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Case Report
34 (
4
); 387-389
doi:
10.25259/ijn_520_23

A Rare Parasitic Infection from the Common Cockroach: A Case of Lophomonas Blattarum from a Tertiary Center in Kerala

Department of Nephrology, Baby Memorial Hospital, Kozhikode, Kerala, India
Department of Pulmonology, Baby Memorial Hospital, Kozhikode, Kerala, India
Department of Microbiology, Baby Memorial Hospital, Kozhikode, Kerala, India

Corresponding author: Sunil George, Department of Nephrology, Baby Memorial Hospital, Kozhikode - 673004, Kerala, India. E-mail: drsunilgeo@gmail.com

Licence
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

How to cite this article: Mavoor PP, George S, Chetambath R, Poornima MV. A Rare Parasitic Infection from the Common Cockroach: A Case of Lophomonas Blattarum from a Tertiary Center in Kerala. Indian J Nephrol. 2024;34:387-9. doi: 10.25259/ijn_520_23

Abstract

Immunocompromised patients are prone to various opportunistic infections. Most of the infections are easily detectable through staining, culture, and polymerase chain reaction techniques. Nevertheless, it is also important to have wet smear examinations of samples. We present a case of pneumonia in a post-transplant recipient who was on immunosuppressants and detected to have an infection from the parasite, lophomonas blattarum, which usually resides in the hindgut of cockroaches.

Keywords

Blattarum
Lophomonas
Pneumonia
Post renal transplant

Introduction

We present a renal allograft recipient with a right upper lobe consolidation caused by lophomonas blattarum, a commensal living in the hindgut of cockroaches. There has been discussions on the need of electron microscopy, and methods relying on polymerase chain reaction for the identification of the organisms. But they are not readily available, and we have identified the organism with staining methods. Though the infection responded to treatment with metronidazole, he had other clinical problems and he succumbed to the illness.

Case Report

A 40-year-old renal allograft recipient presented in May 2023 with anorexia, fatigue, and loose stools of around 1 week duration. He had his first transplant in 2003 with his father as the donor and the second transplant in 2017 with his aunt as the donor. He was on triple immunosuppressants (tacrolimus, deflazacort, and mycophenolate mofetil). Until the COVID pandemic, he was on regular follow-up with stable graft functions (creatinine 1.4 mg/dl). He took a train journey and gave a history of consuming food from a hotel, following which he developed the present symptoms. He also had fever, shortness of breath, and oliguria. The clinical examination showed tachypnoea and oxygen desaturation. He has coarse crackles in the right infrascapular area. Lab parameters are shown in Table 1.

Table 1: Lab parameters
Tests
Hemogram

Hemoglobin 12 g/dl

Total WBC count 25,400/cu.mm

Differential count polymorphs 91.8%

Lymphocytes 3%

Platelet 291,000/cu.mm

Renal functions

Blood urea 105 mg/dl

Serum creatinine 5.6 mg/dl

Liver functions Normal except for mild elevation of aspartate aminotransferase (56 U/L)
Serum proteins

Total protein 6.6 g/dl

Serum albumin 3.4 g/dl

Serum sodium 126 meq/l
Serum potassium 3.3 meq/l
Serum calcium 7.9 g/dl
Serum magnesium 1 mg/dl
Serum phosphorus 1.7 mg/dl
Serum uric acid 15.6 mg/dl
CRP 290 ng/l
PT/INR 14.8 s/1.43
Urine routine Protein 3+, RBC 5–8/hpf, pus cells 0–2/hpf
Blood culture Sterile
Influenza polymerase chain reaction Negative
Comprehensive respiratory panel Streptococcus pneumoniae
Bronchoalveolar lavage Gram stain, culture sensitivity, acid-fast bacilli negative, and cytology negative for malignancy

WBC: white blood cell, CRP: C-reactive protein, PT/INR: prothrombin time/international normalized ratio, RBC: red blood cell

Chest X-ray showed nonhomogeneous opacity in the right upper zone, suggestive of right pneumonia with minimal right pleural effusion. Bronchoalveolar lavage showed motile flagellated trophozoites of Lophomonas blattarum and it was confirmed with special stains [Figure 1].

