Professional Documents
Culture Documents
1
2 9 TREATMENT
ulatory bursa at the posterior. Females have a barber intracranial pressure and eosiniphil counts should rise.
pole shape down the middle of the body, which is cre- Increased levels of eosinophils in the CSF is a trademark
ated by the twisting together of the intestine and uterine of the eosiniphilic meningitis.[3]
tubules. The worms are long and slender - males are 15.9
19 mm in length, and females are 2125 mm in length.[5]
8.2 Brain imaging
Brain lesions, with invasion of both gray and white matter,
7 Life cycle can be seen on a CT or MRI. However MRI ndings tend
to be inconclusive, and usually include nonspecic lesions
The adult form of A. cantonensis resides in the pulmonary and ventricular enlargement. Sometimes a hemorrhage,
arteries of rodents, where it reproduces. After the eggs probably produced by migrating worms, is present and of
hatch in the arteries, larvae migrate up the pharynx and diagnostic value.
are then swallowed again by the rodent and passed in the
stool. These rst stage larvae then penetrate or are swal-
lowed by snail intermediate hosts, where they transform 8.3 Serology
into second stage larvae and then into third stage infective
larvae. Humans and rats acquire the infection when they In patients with elevated eosiniphils, serology can be used
ingest contaminated snails or paratenic (transport) hosts to conrm a diagnosis of Angiostrongylias rather than in-
including prawns, crabs, and frogs, or raw vegetables con- fection with another parasite.[1] There are a number of
taining material from these intermediate and paratenic immunoassays that can aid in diagnosis, however sero-
hosts. After passing through the gastrointestinal tract, the logic testing is available in few labs in the endemic area,
worms enter circulation.[4] In rats, the larvae then migrate and is frequently too non-specic. Some cross reactivity
to the meninges and develop for about a month before has been reported between A. cantonensis and trichinosis,
migrating to the pulmonary arteries, where they fully de- making diagnosis less specic.
velop into adults.[2]
The most denitive diagnosis always arises from the iden-
Humans are incidental hosts; the larvae cannot reproduce tication of larvae found in the CSF or eye, however due
in humans and therefore humans do not contribute to the to this rarity a clinical diagnosis based on the above tests
A. cantonensis life cycle. In humans, the circulating lar- is most likely.
vae migrate to the meninges, but do not move on to the
lungs. Sometimes the larvae will develop into the adult
form in the brain and CSF, but they quickly die, incit-
ing the inammatory reaction that causes symptoms of
9 Treatment
infection.[2]
Treatment of angiostrongyliasis is not well dened, but
most strategies include a combination of anti - parasitics
to kill the worms, steroids to limit inammation as the
8 Diagnosis worms die, and pain medication to manage the symptoms
of meningitis.
Diagnosis of Angiostrongyliasis is complicated due to the
diculty of presenting the angiostrongylus larvae them-
selves, and will usually be made based on the presence of 9.1 Anti-helminthics
eosiniphilic meningitis and history of exposure to snail
hosts. Eosiniphilic meningitis is generally characterized Anti-helminthics are often used to kill o the worms,
as a meningitis with >10 eosiniphils/L in the CSF or at however in some cases this may cause patients to worsen
least 10% eosiniphils in the total CSF leukocyte count.[4] due to toxins released by the dying worms. Albenda-
Occasionally worms found in the cerebrospinal uid or zole, ivermectin, mebendazol, and pyrantel are all com-
surgically removed from the eye can be identied in or- monly used, though albendazole is usually the drug of
der to diagnose Angiostrongyliasis. choice. Studies have shown that anti-helminthic drugs
may shorten the course of the disease and relieve symp-
toms. Therefore anti-helminthics are generally recom-
8.1 Lumbar puncture mended, but should be administered gradually so as to
limit the inammatory reaction.[3]
Lumbar puncture should always be done is cases of sus-
pected meningitis. In cases of eosiniphilc meningitis it
will rarely produce worms even when they are present in 9.2 Anti-inammatories
the CSF, because they tend to cling to the end of nerves.
