Clinical characterization of neuroschistosomiasis due to Schistosoma mansoni and its treatment

Executive summary consensus statement of imported diseases group (GEPI) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SETMSI), on the diagnostic and treatment of imported schistosomiasis

Schistosomiasis is a highly prevalent disease, especially in immigrant populations, and is associated with significant morbidity and diagnostic delays outside endemic areas. For these reasons, the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SEMTSI) have developed a joint consensus document to serve as a guide for the screening, diagnosis and treatment of this disease outside endemic areas. A panel of experts from both societies identified the main questions to be answered and developed recommendations based on the scientific evidence available at the time. The document was reviewed by the members from both societies for final approval.

Infectious Myelitis

Myelitis is an extensive group of pathologies, including inflammatory, demyelinating, and infectious disorders, sometimes mimicking tumors. This article will discuss infectious myelitis, mainly the patterns of spinal cord involvement caused by each infectious agent and the contribution of magnetic resonance imaging as a major tool to establish the specific diagnosis.

Spinal cord Schistosomiasis: A child's case with an unsatisfactory outcome that mimicked an intramedullary neoplasm. A rare case report

Neuroshcistosomiasis is a life-threatening complication of schistosomiasis. Its prevalence in endemic populations is believed to be underreported at 1–4%. We report a four-year-old child who came to our hospital relatively late since the presentation of weakness and incontinence. MRI revealed long segment (T12-L1) ill-defined intramedullary lesions with cord extension having patchy enhancements. Despite the administration of both praziquantel and pulse prednisolone treatment, there was no convincing result. We thus question the role of steroids and praziquantel in individuals with late-diagnosed spinal schistosomiasis.

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Neuroshcistosomiasis is a life-threatening complication of schistosomiasis.

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Its prevalence in endemic populations is believed to be underreported at 1–4%. We report a four-year-old child who came to our hospital relatively late since the presentation of weakness and incontinence.

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MRI revealed long segment ill-defined intramedullary lesions with cord extension having patchy enhancements.

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High power view microscope displayed four schistosome parasites having a ventral horn.

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Despite the administration of both praziquantel and pulse prednisolone treatment, there was no convincing result.

Mechanisms of the host immune response and helminth-induced pathology during Trichobilharzia regenti (Schistosomatidae) neuroinvasion in mice

Helminth neuroinfections represent serious medical conditions, but the diversity of the host-parasite interplay within the nervous tissue often remains poorly understood, partially due to the lack of laboratory models. Here, we investigated the neuroinvasion of the mouse spinal cord by Trichobilharzia regenti (Schistosomatidae). Active migration of T. regenti schistosomula through the mouse spinal cord induced motor deficits in hindlimbs but did not affect the general locomotion or working memory. Histological examination of the infected spinal cord revealed eosinophilic meningomyelitis with eosinophil-rich infiltrates entrapping the schistosomula. Flow cytometry and transcriptomic analysis of the spinal cord confirmed massive activation of the host immune response. Of note, we recorded striking upregulation of the major histocompatibility complex II pathway and M2-associated markers, such as arginase or chitinase-like 3. Arginase also dominated the proteins found in the microdissected tissue from the close vicinity of the migrating schistosomula, which unselectively fed on the host nervous tissue. Next, we evaluated the pathological sequelae of T. regenti neuroinvasion. While no demyelination or blood-brain barrier alterations were noticed, our transcriptomic data revealed a remarkable disruption of neurophysiological functions not yet recorded in helminth neuroinfections. We also detected DNA fragmentation at the host-schistosomulum interface, but schistosomula antigens did not affect the viability of neurons and glial cells in vitro. Collectively, altered locomotion, significant disruption of neurophysiological functions, and strong M2 polarization were the most prominent features of T. regenti neuroinvasion, making it a promising candidate for further neuroinfection research. Indeed, understanding the diversity of pathogen-related neuroinflammatory processes is a prerequisite for developing better protective measures, treatment strategies, and diagnostic tools.

