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1</a>&#41;&#44; so treatment began with metronidazole&#46; The patient&#8217;s postoperative progress was favorable and she was discharged on the fifth day with complete resolution of her respiratory symptoms&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 2&#58;</span> A 52-year-old male patient from a rural area with a history of chronic renal failure was admitted with severe acute respiratory failure&#46; Complete blood count and chest X-ray were performed&#44; and were consistent with community-acquired pneumonia &#40;CAP&#41;&#46; He received empirical antibiotic treatment and oxygen therapy but showed no improvement&#46; In view of the lack of response&#44; bronchoscopy was performed and samples were collected&#46; A direct study showed flagellated parasites and intravenous metronidazole began&#44; with great improvement&#46; The patient completed 20 days of home treatment&#44; 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Treatment started with intravenous metronidazole&#44; and the patient showed gradual improvement&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 6&#58;</span> A 79-year-old female patient from a rural area&#44; with a history of diabetes mellitus receiving treatment with insulin&#44; was admitted for severe respiratory failure requiring orotracheal intubation&#46; Results of the additional examinations including complete blood count and chest CT led to a diagnosis of severe pneumonia&#46; Management began with empirical antibiotic therapy&#44; with no response and gradual deterioration&#46; A bronchoscopy was performed in which infection with <span class="elsevierStyleItalic">Lophomonas blattarum</span> was detected&#44; so treatment with intravenous metronidazole started without improvement&#46; The patient deteriorated progressively and died on day 10&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The species <span class="elsevierStyleItalic">Lophomonas blattarum</span> is a round&#44; oval&#44; or pyriform protozoan&#44; 20&#8722;60&#8239;mm long and 12&#8722;20&#8239;mm wide&#46; It has a granular cytoplasm&#44; and its apical pole has irregular flagellae which vibrate to help it move&#46; These parasites are found in the intestinal tract of some termites and cockroaches&#44; while infection in humans is rare and closely related to states of chronic immunosuppression&#46; The form of transmission is by direct ingestion of the feces of an infected termite or cockroach&#46; The symptoms mimic a respiratory infection and can include cough with or without expectoration&#44; chest pain&#44; respiratory failure&#44; etc&#46;&#44; and bilateral pulmonary infiltrates on chest X-ray&#44; so it is commonly confused with pneumonia&#46; Diagnosis is confirmed by the identification of the parasite in respiratory secretions<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Few cases of lung infection with <span class="elsevierStyleItalic">Lophomonas blattarum</span> have been reported in the literature&#58; most are from China&#44; where 137 cases have been reported to date&#44; while 6&#44; 2&#44; 1&#44; and 1 cases have been reported in Peru&#44; Spain&#44; Mexico and the Arab Emirates&#44; respectively&#46; In previous series&#44; most patients are male&#44; while women predominate in ours&#46; Almost all are adults &#40;3 children in Peru and 1 in Mexico&#41; and are immunocompromised &#40;69&#46;1&#37; in the literature vs&#46; 100&#37; in our study&#41; or have previous or concomitant lung infections&#44; similar to the situation presented in our series<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;13</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In all patients&#44; both in the existing literature and in our series&#44; the symptoms presented are typical of a respiratory infection &#40;cough&#44; expectoration&#44; fever&#44; chest pain&#41;&#44; with a chest X-ray suggestive of pneumonia&#44; so it is often confused with this disease&#46; Diagnosis is based on the direct live observation of the parasite in sputum&#44; bronchoalveolar lavage&#44; bronchial brushing or tracheal aspirate&#46; Care should be taken not to confuse the parasite with ciliated bronchial epithelial cells that resemble <span class="elsevierStyleItalic">Lophomonas</span> morphology in form and characteristics&#44; the main difference being the constant mobility of the parasite &#8212; the vibration of its apical flagellae that it uses to move around can be clearly observed under the microscope<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;13</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Treatment is based on oral or intravenous metronidazole administration for patients weighing over 40&#8239;kg&#46; The dose is 500&#8239;mg every 8&#8239;h for 20&#8211;30 days&#44; depending on the severity of the infection&#44; and for children the dose is calculated at 30&#8211;40&#8239;mg&#47;kg&#47;day divided into 3 doses&#46; No resistance to this treatment has been reported to date<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;13</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion&#44; this is a rare parasitic infection&#44; which should be suspected in individuals with comorbidities that predispose to immunosuppression&#44; who after being in an endemic place develop a lung infection that responds poorly to antibiotic treatment&#46;</p></span>"
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Scientific Letter
Lung infection caused by Lophomonas blattarum
Infección pulmonar por Lophomonas blattarum
Nathalie Pinos Véleza,b,
Corresponding author
nathaliepinos@hotmail.com

Corresponding author.
