“TROPICAL LUNG”

DISEASES
Manuel Calvopiña, MD, MSc, PhD
Universidad de las Américas (UDLA) Quito

DEFINITION. Those pulmonary diseases commonly

encountered in the Tropics that could be infectious
(virus, bacteria, mycobacteria, parasites & fungi) and
noninfectious (occupational, dust).
1. Paragonimiasis 5. Tb 9. Fungi (Histo, Coccidio)
2. Loeffler´s Sd. 6. Echinococcosis 10. Pleural effusion
3. Tropical Pulm.Eos 7. STH parasites (St. St.) 11. Occupational (bagass)
4. Leptospirosis 13. Virus (Covid-19, MERS)
5. Schistosomiasis
 Amphimeriasis
Clonorchis, Opistorchis
Fasciola hepática (Liver)
Paragonimus (lung)

Others: malaria, amoebiasis/ALAbscess

Others: leptospirosis, bartonellosis

Others: Histoplasmosis, Coccidioidomycosis

Others: Angiostrongylus cantonensis

y A. costarricensis. Gnathostoma sp. Others: Zika, yellow fever

Others: Scorpion, wasp, spiders, ants, Myaisis,

Mosquito bites, Paederus, plants, caterpillars.
 The term TROPICS refers to the region of earth lying between the Tropic of
Cancer and the Tropic of Capricorn. In the tropics: warm climate, rain forest,
fauna/flora or biodiversity, poverty, poor education, poor sanitation & safe
water, poor housing, culture…. provide an ideal environment for pathogens,
vectors, and intermediate hosts.
 Why + diseases in the tropics?: warm climate, rainfall, forest, poverty,
fauna/flora or biodiversity, lack of education, safe water, poor housing,
cultural believes, stigma, and poor sanitation (latrines, garbage
disposal, sewage), poor access to health = ideal environment for
pathogens, vectors, and intermediate hosts.
 1. PNEUMONIA
• WHO data showed that pneumonia is the leading cause of
death in children under 5 years of age and is responsible for
16% of deaths. +++ Tropics
PNEUMONIA ETIOLOGY
Pneumonia
 2. TUBERCULOSIS

Pcte acute respiratory failure plus acid fast bacilli stain positive in sputum = Isolation to contain pathogens with airborne transmission
 3. PARASITIC & OTHER PULMONARY
INFECTIONS IN THE TROPICS

Cayambe case. Echinococcus granulosus Riobamba case. Disseminate strongyloidiasis

 Loeffler’s syndrome
Is “simple” pulmonary eosinophilia with no or minimal systemic and pulmonary
symptoms. In STH helminth infections (Ascaris, strongyloidiasis, hookworm &
Schistosoma), the larvae migrate through the lung and in heavy infections can
cause fever, cough, dyspnea, wheezing, hemoptysis, and lung infiltrate. Dg=find
larvae in sputum. Tx=Albendazole.
 Tropical Pulmonary Eosinophilia (TPE)

Is the result of a hypersensitivity reaction to the microfilariae of Wuchereria

bancrofti and Brugia malayi trapped in the pulmonary microcirculation PLUS
hipereosinophilia. (Ecuador not yet).
Treatment consists of diethylcarbamazine (DEC) for at least 3 weeks. Despite treatment with
DEC, about 20% of patients may relapse. Steroids have shown to have a beneficial effect, but
the exact dose and duration is yet to be confirmed.
 Tropical Pulmonary
Eosinophilia (TPE)
• Is caused by immunologic
hyperresponsiveness to Wuchereria
bancrofti, Brugia malayi, or other
microfilariae.
• Clinical presentation consists of
nocturnal cough, wheezing, fever, and
weight loss.
• Chest radiographs show diffuse
interstitial military infiltrates (Fig. 1.6);
there is a high eosinophil count. In
developed countries, serum IgE and anti-
filarial antibodies can be used to confirm
the diagnosis.
• Tx. diethylcarbamazine (DEC) for 3
weeks. 20% relapse. Steroids have
shown to have a beneficial.
 Riobamba-Ecuador. Clinical case
disseminate strongyloidiasis