Antiprotozoal and anthelmintic activity of zinc oxide nanoparticles

Nanomaterials represent a wide alternative for the treatment of several diseases that affect both human and animal health. The use of these materials mainly involves trying to solve the problem of resistance that pathogenic organisms acquire to conventional drugs. A well-studied example that represents a potential component for biomedical applications is the use of zinc oxide (ZnO) nanoparticles (NPs). Its antimicrobial function is related, especially the ability to generate/induce ROS that affects the homeostasis of the pathogen in question. Protozoa and helminths that harm human health and the economic performance of animals have already been exposed to this type of nanoparticle. Thus, through this review, our goal is to discuss the state-of-the-art effect of ZnO NPs on these parasites.

Cerebral mansoni schistosomiasis: a systematic review of 33 cases published from 1989 to 2019

BACKGROUND

We investigated the epidemiology, clinical presentation and outcomes of individuals affected by cerebral schistosomiasis.

METHODS

This systematic review was planned in accordance with current guidelines for performing comprehensive systematic reviews and meta-analysis, including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

RESULTS

Most of patients presented with seizures (48.5%), which is a non-specific symptom despite its high prevalence. There was no specific clinical manifestation that could help the diagnosis, which was made in 69.7% by histopathological analysis of brain tissue.

CONCLUSIONS

Seizures are a non-specific symptom to diagnose patients with cerebral schistosomiasis and accurate clinical indicators need to be derived through further studies.

Infectious Myelopathies

In the setting of both globalization and increasing use of immunosuppressive therapy, infectious myelopathies are an important cause of morbidity worldwide. Clinical spinal cord syndromes related to infection are varied, including transverse myelitis, acute flaccid paralysis related to anterior horn cell involvement, spinal cord compression, chronic spastic paraparesis, and myeloradiculitis. Causative pathogens include viruses, parasites, pyogenic and atypical bacteria, and fungi. The epidemiology, clinical characteristics, diagnosis, and treatment of selected organisms will be discussed in this article.

Spinal neuroschistosomiasis caused by Schistoma mansoni: cases reported in two brothers

Background

Spinal neuroschistosomiasis (SN) is one of the most severe clinical presentations of schistosomiasis infection and an ectopic form of the disease caused by any species of Schistosoma. In Brazil, all cases of this clinical manifestation are related to Schistosoma mansoni, the only species present in the country. Although many cases have been reported in various endemic areas in Brazil, this is the first time in the literature that SN is described in two brothers.

Case presentation

Two cases of SN were accidentally diagnosed during an epidemiological survey in an urban area endemic for schistosomiasis transmission. Both patients complained of low back pain and muscle weakness in the lower limbs. Sphincter dysfunction and various degrees of paresthesia were also reported. The patients’ disease was classified as hepato-intestinal stage schistosomiasis mansoni at the onset of the chronic form. A positive parasitological stool test for S. mansoni, clinical evidence of myeloradicular damage and exclusion of other causes of damage were the basic criteria for diagnosis. After treatment with praziquantel and corticosteroid, the patients presented an improvement in symptoms, although some complaints persisted.

Conclusions

It is important to consider SN when patients come from areas endemic for transmission of schistosomiasis mansoni. Clinical physicians and neurologists should consider this diagnostic hypothesis, because recovery from neurological injuries is directly related to early treatment. As, described here in two brothers, a genetic predisposition may be related to neurological involvement. Primary care physicians should thus try to evaluate family members and close relatives in order to arrive at prompt schistosomiasis diagnosis in asymptomatic individuals and propose treatment in an attempt to avoid progression to SN.

Schistosomiasis: from established diagnostic assays to emerging micro/nanotechnology-based rapid field testing for clinical management and epidemiology

Schistosomiasis is a neglected invasive worm disease with a huge disease burden in developing countries, particularly in children, and is seen increasingly in non-endemic regions through transfer by travellers, expatriates, and refugees. Undetected and untreated infections may be responsible for the persistence of transmission. Rapid and accurate diagnosis is the key to treatment and control. So far, parasitological detection methods remain the cornerstone of Schistosoma infection diagnosis in endemic regions, but conventional tests have limited sensitivity, in particular in low-grade infection. Recent advances contribute to improved detection in clinical and field settings. The recent progress in micro- and nanotechnologies opens a road by enabling the design of new miniaturized point-of-care devices and analytical platforms, which can be used for the rapid detection of these infections. This review starts with an overview of currently available laboratory tests and their performance and then discusses emerging rapid and micro/nanotechnologies-based tools. The epidemiological and clinical setting of testing is then discussed as an important determinant for the selection of the best analytical strategy in patients suspected to suffer from Schistosoma infection. Finally, it discusses the potential role of advanced technologies in the setting near to disease eradication is examined.

