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Rheumatology 2001; 40: 109-110
© 2001 British Society for Rheumatology
Letters to the Editor |
Human toxocariasis as a possible cause of eosinophilic arthritis
Departamento de Clinica Medica, Faculdade de Medicina, Av. Alfredo Balena, 190, B. Sta. Efigênia, CEP: 30. 130–100, MG, Belo Horizonte, MG, Brazil
SIR, We have read with great interest the article by Tay [1], in which he reported 10 cases of eosinophilic arthritis possibly associated with parasitic diseases or caused by an unknown allergen. Treatment with diethylcarbamazine or levamisole in four corticosteroid-resistant patients resulted in complete resolution of the symptoms and disappearance of eosinophilia.
Here we report a similar case. A 39-yr-old man was well until 1 month before admission, when he presented with arthritis involving both ankle joints. There was no report of fever, cough or other constitutional symptoms. He reported contact with pet dogs at home. His clinical examination was remarkable only for swelling, erythema and an increase in the local temperature of both ankle joints. His laboratory work-up revealed eosinophilia of 2300/mm3. An ELISA for Toxocara canis using toxocara excretory–secretory antigen [2, 3] was highly positive. The patient was treated with a 15-day course of indomethacin, and showed incomplete resolution of his symptoms. When serology for toxocariasis was shown to be positive, he received a single dose of ivermectin (12 mg), which has recently been reported to be effective against human toxocariasis [4]. There has been no recurrence of the symptoms 3 months after his discharge.
In a murine model of toxocariasis we have observed the presence of joint swelling in mice infected with T. canis, but we did not perform histopathological analysis. In clinical studies, arthritis has been reported in patients with T. canis infection [5].
Toxocariasis may have been responsible for arthritis in some of the cases reported by Tay [1], as high serum IgE levels, oedema of the feet and skin rash were observed in his patients. Such findings have been described in association with T. canis infection [5, 6], and treatment with diethylcarbamazine, a drug commonly used for visceral larva migrans syndrome, resulted in the resolution of symptoms in steroid-resistant cases [1].
Only two of his seven patients had an increased serum IgE level, a finding that is not expected in toxocaral disease; eosinophilia, another manifestation of parasitic diseases, may be absent in up to 27% of patients with toxocariasis [7].
The basic mechanism of arthritis in visceral larva migrans syndrome is not well understood, but immunological alterations have been reported in the form of positivity for rheumatoid factor [6] and sterile pericardial effusion that resolved with specific treatment for T. canis infection [8].
Further work is needed to define this possible association, and especially the role of repeated infection with T. canis, as reinfection would stimulate a stronger immune response in an already sensitized host. This hypothesis is being considered and pursued by our research group.
Notes
Correspondence to: J. R. Lambertucci. 
Accepted 10 July 2000
References
- Tay CH. Eosinophilic arthritis. Rheumatology1999;38:1188–94.
[Abstract/Free Full Text] - Glickman L, Schantz PM, Dombroske R, Cypess R. Evaluation of serodiagnostic tests for visceral larva migrans. Am J Trop Med Hyg1978;27:492–8.
[Abstract/Free Full Text] - Camargo ED, Nakamura PM, Vaz AJ, Silva MV, Chieffi P, Melo EO. Standardization of dot-ELISA for the serological diagnosis of toxocariasis and comparison of the assay with ELISA. Rev Inst Med Trop São Paulo1992;34:55–60.[ISI][Medline]
- Konate A, Duhamel O, Basset D et al. Toxocarose et troubles fonctionnels intestinaux. Présentation de 4 cas. Gastroenterol Clin Biol1996;20:909–11.[Medline]
- Jacob CMA, Pastorino AC, Peres BA et al. Clinical and laboratory features of visceral toxocariasis in infancy. Rev Inst Med Trop São Paulo1994;36:19–26.[Medline]
- Huntley CC, Costas MC, Lyerly A. Visceral larva migrans syndrome: clinical characteristics and immunologic studies in 51 patients. Pediatrics1965;36:523–36.
[Abstract/Free Full Text] - Taylor MRH, Keane CT, O'Connor P, Mulvihill E, Holland C. The expanded spectrum of toxocaral disease. Lancet1988;692–4.
- Rayes AA, Teixeira DM, Nobre V et al. Visceral larva migrans syndrome complicated by liver abscess: a case report. Scand J Infect Dis1999;31:324–25.[ISI][Medline]
Reply
Mt Elizabeth Medical Centre, 3 Mount Elizabeth, #08-03, Singapore 228510
I thank Drs Rayes and Lambertucci for their interest in and comment on my article on eosinophilic arthritis (EA) [1]. Their report on human toxocariasis as a possible cause of eosinophilic arthritis in one patient highlights the possible presence of occult parasitic infestation in those presenting with hypereosinophilia. Toxocariasis is rare in our country (M. Singh, personal communication) and patients in our series did not have close contact with pets and had no clinical or laboratory findings suggestive of visceral larva migrans [2]. Other occult allergens or agents might have been responsible. Since the publication on EA, three more cases have been studied. They responded promptly to a cysteinyl leukotriene receptor antagonist (montelukast sodium) (two cases) and to a short course of prednisolone (one case), without antihelmintic drugs, suggesting different aetiologies of EA. Further studies are needed.
References
- Tay CH. Eosinophilic arthritis. Rheumatology1999;38:1188–94.
[Abstract/Free Full Text] - Kerr-Muir MG. Toxocara canis and human health. Br Med J1994;309:5–8.
[Free Full Text]
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