• Riobamba hospital. A 57-year-old woman of Ecuadorian nationality, with a

history of type 2 diabetes mellitus. Receiving treatment with 500 mg/day of
metformin.
• She was born and resides in a rural area of Lago Agrio-Amazon.
• 2 months of weight loss, asthenia, decreased appetite, thirsty.
• She went to the emergency room for colicky abdominal pain located in the
hypogastrium of great intensity, which was preceded by 2 soft bloody stools
and nausea that reached vomiting on 10 occasions.
• She presents pale skin, dry oral mucous membranes, tender abdomen with
positive bilateral fist percussion of +++ on the left side.
• Whole leukocyte count 6.500 mm3, eosinophils 8%. Hb of 11 mg/dL, Hcto
23%, IgE elevated.
• On the 8-day hospitalization, a fresh Gram and K0H were performed:
epithelial cells 8-12 xc, numerous piocytes, red blood cells: 18-20 xc,
bacteria: +, Gram+ cocci of 3- 5 xc. Fungus spores negative. Presence of
several nematode larvae=suggestive of Tropical Pulmon Eos.
Riobamba-Ecuador. Clinical case

Paciente con ventilación asistida, Tórax simétrico, expansibilidad pulmonar disminuida

Rx tórax AP. adenopatía hiliar derecha, infiltrado broncoalveolar,, elevación de
hemidiafragma derecho, engrosamiento hiliar derecho, silueta cardiaca de dilatación
grado 2, diafragmas normales.
Sputum. Fresh smear, several active coiled larvae = Strongyloides stercolaris.
DG: Disseminated strongyloidiasis in a inmunossupresed patient.
TX. Ivermectin 0.4 mg/kg for 5 days. Discharged in 4 days.
PULMONARY INFECTIONS IN THE TROPICS.
Leptospirosis
 EOSINOPHILIC PNEUMONIAS

• Systemic helminth infection usually elicits eosinophilia and

increased levels of IgE. Although eosinophilia can be a clue to
a pulmonary helminth infestation, the definitive diagnosis
requires demonstration of ova or larvae in sputum, bronchial
alveolar lavage fluid, pleural fluid, or lung biopsy.

• Schistosomes cause two clinical syndromes. In acute disease,

immature schistosomula pass through the lung and can lead
to fever, eosinophilia, and pulmonary infiltrate. In chronic
schistosomiasis, especially when portal hypertension has led
to venous shunts, eggs can bypass the liver and plug
pulmonary capillaries and arterioles, producing granuloma
and pulmonary hypertension.
• Radiographs may show dilated pulmonary arteries and
arteriovenous abnormalities.
 2. Paragonimiasis
• the lung is the predominantly involved organ.
• The diagnosis must be considered in a patient from
Southeast Asia, Africa & Americas with cough,
hemoptysis (which is recurrent in >80% of cases), a
pulmonary cavity, and pleural effusion.
Endemic in the Americas where Ecuador in the
most affected country both in the coast and in the
Amazon.

Tx. PRAZIQUANTEL 75 mg/kg divided in 3 times for 2 or 3 days

or
TRICLABENDAZOLE 10 mg/kg BID in one day.
WHO 17 May 2021

Foodborne trematode infections

• Foodborne trematode infections cause 2 million life years lost to
disability and death worldwide every year.
• People become infected by eating raw fish, crustaceans or
vegetables that harbour the parasite larvae.
• Foodborne trematodiases are most prevalent in East Asia and South
America.
• Foodborne trematode infections result in severe liver and lung
disease.
• Safe and efficacious medicines are available to prevent and treat
foodborne trematodiases.
• Prevention and management of food-borne trematodes requires
cross-sectoral collaboration on the human-animal and ecosystems
interface.
 WHO 17 May 2021

Foodborne trematode infections

Acquired Natural final

Disease Infectious agent through hosts of the
consumption of infection
Dogs and other
Clonorchis
Clonorchiasis Freshwater fish fish-eating
sinensis
carnivores
Opisthorchis Cats and other
Opisthorchiasis viverrini, Freshwater fish fish-eating
O. felineus carnivores
Fasciola hepatica, Aquatic Sheep, cattle and
Fascioliasis
F. gigantica vegetables other herbivores
Freshwater
Cats, dogs and
crustaceans
Paragonimiasis Paragonimus spp. other crustacean-
(crabs and
eating carnivores
crayfish)
Pto Quito-Ecuador CLINICAL CASE. Pulmonary paragonimiasis
 5. PULMONARY ECHINOCOCCOSIS
The diagnosis of echinococcosis
relies mainly on findings by
ultrasonography and/or other
imaging techniques supported by
positive serologic tests.