Does physical exercise influence in the development of neuroeschistosomiasis?

Neuroschistosomiasis is a severe form of presentation of schistosomiasis in which Schistosoma spp. affects the central nervous system. This is the first study performed to analyze whether there is any relationship between physical effort and the appearance of neuroschistosomiasis, through clinical, molecular and immunological evaluations. An experimental controlled study using 64 male Balb/c inbred mice divided into four groups according to presence or absence of S. mansoni infection and submitted to physical effort or resting was conducted. Thirteen weeks after exercise training, S. mansoni DNA was detected in the brain or spinal cord in about 30% of the infected animals moreover, only S. mansoni-positive samples showed positive labeling for S. mansoni antigens in the brain or spinal cord, with a striking reaction inside the microglia. However, the behavioral tests did not show any clinical symptoms of neuroschistosomiasis in animals submitted to physical effort or in resting. In animals with S. mansoni-positive DNA, immunohistochemical data revealed astrogliosis and microgliosis, elevated IL-10 levels and decreased TNF-α expression. This study demonstrated that isometric exercise does not promote neuroschistosomiasis, furthermore, ectopic forms of schistosomiasis in the central nervous system were largely asymptomatic and exhibited a Th2 immune response profile. More experimental studies are necessary in order to characterize the pathological process of experimental neuroschistosomiasis.

Helminthic Infections of the Central Nervous System

PURPOSE OF REVIEW

This article discusses select helminthic parasitic infections that may affect the central nervous system and reviews the epidemiology, neurologic presentation, recommended diagnostic testing, and treatment approach to these infections.

RECENT FINDINGS

Emigration from and travel to areas endemic for helminthic infections that affect the nervous system has led to increased incidence of parasitic neurologic disease in developed countries, necessitating that neurologists be familiar with the diagnostic and therapeutic approach to these diseases. Evidence is emerging on the optimal treatment for neurocysticercosis, which varies based on the form of the disease in the nervous system.

SUMMARY

Parenchymal neurocysticercosis is a leading cause of acquired epilepsy worldwide, and extraparenchymal neurocysticercosis is responsible for many cases of hydrocephalus. Recognition of the different stages and locations of neurocysticercosis is essential for proper management. Similarly, schistosomiasis constitutes a major cause of myelopathy in endemic areas and requires prompt diagnosis and treatment to avoid permanent deficits.

Schistosomal Myeloradiculopathy - A case report

The most common neurological impairments related to schistosomiasis involve the lower portions of the medulla and the cauda equina. A 22-year-old woman, with no history, signs, or symptoms of hepatointestinal schistosomiasis, presented with lumbar pain associated with acute paresthesia and paresis of the right lower limb. Spinal schistosomiasis was suspected based on the disease progression and radiological findings, and the diagnosis was confirmed after cerebrospinal fluid analysis. The authors emphasize this pathology as important as a differential diagnosis in similar clinical scenarios, especially in endemic areas, because both early diagnosis and treatment are essential to avoid permanent sequelae.

Neuroschistosomiasis mimicking lower back pain: case report of a rare differential diagnosis in a pediatric patient

Background

Spinal myelitis is an infrequent manifestation of spinal cord infection. It is caused by the Schistosoma species, which are endemic in South America, part of the Middle East, and Africa.

