history of chronic urticaria and has been undergoing daily treatment with levocetirizine 5mg. In January 2022, he developed a paroxysmal dry cough without obvious inducement, accompanied by white phlegm, shortness of breath, and chest tightness. The pulmonary function examination conducted in Wuhan revealed mild negative results on the bronchodilation test and diagnosed with lung infection. Despite receiving levofloxacin, the symptoms persisted.In May 2022, the patient sought outpatient care at our hospital. Physical examination revealed a barrel-shaped chest. Laboratory tests showed: white blood cell count of 8.22×109/L, eosinophils count of 0.72×109/L, C-reactive protein count of 5.50mg/L, IgE count of 515IU/ml and an increased eosinophils percentage of 8.8%. The pulmonary function examination showed a 31.6% decrease in FEV1 following inhalation of histamine 8mg (positive histamine stimulation test). A chest CT scan confirmed the presence of pulmonary infection and bronchial asthma. He was prescribed budesonide/fomoterol inhalation, in addiction to montelukast, compound methoxyphenamine capsules, and procaterol. The symptoms had improved compared to before, but were prone to recurrence, indicating the need for further treatment.The patient was hospitalized in May 2022. Rheumatological immune-related tests, aspergillus antibody testing, allergen screening, and bone marrow cytology yielded normal results. Given ceftizoxime sodium 2g bid for a week for intravenous anti-infection treatment, the effect was not satisfactory. Later, hormonotherapy 40mg iv was added for further treatment, considering the infection of Trichomonas. After confirmation, metronidazole 0.5g qd was added for intravenous anti-trichomonas treatment. Following the above treatment, the patient's symptoms improved, and he was eventually discharged.During the follow-up period, the patient remained in good condition. The most recent blood routine showed a white blood cell count of 7.42×109/L, eosinophils count of 0.57×109/L (5.700% eosinophil percentage). A chest CT scan showed no significant abnormalities, indicating a substantial improvement.L. blattarum, a parasitic protozoan, tends to live in a viscous environment. It can invade various tissues and organs of the human body through airway transmission and other means.<a class="elsevierStyleCrossRef" href="#bib0030">2</a> While it primarily infects immunocompromised patients it is relatively rare in children. As shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, the increasing prevalence of bronchoscopic alveolar lavage has simplified the identification of this parasite.<a class="elsevierStyleCrossRef" href="#bib0035">3</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Due to its nonspecific symptoms, it is commonly confused with bronchial asthma. The patient, initially presented with prolonged cough, sputum, and elevated IgE levels, leading to a diagnosis of cough variant asthma. The diagnosis was supported by lung function tests, while allergen screening yielded negative results.Conventional management commenced with empirical antibiotic therapy and treatment for bronchial asthma, but resulted in no response and gradual deterioration. Fortunately, the presence of L. blattarum was detected in the bronchoalveolar lavage fluid. The accurate diagnosis was challenging due to the coexistence of cough variant asthma and chronic urticaria, both contributing to the increased eosinophil count, leading to some confusion.Given the rarity of L. blattarum, there is a limited number of reported cases of pulmonary infection, and a unified treatment plan has yet to be established. Currently, oral or intravenous metronidazole or tinidazole is considered the mainstay of treatment for adults weighing more than 40kg. In this case, the patient initially received intravenous ornidazole at a dose of 500mg daily for 5 days, which resulted in significant improvement.By microscopy, distinguishing L. blattarum from normal bronchial ciliated epithelial cells poses a challenge. Furthermore, due to the lack of specific clinical manifestations, most clinicians currently face the difficulties in identifying the parasite, resulting in misdiagnosis or missed diagnosis and subsequent delays in initiating timely treatment. Moreover, the adverse reactions induced by empiric antibiotic therapy and hormone abuse impose unnecessary burdens on the patients. Hence, medical workers should exercise great caution and conduct thorough examinations and analyses in immunocompromised patients presenting with respiratory symptoms such as cough, sputum, asthma, shortness of breath and allergies to ensure an accurate diagnose.To sum up, the clinical features, transmission routes and pathogenesis of L. blattarum are still not well understood. There is a need for more precise and cost-effective molecular diagnostic techniques to enhance the accuracy of parasite detection, overcoming the limitations associated with morphological characteristics.Ethics declarationThe patients’ informed consent has been obtained for this study.FundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Conflict of interestAll authors have no conflicts of interest. On behalf of all authors, the corresponding author states that there is no conflict of interest." 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(B) Microscopic view of Lophomonas blattarum (×1000, staining): L. blattarum deforms into an ellipsoid and purplish-brown color after staining." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case report of human respiratory hyperflagellate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.X. Chen" 1 => "Z.X. Meng" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "J Jiangxi Med Coll" "fecha" => "1992" "volumen" => "32" "paginaInicial" => "96" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary Infection with Lophomonas blattarum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Q. Ding" 1 => "K. Shen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12098-020-03311-1" "Revista" => array:6 [ "tituloSerie" => "Indian J Pediatr" "fecha" => "2021" "volumen" => "88" "paginaInicial" => "23" "paginaFinal" => "27" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32592000" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and treatment of Lophomonas blattarum infection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.G. Yang" 1 => "Z. Yang" 2 => "Y. Yang" 3 => "B. Yue" 4 => "S.L. Zheng" 5 => "N. Yan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3969/j.issn.1673-4130.2014.03.024" "Revista" => array:2 [ "tituloSerie" => "Int J Lab Med" "fecha" => "2014" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and treatment of Lophomonas blattarum infection in 26 patients with bacterial pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.L. Shi" 1 => "L.H. Li" 2 => "Y. Liao" 3 => "X.N. Li" 4 => "X.Y. Huang" 5 => "J. Liu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi" "fecha" => "2007" "volumen" => "25" "paginaInicial" => "430" "paginaFinal" => "431" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18442004" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016200000005/v1_202403010948/S2387020624000573/v1_202403010948/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016200000005/v1_202403010948/S2387020624000573/v1_202403010948/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624000573?idApp=UINPBA00004N"]

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Vol. 162. Issue 5.

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