Pulmonary cysticercosis in an urban South African child

To the Editor, Cysticercosis is a serious public health problem, predominantly affecting low‐ and middle‐income countries (LMICs). Cysticercosis, the infection with the larval form of the pork tapeworm, Taenia solium, has high prevalence in areas where there are poor sanitary conditions and domestic pig without adequate veterinary control. Humans are the definitive host and pigs are the main source of infection. Human infection occurs when pork is eaten raw or undercooked. Ingested eggs or proglottids hatch into larvae form, which penetrate the intestinal wall into the blood stream and migrate into different organs including subcutaneous tissues, brain, eyes and rarely heart or lung, where they mature into cysticerci. Pulmonary cysticercosis has been rarely described; case reports are predominantly in adults and are usually of disseminated disease. In children the data are very scarce, with a single case report of a 2‐year old child with pulmonary infiltration, eosinophilia and subcutaneous cysticercosis. We describe an 8‐year‐old child with pulmonary cysticercosis who presented to Red Cross Children' s Hospital, Cape Town, South Africa, with a large right pleural effusion. Consent to report this case was obtained from the mother of the child. She presented with 5 days history of cough, fever, and shortness of breath. She resided in a poor informal settlement, in an urban area of Cape Town and had no recent travel history or underlying illness. She had no direct contact with pigs, although consumed cooked pork. There was no known household or close contact with tuberculosis (TB). On examination she was well nourished, with a temperature of 38 degrees Celsius, respiratory rate of 36 breaths per minute and oxygen saturation of 96% in room air. She had mild subcostal chest retractions, tracheal deviation to the left side with dullness to percussion and reduced breath sounds over the right chest. Chest X ray showed complete opacification of the right hemithorax and mediastinal shift to the left (Figure 1). In the emergency unit, 660ml of straw‐colored fluid was aspirated from the right hemithorax and sent for laboratory analysis. A pigtail chest drain was inserted to drain the pleural fluid, which was consistent with an exudate: protein 59 g/L, adenosine deaminase 42.0U/L, with lymphocyte predominance (lymphocytes 856/μl), polymorphonuclear cells 5/μl. Fluid was negative by GeneXpert Ultra for Mycobacterium tuberculosis and negative for bacterial and mycobacterial culture. Laboratory investigations also showed a raised C‐reactive protein of 239mg/L, possibly due to the inflammatory response rather than superimposed bacterial infection. The full blood count showed: white cell count 12.86× 10/L (neutrophils 58%, lymphocytes 28%, monocytes 12%, eosinophils 1%), hemoglobin 12.4 g/dl and platelets 419 ×10/L. Surprisingly, a pale‐pink cystic structure measuring 65 ×25×8mm drained through the pigtail drain; histology showed a degenerate cyst wall composed of oedematous villous‐like projections and comprised of an outer cuticular layer, middle cellular layer, and inner fibrillary layer, in keeping with a degenerate cysticercosis (Figure 2). This cyst was probably located on lung surface or in pleura, hence the resulting pleural effusion. The child was therefore started on albendazole 15mg/kg/day for1 month. In addition to albendazole, she was also started on prednisone 45mg (1 mg/kg/day) for 2 weeks, then weaned off over another 2 weeks. The albendazole and steroid treatment were started after 4 weeks of TB treatment. A CT scan of the brain was done for intracranial cysticercosis, which revealed a nonspecific solitary sub centimeter calcified granuloma abutting the tentorium cerebellum. The CT scan of the brain was done 1 month after albendazole and steroids were initiated. Therefore, this may represent a solitary cysticercal granuloma. This patient did not have an ophthalmological assessment, however there were no clinical symptoms suggestive of ocular cysticercosis. The CT brain also included review of the orbits and did not demonstrate ocular involvement. She was admitted, treated with oral amoxicillin/clavulanic acid 1000mg twice a day for possible bacterial pneumonia, as well as oral TB treatment as per national guidelines. The pleural fluid was suggestive of TB because of lymphocyte predominance, high protein, and high adenosine deaminase. Besides the suggestive pleural fluid and reactive tuberculin skin test of 12mm, other investigations were negative for TB, including a negative history of known TB contact, sputum that was negative for GeneXpert Ultra and culture that was negative for M. tuberculosis. TheTB culture remained negative for a period of 6 weeks. Even though the TB diagnosis was not microbiologically confirmed, we opted to continue to treat for TB as the child resided in a high endemic area for TB. TB treatment comprised of rifampicin 450mg, isoniazid