Case presentation

We report the case of a 13-year-old male adolescent complaining of progressive lower back pain and weakness of the lower extremities for 3 days. Initial magnetic resonance imaging revealed typical transverse myelitis. Subsequently, parasite serology showed a markedly elevated level of Schistosoma antibody titers, and cerebrospinal fluid analysis yielded normal results. Because of our presumptive diagnosis of neuroschistosomiasis, the patient was prescribed an empirical regimen of an anti-parasitic agent, after which his neurological deficit promptly subsided. The patient was followed for 1 year and showed a complete long-term resolution of symptoms.

Conclusions

This case highlights the increasing prevalence of neuroschistosomiasis in recent years, particularly in patients with a history of travel to endemic regions. Moreover, the study reports the clinicoradiological features of this enigmatic disorder. This rare occurrence potentiates further studies to address unanswered questions about neuroschistosomiasis.

Development of an experimental model of schistosomal myeloradiculopathy

Schistosomal myeloradiculopathy (SMR) is a severe form of presentation of schistosomiasis in which Schistosoma spp. affect the spinal cord. The aims of the present study were to develop an animal model of SMR caused by S. mansoni, to characterize both sensory and motor abnormalities in the infected animals, and to investigate the relationship of the sensory, motor and histological findings with the progression of the infection over time. Mechanical sensitivity and behavioral tests were performed followed by euthanasia in male Wistar rats divided into six groups of five animals each, on days 5, 10, 20 and 30 after infection of S. mansoni eggs. The controls were subjected to the same procedure but were administered phosphate-buffered saline (PBS). The spinal cord was removed and subjected to histological analysis. S. mansoni eggs were found in the spinal cord of 25% of the infected animals, which belonged to the groups that exhibited more significant reduction of the superficial mechanical sensitivity, thermal sensitivity and muscle strength. This model proved to be satisfactory to assess functional changes in Wistar rats and might be used in studies investigating the pathogenesis of SMR. To our knowledge, this is the first experimental model of SMR.

Eosinophilia in Infectious Diseases

In determining the etiology of eosinophilia, it is necessary to consider the type of patient, including previous travel and exposure history, comorbidities, and symptoms. In this review, we discuss the approach to the patient with eosinophilia from an infectious diseases perspective based on symptom complexes.

Spinal Cord Schistosomiasis: Two Different Outcomes

Spinal cord schistosomiasis is difficult to diagnose in nonendemic areas. We report the clinical profile of 2 young Saudi males who presented with myelopathy. The first patient arrived at our hospital relatively late, i.e. 3 months following the presentation of initial symptoms, and had received both pulse steroid therapy and a plasma exchange. Praziquantel was administered late and the patient did not recover. The second case presented early, i.e. within around 8 weeks of initial symptoms. This patient received praziquantel without any kind of steroid and had a complete recovery. We concluded that prompt recognition and early treatment with praziquantel is crucial for a better outcome. The role of steroids in these cases still needs to be proven.

Neurologic manifestations of the neglected tropical diseases

BACKGROUND

The World Health Organization has identified 17 neglected tropical diseases (NTDs) that disproportionately affect the world's poorest populations. The neurologic aspects of many of these NTDs have received relatively little attention.

METHODS

A review was performed in PubMed (MedLine) for each NTD by disease name, name of its causative organism, and neurology, neurosurgery, neurologist, brain, spinal cord, peripheral nerve, muscle, nervous system, encephalitis, meningitis, encephalopathy, stroke, neuropathy, and myopathy (1968-Sept. 2013). The Oxford Center for Evidence-based Medicine guidelines were used to determine the level of evidence of neurological involvement and treatment based on the reports identified.

RESULTS

Neurologic manifestations were reported for all NTDs except yaws. Neurologic involvement was described in systematic reviews for four NTDs (Chagas disease, echinococcosis, rabies, cysticercosis) (levels 2a-3a), retrospective cohort studies for six (dengue, human African trypanosomiasis, leishmaniasis, leprosy, onchocerciasis, schistosomiasis) (levels 2b-3b), case series for one (foodborne trematodiasis) (level 4), and case reports for five (Buruli ulcer, dracunculiasis, filariasis, soil-transmitted helminthes, and trachoma). Level 1 evidence for treatment of neurologic manifestations of NTDs was found for human African trypanosomiasis, leprosy, and cysticercosis and level 2 evidence exists for treatment of neurologic involvement in Chagas disease. For the remaining NTDs, treatment of neurologic complications is described in case series and case reports only.

