Page 173 - Medical Parasitology_ A Textbook ( PDFDrive )

166 14 Case Reports

also showed granulomatous inflammation. The histology slide was examined under
electron microscopy, and T. gondii was identified on the basis of ultrastructural
features of the zoites. The organism was confirmed when the skin biopsy was sub-
jected to a nested PCR which successfully amplified a 96-base pair region of the
T. gondii B1 gene. The origin of the T. gondii infection was uncertain. It is likely
that the patient might have a previous latent infection that was reactivated during the
HIV infection. Another possibility is that the patient might have acquired T. gondii
infection following HIV infection. Humoral immunity of the patient might have
been affected as evidenced by the absence of anti-Toxoplasma antibody response.
Despite treatment with standard anti-Toxoplasma drugs which included sulphadia-
zine and pyrimethamine, the lesions failed to resolve. The patient continues to
develop new lesions while on therapy.

Source: Fong, M. Y., K. T. Wong, M. Rohela, L. H. Tan, K. Adeeba, Y. Y. Lee,
and Y. L. Lau. “Unusual manifestation of cutaneous toxoplasmosis in a HIV-
positive patient.” Tropical Biomedicine 27, no. 3 (2010): 447–50.

Learning Points
1. Clinicians have to be aware of opportunistic parasitic infections in immunocom-
promised patients.
2. When faced with difficulty in diagnosing skin lesions, skin biopsy provides sam-
ples that can be used for HPE and PCR which can aid in the diagnosis.

Case 10: Zoonotic Ancylostoma ceylanicum Infection Detected by Endoscopy
Case report: A 58-year-old Chinese woman who presented with upper gastrointes-
tinal (GI) bleeding was admitted to a private hospital for management. She was
passing out black-coloured stool (melaena) 1 to 2 times per day for 1 week. She was
admitted to a local hospital for a similar problem before this admission. She had a
few episodes of dizziness, tightness of chest and cold sweats. There was no history
of fever or weight loss. Laboratory investigations showed a haemoglobin concentra-
tion of 11.4 g/dL, a platelet count of 169,000/μL, a total white blood cell count of
8000/μL, neutrophils of 68%, lymphocytes of 24%, monocytes of 6% , eosinophils
of 1% and basophils of 1%. Liver and renal functions were normal. The patient
underwent oesophagogastroduodenoscopy (OGDS) and colonoscopy. Colonoscopy
showed 3 polyps that were removed by polypectomy. Histopathological examina-
tion (HPE) showed them to be malignant. OGDS showed a gastric ulcer with signs
of bleeding. Biopsy of the ulcer edge proved it to be malignant. Incidentally, a sin-
gle adult blood-filled worm that measured 8–10 mm in size was seen moving on the
duodenal mucosa. The worm was removed and sent to the Parasitology Diagnostic
Laboratory, Department of Parasitology, Faculty of Medicine, University of Malaya
for species identification. Microscopic examination of the worm, including its buc-
cal capsule or mouthpart, showed it to be an adult female hookworm. In addition,
ova that were characteristic of hookworm species were seen in the ruptured uterus.