Journal of Infectious Diseases & Therapy
Open Access

Lophomonas blattarum is a unicellular flagellated parasite, its natural habitats are termites and cockroaches (Periplaneta Americana, Blattella germanica, Blatta oreintalis), and it multiplies in the gut of the insects and is excreted as cysts to the environment. Cyst inhalation is the responsible route for the infection causing lower respiratory tract infections and sinusitis [1,2]. Lophomonas blattarum is a sporadic cause of Community-Acquired Pneumonia (CAP) and it is rarely diagnosed. However, it causes bronchopulmonary disease in both the immunocompromised and immunocompetent patients [3,4]. Hitherto, an unusual microorganism causing CAP should always be in mind, especially when a patient has a refractory history, appropriate previous antimicrobial treatment, and his duration of illness do not match a straightforward case of viral or bacterial pneumonia in adults and pediatric patients, moreover, it was suggested that the closer presence of infected insects in the human environment, the higher the risk of acquiring the infection [3,5]. To our knowledge, those are the first reported cases from Jordan and the Arab countries of Lophomonas blattarum causing bronchopulmonary infections in two patients; an immunocompetent and an immunocompromised patient with a stable chronic lymphocytic leukemia CLL.

Case 1

An 80-year-old male patient with a stable CLL for the last few years, he was admitted in early March 2022 to Al Khalidi Hospital, Amman, Jordan, with the complaint of fever for 3 weeks before admission, in the last week it was high-grade up to 40˚C and was associated with progressive breathlessness on minimal exercise. Two days before his hospital admission, the patient complained of progressive dry cough and right mid-lateral chest pains exacerbated by breathing. Recently, the patient traveled to Dubai and stayed around two weeks with his family, did not eat exotic food, did not deal with pets or animals, and had no allergies. At home, he was prescribed parenteral Meropenem for a week. On admission, he did not appear acutely sick, his pulse rate was 109 beats/min, blood pressure 128/78 mmHg, respiratory rate 22 breaths/min, and temperature 38.8˚C. Chest examination showed bilateral basilar crackles, mostly were more on the right lateral side of the chest. C-RP 260 mg/L, ESR 75 mm, Hgb 162 gm/l, WBC 92.192K, Neutrophils 33%, Lymphocytes 64%, Platelets 527, Procalcitonin 0.232, D-Dimer 0.62 mic/ml, SARS- COV-2 by PCR was negative, serum Galactomannan index was 3.123 on admission (16/3/2022), it was repeated on the next day and was 0.2, buffy Coat no inclusions bodies were seen, blood, urine, and pleural fluid Cultures were sterile, pleural fluid cell count and differential revealed the following; Leucocytes 110 × 10⁶, Erythrocytes 240 × 10⁶, Neutrophils 35%, Lymphocytes 65%. Pleural fluid wet mount staining was negative. Pleural fluid analysis was glucose 116.00 mg/dl, Albumin 1.70 g/dl, Total protein 2.9 gm/dl, and Lactate dehydrogenase 884.0 U/L. KOH preparation, AFB stain, and Ziehl-Nielsen stain were negative. Respiratory panel PCR was a borderline positive Legionella pneumophila. A peripheral blood smear showed no acute leukemic transformation and no evidence of parasites. O₂ Sat at the beginning of the infection was recorded at home at 97%, and on hospital presentation, it was 89%. Chest CT showed right basal bronchopulmonary disease and bilateral mild emphysematous lung changes (Figure 1A). Fiberoptic bronchoscopy revealed no significant changes, and Bronchoalveolar Lavage (BAL) fluid gram-stain showed no bacteria, fluid regular cultures and one-week incubation did not grow microorganisms, AFB stain did not reveal acid-fast bacilli, and six weeks later Loewen-Janstein culture media for tuberculosis did not grow M. tuberculosis. The cytological examination was negative for malignant cells. A BAL fluid wet mount slide showed an oval trophozoite of Lophomonas blattarum (Figure 1B). He developed pleural effusion, it was Gram-stained and cultured, AFB-stained and cultured, with a fluid wet mount examination and a cytological examination, all were negative. During the first few days before the diagnosis of Lophomonas blattarum, he was started on parenteral Ceftriaxone and Moxifloxacin with no improvement. The day the patient was diagnosed with Lophomonas blattarum, parenteral metronidazole 500 mg every 6 hours was started. All other antimicrobials were discontinued. He showed a steady improvement in the patient's condition and was discharged in good condition. During his hospital stay, he was evaluated by his hematologist with no additional intervention as the patient was known to him for years, he has been having a stable CLL course thus far. Ten days later after his discharge from the hospital, he was well, with no fever, and his repeat chest X-Ray showed residual atelectasis in the right lower lung lobe.

