\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{ISOLATED PULMONARY CYSTICERCOSIS IN AN URBAN SOUTH AFRICAN CHILD}



\author[1]{Zandiswa Nowalaza}%
\author[2]{Heather Zar}%
\author[3]{Marco Zampoli}%
\author[2]{Komala  Pillay}%
\author[2]{Shivani  Singh}%
\affil[1]{Red Cross War Memorial Children's Hospital}%
\affil[2]{University of Cape Town}%
\affil[3]{Red Cross War Memorial Children’s Hospital}%


\vspace{-1em}



  
  \date{May 26, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Cysticercosis in humans is a serious public health problem,
predominantly affecting low and middle-income countries (LMICs).
Cysticercosis, the infection with the larval form of the pork tapeworm,
Taenia Solium has high prevalence in areas where there are poor sanitary
conditions and domestic pig without adequate veterinary control. Humans
are the definitive host and pigs are the main source of infection. Human
infection occurs when pork is eaten raw or undercooked. Ingested eggs or
proglottids hatch into larvae form, which penetrate the intestinal wall
into the blood stream and migrate into different organs including
subcutaneous tissues, brain, eyes and rarely heart or lung, where they
mature into cysticerci. Pulmonary cysticercosis has been rarely
described; case reports are predominantly in adults and are usually of
disseminated disease. In children the data are very scarce, with a
single case report of a two-year old child with pulmonary infiltration,
eosinophilia and subcutaneous cysticercosis.%
\end{abstract}%



\sloppy


\textbf{ISOLATED PULMONARY CYSTICERCOSIS IN AN URBAN SOUTH AFRICAN
CHILD}

\textbf{Z Nowalaza, HJ Zar, M Zampoli, K Pillay, S Singh,}

\textbf{Dept Paediatrics \& Child Health, Red Cross War Memorial
Children's Hospital, and SA-MRC Unit on Child \& Adolescent Health, UCT,
SA}

\textbf{To the Editor} : Cysticercosis in humans is a serious public
health problem, predominantly affecting low and middle-income countries
(LMICs) (1, 2). Cysticercosis, the infection with the larval form of the
pork tapeworm, Taenia Solium has high prevalence in areas where there
are poor sanitary conditions and domestic pig without adequate
veterinary control(1). Humans are the definitive host and pigs are the
main source of infection. Human infection occurs when pork is eaten raw
or undercooked. Ingested eggs or proglottids hatch into larvae form,
which penetrate the intestinal wall into the blood stream and migrate
into different organs including subcutaneous tissues, brain, eyes and
rarely heart or lung, where they mature into cysticerci(3). Pulmonary
cysticercosis has been rarely described; case reports are predominantly
in adults and are usually of disseminated disease. In children the data
are very scarce, with a single case report of a two-year old child with
pulmonary infiltration, eosinophilia and subcutaneous cysticercosis (3).

We describe an 8-year-old child with pulmonary cysticercosis who
presented to Red Cross Children' s Hospital, Cape Town, South Africa,
with a large right pleural effusion. She presented with five days of
cough, fever and shortness of breath. She resided in a poor informal
settlement, in an urban area of Cape Town and had no recent travel
history or underlying illness. She had no direct contact with pigs,
although consumed pork. There was no known household or close contact
with tuberculosis (TB). On examination she was well nourished, with a
temperature of 38 degrees Celsius, respiratory rate of 36 breaths per
minute and oxygen saturation of 96 \% in room air. She had mild
subcostal chest retractions, tracheal deviation to the left side with
dullness to percussion and reduced breath sounds on the right chest.

Chest x-ray showed complete opacification of the right hemithorax and
mediastinal shift to the left, fig 1.

Fig 1: Frontal chest Xray showing opacification of the right hemithorax,
and mediastinal shift to the left.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

In the emergency unit, 660 ml of straw-colored fluid was aspirated from
the right hemithorax and sent for laboratory analysis. She was admitted,
treated with oral antibiotics for possible bacterial pneumonia, started
on TB treatment with prednisone and a pigtail chest drain was inserted
to drain the pleural fluid.

