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Beware of the dog

Published:February 20, 2020DOI:https://doi.org/10.1016/j.ejim.2020.02.015

      Case description

      A 24-years old male complained new-onset urinary retention during a return flight from a 1-month trip to Thailand, needed to be urgently catheterized. His past medical history was unremarkable. He is a seasonal worker in vineyards in France and left for Thailand in early September as a volunteer in a kennel. During his journey, he remains free of any symptom but for two isolated episode of diarrhea, upon the arrival in a dog-house. After the landing, he was promptly admitted to our Infectious Diseases Unit: neurological examination reported a symmetrical flaccid paralysis of the lower limbs with hyporeflexia, hypoesthesia, a thoracic sensory level on T4-T5 with both urinary and feces retention. He underwent brain and spine MR (Magnetic Resonance, Image 1)followed by lumbar tap reporting pleocytosis (150 cell/mm3), average glucose and no albumin–cytologic dissociation. Biochemistry was normal except for slightly elevated IgE (178 kU/L), Film-array® on CSF was negative and, empirical treatment with acyclovir and ceftriaxone was started. On day two neurological conditions have worsened and immunoglobulin and steroids were administered.

      What is your diagnosis?

      Neurotoxocariasis

      Discussion section

      In the next days, neural screen antibodies for myelitis were negative as well as, serologies for West Nile Virus, Chikungunya, Dengue, Zika, Enterovirus spp, Parvovirus B19, Tick-borne Encephalitis, Cytomegalovirus, Salmonella spp, Campylobacter spp., Brucella spp., Epstein-Barr virus, Mycoplasma pneumoniae, Treponema spp., HBV, HCV, HIV, HAV, Rickettsia spp., Borrelia spp., Galactomannan and β-D-glucan. After a five-days course of immunoglobulin and a ten days course of high-dosed steroids therapy (1–1.5 mg/Kg), flaccid paralysis improved, with an absent response in sensorial impairment and maintenance of urinary catheter. Ten days after, Toxocara spp. IgG Western Blot has resulted strongly positive. Albendazole was started (400 mg bid) over four weeks with the restoration of micturition, lowering of the sensory level and improvement of gait. Human toxocariasis is a common zoonosis due to the larval stages of the ascarids Toxocara canis. The main risk factor was strictly in contact with dogs and cats. Myelitis is the leading neurological of neurotoxocariasis characterized by MR hyperintensity on T2 and FLAIR sequences, notably located at the thoracic and cervical levels [
      • Sánchez SS
      • García HH
      • Nicoletti A
      Clinical and magnetic resonance imaging findings of neurotoxocariasis.
      ]. On biochemistry, IgE were usually above > 150 kU/L, and eosinophilia occurred in about half of cases [
      • Deshayes S
      • Bonhomme J
      • de La Blanchardière A
      Neurotoxocariasis: a systematic literature review.
      ]. Edeimiological Risk factors, MR compatible lesions, along with microbiological confirmation on serum, and favorable response to anti-helminthic therapy led us to the diagnosis (Fig. 1).
      Fig 1
      Fig. 1Spinal MR with hyperintensity in T2 sequences and hyso-hypointensity in T1 sequences.

      Acknowledgements

      We thank Dott. Silvia Corcione for her patience and competence.

      References

        • Sánchez SS
        • García HH
        • Nicoletti A
        Clinical and magnetic resonance imaging findings of neurotoxocariasis.
        Front. Neurol. 2018; 9: 53https://doi.org/10.3389/fneur.2018.00053
        • Deshayes S
        • Bonhomme J
        • de La Blanchardière A
        Neurotoxocariasis: a systematic literature review.
        Infection. 2016; 44: 565-574https://doi.org/10.1007/s15010-016-0889-8