(a) Wet mount smear (40× magnification), (b) staining with methylene blue (40× magnification), (c) staining with Papanicolaou stain (100× magnification).
Figure 1:
(a) Wet mount smear (40× magnification), (b) staining with methylene blue (40× magnification), (c) staining with Papanicolaou stain (100× magnification).

The acid-fast bacillus culture, fungal smear, and fungal cultures were negative. Stool examination was normal and stool culture was negative. Computed tomography (CT) thorax showed consolidation changes involving the right lung with mediastinal lymph nodes. He was managed with broad-spectrum antibiotics, parenteral metronidazole, along with high flow nasal oxygen (HFNC) and optimization of the dose of immunosuppressants. He was given four sessions of hemodialysis, over a span of a week, he became nonoliguric and could be weaned off from hemodialysis; HFNC could be withdrawn and he maintained adequate saturation on minimal oxygen requirement via nasal cannula. The chest X-ray and CT images before and after treatment are shown in Figure 2.

Images before and after treatment: (a) Chest X-ray before and after treatment. (b) CT images before treatment. (c) CT images after treatment. CT: computed tomography.
Figure 2:
Images before and after treatment: (a) Chest X-ray before and after treatment. (b) CT images before treatment. (c) CT images after treatment. CT: computed tomography.

The patient continued to have hypokalemia and hypomagnesemia with abdominal distension. CT scan of the abdomen showed dilated bowel loops. He had fever spikes and antibiotics were escalated. On the 13th day of hospitalization, he developed acute right-sided abdominal pain with tachypnea, oxygen desaturation, and hypotension requiring multiple vasopressor support suggestive of gastrointestinal sepsis and he expired.

Discussion

Lophomonas blattarum is a flagellate protozoan parasite which was originally described as a commensal in the gut of cockroaches. It causes upper and lower respiratory tract infections.1

All over the world, less than 200 cases have been reported, around 136 from China. Only four25 cases have been reported from India.

The bronchopulmonary site is most commonly infected given the nature of entry of the pathogen by inhalation. Some infrequent sites affected include the maxillary sinus, urinary tract, and uterus. Eosinophilia is found in 21.5–35% of cases only. It has also been reported in an immunocompetent patient.2

Many discussion regarding the correct identification of the parasite and differentiation from ciliated columnar respiratory epithelial cells has been given in the existing literature. The differentiating features are tabulated in Table 2.6

Table 2: Distinguishing features between Lophomonas blattarum and ciliated epithelial cells
Feature Lophomonas blattarum Ciliated epithelial cells

Shape

Pyriform or spherical

Conical or columnar

Flagella/cilia

Flagellar tuft with >50 flagella

Unequal length of flagella

Irregularly arranged

Ciliary tuft with ∼200 cilia

Uniform length

Regularly arranged

Nucleus

Located at the base of the flagellar tuft, both at the anterior end of the cell

Located at the bottom of the cell, opposite to the ciliary tuft, which emerges from the apical face of the cell

Others

The axial filament may be found at the posterior end

No terminal bar below the origin of flagella

Absent

A marked terminal bar at the apical end of the cell is present just below the origin of cilia

The parasite can be stained by the Papanicolaou method, Wheatley’s trichrome stain, or by regular Giemsa or Wright stain. In unstained fresh specimens, a characteristic to-and-fro movement can be seen. The organism may be detected by polymerase chain reaction in the nasal discharge.

Metronidazole is the treatment of choice, at the usual dose of 500 mg every 8 h orally for 7–10 days in adults, and 7.5 mg/kg every 8 h in children. A single intravenous dose of 15 mg/kg over 1 h (as a loading dose), followed by 7.5 mg/kg every 6 h has also been used. Tinidazole is also used as an alternative drug.1

Conclusion

Even when a conventional pathogen has been identified as a cause of respiratory tract infection, it is important to look for such uncommon organisms; right from the initial wet mount smear examination of the bronchoalveolar lavage fluid so that the indicated treatment can be initiated and the infection responds.

Conflicts of interest

There are no conflicts of interest.

References

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