Laboratory investigations showed a C-reactive protein of 239 mg/L, which
was significantly raised. The raised C-reactive protein was probably due
to the inflammatory response rather than superimposed bacterial
infection((1). The full blood count with a white cell count 12.86
x10\textsuperscript{9}/L (neutrophils 58 \%, lymphocytes 28 \%,
monocytes 12 \%, eosinophils 1\%), hemoglobin 12.4 g/dL and platelets
419 x 10\textsuperscript{9}/L. Pleural fluid was consistent with an
exudate: protein 59 g/L, adenosine deaminase 42.0 U/L, with lymphocyte
predominance: lymphocytes 856 /uL, polymorphs 5 /uL. Fluid was negative
by GeneXpert Ultra for \emph{M. tuberculosis} and negative for bacteria
and TB culture. Surprisingly, a pale- pink cystic structure measuring 65
x 25 x 8 mm drained through the pigtail drain; histology showed a
degenerate cyst wall composed of oedematous villous-like projections and
comprising of an outer cuticular layer, middle cellular layer and inner
fibrillary layer, in keeping with a degenerate cysticercosis, Fig 2.
This cyst was probably located on lung surface or in pleura, hence the
result of pleural effusion.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Fig 2: Figure 2A shows a degenerate cyst wall composed of oedematous
villous-like projections.

Figure 2B is a high power view showing the outer cuticular layer
(arrowhead), middle cellular layer(arrow) and inner fibrillary layer
(*).

The child was therefore, started on albendazole 15 mg/kg/day for one
month. A CT scan of the brain was done for intracranial cysticercosis,
which revealed a non- specific solitary sub centimeter calcified
granuloma abutting the tentorium cerebellum.

On follow up at 4 months of albendazole and prednisone, she was
clinically and radiologically much improved. A follow-up CXR showed
resolution of pleural effusion and aerated right lung, fig 3.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Fig 3: Frontal CXR at 4 months follow up, showing complete resolution of
the pleural effusion

This is one of the first reported cases of isolated pulmonary
cysticercosis in a child. Even in the adult population, pulmonary
cysticercosis has usually been reported as part of disseminated disease,
with only four cases of isolated pulmonary cysticercosis reported in
over 20 years(1). Underdiagnosis of pulmonary disease may be a concern,
as it may be difficult to definitively diagnose disease; in our case,
definitive diagnosis was possible with histology. However, in South
Africa and other LMICs, cysticercosis in the form of neurocysticercosis
presenting as epilepsy, is common, and has been recognized as a health
problem for many years(4, 5).

As a result, the World Health Organisation (WHO) guidelines for the
surveillance, prevention and control of cysticercosis, recommend
deworming of all children from one year up to 12 years of age every six
months in endemic areas(6)

The detection of cysticercosis is a public health concern, as it implies
that preventative measures and disease control programs are inadequate .
Health care professionals should ensure that every child they come in
contact with, is up to date with the deworming program, especially in
endemic countries(6)

REFERENCES

1. Chen Y, Wang P, Ding L. Two cases of pulmonary cysticercosis
manifesting as pleural effusion: case report and literature review. J
Thorac Dis. 2017;9(8):E677-E81.

2. Gupta N, Meena M, Harish S, Patil CB, Kewlani JP. A rare case of
pulmonary cysticercosis manifesting as lung cavity with pleural
effusion. Lung India. 2015;32(5):515-7.

3. Salaria M PV, Kochar S, \& Mehta S. Eosinophilia, Pleural Effussion
and Cysticercosis- Unknown association. Indian Pediatrics.
2001(38):671-4.

4. Phiri IK, Ngowi H, Afonso S, Matenga E, Boa M, Mukaratirwa S, et al.
The emergence of Taenia solium cysticercosis in Eastern and Southern
Africa as a serious agricultural problem and public health risk. Acta
Tropica. 2003;87(1):13-23.

5. Krecek RC, Mohammed H, Michael LM, Schantz PM, Ntanjana L, Morey L,
et al. Risk factors of porcine cysticercosis in the Eastern Cape
Province, South Africa. PLoS One. 2012;7(5):e37718.

6. Organization WH. WHO/FAO/OIE guidelines for the surveillance,
prevention and control of taeniosis/cysticercosis: Paris: World
Organisation for Animal Health; 2005.

\selectlanguage{english}
\FloatBarrier
\end{document}

