ANSWER TO THE PHOTO QUIZ

Philip A. Mackowiak, Section Editor

An Incidental Finding From a Blood Smear

(See page 106 for the Photo Quiz.)

Answer: Mansonella ozzardi Microfilaremia

As depicted in Figure 1A, the blood smear shows a microfi-
laria with a compact row of nuclei, a long headspace, a pointed
tail, and a relatively small size. The slides were sent for consul-
tation to the Centers for Disease Control and Preventions

Downloaded from http://cid.oxfordjournals.org/ at UNIVERSIDAD DE LOS ANDES on August 6, 2014

Center for Global Health, Division of Parasitic Diseases and
Malaria DPDx Web Inquiries and were confirmed to be Man-
sonella ozzardi based on the above-mentioned characteristics.
Mansonella ozzardi is a human filarial nematode parasite
found only in parts of the Caribbean and Central and South
America [18]. Infection begins with the bite of the infected
vector (biting midges of the genera Culicoides in the Caribbean
and Simulium blackflies in the Amazon region) [915], which
introduces third-stage filarial larvae onto the skin of the human
host that then develop into adults. The adult nematodes produce
microfilariae that reach the bloodstream.
The prevalence of microfilaremia has ranged from zero to
93% in highly endemic areas [16], but most people infected with
M. ozzardi are asymptomatic [17]. Men are more commonly
microfilaremic than women and the prevalence increases with
age [2, 1719]. Symptoms include articular pain, headache,
fever, lymphadenopathy, cold lower extremities, and red,
itchy cutaneous plaques that have been reported but are rela-
tively infrequent (5%25%) [17]. Eosinophilia can be seen and
is associated with the intensity of the microfilaremia [5].
The infection is diagnosed by microscopic examination of Figure 1. A, Blood smear showing microfilaria with a compact row of
a blood sample, which can be a thick smear stained with Giemsa nuclei and long headspace (arrow). B, Blood smear showing microfilaria
or hematoxylin and eosin, or a skin biopsy. The microfilariae are with a pointed tail (arrow).
nonperiodic [20, 21]. Distinguishing features of this filarial
species include the lack of a sheath, a compact column of nuclei,
a headspace that is more long than wide, a pointed tail devoid of infection of other Mansonella species [27]. No trials with
nuclei, and a relatively small size [22]. doxycycline have been conducted for M. ozzardi infection.
Unlike other filarial species, diethylcarbamazine has little or In Colombia, foci of M. ozzardi infection exist in some of the
no effect on M. ozzardi infections [23]. A single dose of 6 mg of eastern states and in the Amazon region, but no cases have been
ivermectin has been reported to provide short- and long-term reported from the northern Pacific region in the indexed lit-
reduction of microfilaremia and is currently the treatment of erature [18, 2831]. Interestingly, this patient did not present
choice [24]. Severe malaise, chills, fever, and dyspnea have with fever or eosinophilia until after her first chemotherapy
rarely been reported after the administration of ivermectin, and cycle. On day 6 after chemotherapy, she had an eosinophil
patients usually recover rapidly without specific therapy [25]. count of 583 cells/lL and a temperature of 38C, but was
Mansonella ozzardi has been shown to harbor the endosymbi- otherwise asymptomatic and did not present with lymph-
otic bacteria Wolbachia [26]. As for Wuchereria bancrofti, adenopathy or rash. There have been no reports of the exis-
doxycycline has been shown to be an effective therapy for the tence of symptomatic microfilaremia after chemotherapy. This

ANSWER TO THE PHOTO QUIZ d CID 2012:55 (1 July) d 155

patient was treated with 6 mg of ivermectin without compli-
cations and is currently completing a 6-week course of doxy-
cycline.
Note
Potential conflicts of interest. All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.
Alicia Hidron,1,2,3,4 Kenny Galvez,2 Camilo Madrid,4 Adolfo Velez,5
Lina M. Arcila,2 Juan Camilo Perez,2 and Alejandro Velez2,4
1Division of Infectious Diseases, Emory University School of Medicine, Atlanta,
Georgia; 2Hospital Pablo Tobon Uribe, 3Corporacion para Investigaciones
Biologicas, CIB, 4Universidad Pontificia Bolivariana, and 5Universidad CES
Medell
n, Colombia
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Clinical Infectious Diseases 2012;55(1):1556
The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases
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oup.com.
DOI:10.1093/cid/cis125