# First Case Report of Sinusitis withLophomonas blattarum from Iran

Authors: Fariba Berenji; Mahmoud Parian; Abdolmajid Fata; Mahdi Bakhshaee; Fereshte Fattahi
Journal: Case Reports in Infectious Diseases
 (2016)

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## Abstract

Introduction.Lophomonas blattarum is a rare cause of bronchopulmonary and sinus infection. This paper presents a rare case ofLophomonas sinusitis.Case Presentation. The patient was a 31-year-old woman who was admitted because of a history of upper respiratory infection and sinusitis. Direct microscopic examination of the sputum and nasal discharge showed large numbers of livingLophomonas blattarum with irregular movement of flagella. The patient was successfully treated byMetronidazole 750 mg t.i.d. for 30 days.Conclusions. This is the first case report ofLophomonas blattarum sinusitis from Iran.


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## Body

## 1. Introduction

Improving society’s overall hygiene level contributes to prevention and control of parasitic infections. However, other factors including insects’ infestation may complicate control and eradication of parasitic infection.Hypermastigida, together with Trichomonadida, is an order of multi flagellated protozoa belonging to the phylum Parabasalia. This order consists of two suborders: Lophomonadidae and Trichonymphina. Lophomonadidae can be parasitic or symbiotic in the digestive system of termites, cockroaches, and wood roaches [1].Lophomonas blattarum was first described by S. Stein in 1860, from the gut of the cockroachBlatta orientalis [2]. This protozoan is round to oval shape and 20–60 μm in diameter with an apical tuft of numerous flagella.Lophomonas blattarum is a rare cause of bronchopulmonary infection and respiratory symptoms [2].Lophomonas blattarum can occasionally infect humans. Only a few articles reportedL. blattarum and other flagellated protozoa causing bronchopulmonary infections in humans [3–5]. These protozoa more commonly infect immunocompromised individuals [6]. Most reported cases are from China and few from Turkey [7, 8]. This report is the first case ofL. blattarum human infection in Iran.


## 2. Case Presentation

The patient was a 31-year-old woman who was admitted on September 13, 2014, because of a history of upper respiratory infection and sinusitis developed rapidly with progressive headache, fever, dizziness, pain of left ear, and sneezing. The nasal discharge and sputum were occasionally green and sticky. Preadmission antibiotic therapy with Cephalexin was not effective. Ear, Nose, and Throat examination revealed congestion and erythema of nose and throat but normal ears. The patient was a lab technician and made direct smears from her nasal discharge and sputum. Surprisingly she observed moving flagellated protozoa.After referring to our parasitology lab, direct microscopic examinations of the sputum and nasal discharge showed large numbers of livingL. blattarum with irregular movement of flagella (Figure 1).Figure 1
Lophomonas blattarum in direct smear of nasal discharge (40x).Laboratory examination demonstrated a white blood cell count of 8.7 × 103 per liter 7% eosinophils, ESR of 27, and positive C-Reactive Protein. Microbial culture for detection anaerobics was negative.Computed tomography (CT) scan of sinuses demonstrated bilateral maxillary mucosal thickening accompanying osteomeatal complex (OMC) obstruction. Mild ethmoidal involvement especially in left side without bone destruction was considered. Other paranasal sinuses were normal in point of pneumatization without any involvement.There were no respiratory sign and symptoms. Chest X-ray was normal.The patient was treated withMetronidazole 500 mg b.i.d. for 15 days. Her symptoms were relieved after treatment; however, a few protozoa were found in microscopic direct smears of nasal discharge. Additional treatment withMetronidazole 750 mg t.i.d for 15 days cleared the nasal smear.


## 3. Discussion

In recent years there has been an increase of reports coveringLophomonas blattarum bronchopulmonary infection, most notably 60 cases from South of China [2]. There were additional cases from other countries including Spain and Turkey [9].Lophomonas sinusitis, on the other hand, has been rarely reported. This case ofLophomonas sinus infection is the first reported in Iran. Most cases of Lophomonas infection reported in immunocompromised patients [9], but this present case is an immunocompetent patient. Since the real mechanism of transmission has not been clearly described, it is important for clinicians to considerLophomonas blattarum in their differential diagnosis. Additionally, since similar flagellate has been reported in house dust mite intestine there may be a relationship between respiratory allergy andLophomonas blattarum or other flagellate [3]. Therefore, in patients with chronic allergy with no response to treatment, Lophomonas infection andMetronidazole treatment may be considered.



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