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Loiasis: A case of an unusual ocular foreign body
CASE REPORT
loiasis
Loiasis. From the Georgetown-George Washington Emergency Medicine Residency Program* and the Department of Emergency Medicine, Georgetown University Hospital, Washington, DC.
A Case of an Unusual Ocular Foreign Body
B Tilman Jolly, MD* Kerry A Foley, MD t
Received for publication October 23, 1991. Revision received March 5, 1992. Accepted for publication March 17, 1992.
Loiasis is a parasitic illness that is endemic in parts of Central and West Africa. In the United States, infection with Loa Ion is seen in natives from that region of Africa and in those who have traveled to the area, often in the distant past. There can be significant differences in clinical manifestations between the two groups. We present a case of Ioiasis in an African native as well as a discussion of Loa Ion infection in natives and non-natives and current treatment strategies. [Jolly BT, Foley KA: Loiasis: A case of an unusual ocular foreign body,
Ann EmergMed September 1992;21:1153-1156.] INTRODUCTION Infection with Loa loa, a filarial parasite, is endemic in certain parts of Central and West Africa, afflicting an estimated 2 milhon people.J, z I n endemic areas, the infection is so common that 90% of adults have microfilaremiae or symptoms of loiasis, and by 2 years of age, 95% of the population has antibodies to Loa loa antigens.3,4 The two most common manifestations are "Calabar swelhngs," a type of localized angioedema, and subconjunctival migration of worms.57 Visitors to endemic areas may contract loiasis and exhibit a hyper-responsive syndrome with greater evidence of systemic illness than native Africans. 6 The increasing ease of foreign travel can be a factor in the presentation by patients with varying exotic illnesses to US emergency departments. We present a case of loiasis in an African native who had been in the United States for six years before developing any symptoms of the illness. We also discuss characteristics of the infection in natives and visitors to endemic areas along with current treatment strategies. CASE REPORT An otherwise healthy 36-year-old foreign-born man presented to the ED of a large university hospital at approximately 10:00 AM complaining of pain and a foreign body sensation in his left eye of three days' duration. He denied any visual disturbance but did report seeing a "moving vein" in his eye when he looked in a mirror. He denied fever, chills, or skin changes. Two ophthalmologists had seen the patient within the previous several days. The patient reported that one told him that his eye was normal, and the other told him that he
SEPTEMBER1992
21:9 ANNALSOF EMER6ENCYMEDICiNE
1153/157
LOIASIS Jolly & Foley
might have a worm but that it was not visible at the time of examination. No treatment was instituted. The patient was a native of Ghana who had been in the United States for six years with no travel back to Africa. He reported having lived in Nigeria several years before he left Ghana. He was not receiving medication and had no known allergies. The patient was afebrile. Examination of the skin showed no rashes or areas of edema. Examination of the eyes revealed the only remarkable physical finding. Visual acuity was 20/20 in both eyes. I n the left eye, there was mild conjunctival infection, and in the superior fornix there was a mobile worm (Figure 1). The remainder of the eye examination was unremarkable. CBC showed a hemoglobin of 16.5 g/dL; hematocrit, 46.5%; platelet count, 344,000 L-l; and WBC count, 7,100 pL -1. The differential was 53% neutrophils, 32% lymphocytes, 1% monocytes, and 14% eosinophils. A peripheral blood smear revealed multiple easily located microfilariae (Figure 2). The ophthalmology service was consulted. With the patient under local anesthesia (proparacaine), the worm was removed through a small opening in the conjunctiva. Interestingly, the local anesthetic had no effect on the motility of the worm, which measured 5.5 cm in length. The patient was referred to the Clinical Parasitology Section at the National Institutes of Health, Bethesda, Maryland, where he was admitted. His worm b u r d e n was noted to be 2,000 microfilariae/mL, so plasmapheresis was undertaken to enable him to better tolerate treatment. When his worm count was reduced to 800 microfilariae/mL, he was started on a three-week course of diethylcarbamazine at a dosage of 10 mg/kg/day along with corticosteroids to reduce the inflammatory reaction to treatment. By day 3, his blood had been cleared of worms, and he was able to continue therapy as an outpatient. He has continued to do well. Our patient's eosinophilia reached a peak of 36% during treatment and then returned gradually toward normal levels. Interestingly, the patient recalled some problems with palpitations in the past, prompting a concern about endomyocardial fibrosis. Holter monitoring and echocardiography were unrevealing, and the patient had no further problems.
