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Meningitis and radiculomyelitis caused by Angiostrongylus cantonensis.

To the Editor: Angiostrongylus cantonensis infection is endemic in regions such as Southeast Asia, China, the Pacific Basin, and the Caribbean, but international travel has spread the disease elsewhere, including Europe (1-10). Dissemination of the parasite to many regions has also occurred because of the ship-borne international migration of rats and the diversity of potential intermediate hosts. The target organ in humans is the central nervous system in which an eosinophilic reaction develops in response to dying larvae. We report a case of eosinophilic meningitis and lumbosacral myeloradiculopathy caused by A. cantonensis and present a review of cases of A. cantonensis infections from Europe.

A 47-year-old merchant seaman was admitted to the University Hospital of Infectious Diseases, Zagreb, Croatia, in March, 2006 on the 17th day of illness because of fever, headache, vomiting, and constipation. At the end of the first week of illness, paresthesias developed in his feet; on the 10th day of illness, he also noticed difficulties with urination. He had returned from a 1-month trip to Southeast Asia (Malaysia and Singapore) 35 days before the onset of symptoms and recalled eating vegetables and salads. He also consumed shrimp, but he believed that they were from salt water. On physical examination, we noticed increased muscle tone, tremor of the tongue and upper limbs, and decreased deep tendon reflexes of the lower limbs. He experienced urinary retention, and catheterization was required. Saddle anesthesia was observed. There was no neck stiffness, and the results of the rest of the physical examination were normal.

His blood leukocyte count was 11.5 x [10.sup.9]/L with 80% neutrophils, 12% lymphocytes, 4% monocytes, 2% basophils, and 2% eosinophils. Cerebrospinal fluid (CSF) analysis showed 320 cells/[micro]L with 6.5% eosinophils (21 eosinophils/[micro]L). Results of CSF testing by PCR for herpes simplex virus 1 (HSV-1) and HSV-2 DNA were negative, as were cultures for bacteria, mycobacteria, and fungi. Results of serum and CSF antibody tests for Borrelia burgdorferi, Treponema pallidum, HSV-1, HSV-2, tick-borne encephalitis virus, Toxoplasma gondii, Taenia solium, Toxocara spp., and Trichinella spp. were also negative. Results of stool examination for Ascaris lumbricoides, Trichuris trichiura, Taenia spp., Giardia intestinalis, Strongyloides spp., and Entamoeba histolytica were negative. The patient was also negative for HIV by ELISA. Magnetic resonance imaging scans of the brain and spine were unremarkable. A. cantonensis infection was diagnosed by immunoblot testing at the Department of Helminthology, Faculty of Tropical Medicine, Mahidol University, Bangkok. Antibodies against A. cantonensis 31-kDa antigen were detected in serum and CSF of the patient; antibodies against Gnathostoma spinigerum were not detected.

Treatment was symptomatic; to lessen the headache, 4 lumbar punctures were performed. After 1 month, the patient's general condition was greatly improved; however, minor symptoms such as diminished concentration, slow thinking, and mild headache persisted. Urinary retention lasted for 38 days, and the patient had occasional mild headaches and paresthesia in his feet for the next 5 months.

Because large numbers of persons from Europe travel to destinations where angiostrongyliasis is endemic, it is somewhat surprising that the infection has been rarely described in Europe. In a Google and Medline Internet literature search, we identified 9 additional case reports and 1 report on a cluster of 5 A. cantonensis infections. The first report was in a 14-month-old child born in Tahiti who became ill in France in 1988 (1). Eight cases, as did our case, involved travelers returning to Europe after a visit to disease-endemic areas (2-9) (Table). Not all cases were serologically confirmed, most likely because antibody tests for A. cantonensis infection have not been widely available. In a retrospective cohort study, 5 French policemen, who returned from French Polynesia with severe headache and blood eosinophilia, were believed to have eosinophilic meningitis caused by A. cantonensis (10). However, CSF examination was performed in only 1 patient, and none of the cases were serologically confirmed.

Definitive diagnosis of angiostrongyliasis would require identification of larvae or young adults in human tissue, such as the brain, CSF, and eye chamber, which is rarely achieved. Thus, the diagnosis is usually made on the basis of serologic test results. Specific A. cantonensis antigens (29 kDa, 31 kDa, and 32 kDa) were identified; antibodies against these antigens can be detected by ELISA, dot-blot ELISA, or Western blot.

In most patients, A. cantonensis causes a benign and self-limiting disease; treatment is usually symptomatic. Data are limited, but mostly favorable, on the use of steroids, albendazole, and mebendazole. However, the administration of antihelmintics without steroids is not recommended because such treatment might elicit deleterious inflammatory responses to dying worms within the nervous system or ocular structures.

In summary, the presence of headache, fever, and paresthesias in travelers returning from disease-endemic areas should alert clinicians to the possibility of eosinophilic meningitis caused by A. cantonensis. With growing international travel, physicians may encounter A. cantonensis infection more frequently.


We thank our patient for his consent to publish this case report.


(1.) Scemama M, Chiron C, Georges P, Dulac O. Radiculomyeloencephalitis caused by Angiostrongylus cantonensis in children. Arch Fr Pediatr. 1988;45:417-9.

(2.) Vuadens P, Regli F. Eosinophil meningoradiculitis caused by Angiostrongylus cantonensis. Rev Neurol (Paris). 1995;151:354-6.

(3.) Thobois S, Broussolle E, Aimard G, Chazot G. Ingestion of raw fish: a cause of eosinophilic meningitis caused by Angiostrongylus cantonensis after a trip to Tahiti. Presse Med. 1996;25:508.

