title: A severe case of Angiostrongylus eosinophilic meningitis with encephalitis and neurologic sequelae in Hawa'i.
abstract: Angiostrongylus eosinophilic meningitis is caused by infection with larvae of the rat lungworm, Angiostrongylus cantonensis. We report the case of an adult who ingested a raw, giant African snail (Achatina fulica) on the island of O'ahu in Hawa'i and developed an eosinophilic meningoencephalitis with severe headache, confusion, sixth cranial nerve palsy, ataxia, limb weakness, and paresthesia. He was treated with lumbar punctures to relieve pressure, high dose corticosteroids, and 14 days of albendazole. He had a prolonged convalescence, requiring 3 months of prednisone, and still had evidence of motor nerve weakness 4 months after exposure. A field investigation at the site of exposure yielded 5 of 9 Achatina fulica snails with evidence of A. cantonensis DNA by PCR. Cerebrospinal fluid samples from the patient were negative acutely but positive on day 15 of symptoms, using an investigational, real-time PCR assay. We discuss clinical management of this case in light of the current medical literature.
authors.affiliation: Departments of Family Practice, Tripler Army Medical Center, Honolulu, HI, USA.
authors.forename: Edward
authors.initials: E
authors.lastname: Kwon
authors.forename: Tomas M
authors.initials: TM
authors.lastname: Ferguson
authors.forename: Sarah Y
authors.initials: SY
authors.lastname: Park
authors.forename: Augustina
authors.initials: A
authors.lastname: Manuzak
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Qvarnstrom
authors.forename: Stephen
authors.initials: S
authors.lastname: Morgan
authors.forename: Paul
authors.initials: P
authors.lastname: Ciminera
authors.forename: Gerald S
authors.initials: GS
authors.lastname: Murphy
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D015766:Albendazole / Q000627:therapeutic use; D017185:Angiostrongylus cantonensis / Q000302:isolation & purification*; D000818:Animals; D000871:Anthelmintics / Q000627:therapeutic use; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D004802:Eosinophilia / Q000175:diagnosis* / Q000469:parasitology / Q000628:therapy*; D016266:Food Parasitology; D006801:Humans; D008297:Male; D008590:Meningoencephalitis / Q000175:diagnosis* / Q000469:parasitology / Q000628:therapy*; D011241:Prednisone / Q000627:therapeutic use; D012908:Snails / Q000469:parasitology; D013129:Spinal Puncture; D017206:Strongylida Infections / Q000150:complications* / Q000188:drug therapy / Q000635:transmission; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D000871:Anthelmintics; D000893:Anti-Inflammatory Agents; D015766:Albendazole; D011241:Prednisone
keywords: Achatina fulica; Albendazole; Angiostrongylus cantonensis; Angiostrongylus eosinophilic meningitis; Case report; Cerebral angiostrongyliasis; Corticosteroid; Eosinophilic meningitis; Hawa‘i; Human; Meningoencephalitis; Neuroangiostrongyliasis; Radiculomeningoencephalitis; Snail
references.citation: Appl Environ Microbiol. 2010 Aug;76(15):5287-9
references.pmid: 20543049
references.citation: Am J Epidemiol. 1967 Jan;85(1):17-44
references.pmid: 6066788
references.citation: Am J Trop Med Hyg. 2011 Oct;85(4):685-90
references.pmid: 21976573
references.citation: Am J Med. 2004 Nov 15;117(10):802-3
references.pmid: 15541333
references.citation: Curr Infect Dis Rep. 2003 Aug;5(4):322-328
references.pmid: 12866984
references.citation: Am J Trop Med Hyg. 1982 Nov;31(6):1114-22
references.pmid: 7149098
