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ABSTRACT |
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INTRODUCTION |
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The subject of the present report showed symptoms and signs of hypersensitivity such as hypotension and skin eruption after praziquantel medication for the treatment of clonorchiasis. We present the clinical findings for this subject.
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CASE REPORT |
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At the emergency department, he had an appearance of fainting. A physical examination showed a blood pressure of 50/30 mm of Hg, a weak rapid pulse of 99 beats per minute, respiratory rate of 28 per minute, a temperature of 36.5°C, and a weight of 70 kg. His breathing and heart beat sound were clear. He was conscious and could verbalize, and complained of itching, breathing difficulty, chest tightness, and dizziness. Urticaria affected his entire body, especially the chest, back, and abdomen, where it was severe and aggravated by scratching. Laboratory findings were as follows: white blood cell count =19,100/mm3, hemoglobin level = 17.2 g/dL, platelet count = 184,000/µL, aspartate aminotransferase/alanine aminotransferase = 132/81 U/L, blood urea nitrogen = 54 mmol/L, creatinine = 76 µ mol/L, Na = 142 mmol/L, K = 3.29 mmol/L, and Cl = 94.7 mmol/L. and Tests results for hepatitis B surface antigen and antibodies to hepatitis B surface antigen, hepatitis B core antigen, and hepatitis C virus were negative. He was diagnosed as having an anaphylactic or hypersensitive reaction induced by praziquantel.
He received an emergent stomach wash by intubation, oxygen inhalation, injection of 0.5 mg of adrenaline hydrochloride, 20 mg of dexamethasone, and 25 mg of poromethazine hydrochloride intramuscularly, and an intravenous injection of 500 mL of 706 hydroxyethyl starch. One hour after receiving this medication, his blood pressure was 110/70 mm of Hg. One day after admission and medication, his symptoms of chest tightness and dyspnea subsided. After a two-day hospital stay, all of his vital signs were within normal ranges and symptoms had improved to the extent that he was discharged. He was advised to report this episode to doctors whenever he received further medication because of the possibility that he might also be hypersensitive to other drugs.
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DISCUSSION |
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Anaphylactic drug reactions of this type can be induced by any type of natural or synthetic drugs, but are rarely induced by praziquantel. Only two cases have been associated with praziquantel: one was a 46-year-old woman with chronic schistosomiasis in China,2 and the other was of a 10-year-old boy with neurocysticercosis in the United States.3 However, no cases have been recorded in Africa, where use of praziquantel consumption is the highest.
Neurocysticercosis and schistosomiasis are commonly associated with some serious adverse reactions to praziquantel.4,5 These serious reactions are known to be induced by exposure of the host to a large bolus of antigens and tissues released suddenly by dead worms. Dead worms in the brain or blood vessels are disintegrated and cleared from the tissue after treatment, and inevitably induce severe inflammation and strong antigenic stimulation. Treatment of cases with schistosomiasis mansoni increases specific IgE and Th2 responses.6 In particular, plasma levels of interleukin-5 were transiently increased in most patients with schistosomiasis one day after treatment, and these increases showed a correlation with infection intensity.7 In this context, anaphylaxis may be caused during treatment of schistosomiasis or neurocysticercosis per se by antigenic proteins released from eggs, teguments, and the cystic fluids of dead worms.4,5
The anaphylactic reaction in this patient was not associated with tissue or immune reactions to dead worms but with praziquantel. Most dead worms of Clonorchis are discharged from the bile duct in the bile and feces within a few days of initiation of treatment and stop producing eggs or antigens. Animal experiments in our laboratory have repeatedly demonstrated that only a few dead worms are found in the lumen of the bile duct two weeks after the treatment. Although the dead worms still remain in the bile duct, their bodies are not disintegrated in the tissue but in the lumen of the bile duct. When the pharmacokinetics of praziquantel is considered, the plasma concentration of praziquantel increases to an effective level after one hour, and Clonorchis worms in the bile duct lumen are killed at least after two or more hours by this drug.8 In the present case, however, the hypersensitivity symptoms suddenly appeared 30 minutes after the first dose of medication. Thirty minutes is the point at which praziquantel tablets dissolve and the beginning of absorption in the stomach or intestine. The time point is too early for the death of the worms. In this context, a sudden increase in antigenic stimulation caused by dead worms is not a burden to the host after treatment in the present case.
Praziquantel is known to cause several adverse reactions.1 The common adverse reactions are neurologic and digestive symptoms: neurologic symptoms are headache, dizziness, and sleepiness; digestive symptoms are abdominal discomfort, nausea, vomiting, and diarrhea.1 However, all of these symptoms are mild and transient, and require no specific therapy. Only an anaphylactic reaction requires hospitalization because this reaction is often associated with hypotensive shock and life-threatening airway obstruction caused by bronchospasm.9 The patient in this study complained of respiratory difficulties during the initial onset phase but his lung auscultation sounds were clear without wheezing or rale. At the emergency department, his respiration difficulty appeared only mild, and seemed to be an outcome of low blood pressure, not a bronchospasm. Moreover, laboratory data showed leukocytosis, which may have been related to the anaphylactic reaction.
The case in this study had a history of praziquantel administration eight years before the present episode. At that time, he took the drug without having an adverse reaction, and the previous administration of praziquantel may have sensitized him to the drug. He probably became reinfected after this treatment because he lived in an area endemic for clonorchiasis and enjoyed eating raw fish. There were no data for quantitative evaluation of the infection intensity, and he was not properly examined after this episode because of poor compliance. We recommend that he should be examined again, that egg counts be determined, and that he be retreated with albendazole instead of praziquantel.
Praziquantel causes anaphylactic type adverse reactions only on rare occasions. However, doctors and field workers should be aware of these reactions and the common adverse effects of praziquantel on memory.
Received September 14, 2006. Accepted for publication November 28, 2006.
* Address correspondence to Sung-Tae Hong, Department of Parasitology and Tropical Medicine, and Institute of Endemic Diseases, Seoul National University College of Medicine, Seoul 110-799, Korea. E-mail: hst{at}snu.ac.kr 
Authors’ addresses: Chenghua Shen, Min-Ho Choi, Young Mee Bae, and Sung-Tae Hong, Department of Parasitology and Tropical Medicine, and Institute of Endemic Diseases, Seoul National University College of Medicine, Seoul 110-799, Republic of Korea. Gui Yu, Heilongjiang Provincial Zhaoyuanxian Center for Disease Control and Prevention, Zhaoyuan 166500, People’s Republic of China. Shuhua Wang, Department of Internal Medicine, Heilongjiang Provincial Zhaoyuan People’s Hospital, Zhaoyuan, 166500, People’s Republic of China.
Reprint requests: Sung-Tae Hong, Department of Parasitology and Tropical Medicine, and Institute of Endemic Diseases, Seoul National University College of Medicine, Seoul 110-799, Republic of Korea.
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