Figure 1. Appearance of the subconjunctival worm (arrow)
1 5 8 / 1 1 54
DISCUSSION
Loiasis is a filarial infection caused by the L e a loa worm, also known as the African eye worm. It was first described by Mongin in 1770.8, 9 Ghana, the patient's home country, usually is not considered to he within the endemic area, but Nigeria, a country the patient had visited, frequently is implicated as an area of high infestation. The worm can grow to a length of 30 to 70 mm. The life cycle has been well described.a, 5 A tabanid fly (deerfly) of the genus C h r y s o p s bites an infected h u m a n host and acquires an immature form of the worm. Within two weeks, the fly becomes infectious and transmits the microfilariae to another h u m a n host. The worms then mature within six months and may survive for as long as 15 years. Macrofilariae are the adult worms, which cause most of the symptoms, whereas microfilariae are the larval forms present in the blood. 10 Presence of microfilariae in the blood follows a d i u r n a l variation, reaching a peak at midday, which made the our patient's presentation timely.a,5,11 Skin and eye findings make up the most typical presentation. Calabar swellings frequently are described and are thought to represent localized angioedema resulting from the host's response to the L o a antigen.a,6 There may not be a worm present within the area of swelling, and a Calabar swelling may present after treatment has eliminated the worm. 5 The localized swelling typically is nonpitting and painless, although it may be painful if it is over a joint. Calabars usually are present only one at a time and last for approximately three days. They may be warm but will not suppurate.5,6,1-2 Subconjunctival migration of the adult worm is a frequent and often solitary complaint. There are few symptoms beyond the actual sensation of the worm's presence and a local conjunctivitis.5 Intraocular migration of the worm is rare in this filarial illness. 9 Nutman et al studied the clinical and immunologic differences in infection between natives and non-natives of endemic areas.6,13 Natives rarely manifest systemic symptoms but often are microfilaremic. Non-natives frequently complain of allergic symptoms and angioedema and can become quite debilitated. Eosinophilia, common in loiasis as in other parasitic illnesses, may be more prominent (30% to 40%) in nonFigure
2.
Microfilariae evident on a routine blood smear
ANNALS OF EMERGENCY MEDICINE
21:9
SEPTEMBER 1992
LOIASIS
Jolly & Foley
natives. 12 I n one group of non-natives, only 15% had microfilaremiae, whereas 80% complained of pruritis and 90% had total eosinophil counts of more than 3,000 ram-1. +,6 In fact, pruritis may be the only symptom, a The reasons for these clinical differences may be found among immunologic data. Temporary residents with loaisis demonstrate increases in nonspecific immunoglobulin (Ig)E and parasite-specific IgG. The IgG may be responsible for the dearth of parasites in the blood and the IgE may account for the allergic symptoms, but further study is required, including documentation of the immunologic response of natives. 12 A number of unusual manifestations of Loa loa infection have been reported, including nephropathy, retinopathy, arthritis, peripheral neuropathy, and lymphedema. A characteristic pattern of local lymphadenitis in loiasis was noted by Paleologo et al. 8 Patients with fdariasis and hypereosino-philia have suffered from endomyocardial fibrosis, but no clear cause-and-effect relationship has been estabhshed. 6 Corrigan and Hill reported a case of embohc retinal artery occlusion in a patient with loiasis. ~4 Worms have been noted in all areas of the skin, on a gynecologic smear, and in ascitic fluid. 11,15,16 Capture of the worm or demonstration of microfilariae in the blood can be diagnostic, Indirect evidence of infection can be obtained through the use of fluorescent antibody testing and hemagglutination techniques. 