Ultrasound guided fine needle

biopsy may be useful for
confirmation of diagnosis; during
such procedures precautions
must be taken to control allergic
reactions or prevent secondary
recurrence in the event of
leakage of hydatid fluid or
protoscolices. Rupture of hydatic cyst
= Anaphylaxis
 CAYAMBE-ECUADOR CASE (H. de Calderon-Quito) Pulmonary Hydatidosis or Echinococcosis
The larval form of the Taeniidae Echinococcus spp is the causative agent of hydatidosis. Echinococcus
spp use canine (DOGS) as a definitive host and cattle or humans as intermediate host.
Four species of Echinococcus have been found infecting humans: E. granulosus, E. multilocularis. E.
vogeli and E. oligarthus both neotropical species infecting in South American countries. Its distribution is
worldwide. In Ecuador, rare cases are described; however, diagnosed cases are not uncommon in
Andean hospitals. The main specie identified in Ecuador is E. vogueli in cases from the Amazon region
and Pacific side & E. granulosus in the Andes.
Here, we present a human case in a woman of 64 years old living in a rural area of the Andes region of
Cayambe-Ecuador. She presented with respiratory symptomatology of dyspnea of 3 years evolution.
Chest X-ray=single cyst. Tx with albendazole and control by RX and TAC after 6 months, cyst still there.
She underwent surgery to remove the cyst. Histopathology showed protoscolex & hooks.

Figura 3. RX tórax, AP Y LATERAL, se observa imagen radiopaca ovalada, con borde bien
definidos, homogénea, ubicada en base pulmonar izquierda con signo de silueta negativa, por lo
que se sugiriere complementar el estudio con TC de tórax, posible quiste hidatídico.
 Hydatidosis Treatment
Surgery is the most common form of treatment for
echinococcosis, although removal of the
parasite mass is not usually 100% effective.
Before and after surgery, medication (albendazol
or praziquantel) may be necessary to keep the
cyst from recurring.

The drug of choice for treatment echinococcosis

is albendazole and Praziquantel. Some authors
combine both.
4. PULMONARY FUNGI

• Histoplasmosis
•Coccidioidomycosis
•Paracoccidioidiomycosis
Jumandy caves-Ecuador cases.
Histoplasmosis Int Marit Health. 2012;63(1):59-62.
Outbreak of pulmonary histoplasmosis involving a group of four
Caves & bats. Polish travellers returning from Ecuador.

Abstract
Exploring caves is, without doubt, a very exciting adventure;
however, it carries some dangers. 3 of 4 travellers were admitted
to hospital with lung changes after returning from Ecuador
Amazon.
Epidemiological studies revealed that the travellers visited caves
infested by bats and had contact with bats' guano. They gave a
history of fever, fatigue, myalgia, dry cough, and chest pain during
the stay or just after returning from Ecuador. In 2 patients,
symptoms persisted in mild nature. Chest X-ray films showed
diffuse nodules (coin-like lesions) in the lungs in each case.
Histoplasmosis was taken into consideration. Differential
diagnosis included paragonimiasis, pulmonary tuberculosis, and
pulmonary infection of other causes, direct examination of
sputum was negative, cultures were negative. Final diagnosis was
made on epidemiological histories, as well as typical radiological
changes, and was supported by positive tests for antibodies to
Histoplasma capsulatum. Immunodiffusion test (ID), complement
fixation test (CFTs), and Western blot test were positive.
In all cases antifungal treatment with Itraconazole were useful.
Use face mask!!! Persons who are going to explore caves should be equipped with
anti-dusk masks to prevent pulmonary histoplasmosis. The threat
of H. capsulatum infection in bat-inhabited caves should be
emphasized to travellers and also to physicians.
 Histoplasmosis & Coccidioidomycosis
• HISTOPLASMA CAPSULATUM. The organism grows in soils
enriched with bat and bird droppings, and human infection
generally occurs after dust inhalation of disturbed soil.
• Symptoms develop within 2 weeks of exposure.
Reticulonodular shadowing on chest RX is common, often
with mediastinal lymphadenopathy.
• Detection of the histoplasma antibody in urine or serum is
the most sensitive and widely used diagnostic method.
• Detection of COCCIDIOIDOMYCOSIS
(Coccidioides immitis) is similar but
radiologically a cavitating pneumonia
may be seen.
6. PLEURAL EFFUSSION
PLEURAL EFFUSSION caused by Paragonimus
(Pto Quito-ECUADOR case)
 7. OCCUPATIONAL & DUST LUNG DISEASES

• The occupational disorders result from human social activity,

and as such are preventable. The dusts that provoke
occupational disorders can be classified into those that
induce:
• Granulomatous reaction (e.g., beryllium, talc and organic
antigens);
• Those that cause fibrosis (e.g., silica, asbestos, and coal);
• Those that cause neither inflammation nor fibrosis, thus
remaining inert (e.g., iron, barium, and tin).
• Poorly recognized occupational diseases in the tropics are
byssinosis (due to cotton dust), mostly in Asia and Africa;
bagassosis (due to sugar cane), mostly in Americas, Cuba, and
India; and hypersensitivity pneumonitis.