Figure 1: (A) Chest CT findings of the CLL patient demonstrating the right Basal infiltrate, a pattern described as a bronchopulmonary disease. (B) The BAL fluid of the CLL patient demonstrates Lophomonas blattarum (solid arrow), note: that the cytoplasm is granular with big particles (food phagocytosis), and the nucleus appears as a dark structure next to the flagella. An adjacent bronchial ciliated cell for comparison (open arrow). Wet mount, light microscopy magnification X 400.

Case 2

A thirty-three-year-old female dentist is known to have a migraine headache, otherwise, she was medically free. She was well until 22 days before her hospital admission in late March 2022. At first, as an outpatient, she was seen by several physicians and was diagnosed with an influenza-like illness on repeated visits. Later she presented with non-resolving pneumonia, and she was prescribed several antibacterial and steroids without a tangible benefit. Her symptoms were progressively worsening with right lower thoracic pain, dry cough, night sweats, shortness of breath which increased on deep breathing for 12 days, and arthralgia, but no fever, chills, or rigors. She was not a smoker, had no known allergies, no travel, did not eat exotic food, did not deal with pets or animals, and she did not sleep out. On admission, her BP was 115/60 mmHg, Temperature 36.9˚C, breathing rate 21/min, O₂ Sat 91. There was crepitation in the right lateral lower chest but no other findings were detected. On admission, she received parenteral antibiotics without improvement. Her blood cultures did not grow microorganisms, urine Legionella antigen was negative, and Qiagen (20) respiratory panel was negative. Her complete blood count, kidney and liver blood tests were normal, D-Dimer was 0.42 ug/ml, galactomannan index 0.26. Pleural fluid aspiration analysis was transudate, and no bacteria or fungi were seen or cultured. Doppler ultrasound demonstrated no lower limbs deep venous thrombosis. Initial CT chest showed lower right Lung wedge infiltrate suspected to be pulmonary embolism (Figure 2A), a pulmonary CT angiogram did not demonstrate embolism but showed increasing right lower lobe infiltrate compared with the previous chest CT (Figure 2B). Bronchoscopy did not reveal an endobronchial abnormality, fluids were tested for gram stain, AFB stains, regular and tuberculosis cultures, and cytological examination, all were normal. A wet mount of the BAL fluid examined under light microscopy demonstrated a pear-shaped unicellular organism with actively moving apical flagella identified as Lophomonasblattarum (Video. https://youtube.com/shorts/ifWVTvkunjk?feature=share). The previous antimicrobials were discontinued and metronidazole was started at 500 mg IV every 6 hours, with a rapid clinical improvement. She was discharged home on oral metronidazole with subsiding symptoms. She was re-evaluated as an outpatient; her pain and CXR continue to improve.

Figure 2: (A) In the second immunocompetent patient, a chest CT scan demonstrated a right-side wedge-shaped pleural-based infiltrate, and (B) a chest CT angiography did not confirm a pulmonary embolism but increasing infiltrate.