12 The typical physical findings along with eosinophilia and an appropriate travel history may be sufficient evidence to begin treatment. The treatment of choice for infection with Loa loa is diethylcarbamazine at a dosage of 5 to 10 mg/kg/day. Nutman et al achieved complete response to treatment using a single 21-day course in 11 of 20 patients. 17 The other nine required further treatment for recurrent eosinophilia or Calabars swelling, b u t all patients were clear of worms at one-year follow-up. All patients demonstrated decreases in eosinophilia and antibody titers. 6 Post-treatment encephalitis has been observed. This potentially dangerous entity may be secondary to either a Herxheimer-like reaction or an allergic reaction to the dying worms. A lower dose of the drug in the first few days of therapy has been used to avoid this complication in patients with high peripheral worm counts. 1,5 As with our patient, plasmapheresis has been used to decrease the worm b u r d e n in order to avoid this sideeffect of treatment, la Prophylaxis is a consideration in patients who may travel to endemic areas. Diethylcarbamazine at a dosage of 5 mg/kg/day for three days each month has been used.i N n t m a n et al used • a dosage of 300 mg once a week in a randomized, placebocontrolled, double-blind trial. 17 Based on this study's results, prophylaxis was recommended for those at high risk, and further study was recommended for others. Diethylcarbamazine's broad antifilarial spectrum may make it useful as prophylaxis for other illnesses. 19
SEPTEMBER 1992
21:9
ANNALS OF EMERGENCY MEDICINE
SUMMARY
Infection with Loa lea and other filarial parasites is common in many parts of the world but is seen rarely by most physicians in the United States. We present a case of loiasis in an African native who had not visited Africa in six years. Unusual physical findings, eosinophilia, and a history of travel, possibly in the distant past, to an endemic area should raise the suspicion of a parasitic illness. Diagnosis can be simple in certain cases and very difficult in others. Referral to an expert in parasitology for definitive treatment should be u n d e r t a k e n once serious systemic illness has been ruled out. REFERENCES 1. Fain A: Les problemes actuele de la Ioase. Bull WHO 1978;56:155-176 (with English summary). 2. Egwang TG, Dupont A, Leclerc A, et al: Differential recognition of Loa IDa antigens by sera of human subjects from a Ioaisis endemic zone. Am J Trop Med Hyg 1989;41:664673. 3. Noireau F, Nzoulani A, Sinda D, et al: Transmission indices of Loa IDa in the Chaillu mountains, Congo. Am J Trop Med Hyg 1990;43:282-288. 4+Hubler WR, Gregory JF, Knox JM, et al: Loaisis: A case report and review of the literature. Arch Dermato11973;108:835-836. 5. Farrer WE, Wittnar M, Tanowitz HB: African eye worm (Loa IDa) in a tourist. Ann Ophthalmo11981;13:1177-1179. 6. Nutman TG, Miller KD, Mulligan M, at al: Loa IDa infection in temporary residents of endemic regions: Recognition of a hyperresponsive syndrome with characteristic clinical manifestations. JlnfectDis 1986;154:10-18. 7. Grigsby ME, Kerler DH: Loa IDa in the District of Columbia: A case report. J Nail Med Assoc 1971;63:198-201. 8. Paleologo EP, Neafie RC, Connor DH: Lymphadenitis caused by Loa IDa.AmJ Trop Med Hyg 1984;33:395-402. 9. Carme B, Mamboueni JP, Copin N, et al: Clinical and biological study of Loa IDa filariasis in Congolese. Am J Trap MealHyg 1989;41:331-337. 10. Muylle L, Taelman H, Moldenhauer R, et al: Usefulness of apheresis to extract microfilarias in management of Ioiasis. BrMedJ 1983;287:519-520. 11. Gibbs RD: Loiasis: Report of three cases and literature review. JNatlMedAssoc 1979;71:853-854. 12. Sacks HN, Williams DN, Eifrig DE: Loiasis: Report of a case and review of the literature. Arch Intern Mad 1976;136:914-915. 13. Nutman TB, Reese W, Poindexter RW, et al: Immunologic correlates of the hyperresponsive syndrome of Ioiasis. J InfectDis 1988;157:544-550. 14. Corrigan M J, Hill DW: Retinal artery occlusion in roiasis. BrJ Ophthalmol 1968;52:477-480. 15. Calrihan TR, 0ertel YC, Mendoza M: Loa lea in a gynecologic smear. Am J Trap Med Hyg 1977;26:572-573. 16. Hautekeete ML, Pialoux 6, Mareelrin P, et al: Presence of Loa IDa microfilariae in ascitic fluid (letter). J InfectOis 1989;160:559-560. 17. Nutman TB, Miller KD, Mulligan M, et al: Diethylcarbamazine prophylaxis for human Ioiasis: Results of a double+blind study. NEnglJ Med1988;319:752-756. 18. Taelman H, Muylle L: More uses for apheresis (letter). JAMA 1985;254:2064. 19. Richard-Lenoble D, Kombila M, Rupp EA, et al: Ivermectin in Ioiasis and concomitant 0 volvulus and M perstans infections. Am J Trop Mad Hyg 1988;39:480-483.
