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shortness of breath and wheezing&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> Chest radiograph findings usually demonstrates peripherally basal opacities&#44; although they can be present in different ways&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> An allergic response is responsible for the presence of respiratory symptoms and radiological manifestations&#44; which can be seen as a transient nodular or diffuse pulmonary infiltrates &#40;Loeffler&#39;s syndrome&#41; or as a chronic eosinophilic pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> However&#44; spontaneous pneumothorax has also been described in literature in the context of Ascaris infection&#44; but it constitutes a rare event&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Here&#44; we report a case of pneumothorax due to <span class="elsevierStyleItalic">AL</span> larvae in a young female&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 26 years-old woman was admitted to Pulmonology Department in April 2018&#46; Her past medical history included chronic rhinosinusitis&#44; without other relevant pathological antecedents&#46; She had no smoking history&#44; allergies or previous surgeries&#44; and no usual medication&#44; drugs or alcohol consumption&#46; No recent travel abroad or exposure to unpasteurized or uncooked foods&#46; Patient resided in an urban area with good conditions&#44; but had a non-dewormed cat at home&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Patient had a history of exertional dyspnoea since February 2018&#44; with no other relevant symptoms&#46; Because of this&#44; a chest X-ray was performed&#44; and the diagnosis of a total left pneumothorax was made &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>I&#41;&#46; Patient was then admitted to the emergency department where she was aware&#44; collaborative and focused&#46; Hydrated&#46; Afebrile&#46; Hemodynamically stable&#46; No respiratory distress&#46; SpO<span class="elsevierStyleInf">2</span> &#40;FiO<span class="elsevierStyleInf">2</span> 21&#37;&#41;&#58; 98&#37;&#46; At pulmonary auscultation&#58; normal right sounds and decreased left sounds&#46; Haematological and biochemical profiles&#44; and arterial blood gas analysis &#40;ABG&#41; were normal&#46; Thoracic drainage was placed at the fifth intercostal space&#44; without complications&#46; The presence of a high alveolar-pleural fistula debit was observed and lung expansion was not achieved&#46; Chest computed-tomography-scan showed total collapse of the left lung&#44; emphysema&#44; densification areas and minimal pleural effusion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>II&#41;&#46; Bronchofibroscopy did not showed endobronchial lesions&#46; Due to chest drainage failure&#44; a video-assisted thoracoscopy surgery was performed&#44; revealing a giant pulmonary bubble that was resected and several pleural implants were biopsied&#46; Talc pleurodesis was also made&#46; The expanded lung tissue showed a large number of eosinophils and scattered mesothelial fragments&#44; consistent with an eosinophilic pleurisy&#46; Histological examination showed an encysted <span class="elsevierStyleItalic">AL</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>III&#41;&#46; After surgery&#44; a complete pneumothorax resolution was verified&#46; Stool parasitology was negative&#44; and the patient was treated with albendazole&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">There was no recurrence of pneumothorax and haematological profile never revealed peripheral eosinophilia&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lung parasitic infections can be present in immunocompetent and immunocompromised patients&#44; and may affect respiratory system in different ways&#46; <span class="elsevierStyleItalic">AL</span> is mainly seen in poor sanitation areas&#44; where there is faecal contamination of soil or food&#46; Disease transmission is faecal&#8211;oral&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Most <span class="elsevierStyleItalic">AL</span>-infected patients do not have significant respiratory symptoms during larvae&#8217; maturation or migratory phases&#44; and its presence is a very uncommon finding&#44; making this a rare cause of pneumothorax&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">With increased travel and migration&#44; parasitic lung and pleural diseases have raising in developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Indeed&#44; clinical presentations and radiographic findings of several of these infections may mimic respiratory diseases&#46; For all this&#44; it is essential to consider parasitic infections in the differential diagnosis of lung diseases&#46;</p></span>"
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Scientific Letter
Pneumothorax Due to Ascaris lumbricoides Larvae
Neumotórax originado por larvas de Ascaris lumbricoides
Vanessa Santosa,
Corresponding author
vferreirads@gmail.com

Corresponding author.