CONCLUSIONS

Neurologic manifestations of NTDs cause significant morbidity and mortality, although limited evidence exists on how best to treat these neurologic complications. Increased awareness of neurologic manifestations of the NTDs can increase their early identification and treatment, contributing to ongoing elimination and eradication campaigns.

Increased IL-17, a Pathogenic Link between Hepatosplenic Schistosomiasis and Amyotrophic Lateral Sclerosis: A Hypothesis

The immune system protects the organism from foreign invaders and foreign substances and is involved in physiological functions that range from tissue repair to neurocognition. However, an excessive or dysregulated immune response can cause immunopathology and disease. A 39-year-old man was affected by severe hepatosplenic schistosomiasis mansoni and by amyotrophic lateral sclerosis. One question that arose was, whether there was a relation between the parasitic and the neurodegenerative disease. IL-17, a proinflammatory cytokine, is produced mainly by T helper-17 CD4 cells, a recently discovered new lineage of effector CD4 T cells. Experimental mouse models of schistosomiasis have shown that IL-17 is a key player in the immunopathology of schistosomiasis. There are also reports that suggest that IL-17 might have an important role in the pathogenesis of amyotrophic lateral sclerosis. It is hypothesized that the factors that might have led to increased IL-17 in the hepatosplenic schistosomiasis mansoni might also have contributed to the development of amyotrophic lateral sclerosis in the described patient. A multitude of environmental factors, including infections, xenobiotic substances, intestinal microbiota, and vitamin D deficiency, that are able to induce a proinflammatory immune response polarization, might favor the development of amyotrophic lateral sclerosis in predisposed individuals.

Tropical myelopathies

A large number of causal agents produce spinal cord lesions in the tropics. Most etiologies found in temperate regions also occur in the tropics including trauma, herniated discs, tumors, epidural abscess, and congenital malformations. However, infectious and nutritional disorders occur with higher prevalence in tropical regions. Among the most common infectious etiologies are tuberculous Pott's disease, brucellosis, and neuroborreliosis. Parasitic diseases such as schistosomiasis, neurocysticercosis, and eosinophilic meningitis are frequent causes of nontraumatic paraplegia. The retrovirus HTLV-1 is a cause of tropical spastic paraparesis. Nutritional causes of paraparesis include deficiencies of vitamin B12 and folate; endemic clusters of konzo and tropical ataxic myeloneuropathy are associated in Africa with malnutrition and excessive consumption of cyanide-containing bitter cassava. Other toxic etiologies of tropical paraplegia include lathyrism and fluorosis. Nutritional forms of myelopathy are associated often with optic and sensory neuropathy, hence the name tropical myeloneuropathies. Acute transverse myelopathy is seen in association with vaccination, infections, and fibrocartilaginous embolism of the nucleus pulposus. Multiple sclerosis and optic myelopathy occur in the tropics but with lesser prevalence than in temperate regions. The advent of modern imaging in the tropics, including computed tomography and magnetic resonance imaging, has allowed better diagnosis and treatment of these conditions that are a frequent cause of death and disability.

Rickettsiae, protozoa, and opisthokonta/metazoa

Rhizobiales (formerly named Rickettsiales) cause in rare instances meningitis and meningovasculitis, respectively. In case of history of exposure, infection by Rhizobiales needs to be considered since both diagnosis and therapy may be extremely difficult and pathogen-specific. The same applies to protozoa; in this chapter, Babesia species, free-living amoebae and Entamoeba histolytica infection, including severe meningitis and brain abscess, infection by Trypanosoma species (South American and African trypanosomiasis) are discussed with respect to history, epidemiology, clinical signs, and symptoms as well as differential diagnosis and therapy. Parasitic flatworms and roundworms, potentially able to invade the central nervous system, trematodes (flukes), cestodes (in particular, Cysticercus cellulosae), but also nematodes (in particular, Strongyloides spp. in the immunocompromised) are of worldwide importance. In contrast, filarial worms, Toxocara spp., Trichinella spp., Gnathostoma and Angiostrongylus spp. are seen only in certain geographically confined areas. Even more regionally confined are infestations of the central nervous system by metazoa, in particular, tongue worms (=arthropods) or larvae of flies (=maggots). The aim of this chapter is (1) to alert the neurologist to these infections, and (2) to enable the attending emergency neurologist to take a knowledgeable history, with an emphasis on epidemiology, clinical signs, and symptoms as well as therapeutic management possibilities.