1155/ I 59
LOIASIS
Jolly & Foley
The authorsthank RichardRothman,MD for his pictures of the patient.They also thank ThomasNutman, MD, for sharing informationregardingthe continuingcare of the patient.
160/1156
Addressfor reprints: B Tilman Jolly, MD Departmentof EmergencyMedicine The GeorgeWashington UniversityMedical Center 2140 PennsylvaniaAvenue NW Washington, DC 20037
ANNALS OF EMERGENCY MEDICINE 2 1 : 9 SEPTEMBER1992
loiasis
Loiasis. From the Georgetown-George Washington Emergency Medicine Residency Program* and the Department of Emergency Medicine, Georgetown University Hospital, Washington, DC.
A Case of an Unusual Ocular Foreign Body
B Tilman Jolly, MD* Kerry A Foley, MD t
Received for publication October 23, 1991. Revision received March 5, 1992. Accepted for publication March 17, 1992.
Loiasis is a parasitic illness that is endemic in parts of Central and West Africa. In the United States, infection with Loa Ion is seen in natives from that region of Africa and in those who have traveled to the area, often in the distant past. There can be significant differences in clinical manifestations between the two groups. We present a case of Ioiasis in an African native as well as a discussion of Loa Ion infection in natives and non-natives and current treatment strategies. [Jolly BT, Foley KA: Loiasis: A case of an unusual ocular foreign body,
Ann EmergMed September 1992;21:1153-1156.] INTRODUCTION Infection with Loa loa, a filarial parasite, is endemic in certain parts of Central and West Africa, afflicting an estimated 2 milhon people.J, z I n endemic areas, the infection is so common that 90% of adults have microfilaremiae or symptoms of loiasis, and by 2 years of age, 95% of the population has antibodies to Loa loa antigens.3,4 The two most common manifestations are "Calabar swelhngs," a type of localized angioedema, and subconjunctival migration of worms.57 Visitors to endemic areas may contract loiasis and exhibit a hyper-responsive syndrome with greater evidence of systemic illness than native Africans. 6 The increasing ease of foreign travel can be a factor in the presentation by patients with varying exotic illnesses to US emergency departments. We present a case of loiasis in an African native who had been in the United States for six years before developing any symptoms of the illness. We also discuss characteristics of the infection in natives and visitors to endemic areas along with current treatment strategies. CASE REPORT An otherwise healthy 36-year-old foreign-born man presented to the ED of a large university hospital at approximately 10:00 AM complaining of pain and a foreign body sensation in his left eye of three days' duration. He denied any visual disturbance but did report seeing a "moving vein" in his eye when he looked in a mirror. He denied fever, chills, or skin changes. Two ophthalmologists had seen the patient within the previous several days. The patient reported that one told him that his eye was normal, and the other told him that he
SEPTEMBER1992
21:9 ANNALSOF EMER6ENCYMEDICiNE
1153/157
LOIASIS Jolly & Foley
