4 NEWS
4 NEWS
15 SEPTEMBER 2023 ausdoc . com . au
Python parasite invades brain
Aussie woman is world ’ s first human case .
Kemal Atlay WHAT was initially suspected as a run-of-the-mill case of atypical pneumonia became a world first after Australian doctors removed a live and “ wriggling ” parasitic worm from a woman ’ s brain .
The patient , from southeastern NSW , first presented to a local hospital in early 2021 , but it was not until almost 18 months later that the nematode — identified as
Ophidascaris robertsi — was discovered , making hers the first case of human infection with a worm typically found in local carpet pythons .
The 64-year-old ’ s initial symptoms were abdominal pain and diarrhoea , the doctors reported , followed by dry cough and night sweats .
She had a history of diabetes , hypothyroidism and depression .
Her eosinophil count was
OLOPATADINE HYDROCHLORIDE + MOMETASONE FUROATE MONOHYDRATE
Combination NASAL SPRAY for allergic rhinitis
In patients 6 years of age and older . 1
MOMETASONE FUROATE Corticosteroid for long-lasting relief 1 , 2
OLOPATADINE Antihistamine for fast symptom relief 1 , 2
≥6 yrs
Fast onset of action † 3 , 4 For patients ≥6 yrs 1 significantly elevated at 9.8 x 109 cells / L , as were platelets ( 617 x 109 cells / L ) and CRP ( 102mg / L ). Haemoglobin was low at 99g / L .
She was treated for community-acquired pneumonia with doxycycline .
But persisting symptoms prompted a CT of the chest and abdomen , which showed multifocal pulmonary opacities with surrounding ground-glass changes , plus
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* Improvement in allergic rhinitis symptoms and quality of life measures vs placebo ( p < 0.05 ). 1 , 3 – 5
hepatic and splenic lesions .
“ Bronchoalveolar lavage revealed 30 % eosinophils without evidence of malignancy or pathogenic micro-organisms , including helminths ,” the doctors wrote .
The diagnosis was revised to eosinophilic pneumonia with unclear aetiology , and treatment was switched to prednisolone 25mg / day .
But again , her symptoms
TWICE as effective as mometasone furoate alone ( for nasal and ocular symptoms ) ‡ 1 , 3 , 4 , 6 , 7
†
iTNSS ; p < 0.05 vs placebo in patients ≥12 yrs . ‡ 104 % relative improvement with Ryaltris vs MF ( placebo-subtracted rT7SS results , post-hoc , pooled analysis of 3 double-blind , randomised , placebo-controlled 14-day studies in patients ≥12 yrs .); p < 0.001 ( N = 2,971 ). 7
Ryaltris is generally well tolerated , with similar incidences of adverse events to placebo and individual monotherapies . 1 , 3-5
In 6-11 year old children , periodic review of corticosteroid use is recommended .
PBS Information : This product is not listed on the PBS .
Please refer to the full Ryaltris Product Information before prescribing , which can be accessed by scanning the QR code . iTNSS : instantaneous total nasal symptom score . MF : Mometasone furoate . rT7SS : Reflective total of 7 ( 4 rhinitis + 3 ocular ) symptom scores .
References : 1 . Ryaltris Approved Product Information . 2 . Bousquet J et al . Allergy 2008 ; 63:8 – 160 . 3 . Gross GN et al . Ann Allergy Asthma Immunol 2019 ; 122:630 – 638 . 4 . Hampel FC et al . Allergy Asthma Proc 2019 ; 40 ( 4 ): 261 – 272 . 5 . Segall N et al . Allergy Asthma Proc 2019 ; 40 ( 5 ): 301 – 310 . 6 . Andrews CP et al . Ann Allergy Asthma Immunol 2020 ; 124 ( 2 ): 171 – 178 . 7 . Meltzer E et al . Poster presented at the European Respiratory Society ( ERS ) International Congress , 4 – 8 September 2021 , Barcelona . Data on file .
Ryaltris ® is a registered trademark of Glenmark Specialty SA . Seqirus ( Australia ) Pty Ltd . Melbourne , Victoria , Australia . ABN 66 120 398 067 . Medical Information : 1800 642 865 . AU-RYAL-23-0027 . Date of Preparation : April 2023 . 2004119 .
persisted . And repeat CT three weeks later showed “ migratory ” pulmonary opacities .
Bacterial , fungal and mycobacterial cultures were negative , and no parasites were found in her faeces .
The doctors subsequently treated her for T-cell-driven hypereosinophilic syndrome with prednisolone 50mg / day and mycophenolate 1g bd .
She also received ivermectin ( 200μg / kg orally ) for two consecutive days and a repeat dose after 14 days , despite testing negative for strongyloides , in case of a false-negative result and taking into account her history of travel to South Africa , Asia and Europe .
Further imaging in mid- 2021 showed improvements in pulmonary and hepatic lesions .
In January 2022 , the doctors prescribed mepolizumab ( 300mg every four weeks ) and were finally able to taper her prednisolone dose when her eosinophil count returned to normal .
However , after experiencing new-onset forgetfulness and worsening depression , a brain MRI showed a 13mm x 10mm peripherally enhancing right frontal lobe lesion . The subsequent open biopsy left the doctors shocked .
“ We noted a string-like structure within the lesion , which we removed ; it was a live and motile helminth ( 80mm long , 1mm diameter ),” they wrote .
It was later identified as a third-stage larva of O . robertsi .
They said the patient — who lived near a lake area inhabited by carpet pythons and collected native vegetation for cooking — may have “ inadvertently consumed O . robertsi eggs either directly from the vegetation or indirectly by contamination of her hands or kitchen equipment ”.
The extended immunosuppression may have enabled the worm to migrate to the CNS , they added .
After the worm was removed , a progress CT showed resolution of pulmonary and hepatic lesions but unchanged splenic lesions . She received a repeat two-day course of ivermectin , albendazole 400mg bd for four weeks and a weaning course of dexamethasone starting at 4mg bd for 10 weeks . All other immunosuppression was stopped .
Her eosinophil count remained normal six months post-surgery , but her neuropsychiatric symptoms persisted . Emerg Infect Dis 2023 ; 11 Aug . See cartoon , page 13