Host-parasite relationship of Angiostrongylus cantonensis. 2. Angiotropic behaviour and abnormal site development

Angiostrongylus cantonensis in travelers: clinical manifestations, diagnosis, and treatment

PURPOSE OF REVIEW

Angiostrongylus cantonensis eosinophilic meningitis is a neglected, yet important emerging disease, which has been increasingly recognized in travelers. In this review, we describe the occurrence of the disease in travelers, sources of infection, clinical manifestations, diagnosis, and currently recommended treatment.

RECENT FINDINGS

Various intermediate hosts and/or paratenic hosts can be the source of infection in humans. Serological tests for antibody may be negative early in the course of the disease but PCR for antigen detection in the CSF has recently been developed and may help to make the diagnosis at an earlier stage. High-dose corticosteroids (e.g. prednisolone 60 mg per day for at least 1-2 weeks) are currently the recommended treatment. Efficacy and safety of antihelminthic drugs for treatment remains controversial because of theoretical concerns that they may worsen the inflammatory response to dead and dying worms. Previous clinical trials were conducted with small numbers of participants and were underpowered. Further well designed clinical trials are urgently needed.

SUMMARY

Awareness about increasing numbers of A. cantonensis eosinophilic meningitis in travelers is very important. Travelers should be advised about possible sources of infection. Diagnosis should be confirmed by antigen or antibody detection in blood or CSF. High-dose corticosteroids are the recommended treatment. The efficacy of various antihelminthic drugs is unproven. A large-scale, double-blind, randomized, controlled trial of antihelminthic drug involving antihelminthic drugs such as albendazole is necessary to prove the efficacy before formally advocating their use on a regular basis.

Evolutionary factors influencing the nature of parasite specificity

This article considers how specificity patterns are shaped during the course of parasite evolution. Parasites are first and foremost specific to site, or microhabitat; host ranges are far more subject to change than is microhabitat. Specificity results from a number of convergent phenomena starting with habits (microhabitat and feeding styles) of free-living progenitors and the way in which the parasitic association arises (e.g., passive oral contamination as opposed to intrusive entry). These bias the types of interaction parasites have with the host, and, through this, the way specificity develops. Host ecology acts as an external factor affecting specificity and predominates in parasites that interact minimally with the hosts physiological and immune systems. Coevolutionary factors are more important in parasites that feed on host tissues or occur in extraintestinal sites. Here, parasites must present the right cues, and respond appropriately to the host defense system. The ability to generalize these cues and responses across host boundaries may act as a constraint on host range. The functional role of the host in the parasite life history also affects the degree of specificity; thus, parasites may act as host generalists in hosts that act as trophic channels to the final host. The role of competition in determining specificity is difficult to assess. However, competition has been reported to influence microhabitat and host distribution through interactive site selection and/or competitive seclusion.

Experimental infection routes of Angiostrongylus cantonensis in mice

Stomach intubation is the most common method used in the experimental infection of animals with Angiostrongylus cantonensis. In order to compare the effectiveness of other possible transmission methods, groups of BALB/c mice were given infective third-stage larvae of A. cantonensis by different routes including intraperitoneal or subcutaneous injections, and penetration of anal mucosa, vaginal mucosa, conjunctival mucosa, lacerated skin, unabraded skin, foot pad and tail skin, while stomach intubation was used as control. Recovery of fifth-stage larvae was higher in mice inoculated with third-stage larvae subcutaneously. Successful infections were established through all experimental transmission routes except tail skin penetration. This study suggests that oral infection may not be the only route for the transmission of human angiostrongyliasis, and subcutaneous infection may be a better method for experimental infection.

Four documented cases of eosinophilic meningoencephalitis due to Angiostrongylus cantonensis in Hong Kong

4 cases of eosinophilic meningoencephalitis in Hong Kong are described. The major clinical features of the patients, who were 2-60 years old, were low grade fever, headache, mild meningeal signs, right facial palsy or hemiplegia. Eosinophilia in the peripheral blood and eosinophilic pleocytosis were prominent. Computerized tomography scans of brain showed a small area of attenuation with surrounding hypodense area; the lesion was resolved 1-2 months after admission to hospital. Electroencephalograms revealed abnormally slow dysrhythmia. Sections of a nematode observed in the brain of a patient who died were identified as those of young adult Angiostrongylus cantonensis. High ELISA titres against the crude antigens of this nematode were also noted in the serum of 3 patients. The disease is probably under-recognized in Hong Kong.