, João Macielb, Susana Guimarãesc, David Araújoa
a Pulmonology Department, Centro Hospitalar de São João, EPE, Porto, Portugal
b Thoracic Department, Centro Hospitalar de São João, EPE, Porto, Portugal
c Pathology Department, Centro Hospitalar de São João, EPE, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ascaris lumbricoides &#40;AL&#41;</span>&#44; popularly known as roundworm&#44; is a nematode species belonging to the <span class="elsevierStyleItalic">Ascarididae</span> family&#44; involved in the most common worldwide intestinal helminthic infection &#40;Ascariasis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> This nematode reaches gastrointestinal tract &#40;GI&#41; through ingestion of food&#47;fluids contaminated with faeces&#44; and in small intestine they migrate into pulmonary circulation&#44; where they mature causing capillaries and alveolar walls destruction&#46; Clinical presentation may vary from malaise&#44; fever&#44; loss of appetite&#44; myalgia and headache to respiratory symptoms&#44; which includes sputum-productive cough&#44; chest pain&#44; haemoptysis&#44; shortness of breath and wheezing&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> Chest radiograph findings usually demonstrates peripherally basal opacities&#44; although they can be present in different ways&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> An allergic response is responsible for the presence of respiratory symptoms and radiological manifestations&#44; which can be seen as a transient nodular or diffuse pulmonary infiltrates &#40;Loeffler&#39;s syndrome&#41; or as a chronic eosinophilic pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> However&#44; spontaneous pneumothorax has also been described in literature in the context of Ascaris infection&#44; but it constitutes a rare event&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Here&#44; we report a case of pneumothorax due to <span class="elsevierStyleItalic">AL</span> larvae in a young female&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 26 years-old woman was admitted to Pulmonology Department in April 2018&#46; Her past medical history included chronic rhinosinusitis&#44; without other relevant pathological antecedents&#46; She had no smoking history&#44; allergies or previous surgeries&#44; and no usual medication&#44; drugs or alcohol consumption&#46; No recent travel abroad or exposure to unpasteurized or uncooked foods&#46; Patient resided in an urban area with good conditions&#44; but had a non-dewormed cat at home&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Patient had a history of exertional dyspnoea since February 2018&#44; with no other relevant symptoms&#46; Because of this&#44; a chest X-ray was performed&#44; and the diagnosis of a total left pneumothorax was made &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>I&#41;&#46; Patient was then admitted to the emergency department where she was aware&#44; collaborative and focused&#46; Hydrated&#46; Afebrile&#46; Hemodynamically stable&#46; No respiratory distress&#46; SpO<span class="elsevierStyleInf">2</span> &#40;FiO<span class="elsevierStyleInf">2</span> 21&#37;&#41;&#58; 98&#37;&#46; At pulmonary auscultation&#58; normal right sounds and decreased left sounds&#46; Haematological and biochemical profiles&#44; and arterial blood gas analysis &#40;ABG&#41; were normal&#46; Thoracic drainage was placed at the fifth intercostal space&#44; without complications&#46; The presence of a high alveolar-pleural fistula debit was observed and lung expansion was not achieved&#46; Chest computed-tomography-scan showed total collapse of the left lung&#44; emphysema&#44; densification areas and minimal pleural effusion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>II&#41;&#46; Bronchofibroscopy did not showed endobronchial lesions&#46; Due to chest drainage failure&#44; a video-assisted thoracoscopy surgery was performed&#44; revealing a giant pulmonary bubble that was resected and several pleural implants were biopsied&#46; Talc pleurodesis was also made&#46; The expanded lung tissue showed a large number of eosinophils and scattered mesothelial fragments&#44; consistent with an eosinophilic pleurisy&#46; Histological examination showed an encysted <span class="elsevierStyleItalic">AL</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>III&#41;&#46; After surgery&#44; a complete pneumothorax resolution was verified&#46; Stool parasitology was negative&#44; and the patient was treated with albendazole&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">There was no recurrence of pneumothorax and haematological profile never revealed peripheral eosinophilia&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lung parasitic infections can be present in immunocompetent and immunocompromised patients&#44; and may affect respiratory system in different ways&#46; <span class="elsevierStyleItalic">AL</span> is mainly seen in poor sanitation areas&#44; where there is faecal contamination of soil or food&#46; Disease transmission is faecal&#8211;oral&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Most <span class="elsevierStyleItalic">AL</span>-infected patients do not have significant respiratory symptoms during larvae&#8217; maturation or migratory phases&#44; and its presence is a very uncommon finding&#44; making this a rare cause of pneumothorax&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">With increased travel and migration&#44; parasitic lung and pleural diseases have raising in developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Indeed&#44; clinical presentations and radiographic findings of several of these infections may mimic respiratory diseases&#46; For all this&#44; it is essential to consider parasitic infections in the differential diagnosis of lung diseases&#46;</p></span>"
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