might have a worm but that it was not visible at the time of examination. No treatment was instituted. The patient was a native of Ghana who had been in the United States for six years with no travel back to Africa. He reported having lived in Nigeria several years before he left Ghana. He was not receiving medication and had no known allergies. The patient was afebrile. Examination of the skin showed no rashes or areas of edema. Examination of the eyes revealed the only remarkable physical finding. Visual acuity was 20/20 in both eyes. I n the left eye, there was mild conjunctival infection, and in the superior fornix there was a mobile worm (Figure 1). The remainder of the eye examination was unremarkable. CBC showed a hemoglobin of 16.5 g/dL; hematocrit, 46.5%; platelet count, 344,000 L-l; and WBC count, 7,100 pL -1. The differential was 53% neutrophils, 32% lymphocytes, 1% monocytes, and 14% eosinophils. A peripheral blood smear revealed multiple easily located microfilariae (Figure 2). The ophthalmology service was consulted. With the patient under local anesthesia (proparacaine), the worm was removed through a small opening in the conjunctiva. Interestingly, the local anesthetic had no effect on the motility of the worm, which measured 5.5 cm in length. The patient was referred to the Clinical Parasitology Section at the National Institutes of Health, Bethesda, Maryland, where he was admitted. His worm b u r d e n was noted to be 2,000 microfilariae/mL, so plasmapheresis was undertaken to enable him to better tolerate treatment. When his worm count was reduced to 800 microfilariae/mL, he was started on a three-week course of diethylcarbamazine at a dosage of 10 mg/kg/day along with corticosteroids to reduce the inflammatory reaction to treatment. By day 3, his blood had been cleared of worms, and he was able to continue therapy as an outpatient. He has continued to do well. Our patient's eosinophilia reached a peak of 36% during treatment and then returned gradually toward normal levels. Interestingly, the patient recalled some problems with palpitations in the past, prompting a concern about endomyocardial fibrosis. Holter monitoring and echocardiography were unrevealing, and the patient had no further problems.
Figure 1. Appearance of the subconjunctival worm (arrow)
1 5 8 / 1 1 54
DISCUSSION
Loiasis is a filarial infection caused by the L e a loa worm, also known as the African eye worm. It was first described by Mongin in 1770.8, 9 Ghana, the patient's home country, usually is not considered to he within the endemic area, but Nigeria, a country the patient had visited, frequently is implicated as an area of high infestation. The worm can grow to a length of 30 to 70 mm. The life cycle has been well described.a, 5 A tabanid fly (deerfly) of the genus C h r y s o p s bites an infected h u m a n host and acquires an immature form of the worm. Within two weeks, the fly becomes infectious and transmits the microfilariae to another h u m a n host. The worms then mature within six months and may survive for as long as 15 years. Macrofilariae are the adult worms, which cause most of the symptoms, whereas microfilariae are the larval forms present in the blood. 10 Presence of microfilariae in the blood follows a d i u r n a l variation, reaching a peak at midday, which made the our patient's presentation timely.a,5,11 Skin and eye findings make up the most typical presentation. Calabar swellings frequently are described and are thought to represent localized angioedema resulting from the host's response to the L o a antigen.a,6 There may not be a worm present within the area of swelling, and a Calabar swelling may present after treatment has eliminated the worm. 5 The localized swelling typically is nonpitting and painless, although it may be painful if it is over a joint. Calabars usually are present only one at a time and last for approximately three days. They may be warm but will not suppurate.5,6,1-2 Subconjunctival migration of the adult worm is a frequent and often solitary complaint. There are few symptoms beyond the actual sensation of the worm's presence and a local conjunctivitis.5 Intraocular migration of the worm is rare in this filarial illness. 9 Nutman et al studied the clinical and immunologic differences in infection between natives and non-natives of endemic areas.6,13 Natives rarely manifest systemic symptoms but often are microfilaremic. Non-natives frequently complain of allergic symptoms and angioedema and can become quite debilitated. Eosinophilia, common in loiasis as in other parasitic illnesses, may be more prominent (30% to 40%) in nonFigure
2.
