Toksokariyaza Bağlı Bir Transvers Miyelit Olgusu ve Tanıda Yerel Antikor Üretiminin Önemi
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Tarih
2016
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Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Toksokariyaz, dünyada yaygın olarak görülen, Toxocara canis veya daha az oranda T.catis tarafından oluşturulan bir parazit enfeksiyonudur. İnsanlarda klinik spektrum, alınan parazitin miktarına, larvanın göçtüğü bölgeye ve konağın infl amatuvar yanıtına bağlı olarak asemptomatik enfeksiyondan ciddi organ hasarına kadar değişebilir. Toksokariyaza bağlı transvers miyelit (TM) oldukça nadir görülen bir hastalık olup, literatürde çoğunlukla olgu sunumları şeklinde rapor edilmiştir. Bu raporda, transvers miyelit (TM) gelişen ve serolojik olarak nörotoksokariyaz tanısı konulan bir olgu sunulmuştur. Yaklaşık iki yıl önce sırt ağrısı yakınmasıyla başvurduğu bir merkezde TM tanısı konulan 44 yaşındaki erkek hasta, altı ay süreyle pregabalin ve steroid-dışı ilaç tedavisi almış, ancak lezyonlarda ilerleme olunca başka bir merkezde üç ay süreyle yüksek doz kortikosteroid tedavisi uygulanmıştır. Altı aylık takipte iyileşme saptanan olgu, bir yıl sonra yakınmaların tekrarlaması üzerine hastanemize başvurmuştur. Yapılan manyetik rezonans görüntüleme (MRG) tetkikinde, daha alt segmentte TM tanısı konmuştur. Sol alt ekstremitede güçsüzlük ve uyuşma yakınmaları olan olgunun anamnezinde kedi ve köpeklerle temas veya kırsal kesimde yaşama öyküsü yoktur. Fiziksel incelemede, kraniyal sinir muayeneleri, yüzeyel ve derin duyu muayenesi normal olarak saptanmış, motor defi sit ve patolojik refl eks izlenmemiş, derin tendon refl eksleri normoaktif olarak tespit edilmiştir. Laboratuvar tetkiklerinde hemogram ve biyokimyasal testler normal, PPD negatif olup, dışkıda parazit kist ve yumurtası görülmemiştir. Viral hepatit göstergeleri, anti-HIV, toksoplazma-IgM, CMV-IgM, rubella-IgM, EBV-VCA-IgM, VDRL, Brucella tüp aglütinasyonu, ekinokok antikorları, otoantikor testleri ve nöromyelitis optika testleri negatiftir. Alınan BOS örneğinin incelemesinde, lökosit sayısı 20/mm3 olarak belirlenmiş (mononükleer karakterde), protein 45 mg/dl, glukoz ve klor düzeyleri normal bulunmuştur. Hastanın hem serum hem de BOS örneğinde, Western blot (WB) yöntemiyle Toxocara-IgG antikor pozitifl iği saptanmıştır. Tekrarlanan WB testinde her iki örnekte de düşük molekül ağırlıklı (30-40 kDa) bantlar tespit edilmiş ve BOS'da lokal antikor üretimini düşündüren daha yoğun bantlar izlenmiştir. Bunun üzerine olguya nörotoksokariyaz tanısı konularak, kortikosteroid ile birlikte mebendazol tedavisi altı hafta süreyle uygulanmıştır. Klinik yanıt alınan olguda, iki ay sonra yapılan kontrol MRG'de miyelit bulgularında belirgin düzelme saptanmıştır. Sonuç olarak, santral sinir sistemi tutulumunun çok nadir görülmesine karşın, TM'nin ayırıcı tanısında toksokariyaz mutlaka akla gelmeli ve tanı için hem serum hem de BOS'da uygun serolojik testler yapılmalıdır
Toxocariasis caused by Toxocara canis or less frequently by T.catis is a common parasitic infection worldwide. Clinical spectrum in humans can vary from asymptomatic infection to serious organ disfunction depending on the load of parasite, migration target of the larva and the infl ammatory response of the host. Transverse myelitis (TM) due to toxocariasis is an uncommon illness identifi ed mainly as case reports in literature. In this report, a case of TM who was diagnosed as neurotoxocariasis by serological fi ndings has been presented. A 44-year-old male patient complained with backache was diagnosed as TM in a medical center in which he has admitted two years ago, and treated with pregabalin and nonsteroidal drugs for six months. Because of the progression of the lesions he readmitted to another center and treated with high dose steroid therapy for three months. After six months of follow up, improvement has been achieved, however, since his symptoms reccurred in the following year he was admitted to our hospital. Magnetic resonance imaging (MRI) examination revealed a TM in a lower segment of spinal cord. He was suffering with weakness and numbness in the left lower extremity. There was no history of rural life or contact with cats or dogs in his anamnesis. Physical examination revealed