In 1993, the first case of Lophomonas blattarum bronchopulmonary disease was reported from China and it was followed by many other reports from the southern China mainland [6,7]. Subsequently, many reports followed from a few parts of the world, namely Turkey, Peru, Spain, Iran, India, Malaysia, Mexico, and Panama, [5,8-14]. Still, Lophomonas blattarum remains rarely reported as a cause of upper and lower respiratory tracts infections [1,15], possibly due to its uncommon sporadic occurrences, or it may have been frequently missed due to low suspicion as a cause of pneumonia, hence, the infrequent wet-mount examination of the BAL respiratory fluids, and almost the lack of utilization of the molecular approach and electron microscopy [16-18]. The radiological examination may assist to some extent in suspecting an unusual pathogen causing pulmonary infection when an unexpected clinical scenario finding is associated with an unmatched radiological finding, like migratory pneumonia, occasional unexpected bronchiectasis, pulmonary abscess, and hydrothorax not well-matched with the extent of the infiltrate seen on the chest CT [19]. Both, of the currently reported patients, had pleural effusions more than what was expected from the extent of the radiological findings they had. However, reasonable clinical support to suspect the diagnosis of an uncommon pathogen causing bronchopulmonary disease is a group of patients with high treatment-resistant respiratory infections, this may draw the attention to unusual pathogens including Lophomonas blattarum Infection [20]. Besides, physicians should not focus on using sequential and combination antibacterials in an attempt to elicit a clinical response, rather, initiating a proper workup like BAL fluid for a routine examination, in addition, a wet mount examination may reveal Lophomonas or other potential reasons for the “treatment-resistant cases” [21,22].

In the current two patients, the first patient received home parenteral antimicrobials for a few days, in addition to the oral ones to “normalize temperature” as soon as possible without a meticulous evaluation, while the second patient received several antibacterials despite the absence of response, but repeated prescription of antibacterials was continually trying to attain a clinical response trying to ameliorate cough and to normalize her chest x-ray.

In conclusion, and up to our knowledge, Lophomonas blattarum is reported for the first time in Jordan, and other Arab countries. A high index of suspicion should always be kept in mind seeking an unusual microorganism as the causative agent of community-acquired pneumonia. A wet mount examination of the BAL fluids should be requested when an unfamiliar clinical presentation and a lack of response occur in a patient under recommended antimicrobials treatment, and a delay in clinical response would be an eye opener.

No ethical issues for the manuscript.

All authors have no conflict of interest for the manuscript.

None.

1. Berenji F, Parian M, Fata A, Bakhshaee M, Fattahi F (2016) First case report of sinusitis with Lophomonas blattarum from Iran. Case Rep Infect Dis 2016:2614187.

   [Crossref] [Google Scholar] [PubMed]

2. Yao GZ, Zeng LQ, Zhang B, Chang ZS (2008) Bronchopulmonary Lophomonas blattarum infection: two cases report and literature review. Case Rep 47:634-637.

   [Google Scholar] [PubMed]

3. Martinez-Girón R, van Woerden HC (2013) Lophomonas blattarum and bronchopulmonary disease. J med microbial 62:1641-1648.

   [Crossref] [Google Scholar] [PubMed]

4. Tyagi R, Anand KB, Teple K, Negi RS (2016) Lophomonas blattarum infection in an immunocompetent patient. Lung India 33:667.

   [Crossref] [Google Scholar] [PubMed]

5. Saldaña NG, Mendoza FJ, Larrauri FR, Trujillo DM, Montoya EV, et al. (2017) Bronchopulmonary infection by Lophomonas blattarum in a pediatric patient after hematopoietic progenitor cell transplantation: First report in Mexico. J Thorac Dis 9:E899-E902.

   [Crossref] [Google Scholar] [PubMed]

6. Chen SX, Meng ZX (1993) Report on one case of Lophomonas blattarum in the respiratory tract. Chinese J Parasitol Parasit Dis 11:28.
7. Xue J, Li YL, Yu XM, Li DK, Liu MF, et al. (2014) Bronchopulmonary infection of Lophomonas blattarum: A case and literature review. Korean J parasitol 52:521.

   [Crossref] [Google Scholar] [PubMed]

8. Chaudhury A, Parija SC (2020) Lophomonas blattarum: A new flagellate causing respiratory tract infections. Trop Parasitol 10:7-11.