Microfilariae evident on a routine blood smear
ANNALS OF EMERGENCY MEDICINE
21:9
SEPTEMBER 1992
LOIASIS
Jolly & Foley
natives. 12 I n one group of non-natives, only 15% had microfilaremiae, whereas 80% complained of pruritis and 90% had total eosinophil counts of more than 3,000 ram-1. +,6 In fact, pruritis may be the only symptom, a The reasons for these clinical differences may be found among immunologic data. Temporary residents with loaisis demonstrate increases in nonspecific immunoglobulin (Ig)E and parasite-specific IgG. The IgG may be responsible for the dearth of parasites in the blood and the IgE may account for the allergic symptoms, but further study is required, including documentation of the immunologic response of natives. 12 A number of unusual manifestations of Loa loa infection have been reported, including nephropathy, retinopathy, arthritis, peripheral neuropathy, and lymphedema. A characteristic pattern of local lymphadenitis in loiasis was noted by Paleologo et al. 8 Patients with fdariasis and hypereosino-philia have suffered from endomyocardial fibrosis, but no clear cause-and-effect relationship has been estabhshed. 6 Corrigan and Hill reported a case of embohc retinal artery occlusion in a patient with loiasis. ~4 Worms have been noted in all areas of the skin, on a gynecologic smear, and in ascitic fluid. 11,15,16 Capture of the worm or demonstration of microfilariae in the blood can be diagnostic, Indirect evidence of infection can be obtained through the use of fluorescent antibody testing and hemagglutination techniques. 12 The typical physical findings along with eosinophilia and an appropriate travel history may be sufficient evidence to begin treatment. The treatment of choice for infection with Loa loa is diethylcarbamazine at a dosage of 5 to 10 mg/kg/day. Nutman et al achieved complete response to treatment using a single 21-day course in 11 of 20 patients. 17 The other nine required further treatment for recurrent eosinophilia or Calabars swelling, b u t all patients were clear of worms at one-year follow-up. All patients demonstrated decreases in eosinophilia and antibody titers. 6 Post-treatment encephalitis has been observed. This potentially dangerous entity may be secondary to either a Herxheimer-like reaction or an allergic reaction to the dying worms. A lower dose of the drug in the first few days of therapy has been used to avoid this complication in patients with high peripheral worm counts. 1,5 As with our patient, plasmapheresis has been used to decrease the worm b u r d e n in order to avoid this sideeffect of treatment, la Prophylaxis is a consideration in patients who may travel to endemic areas. Diethylcarbamazine at a dosage of 5 mg/kg/day for three days each month has been used.i N n t m a n et al used • a dosage of 300 mg once a week in a randomized, placebocontrolled, double-blind trial. 17 Based on this study's results, prophylaxis was recommended for those at high risk, and further study was recommended for others. Diethylcarbamazine's broad antifilarial spectrum may make it useful as prophylaxis for other illnesses. 19
SEPTEMBER 1992
21:9
ANNALS OF EMERGENCY MEDICINE
SUMMARY
