Baylisascaris procyonis and Herpes Simplex Virus 2 Coinfection Presenting as Ocular Larva Migrans with Granuloma Formation in a Child

Abstract

Abstract. Ocular Baylisascaris procyonis infection results from ingestion of infective eggs of B. procyonis, the raccoon ascarid. Herpes simplex virus type 2 (HSV-2) infection of the retina is the result of either primary infection or reactivated disease. Herein, we report a case of a 12-year-old female resident of the Bronx in New York City, who presented with pan-uveitis and vision loss. Initial evaluation for etiologic causes was nondiagnostic. Serology for anti-Baylisascaris procyonis antibodies in serum and vitreous fluid were both positive. Polymerase chain reaction (PCR) of vitreous fluid was positive for HSV-2. Treatment with vitrectomy, albendazole, and acyclovir resulted in mild improvement of visual acuity. The atypical presentation of B. procyonis in this case, as ocular larva migrans with a peripheral granuloma and retinal detachment, underscores the importance of maintaining a high degree of suspicion for this pathogen even in non-diffuse unilateral subacute neuroretinitis (DUSN) patients in urban areas. This case further illustrates that it is possible to have coexisting infections in cases of posterior uveitis.Baylisascaris procyonis is a large ascarid that commonly parasitizes raccoons in North America and Europe.1 It is a common cause of clinical larva migrans in animals and also affects humans, causing either neural larva migrans (NLM) affecting the nervous system and/or ocular larva migrans (OLM) and diffuse unilateral subacute neuroretinitis (DUSN) causing visual impairment.1-3 Animals and humans become infected by ingesting infective eggs from areas or articles contaminated with raccoon feces. 1 We diagnosed a young girl with Baylisascaris OLM, from the Borough of the Bronx in New York City. This patient is of particular interest because she had an atypical presentation for Baylisascaris OLM and was positive for anti-B. procyonis antibodies in her vitreous fluid as well as being seropositive in serum. In addition, polymerase chain reaction (PCR) testing of the vitreous fluid was positive for Herpes simplex virus-2 (HSV-2) DNA. The patient had mild improvement in visual acuity after diagnostic and therapeutic vitrectomy and treatment with albendazole and acyclovir. CASE REPORTThe patient was a 12-year-old female born and raised in the Bronx, New York City, in an area bordering the suburban County of Westchester. She presented to the emergency department of the Jacobi Medical Center, Bronx, New York City, complaining of "redness and pain" in and about her right eye after reportedly being "poked" in that eye 5 days before. Her medical history included perinatal exposure to human immunodeficiency virus (HIV), bronchiolitis, attention deficit hyperactivity disorder, and she wore corrective glasses for astigmatism from age 2 to 7 years. There was a puppy in the household and she reported having played with several stray cats and had seen raccoons in the neighborhood. There was no history of pica and the remainder of the review of systems was negative.Initially, her best corrected visual acuity wa...

Update on Baylisascariasis, a Highly Pathogenic Zoonotic Infection

“…The latter case is unique in that the patient did not present with typical DUSN lesions but instead presented with advanced granulomatous OLM with retinal detachment similar to that seen in toxocariasis. She was also seropositive for Baylisascaris in both serum and vitreous fluid (114). Other cases of Baylisascaris OLM or OLM-DUSN with granuloma formation are expected to occur, since granulomas, along with lesions of DUSN, were also noted in nonhuman primates and rodents experimentally infected with B. procyonis (99,113).…”

“…Nematode larvae that cause DUSN are typically separated into two size ranges, "small" (500 to 700 m in length) and "large" (1,500 to 2,000 m in length), and Baylisascaris is considered the primary etiological agent of the lat- OLM-DUSN shortly after they obtained pet raccoons (74,75). Cases have occurred in residents or hunters in rural areas (22,109,112) and in suburban areas (36,38,40,105) as well as in a highly urban area (New York City) (31,114). The latter case is unique in that the patient did not present with typical DUSN lesions but instead presented with advanced granulomatous OLM with retinal detachment similar to that seen in toxocariasis.…”

“…(575 to 700 by 22 m) (22,31,74,75,110). For several patients with OLM-DUSN, a history of exposure to raccoons and raccoon feces in the surroundings of the patient's residence or neighborhood or through their activities was noted (22,31,109,112,114), and two patients had pet raccoons (74,75). This is consistent with the finding of a large nematode larva in the patient's eye, further supporting a diagnosis of baylisascariasis, even though serology results were indeterminate.…”