Larvae are present in the CSF in only 1.9-10% of cases.[3] Anti-helminthics should generally be paired with corti-
However, as a case of eosiniphilic meningitis progresses, costeroids in severe infections to limit the inammatory
11.1 Recommendations for individuals 3
reaction to the dying parasites. Studies suggest that a outside endemic areas is important to limit the spread of
two-week regimen of a combination of mebedizole and the disease.[9] There are no vaccines in development for
prednisolone signicantly shortened the course of the dis- angiostrongyliasis.
ease and length of associated headaches without observed
harmful side eects.[6] Other studies suggest that alben-
dazole may be more favorable, because it may be less like 11.1 Recommendations for individuals
to incite an inammatory reaction.[7] The Chinese herbal
medicine long-dan-xie-gan-tan (LDGXT) has also been To avoid infection when in endemic areas, travelers
shown to have a similar anti inammatory eect, and in should:
mild cases may be used alone to relieve symptoms while
infection resolves itself.[7] Avoid consumption of uncooked vectors, such as
snails and freshwater prawns
9.3 Symptomatic treatment Avoid drinking water from open sources, which may
have been contaminated by vectors
Symptomatic treatment is indicated for symptoms such as
nausea, vomiting, headache, and in some cases, chronic Prevent young children from playing with or eating
pain due to nerve damage or muscle atrophy. live snails
10 Epidemiology 12 References
[1] Baheti NN & Sreedharan M et al (2008). Eosinophilic
A. cantonensis and its vectors are endemic to Southeast
meningitis and an ocular worm in a patient from Kerala,
Asia and the Pacic Basin.[1] The infection is becoming
south India J. Neurol. Neurosurg. Psychiatry 79 (271).
increasingly important as globalization allows it to spread
to more and more locations, and as more travelers en- [2] David, John T. and Petri, William A Jr. Markell and
counter the parasites. The parasites probably travel ef- Voges Medical Parasitology. St. Louis, MO: El Sevier,
fectively through rats traveling as stowaways on ships, and 2006.
through the introduction of snail vectors outside endemic
[3] Hua Li, Feng Xu, Jin-Bao Gu and Xiao-Guang Chen
areas. (2008). Case Report: A Severe Eosinophilic Menin-
Although mostly found in Asia and the Pacic where goencephalitis Caused by Infection of Angiostrongylus
asymptomatic infection can be as high as 88%, human cantonensis. Am. J. Trop. Med. Hyg., 79(4): 568570.
cases have been reported in the Caribbean, where as [4] L. Ramirez-Avila (2009). Eosinophilic Meningitis due
much as 25% of the population may be infected. In the to Angiostrongylus and Gnathostoma Species. Emerging
United States, cases have been reported in Hawaii, which Infections, 48: 322-327.
is in the endemic area [5]. The infection is now endemic
in wildlife and a few human cases have also been reported [5] Syed, Soa. Mulcrone, Renee Sherman; O'Connor,
in areas where the parasite was not originally endemic, Barry, eds. Angiostrongylus cantonensis. Animal Di-
such as New Orleans and Egypt. versity Web. Retrieved 2017-04-04.
The disease has also arrived in Brazil, where there were [6] V Chotmongkol and K Sawadpanitch et al. (2006).
34 conrmed cases from 2006 to 2014, including one Treatment of Eosiniphilic Meningitis with a Combina-
death.[8] The giant African land snail, which can be a vec- tion of Prednisolone and Mebendazole. Am. J. Trop.
Med. Hyg., 74(6): 11221124.
tor of the parasite, has been introduced to Brazil as an
invasive species and is spreading the disease. There may [7] SC Lai, KM Chen, YH Chang and HH Lee (2008).
be more undiagnosed cases, as Brazilian physicians are Comparative ecacies of albendazole and the Chi-
not familiar with the eosinophilic meningitis associated nese herbal medicine long-dan-xie-gan-tan, used alone
to angiostrongyliasis and misdiagnose it as bacterial or or in combination, in the treatment of experimental
viral.[8] eosinophilic meningitis induced by Angiostrongylus can-
tonensis. Annals of Tropical Medicine & Parasitology,
102(2): 143150.
11 Public health and prevention [8] Thom, Clarissa (2014-08-04). Meningite transmitida
por parasita avana no Brasil [Meningitis transmitted by
There are many public health strategies that can drasti- parasite increases in Brazil]. O Estado de S. Paulo (in Por-
tuguese). Retrieved 2014-08-04.
cally limit the transmission of A. cantonensis by limiting
contact with infected vectors. Vector control may be pos- [9] JE Alicata (1991). The Discovery of Angiostrongylus
sible, but has not been very successful in the past. Edu- Cantonensis as a Cause of Human Eosiniphilc Meningi-
cation to prevent the introduction of rats or snail vectors tis. Parasitology Today, 7(6): 151-153.
4 13 EXTERNAL LINKS
13 External links
Parasites - Angiostrongyliasis (also known as An-
giostrongylus Infection)". CDC. 2015-12-28. Re-
trieved 2017-04-04.
14.2 Images