Meningitis and radiculomyelitis caused by Angiostrongylus cantonensis.
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.
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(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
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: email@example.com
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 Islands France, 2008 26-36/M French Uncooked ([section]) Polynesia freshwater prawns Croatia 47/M Malaysia, Vegetables, Singapore salads, shrimp Country, year of report Clinical features Diagnosis France, 1988 Eosinophillic IFA meningoencephalitis, lumbosacral myeloradiculitis, tetraplegia coma, hypertensive hydrocephalus, paresthesias Switzerland, Eosinophilic meningoradiculits Clinical 1995 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 thigh) 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, feet) France, 2008 Eosinophilic meningitis ([paragraph]) Clinical ([section]) Croatia Eosinophilic meningitis, WB lumbosacral myeloradiculitis conus medullaris syndrome), generalized paresthesias Country, year of report Treatment Ref. France, 1988 Thiabendazole, (1) steroids, ventriculoperitoneal catheter Switzerland, Supportive (2) 1995 France, 1996 Supportive (3) France, 2002 Ivermectin (4) Supportive (5) Albendazole, (6) steroids Italy, 2007 Mebendazole, ([dagger]) (7) steroids UK, 2007 Supportive (8) Belgium, Albendazole, (9) 2008 steroids France, 2008 Ivermectin (1 (10) ([section]) patient) or albendazole; steroids (1 patient) Croatia Supportive This (repeated lumbar study puncture) * Ref., reference; IFA, immunofluorescent antibody assay; WB, Western blot. ([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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|Author:||Maretic, Tomislav; Perovic, Marta; Vince, Adriana; Lukas, Davorka; Dekumyoy, Paron; Begovac, Josip|
|Publication:||Emerging Infectious Diseases|
|Article Type:||Clinical report|
|Date:||Jun 1, 2009|
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