title: Eosinophilic meningitis caused by Angiostrongylus cantonensis: report of 17 cases.
abstract: OBJECTIVE
  To describe two outbreaks of Angiostrongylus cantonensis infection that occurred in Kaohsiung, Taiwan, during 1998 and 1999, and to characterize the source of the outbreaks and the clinical manifestations of the disease.
  
  
  METHODS
  We performed a retrospective cohort study among Thai laborers with eosinophilic meningitis who ate raw snails (Ampullarium canaliculatus), as well as an environmental surveillance of larvae in snails.
  
  
  RESULTS
  We enrolled 17 Thai laborers in whom severe headache and eosinophilia developed within 4 to 23 days after eating raw snails. Twelve (71%) developed eosinophilic meningitis. Third-stage larvae were found in the cerebrospinal fluids of 2 patients and in all 12 tested snails. Specific antibodies to A. cantonensis were detected in serum from 16 of the patients and in cerebrospinal fluid from 5 of the patients. Central nervous system manifestations included headache (n = 17 [100%]), fever (n = 11 [65%]), Brudzinski's sign/stiff neck (n = 11 [65%]), hyperesthesia (n = 3 [18%]), cranial nerve palsy (n = 2 [12%]), diplopia (n = 2 [12%]), and ataxia (n = 1 [6%]). Laboratory findings included peripheral eosinophilia (n = 15 [88%]) and cerebrospinal fluid eosinophilia (n = 12 [71%]); elevated immunoglobulin (Ig) E levels (n = 13 [100%]); and transient increases in white blood cell count (n = 7 [41%]) and in serum levels of creatine kinase (n = 7 [41%]), transaminase (n = 3 [18%]), and lactate dehydrogenase (n = 2 [12%]). The severity of illness and eosinophilia were correlated with the number of ingested snails. Meningeal and basal ganglion enhancement was noted on magnetic resonance imaging in several patients. Treatment with mebendazole combined with glucocorticosteroids appeared to shorten the course of the infection, but not the number of relapses. The eosinophil count fell to normal within 3 months, but IgE levels remained elevated for as long as 6 months. All patients recovered with minimal neurologic sequelae.
  
  
  CONCLUSIONS
  Eosinophilic meningitis caused by A. cantonensis should be considered in patients who have headache or central nervous system manifestations after eating raw snails.
authors.affiliation: Department of Medicine, Section of Infectious Diseases, Veterans General Hospital-Kaohsiung, Kaohsiung, Taiwan.
authors.forename: H C
authors.initials: HC
authors.lastname: Tsai
authors.forename: Y C
authors.initials: YC
authors.lastname: Liu
authors.forename: C M
authors.initials: CM
authors.lastname: Kunin
authors.forename: S S
authors.initials: SS
authors.lastname: Lee
authors.forename: Y S
authors.initials: YS
authors.lastname: Chen
authors.forename: H H
authors.initials: HH
authors.lastname: Lin
authors.forename: T H
authors.initials: TH
authors.lastname: Tsai
authors.forename: W R
authors.initials: WR
authors.lastname: Lin
authors.forename: C K
authors.initials: CK
authors.lastname: Huang
authors.forename: M Y
authors.initials: MY
authors.lastname: Yen
authors.forename: C M
authors.initials: CM
authors.lastname: Yen
mesh_terms: D000328:Adult; D000368:Aged; D017185:Angiostrongylus cantonensis / Q000276:immunology / Q000302:isolation & purification*; D000818:Animals; D000909:Antibodies, Helminth / Q000097:blood / Q000134:cerebrospinal fluid; D004196:Disease Outbreaks; D004435:Eating; D004804:Eosinophils; D005260:Female; D006801:Humans; D007958:Leukocyte Count; D008279:Magnetic Resonance Imaging; D008297:Male; D008581:Meningitis / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology / Q000469:parasitology*; D008875:Middle Aged; D012189:Retrospective Studies; D012908:Snails; D017206:Strongylida Infections / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology / Q000469:parasitology; D013624:Taiwan / Q000453:epidemiology
chemical_list: D000909:Antibodies, Helminth