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An Unusual Case of Hypereosinophilia and Abdominal Pain: An Outbreak of Trichostrongylus Imported From New Zealand
Emma C. Wall, MRCP DTM&H,∗ Neha Bhatnagar, MRCP, MRCPath,† Julie Watson, PhD,∗ and Tom Doherty, FRCP DTM&H∗
∗ Departments

of Tropical Medicine and Clinical Parasitology, Hospital for Tropical Diseases, London, UK; † Department of Haematology, Royal Cornwall Hospital, Truro, Cornwall, UK DOI: 10.1111/j.1708-8305.2010.00474.x

We report an outbreak of severe symptomatic Trichostrongylus spp. in travelers visiting a sheep farm in New Zealand. The unusual source of the outbreak was traced as the use of sheep manure as an organic fertilizer on a salad garden.

Case Report

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62-year-old Caucasian woman presented to her general practitioner (GP) in Cornwall, UK, following a month long trip to visit friends in Australia and New Zealand in December 2008. She spent a week on a sheep farm in New Zealand. Shortly afterwards she felt dizzy and nauseated. She then developed abdominal pain and bloating, followed by diarrhea and weight loss of 2 kg. Initial investigations performed by her GP showed a total white cell count of 19.9 × 109 /L (4–10 × 109 ) with an eosinophil count of 9.6 × 109 /L (0.1–0.4 × 109 ). Based on these results she was referred to the local hematology service for further investigation of hypereosinophilia. Clinical evaluation at the Royal Cornwall Hospital did not identify any hepatosplenomegaly or lymphadenopathy. Further investigations showed normal vitamin B12 concentration, autoantibody profile, immunoglobulins, and protein electrophoresis with no evidence of cardiac or pulmonary damage (normal chest radiograph [CXR], pulmonary function tests, electrocardiogram [ECG], cardiac enzymes, and echocardiogram). Peripheral blood and bone marrow T-cell populations had a normal immunophenotype and Tcell receptor rearrangement studies were negative. Bone marrow aspirate showed an active marrow with 60%

eosinophils and eosinophilic precursors. This was confirmed on bone marrow trephine with no increase in mast cells. Despite these normal investigations, the eosinophil count continued to rise rapidly, reaching a peak value of 17.9 × 109 /L. Two months after her initial assessment and during investigations at the Royal Cornwall Hospital, the patient received an e-mail from two friends who had been on the same trip, both of whom had developed similar symptoms. Both had been investigated in New Zealand and found to have a peripheral eosinophilia with Trichostrongylus spp. seen on stool microscopy. Subsequent correspondence established that the farm in New Zealand used sheep manure as an organic fertilizer for their vegetable garden. The faeces from these sheep were subsequently found to be positive for Trichostrongylus spp. On receipt of the first email the patient discussed her symptoms with her GP and was referred to the Hospital for Tropical Diseases (HTD) for specialist evaluation. Examination of a stool sample revealed ova of Trichostrongylus spp. (Figure 1). She was treated with albendazole 400 mg twice daily for 3 days and recovered fully within 6 weeks. Her peripheral eosinophilia was also resolved completely. Discussion Trichostrongylus species (pseudo-hookworm) are a group of zoonotic helminths infecting herbivorous animals. The prevalence of human infection is very high among farmers in the developing world where close contact between humans and animals occurs and good sanitation is often not available.1 Infections in pastoralists have
© 2010 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine 2011; Volume 18 (Issue 1): 59–60

Corresponding Author: Emma C. Wall, MRCP DTM&H, Departments of Tropical Medicine and Clinical Parasitology, Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London WC1E 6JB, UK. E-mail: emma.wall@doctors.org.uk