references.citation: Am J Trop Med Hyg. 1988 Aug;39(2):191-5
references.pmid: 3407839
references.citation: Southeast Asian J Trop Med Public Health. 1991 Dec;22 Suppl:194-9
references.pmid: 1822885
references.citation: Intern Med J. 2004 Apr;34(4):217-8
references.pmid: 15086709
references.citation: Int J Infect Dis. 2009 Jul;13(4):425-31
references.pmid: 19117782
references.citation: Exp Parasitol. 2006 May;113(1):8-15
references.pmid: 16410005
references.citation: Rev Inst Med Trop Sao Paulo. 2003 Sep-Oct;45(5):295-7
references.pmid: 14743672
references.citation: Am J Trop Med Hyg. 1976 Mar;25(2):233-49
references.pmid: 1259085
references.citation: Mil Med. 2003 Oct;168(10):817-21
references.pmid: 14620646
references.citation: Trans R Soc Trop Med Hyg. 2008 Oct;102(10):990-6
references.pmid: 18501934
references.citation: Trans R Soc Trop Med Hyg. 1987;81(5):807-10
references.pmid: 3450002
references.citation: Am J Trop Med Hyg. 2006 Jun;74(6):1122-4
references.pmid: 16760531
references.citation: Southeast Asian J Trop Med Public Health. 1978 Jun;9(2):161-70
references.pmid: 725650
references.citation: Am J Trop Med Hyg. 1969 Mar;18(2):206-16
references.pmid: 5777734
references.citation: J Helminthol. 2006 Sep;80(3):249-54
references.pmid: 16923267
references.citation: West J Med. 1993 Jul;159(1):78-80
references.pmid: 8123100
references.citation: Lancet Infect Dis. 2008 Oct;8(10):621-30
references.pmid: 18922484
references.citation: Am J Trop Med Hyg. 1975 Nov;24(6 Pt 1):921-31
references.pmid: 1200257
references.citation: Parasitol Today. 1991 Jun;7(6):151-3
references.pmid: 15463478
references.citation: Southeast Asian J Trop Med Public Health. 2002 Jun;33(2):231-4
references.pmid: 12236418
references.citation: Clin Infect Dis. 2009 Feb 1;48(3):322-7
references.pmid: 19123863
references.citation: J Microbiol Immunol Infect. 2011 Oct;44(5):382-9
references.pmid: 21524976
references.citation: Int J Infect Dis. 1999 Spring;3(3):161-3
references.pmid: 10460929
references.citation: Clin Infect Dis. 2000 Sep;31(3):660-2
references.pmid: 11017811
references.citation: Am J Trop Med Hyg. 2009 Sep;81(3):443-5
references.pmid: 19706911
references.citation: Soc Sci Med. 1992 Jan;34(2):199-212
references.pmid: 1738873
references.citation: Am J Med. 2001 Aug;111(2):109-14
references.pmid: 11498063
references.citation: Appl Environ Microbiol. 2007 Mar;73(5):1415-9
references.pmid: 17194836
references.citation: J Travel Med. 2009 Jul-Aug;16(4):267-75
references.pmid: 19674268
references.citation: JAMA. 1962 Feb 24;179:620-4
references.pmid: 14493905
references.citation: Clin Microbiol Rev. 2009 Apr;22(2):322-48, Table of Contents
references.pmid: 19366917
references.citation: Am J Trop Med Hyg. 1964 Jul;13:589-90
references.pmid: 14196058
references.citation: Am J Trop Med Hyg. 1967 Jul;16(4):454-61
references.pmid: 4952148
references.citation: N Engl J Med. 2002 Feb 28;346(9):668-75
references.pmid: 11870244
references.citation: Hawaii J Med Public Health. 2013 Jun;72(6 Suppl 2):35-40
references.pmid: 23901382
references.citation: Parasitol Res. 2007 May;100(6):1293-6
references.pmid: 17177056
references.citation: Emerg Infect Dis. 2007 Nov;13(11):1675-80
references.pmid: 18217550
references.citation: Hawaii J Med Public Health. 2013 Jun;72(6 Suppl 2):63-9
references.pmid: 23901387
references.citation: Med J Aust. 1999 Jun 7;170(11):517-8
references.pmid: 10397038
references.citation: Parasitol Res. 2004 Jul;93(4):311-7
references.pmid: 15179507