   [Crossref] [Google Scholar] [PubMed]

9. Zerpa R, Ore E, Patiño L, Espinoza YA (2010) Lophomonas sp. in respiratory tract secretions in hospitalized children with severe lung disease. Rev Peru Med Exp Salud Publica 27:575-577.

   [Crossref] [Google Scholar] [PubMed]

10. Moya-Salazar J, Salazar-Hernandez R, Lopez-Hinostroza M, Contreras-Pulache H (2021) Lophomonas isolation in sputum sample at Peru. Lung India 38:359.

    [Crossref] [Google Scholar] [PubMed]

11. Fakhar M, Nakhaei M, Sharifpour A, Safanavaei S, Abedi S, et al. (2021) Morphological and molecular identification of emerged Lophomonas blattarum infection in Mazandaran Province, northern Iran: first registry-based study. Acta Parasitologica 66:1510-1516.

    [Crossref] [Google Scholar] [PubMed]

12. Thakur C, Verma S, Negi RS, Kumar V (2017) Lophomonas blattarum co-infection in a patient with multidrug-resistant tuberculosis. Int J of Tuberc Lung Dis 21:1185-1187.

    [Crossref] [Google Scholar] [PubMed]

13. Wahid W, Ahmad Fahmi NA, Mohd Salleh AF, Mohd Y (2019) “Bronchopulmonary lophomoniasis: A rare cause of pneumonia in an immunosuppressed host”. Respir med case rep 28:100939.

    [Crossref] [Google Scholar] [PubMed]

14. Sobarzo R, Vargas G, Pinto M, Magallón-Tejada A (2013) “Lophomonas blattarum detection in methylene blue-stained sputum samples from adults individuals inhabitants of urban area of Chiriqui province”. Tecnociencia 22:5-15.

    [Google Scholar]

15. Yao GZ, Zeng LQ, Zhang B, Chang ZS (2008) Bronchopulmonary Lophomonas blattarum infection: Two cases report and literature review. Zhonghua nei ke za zhi 47:634-637.

    [Google Scholar] [PubMed]

16. Singhal T (2021) Are Pediatric Infections with Lophomonas blattarum Being Missed? Indian J Pediat 88:7-8.

    [Crossref] [Google Scholar] [PubMed]

17. Nakhaei M, Fakhar M, Sharifpour A, Banimostafavi ES (2022) First Co-morbidity of Lophomonas blattarum and COVID-19 Infections: Confirmed Using Molecular Approach. Acta parasitol 22:1-4.

    [Crossref] [Google Scholar] [PubMed]

18. Li R, Gao ZC (2016) Lophomonas blattarum infection or just the movement of ciliated epithelial cells? Chin Med J 129:739-42.

    [Crossref] [Google Scholar] [PubMed]

19. Yao G, Zhou B, Zeng L (2009) Imaging characteristics of bronchopulmonary Lophomonas blattarum infection: Case report and literature review. J thorac imaging 24:49-51.

    [Crossref] [Google Scholar] [PubMed]

20. Berenji F, Fata A, Vakili V, Sayedi SJ, Abdollahi B (2021) Unexpected high rate of Lophomonas blattarum in resistant upper and lower respiratory infection. Int J Med Res & Health Sci 5:74-80.

    [Google Scholar]

21. Tsai CM, Wong KS, Lee WJ, Hsieh KS, Hung PL, et al. (2017) Diagnostic value of bronchoalveolar lavage in children with nonresponding community-acquired pneumonia. Pediatr Neonatol 58:430-436.

    [Crossref] [Google Scholar] [PubMed]

22. Dalhoff K, Braun J, Lipp R, Wießmann KJ, Hollandt H, et al. (1993) Diagnostic value of bronchoalveolar lavage in patients with opportunistic and nonopportunistic bacterial pneumonia. Infection 21:291-296.

    [Crossref] [Google Scholar] [PubMed]