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Ditrich O. Pathology 1995. Differential diagnosis of Trichostrongylus and hookworm eggs via PCR using ITS-1 sequence. Trichostrongylus orientalis is the most recognized. Walker JC. 18: 59–60 The authors would like to thank Dr Chris Morley. et al.8 being endemic in sheep throughout the country. been reported throughout the world. Morris CA. This is due to stringent laws preventing the use of untreated animal manure as a crop fertilizer. 84:184–193. Sangster NC. there are no reported cases of human infection with Trichostrongylus spp. Guevart E. Leathwick DM. Human infection is usually mild with abdominal bloating and minimal systemic symptoms. Korean J Parasitol 2009. Bouaphan S. 7. Detailed species diagnosis is only possible through DNA analysis. Vet Rec 2008. et al. Acknowledgments Figure 1 Ova of Trichostrongylus spp. N Z Vet J 2001.9 Five cases were reported J Travel Med 2011. Med J Aust 2006. no published cases appear in the literature from New Zealand. Dei-Cas E. Sim S. 162:546–550. A low-grade peripheral eosinophilia is often noted.60 Wall et al. South Africa: epidemiology and control. from the stool sample provided by the patient. and physicians in UK and New Zealand facilitated a rapid investigation of the cause of the outbreak. Human infestation by Trichostrongylus vitrinus in Morocco. particularly Trichostrongylus colubriformis. Phenotypic markers for selection of nematode-resistant sheep. Int J Parasitol 1996. Afr Health Sci 2005. New Zealand. Adams JF. Viengsay M. species analysis was not performed. 5:276–280. Abdominal pain and eosinophilia in suburban goat keepers—trichostrongylosis [corrected]. 9. Ralph A. et al. but detailed surveys of people in endemic areas are lacking.6 The patient in this case had unusually severe symptoms. Markus MB. 27:182–185. Lee JH. for tracing the source of the Trichostrongylus from the sheep manure that was being used as an organic fertilizer in the salad garden. In the UK. Adams VJ. acquired in this country. are classically large measuring approximately 80 × 40 µm) and shape. from rural Australia with the same transmission method proposed. and the extensive use of chemical spraying. Trichostrongylus spp.10 Hypereosinophilia is a rare condition and this case highlights a very unusual zoonotic cause. Human trichostrongyliasis in Queensland. 59:636–638. Boreham RE. Several cases of infection with Trichostrongylus spp. Vlassoff A. despite Trichostrongylus spp. 6. Trichostrongylus spp. are endemic in herbivores. and Trichostrongylus vitrinusn7. 4. Ann Parasitol Hum Comp 1984. 10. The epidemiology of nematode infections of sheep. Giboda M. Trichostrongylus capricola. Declaration of Interests The authors state that they have no conflicts of interest to declare. Paradoxical helminthiasis and giardiasis in Cape Town. Green RS. 47(Suppl):S133–S141. Unexplained eosinophilia may be due to zoonotic parasitic infections and therefore difficult to diagnose. Bull Soc Pathol Exot 1991. Epidemiology of gastrointestinal nematode parasitism in a commercial sheep flock and its implications for control programmes.5 However. Due to her rapid response to treatment. diagnosis. Korean J Parasitol 2007. most commonly sheep. 45:69–74.. Of the species of Trichostrongylus which cause disease in humans. two men became symptomatic after manure from a pet goat was used to fertilize an organic suburban garden. Douch PG. Sargison ND. friends.2 – 4 Humans usually become infected through consumption of food or water contaminated with animal faeces. commonly where faeces are used as a fertilizers. Yong TS. 3. Heath AC. . References 1. particularly as all species respond to the same drug therapy. and treatment for all those who were affected. 49:213–221. et al. Parasitic infections should always be included in the differential diagnosis of unexplained eosinophilia. 8. with particularly high prevalence in Asia and the Middle East. 184:467–469. Penny CD. 5. McCowan MJ. BVSc BSc (Hons) MVPHMgt Ministry of Agriculture. et al. Wilson DJ. In one report from urban Sydney. Australia. which is not commonly performed due to its complexity and expense. Epidemiology of intestinal parasitosis in Laos (with antiamoebic antibody levels). separation of grazing land from cultivation of raw foods. ova are identified on stool microscopy and differentiated by experienced microscopists from hookworm and Strongyloides ova by size (Trichostrongylus spp. O’Sullivan MV. Youn H. Review of zoonotic parasites in medical and veterinary fields in the Republic of Korea. 2. Ryan AE. this may relate to the high parasitic load. The use of electronic communication in this case among the patient. have been reported in Australia but before this outbreak. Scott PR. Poirriez J. 26:899–911.