(4.) de Roux-Serratrice C, Allegre T, Bensaid T, Bigorgne C, Vassal D, Cailleres S. Eosinophilic meningitis on returning from Tahiti. Presse Med. 2002;31:1219.

(5.) Bartschi E, Bordmann G, Blum J, Rothen M. Eosinophilic meningitis due to Angiostrongylus cantonensis in Switzerland. Infection. 2004;32:116-8. DOI: 10.1007/ s15010-004-3028-x

(6.) Rau C, Bialek R, Richter S, Lindner A. Headache after a stay in the Dominican Republic. Dtsch Med Wochenschr. 2006;131:1656-9. DOI: 10.1055/s-2006-947812

(7.) Leone S, De Marco M, Ghirga P, Nicastri E, Esposito M, Narciso P. Eosinophilic meningitis in a returned traveler from Santo Domingo: case report and review. J Travel Med. 2007;14:407-10. DOI: 10.1111/j.1708-8305.2007.00152.x

(8.) Jones M, Mohanraj R, Shaunak S. Eosinophillic meningitis due to Angiostrongylus cantonensis: first reported case in the UK. Adv Clin Neurosci Rehabil. 2007;6:20-1.

(9.) Ali AB, Van den Enden E, Van Gompel A, Van Esbroeck M. Eosinophilic meningitis due to Angiostrongylus cantonensis in a Belgian traveler. Travel Med Infect Dis. 2008;6:41-4. DOI: 10.1016/j.tmaid.2007.09.001

(10.) Malvy D, Ezzedine K, Receveur MC, Pistone T, Crevon L, Lemardeley P, et al. Cluster of eosinophilic meningitis attributable to Angiostrongylus cantonensis infection in French policemen troop returning from the Pacific Islands. Travel Med Infect Dis. 2008;6;301-4. DOI: 10.1016/j. tmaid.2008.06.003

DOI: 10.3201/eid1506.081263

Tomislav Maretic, Marta Perovic, Adriana Vince, Davorka Lukas, Paron Dekumyoy, and Josip Begovac

Address for correspondence: Tomislav Maretic, University Hospital for Infectious Diseases, Dr Fran Mihaljevic, Mirogojska 810 000 Zagreb, Croatia; email:

Author affiliations: University Hospital for Infectious Diseases Dr Fran Mihaljevic, Zagreb, Croatia (T. Maretic, M. Perovic, A. Vince, D. Lukas, J. Begovac); and Mahidol University, Bangkok, Thailand (P. Dekumyoy)
Table. Epidemiologic and clinical findings from 11 reported
case-patients with Angiostrongylus cantonensis infection, Europe *

Country, Patient
year of age, y/ Possible country Suspected
report sex of origin food

France, 1988 1/F Tahiti Not reported

Switzerland, 46/F Tahiti Freshwater
1995 shrimp

France, 1996 25/F Tahiti Raw fish

France, 2002 16/M Tahiti Not reported

Italy, 2007 30/M Dominican Freshwater
 Republic shrimp

UK, 2007 30, F Thailand Snails

Belgium, 22/F Costa Rica, Sashimi,
2008 Ecuador, Chile, ceviche (raw
 Argentina, Fiji fish), salads

France, 2008 26-36/M French Uncooked
([section]) Polynesia freshwater

Croatia 47/M Malaysia, Vegetables,
 Singapore salads,

year of
report Clinical features Diagnosis

France, 1988 Eosinophillic IFA
 lumbosacral myeloradiculitis,
 tetraplegia coma, hypertensive
 hydrocephalus, paresthesias
Switzerland, Eosinophilic meningoradiculits Clinical

France, 1996 Eosinophilic meningitis, Clinical
 paresthesias (left lower leg)

France, 2002 Eosinophilic IFA
 meningoencephalitis, cranial
 palsy (n. abducens), cerebellar
 syndrome, paresthesias
 Eosinophilic meningitis, WB
 generalized hyperesthesias
 Eosinophilic meningitis, WB
 paresthesias (right elbow, right

Italy, 2007 Eosinophilic meningitis, Clinical
 generalized paresthesias

UK, 2007 Eosinophilic meningitis, cranial Serologic
 nerve palsy (right n. abducens), ([double
 altered sensation (lateral border dagger])
 of right leg)

Belgium, Eosinophilic meningitis, WB
2008 paresthesias (left hemithorax,

France, 2008 Eosinophilic meningitis ([paragraph]) Clinical

Croatia Eosinophilic meningitis, WB
 lumbosacral myeloradiculitis
 conus medullaris syndrome),
 generalized paresthesias

year of
report Treatment Ref.

France, 1988 Thiabendazole, (1)

Switzerland, Supportive (2)

France, 1996 Supportive (3)

France, 2002 Ivermectin (4)

 Supportive (5)

 Albendazole, (6)

Italy, 2007 Mebendazole, ([dagger]) (7)

UK, 2007 Supportive (8)

Belgium, Albendazole, (9)
2008 steroids

France, 2008 Ivermectin (1 (10)
([section]) patient) or
 steroids (1 patient)

Croatia Supportive This
 (repeated lumbar study

* Ref., reference; IFA, immunofluorescent antibody assay; WB, Western

([dagger]) One dose only.

([double dagger]) Method not specified.

([section]) Five French policemen.

([paragraph]) Diagnosis confirmed by cerebrospinal fluid analysis in
only 1 patient.

The patient thought he consumed saltwater shrimp but was uncertain.
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Article Details
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Title Annotation:LETTERS
Author:Maretic, Tomislav; Perovic, Marta; Vince, Adriana; Lukas, Davorka; Dekumyoy, Paron; Begovac, Josip
Publication:Emerging Infectious Diseases
Article Type:Clinical report
Geographic Code:9THAI
Date:Jun 1, 2009
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