normal cranial nerve functions, sensory and motor functions. There has been no pathological refl exes, and deep tendon refl exes were also normal. Laboratory fi ndings yielded normal hemogram and biochemical tests, negative PPD and parasitological examination of stool were negative for cysts and ova. Viral hepatitis markers, anti-HIV, toxoplasma-IgM, CMV-IgM, rubella-IgM, EBV-VCA-IgM, VDRL, Brucella tube agglutination, echinococcus antibody, autoantibody tests and neuromyelitis optica test were negative. Examination of CSF showed 20 cells/mm3 (mononuclear cells), 45 mg/dl protein and normal levels of glucose and chlorine. In both serum and CSF samples of the patient Toxocara-IgG antibodies were detected by Western blot (WB) assay. Low molecular weight bands (30-40 kDa) were detected in both of the samples by repeated WB testing. CSF revealed more intense bands suggesting local antibody production. Therefore the patient was diagnosed as neurotoxocariasis, and treated with steroid and mebendazole for six weeks. Clinical improvement was detected in the case and thoracic MRI revealed signifi cant improvement in myelitis signs two months after treatment. In conclusion, toxocariasis should be considered in the differential diagnosis of TM although the involvement of central nervous system is rare and serological testing should be performed properly in the serum and CSF samples for the diagnosis
Toxocariasis caused by Toxocara canis or less frequently by T.catis is a common parasitic infection worldwide. Clinical spectrum in humans can vary from asymptomatic infection to serious organ disfunction depending on the load of parasite, migration target of the larva and the infl ammatory response of the host. Transverse myelitis (TM) due to toxocariasis is an uncommon illness identifi ed mainly as case reports in literature. In this report, a case of TM who was diagnosed as neurotoxocariasis by serological fi ndings has been presented. A 44-year-old male patient complained with backache was diagnosed as TM in a medical center in which he has admitted two years ago, and treated with pregabalin and nonsteroidal drugs for six months. Because of the progression of the lesions he readmitted to another center and treated with high dose steroid therapy for three months. After six months of follow up, improvement has been achieved, however, since his symptoms reccurred in the following year he was admitted to our hospital. Magnetic resonance imaging (MRI) examination revealed a TM in a lower segment of spinal cord. He was suffering with weakness and numbness in the left lower extremity. There was no history of rural life or contact with cats or dogs in his anamnesis. Physical examination revealed normal cranial nerve functions, sensory and motor functions. There has been no pathological refl exes, and deep tendon refl exes were also normal. Laboratory fi ndings yielded normal hemogram and biochemical tests, negative PPD and parasitological examination of stool were negative for cysts and ova. Viral hepatitis markers, anti-HIV, toxoplasma-IgM, CMV-IgM, rubella-IgM, EBV-VCA-IgM, VDRL, Brucella tube agglutination, echinococcus antibody, autoantibody tests and neuromyelitis optica test were negative. Examination of CSF showed 20 cells/mm3 (mononuclear cells), 45 mg/dl protein and normal levels of glucose and chlorine. In both serum and CSF samples of the patient Toxocara-IgG antibodies were detected by Western blot (WB) assay. Low molecular weight bands (30-40 kDa) were detected in both of the samples by repeated WB testing. CSF revealed more intense bands suggesting local antibody production. Therefore the patient was diagnosed as neurotoxocariasis, and treated with steroid and mebendazole for six weeks. Clinical improvement was detected in the case and thoracic MRI revealed signifi cant improvement in myelitis signs two months after treatment. In conclusion, toxocariasis should be considered in the differential diagnosis of TM although the involvement of central nervous system is rare and serological testing should be performed properly in the serum and CSF samples for the diagnosis
Açıklama
Anahtar Kelimeler
Mikrobiyoloji
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Mikrobiyoloji Bülteni
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Cilt
50
Sayı
3
