A 17-year-old presents to the ED after returning from vacation in Hawaii with his family. While on vacation, they went hiking on a dusty trail while barefoot, jet-skiing in the ocean where he accidentally inhaled water, spelunking, and his brother recalls one meal where he saw a live slug on his brother’s local salad and dared him to eat it (which he did).
Upon returning home 3 weeks later, he develops a severe bifrontal headache without cranial nerve deficits. Upon presentation he is noted to have 5% peripheral eosinophilia. CT scan did not reveal any focal lesions. CSF is obtained: cloudy, 20% eosinophils, normal glucose, and elevated protein. He was given albendazole empirically for treatment without improvement Over the next few days, his headache worsens and develops nausea, vomiting, and facial nerve paralysis.
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Correct Answer: Angiostrongylus.
This question highlights a case of eosinophilic meningitis. Eosinophilic meningitis is defined as >10 eosinophils/mm3 in the CSF or >10% of CSF WBCs.
The differential diagnosis is relatively narrow and shown below.
Angiostrongylus catonensis is usually found in Southeast asia and the Pacific basin but may also be found in Australia, the Caribbean, Hawaii, and Louisiana. Primary risk factors include ingestion of raw or undercooked infected snails/slugs or exposure to snail/slug slime (can occur with uncleaned garden produce).
There is no specific treatment given self-limited course other than supportive care. Anthelminthic agents may elicit an inflammatory response due to dying organisms and exacerbation of neurologic symptoms.
Corticosteroids may relieve symptoms, one randomized trial demonstrated some improvement of headache and intracranial pressure.
Exposures to be aware of for other parasites:
- Gnathostomiasis is associated with undercooked fish, poultry or snake meat. Primarily seen in Southeast Asia.
- Baylisascaris is associated with ingestion of eggs shed by raccoons and dogs, usually contracted by playing in dirt. Primarily seen in the United States.
Question written by Nico Herrera at UAB
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This question was uploaded on 4/13/2022