Central nervous system infections in travelers

International travelers commonly contract infections while abroad, many of which are primary neurological diseases or have potential neurological sequelae. The implications of these neuroinfectious diseases extend beyond the individual, since returning travelers may contribute to the spread of infection in novel areas. In this review, we discuss signs, symptoms, treatments, and prophylaxes for these infections, as well as emerging trends with regard to neuroinfectious diseases of the returning traveler.

Mansonic neuroschistosomiasis

Mansonic neuroschistosomiasis (MN) is not only the most common but also the most serious ectopic presentation of the infection by Schistosoma mansoni. Both, brain and spinal cord can be independently affected by the infection, but the later is more frequently affected. Brain MN by itself is due to the presence of eggs and/or adult worms in situ and can be symptomatic or asymptomatic. Unlike the brain MN, spinal cord mansonic neuroschistosomiasis is more frequently symptomatic. In both forms the intensity, the seriousness and also the clinical characteristics of signs and symptoms depend on the amount of eggs in the compromised region and on the intensity of the inflammatory reaction surrounding the eggs. Cerebrospinal fluid examination and magnetic resonance imaging are important diagnostic tools. Both corticosteroids and drugs against S. mansoni are used in the treatment. The outcome may largely depend upon the prompt use of these drugs.

Spinal cord schistosomiasis: unexpected postmortem finding

OBJECTIVES

To report a case of a US resident, originally from Liberia, with chronic hepatitis C infection who developed acute neurologic symptoms of the lower limbs.

METHODS

Our case is compared to previously reported similar cases, with emphasis on clinical symptoms, investigations, diagnosis, and prognosis.

RESULTS

The patient was transferred to the University of Iowa Hospital and Clinics for further management of severe retroperitoneal bleeding and died 2 days after admission. The diagnosis of schistosomiasis was established on examination of the spinal cord at autopsy, where multiple Schistosoma mansoni eggs were seen in the vasculature of the spinal cord.

CONCLUSIONS

The diagnosis of schistosomiasis may go undiagnosed in countries where the disease is not endemic but should be considered when investigating spinal cord disease in patients native to an endemic area or international travelers.

Schistosomiasis of the nervous system

Schistosomiasis is a parasitic disease caused by blood flukes of the genus Schistosoma. Currently 200 million people worldwide are infected. Neurological manifestations are a result of the inflammatory response of the host to egg deposition in the brain and spinal cord and is usually seen in patients with recent infection with no evidence of systemic illness. Cerebral and cerebellar disease can result in headache, seizure, and increased intracranial pressure. Cerebral schistosomiasis is more common in Schistosoma japonicum, but increasing cases due to Schistosoma mansoni are being reported in the literature. Other complications of cerebral schistosomiasis include delirium, loss of consciousness, visual field impairment, focal motor deficits, and ataxia. Myelopathy is the most common neurological manifestation of Schistosoma mansoni and the conus medullaris and cauda equine are the most common sites of involvement. Severe disease can result in flaccid paraplegia with areflexia, sphincter dysfunction, and sensory disturbance. Early recognition and prompt treatment are essential when physicians are faced with schistosomiasis involving the central nervous system. Schistosomicidal drugs, such as praziquantel, steroids and surgery, are the mainstay of therapy for this severe form of schistosomiasis.

