An atypical tale of Loffler syndrome in the tropics

Dear Editor,

We read with great interest the recently published report ‘Löffler's syndrome associated with cutaneous larva migrans’. ¹ This report has a few atypical issues which are relevant to current clinical practice.

Cutaneous larva migrans (CLM) are caused by animal hookworms which cannot complete their life cycle in humans. Their movement is rather arrested in subepidermal tissues and presents like serpiginous tracks known as CLM. The movement is associated with intense pruritus and peripheral eosinophilia.

Loffler syndrome is caused by the transmigration of Ascaris lumbricoides, Ascaris suum, hookworms (Ancylostoma duodenale and Necator americanus) and Strongyloides stercoralis. They have similar life cycles in which infecting larvae reach the lungs via the bloodstream and penetrate alveoli to reach the airways. ² Ascaris is the most common cause of this syndrome but animal hookworms like Ancylostoma braziliense may also cause it secondary to CLM.

Loffler syndrome presents with cough, dyspnoea, wheezing, and occasionally fever and blood-tinged sputum. The presentation of this case was atypical as he had no allergic symptoms or shortness of breath though chest computed tomography (CT) showed extensive ground glass opacities. Lung infiltrates are usually migratory. He also had marked peripheral eosinophilia which is found in the pulmonary phase of the syndrome. It is usually more than 10%. ³ Sputum may show Charcot Layden crystals. ⁴ His manifestation was predominantly cutaneous though there is extensive pulmonary involvement and peripheral eosinophilia. Respiratory system examination was also normal as mentioned by the authors. The majority of the case reports mentioned by the authors also had prominent respiratory symptoms.^1,5

The pathology behind the Loffler syndrome is eosinophilic pneumonitis which commonly presents with wheezing and breathing difficulty which was not found in this case. The treatment consists of anthelmintics and systemic steroids after ruling out strongyloidiasis. The authors mentioned that the patient received inhaled steroids in the form of budesonide and bronchodilator levosalbutamol though he had no wheezing or shortness of breath.

His radiological picture was also quite atypical. It usually presents like small wedge-shaped nodules or ground glass opacities. It is also often migratory. In this case, CT showed extensive ground glass opacities involving more than 75% of the visible parenchyma mimicking viral interstitial pneumonitis or pulmonary haemorrhage.^6,7

Anthelminthic is not advised during the pulmonary phase of the illness as it may exacerbate the infiltration causing clinical worsening. But CLM has no trans pulmonary migration hence it can be safely given as rightly done by the authors. Treatment response was prompt and a repeat lung imaging might better be done to document radiological resolution.