, Ricardo Ordoñez Vintimillab, Solmayra Agreda Orellanac
a Unidad de Pulmonar, Hospital José Carrasco Arteaga, Cuenca, Ecuador
b Unidad de Cirugía de Tórax, Hospital Universitario del Río, Cuenca, Ecuador
c Laboratorio, Hospital Universitario del Río, Cuenca, Ecuador
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1</a>&#41;&#44; so treatment began with metronidazole&#46; The patient&#8217;s postoperative progress was favorable and she was discharged on the fifth day with complete resolution of her respiratory symptoms&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 2&#58;</span> A 52-year-old male patient from a rural area with a history of chronic renal failure was admitted with severe acute respiratory failure&#46; Complete blood count and chest X-ray were performed&#44; and were consistent with community-acquired pneumonia &#40;CAP&#41;&#46; He received empirical antibiotic treatment and oxygen therapy but showed no improvement&#46; In view of the lack of response&#44; bronchoscopy was performed and samples were collected&#46; A direct study showed flagellated parasites and intravenous metronidazole began&#44; with great improvement&#46; The patient completed 20 days of home treatment&#44; with complete resolution&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 3&#58;</span> A 55-year-old male patient from an urban area with a history of pulmonary tuberculosis treated with isoniazid and rifampicin was admitted for severe respiratory failure requiring orotracheal intubation&#46; Due to a high suspicion of superinfection&#44; empirical antibiotic therapy began&#44; but given the lack of response&#44; bronchoscopy was performed and direct examination of the sample showed a flagellated protozoan &#40;<span class="elsevierStyleItalic">Lophomonas blattarum</span>&#41;&#46; Treatment began with intravenous metronidazole&#44; and the patient improved progressively&#46; He remained in hospital until 7 days of intravenous treatment were completed and was discharged with oral metronidazole&#46; He remains in good condition&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 4&#58;</span> A 59-year-old female patient from a rural area&#44; with a history of renal cell carcinoma in remission&#44; was admitted with a severe respiratory process&#46; Chest CT was consistent with CAP&#44; so empirical antibiotic therapy began&#44; with partial improvement&#46; Direct examination of sputum revealed flagellated parasites &#40;<span class="elsevierStyleItalic">Lophomonas blattarum</span>&#41;&#44; so treatment was supplemented with oral metronidazole&#46; The patient improved quickly and was discharged to complete the regimen at home&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 5&#58;</span> A 69-year-old female patient from a rural area&#44; with a history of chronic renal failure receiving dialysis&#44; was admitted for respiratory symptoms&#46; Chest CT and complete blood count were consistent with severe pneumonia&#44; so she started empirical antibiotic therapy&#44; without improvement&#46; Samples were obtained by bronchoscopy and direct examination showed <span class="elsevierStyleItalic">Lophomonas blattarum</span>&#46; Treatment started with intravenous metronidazole&#44; and the patient showed gradual improvement&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 6&#58;</span> A 79-year-old female patient from a rural area&#44; with a history of diabetes mellitus receiving treatment with insulin&#44; was admitted for severe respiratory failure requiring orotracheal intubation&#46; Results of the additional examinations including complete blood count and chest CT led to a diagnosis of severe pneumonia&#46; Management began with empirical antibiotic therapy&#44; with no response and gradual deterioration&#46; A bronchoscopy was performed in which infection with <span class="elsevierStyleItalic">Lophomonas blattarum</span> was detected&#44; so treatment with intravenous metronidazole started without improvement&#46; The patient deteriorated progressively and died on day 10&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The species <span class="elsevierStyleItalic">Lophomonas blattarum</span> is a round&#44; oval&#44; or pyriform protozoan&#44; 20&#8722;60&#8239;mm long and 12&#8722;20&#8239;mm wide&#46; It has a granular cytoplasm&#44; and its apical pole has irregular flagellae which vibrate to help it move&#46; These parasites are found in the intestinal tract of some termites and cockroaches&#44; while infection in humans is rare and closely related to states of chronic immunosuppression&#46; The form of transmission is by direct ingestion of the feces of an infected termite or cockroach&#46; The symptoms mimic a respiratory infection and can include cough with or without expectoration&#44; chest pain&#44; respiratory failure&#44; etc&#46;&#44; and bilateral pulmonary infiltrates on chest X-ray&#44; so it is commonly confused with pneumonia&#46; Diagnosis is confirmed by the identification of the parasite in respiratory secretions<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Few cases of lung infection with <span class="elsevierStyleItalic">Lophomonas blattarum</span> have been reported in the literature&#58; most are from China&#44; where 137 cases have been reported to date&#44; while 6&#44; 2&#44; 1&#44; and 1 cases have been reported in Peru&#44; Spain&#44; Mexico and the Arab Emirates&#44; respectively&#46; In previous series&#44; most patients are male&#44; while women predominate in ours&#46; Almost all are adults &#40;3 children in Peru and 1 in Mexico&#41; and are immunocompromised &#40;69&#46;1&#37; in the literature vs&#46; 100&#37; in our study&#41; or have previous or concomitant lung infections&#44; similar to the situation presented in our series<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;13</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In all patients&#44; both in the existing literature and in our series&#44; the symptoms presented are typical of a respiratory infection &#40;cough&#44; expectoration&#44; fever&#44; chest pain&#41;&#44; with a chest X-ray suggestive of pneumonia&#44; so it is often confused with this disease&#46; Diagnosis is based on the direct live observation of the parasite in sputum&#44; bronchoalveolar lavage&#44; bronchial brushing or tracheal aspirate&#46; Care should be taken not to confuse the parasite with ciliated bronchial epithelial cells that resemble <span class="elsevierStyleItalic">Lophomonas</span> morphology in form and characteristics&#44; the main difference being the constant mobility of the parasite &#8212; the vibration of its apical flagellae that it uses to move around can be clearly observed under the microscope<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;13</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Treatment is based on oral or intravenous metronidazole administration for patients weighing over 40&#8239;kg&#46; The dose is 500&#8239;mg every 8&#8239;h for 20&#8211;30 days&#44; depending on the severity of the infection&#44; and for children the dose is calculated at 30&#8211;40&#8239;mg&#47;kg&#47;day divided into 3 doses&#46; 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ISSN: 15792129
Original language: English
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