Infectious myelopathies

Every genus of microorganism, as well as prions, has been associated with disease of the spinal cord. The spectrum of pathogens resulting in myelopathy varies with the population. Myelopathy is uniquely associated with certain retroviruses, particularly HIV type 1 and human T-cell lymphotropic virus type I, but the myelopathies that occur with these viruses are chiefly limited to "at risk" populations. In the immunocompromised population, a diverse array of pathogens may cause spinal cord disease, especially viruses from the Herpesviridae family, most notably cytomegalovirus and varicella-zoster virus. The prototypical myelopathy resulting from bacterial infection is tabes dorsalis, but this disorder is vanishingly rare in the modern era. In developing countries, Mycobacterium tuberculosis and schistosomiasis remain significant causes of myelopathy.

Cerebral vasculitis associated with Schistosoma mansoni infection

Background

Cerebral involvement in schistosomiasis is not rare, but it is underdiagnosed because of the lack of clinical suspicion and the frequency of asymptomatic forms. Neurologic complications are generally supported by granuloma formation around ectopic eggs which have migrated to the brain. Moreover, vascular lesions and cerebral arteritis have been well documented in histopathological studies. Nevertheless, cerebral vasculitis in later stages of the Schistosoma mansoni infection have not yet been described in living subjects.

Case presentation

A 28-year-old french woman had a stroke linked with cerebral vasculitis, 6 monthes after returning from Burkina-Faso. At the same time, a S. mansoni disseminated infection was diagnosed. She suffered from a new stroke after undertaking praziquantel therapy, which lead us to associate the S. mansoni infection and cerebral vasculitis.

Conclusion

This is the first report of such association, since cerebral vasculitis has never been described in later stages of the S. mansoni infection. Although the causal link between the two pathologies could not be proved, we suggest that S. mansoni is able to cause severe vascular damage in cerebral vessels. Schistosomiasis must be investigated in the event of a brain infarct in young people, particularly in patients originating or returning from an endemic area.

[Myelopathy due to Schistosoma mansoni]

INTRODUCTION

Neurological complications of schistosomiasis remain exceptional even in hyperendemic area.

CASE REPORT

We report a 26-year-old Senegalese man, without past medical history, who was admitted for spastic paraplegia, acute retention of urine, and pain in low back and lower limbs. The final diagnosis was spinal cord schistosomiasis. Diagnosis was based on the endemic context, MRI medullar conus imaging, schistosoma serology in cerebrospinal fluid and blood, and the absence of other cause of myelopathy. Treatment was based on praziquantel, corticosteroids and physiotherapy. The outcome was favorable after a 2-year follow-up.

CONCLUSION

Schistosomiasis should be included in the differential diagnosis of myelopathy in patients living actually, or even traveled in the past, in endemic tropical areas.

Helminth infections of the central nervous system occurring in Southeast Asia and the Far East

Although helminth infections of the central nervous system (CNS) are rare, their public health implications must not be neglected. Indeed, several helminth species can cause cerebrospinal infections, especially if humans serve as intermediate or non-permissive host. The diagnosis of cerebrospinal helminthiases is difficult, and the detection of parasites in cerebrospinal fluid is rarely successful. Cerebrospinal helminth infections therefore often remain undetected, and hence prognosis is poor. Increases in tourism and population movements are risk factors for cerebrospinal helminthiases and infections pose particular challenges to clinicians in non-endemic areas. In this review, we focus primarily on food-borne helminthiases that are endemic and often emerging in Southeast Asia and the Far East, namely angiostrongyliasis, gnathostomiasis, sparganosis, paragonimiasis and cysticercosis. Additionally, we discuss neuroschistosomiasis, a disease that is transmitted through human-water contact. For each disease, we describe the pathogen, its transmission route and possible mechanisms for entering the CNS. We also summarise common signs and symptoms, challenges and opportunities for diagnosis, treatment, clinical management, geographical distribution and epidemiology. The adoption of a comprehensive set of diagnostic criteria for different cerebrospinal helminthiases is proposed, including epidemiological history, typical signs and symptoms, neuroimaging and laboratory findings. Finally, risk factors, and research needs for enhanced patient management and population-based control measures are discussed.