Infection with Loa lea and other filarial parasites is common in many parts of the world but is seen rarely by most physicians in the United States. We present a case of loiasis in an African native who had not visited Africa in six years. Unusual physical findings, eosinophilia, and a history of travel, possibly in the distant past, to an endemic area should raise the suspicion of a parasitic illness. Diagnosis can be simple in certain cases and very difficult in others. Referral to an expert in parasitology for definitive treatment should be u n d e r t a k e n once serious systemic illness has been ruled out. REFERENCES 1. Fain A: Les problemes actuele de la Ioase. Bull WHO 1978;56:155-176 (with English summary). 2. Egwang TG, Dupont A, Leclerc A, et al: Differential recognition of Loa IDa antigens by sera of human subjects from a Ioaisis endemic zone. Am J Trop Med Hyg 1989;41:664673. 3. Noireau F, Nzoulani A, Sinda D, et al: Transmission indices of Loa IDa in the Chaillu mountains, Congo. Am J Trop Med Hyg 1990;43:282-288. 4+Hubler WR, Gregory JF, Knox JM, et al: Loaisis: A case report and review of the literature. Arch Dermato11973;108:835-836. 5. Farrer WE, Wittnar M, Tanowitz HB: African eye worm (Loa IDa) in a tourist. Ann Ophthalmo11981;13:1177-1179. 6. Nutman TG, Miller KD, Mulligan M, at al: Loa IDa infection in temporary residents of endemic regions: Recognition of a hyperresponsive syndrome with characteristic clinical manifestations. JlnfectDis 1986;154:10-18. 7. Grigsby ME, Kerler DH: Loa IDa in the District of Columbia: A case report. J Nail Med Assoc 1971;63:198-201. 8. Paleologo EP, Neafie RC, Connor DH: Lymphadenitis caused by Loa IDa.AmJ Trop Med Hyg 1984;33:395-402. 9. Carme B, Mamboueni JP, Copin N, et al: Clinical and biological study of Loa IDa filariasis in Congolese. Am J Trap MealHyg 1989;41:331-337. 10. Muylle L, Taelman H, Moldenhauer R, et al: Usefulness of apheresis to extract microfilarias in management of Ioiasis. BrMedJ 1983;287:519-520. 11. Gibbs RD: Loiasis: Report of three cases and literature review. JNatlMedAssoc 1979;71:853-854. 12. Sacks HN, Williams DN, Eifrig DE: Loiasis: Report of a case and review of the literature. Arch Intern Mad 1976;136:914-915. 13. Nutman TB, Reese W, Poindexter RW, et al: Immunologic correlates of the hyperresponsive syndrome of Ioiasis. J InfectDis 1988;157:544-550. 14. Corrigan M J, Hill DW: Retinal artery occlusion in roiasis. BrJ Ophthalmol 1968;52:477-480. 15. Calrihan TR, 0ertel YC, Mendoza M: Loa lea in a gynecologic smear. Am J Trap Med Hyg 1977;26:572-573. 16. Hautekeete ML, Pialoux 6, Mareelrin P, et al: Presence of Loa IDa microfilariae in ascitic fluid (letter). J InfectOis 1989;160:559-560. 17. Nutman TB, Miller KD, Mulligan M, et al: Diethylcarbamazine prophylaxis for human Ioiasis: Results of a double+blind study. NEnglJ Med1988;319:752-756. 18. Taelman H, Muylle L: More uses for apheresis (letter). JAMA 1985;254:2064. 19. Richard-Lenoble D, Kombila M, Rupp EA, et al: Ivermectin in Ioiasis and concomitant 0 volvulus and M perstans infections. Am J Trop Mad Hyg 1988;39:480-483.
1155/ I 59
LOIASIS
Jolly & Foley
The authorsthank RichardRothman,MD for his pictures of the patient.They also thank ThomasNutman, MD, for sharing informationregardingthe continuingcare of the patient.
160/1156
Addressfor reprints: B Tilman Jolly, MD Departmentof EmergencyMedicine The GeorgeWashington UniversityMedical Center 2140 PennsylvaniaAvenue NW Washington, DC 20037
ANNALS OF EMERGENCY MEDICINE 2 1 : 9 SEPTEMBER1992