Helminthic invasion of the central nervous system: many roads lead to Rome

Invasion of the central nervous system (CNS) by parasitic worms often represents most severe complication of human helminthiasis. The pathways from the portal of entry to the CNS are manifold and differ from species to species. In this mini-review, we analysed the contemporary knowledge and current concepts of the routes pathogenic helminths take to gain access to brain, spinal cord and subarachnoid space.

Research development of the pathogenesis pathways for neuroschistosomiasis

The infection of the central nervous system (CNS) by schistosome may or may not have clinical manifestations. When symptomatic, neuroschistosomiasis (NS) is one of the most severe presentations of schistosome infection. Among the NS symptoms, cerebral invasion is mostly caused by Schistosoma japonicum (S. japonicum), and the spinal cord symptoms are mainly caused by S. mansoni or S. haematobium. There are 2 main pathways by which schistosomes cause NS: egg embolism and worm migration, via either artery or vein system, especially the valveless perivertebral Batson's plexus. The adult worm migrates anomalously through the above pathways to the CNS where they lay eggs. Due to the differences in species of schistosomes and stages of infection, mechanisms vary greatly. The portal hypertension with hepatosplenic schistosomiasis also plays an important role in the pathogenesis. Here the pathways through which NS occurs in the CNS were reviewed.

Two patients with imported acute neuroschistosomiasis due to Schistosoma mansoni

We report the case of two brothers who returned from Madagascar presenting all the acute phase symptoms of a primary invasive Schistosoma mansoni infection, together with brain involvement characterized by acute encephalitis. This rarely described issue should be considered in travelers returning from endemic areas with acute neurological symptoms.

[Parasitic diseases of the central nervous system]

Central nervous system infections and infestations by protozoa and helminths constitute a problem of increasing importance throughout all of central European and northern/western countries. This is partially due to the globalisation of our society, tourists and business people being more frequently exposed to parasitic infection/infestation in tropical countries than in moderate climate countries. On top of that, migrants may import chronic infestations and infections with parasitic pathogens, eventually also--sometimes exclusively--involving the nervous system. Knowledge of epidemiology, initial clinical signs and symptoms, diagnostic procedures as well as specific chemotherapeutic therapies and adjunctive therapeutic strategies is of utmost important in all of these infections and infestations of the nervous systems, be it by protozoa or helminths. This review lists, mainly in the form of tables, all possible infections and infestations of the nervous systems by protozoa and by helminths. Besides differentiating parasitic diseases of the nervous system seen in migrants, tourists etc., it is very important to have in mind that disease-related (e.g. HIV) or iatrogenic immunosuppression has led to the increased occurrence of a wide variety of parasitic infections and infestations of the nervous system (e. g. babesiosis, Chagas disease, Strongyloides stercoralis infestation, toxoplasmosis, etc.).

Cerebral neuroschistosomiasis: a rare clinical presentation and review of the literature

The symptomatic presentation of cerebral schistosomiasis is uncommon. The case of a 25-year-old woman from Equatorial Guinea with headache and seizures secondary to cerebral neuroschistosomiasis, as confirmed by histopathological examination and microbiological study, is presented. A review of the literature on this subject is also provided.

Update on eosinophilic meningoencephalitis and its clinical relevance

Eosinophilic meningoencephalitis is caused by a variety of helminthic infections. These worm-specific infections are named after the causative worm genera, the most common being angiostrongyliasis, gnathostomiasis, toxocariasis, cysticercosis, schistosomiasis, baylisascariasis, and paragonimiasis. Worm parasites enter an organism through ingestion of contaminated water or an intermediate host and can eventually affect the central nervous system (CNS). These infections are potentially serious events leading to sequelae or death, and diagnosis depends on currently limited molecular methods. Identification of parasites in fluids and tissues is rarely possible, while images and clinical examinations do not lead to a definitive diagnosis. Treatment usually requires the concomitant administration of corticoids and anthelminthic drugs, yet new compounds and their extensive and detailed clinical evaluation are much needed. Eosinophilia in fluids may be detected in other infectious and noninfectious conditions, such as neoplastic disease, drug use, and prosthesis reactions. Thus, distinctive identification of eosinophils in fluids is a necessary component in the etiologic diagnosis of CNS infections.