Angiostrongylus cantonensis eosinophilic meningitis: a clinical study of 42 consecutive cases in French Polynesia

The recent introduction of Angiostrongylus cantonensis and its intermediate host Achatina fulica into Guadeloupe detected by phylogenetic analyses

BACKGROUND

Angiostrongylus cantonensis (rat lungworm) is the main pathogen responsible for eosinophilic meningitis in humans. One of its intermediate snail hosts, Achatina fulica, was already present in many countries around the world before it appeared in the West Indies in the late 1980s. In the French territories in the Caribbean and northern South America, the first cases of human neuroangiostrongyliasis were reported in Martinique, Guadeloupe and French Guiana in 2002, 2013 and 2017, respectively. In order to better characterize angiostrongyliasis in Guadeloupe, particularly its geographical origin and route of introduction, we undertook molecular characterization of adult worms of Angiostrongylus cantonensis and its intermediate host Achatina fulica.

METHODS

Genomic DNA of adult Angiostrongylus cantonensis and Achatina fulica was extracted and amplified by polymerase chain reaction (PCR) targeting the mitochondrial genes cytochrome B and C for A. cantonensis and 16S ribosomal RNA for A. fulica. The PCR products were sequenced and studied by phylogenetic analysis.

RESULTS

Cytochrome B and cytochrome C molecular markers indicate a monophyletic lineage of A. cantonensis adult worms in Guadeloupe. Two sequences of A. fulica were identified.

CONCLUSIONS

These results confirm the recent introduction of both Angiostrongylus cantonensis and Achatina fulica into Guadeloupe. Achatina fulica in Guadeloupe shares a common origin with those in Barbados and New Caledonia, while Angiostrongylus cantonensis in Guadeloupe shares a common origin with those in Brazil, Hawaii and Japan.

Paratenic hosts of Angiostrongylus cantonensis and their relation to human neuroangiostrongyliasis globally

The nematode parasite Angiostrongylus cantonensis (rat lungworm) has a complex life cycle involving rats (definitive hosts) and gastropods (intermediate hosts), as well as various paratenic hosts. Humans become infected and develop rat lungworm disease (neuroangiostrongyliasis) when they consume intermediate or paratenic hosts containing the infective parasite larvae. This study synthesizes knowledge of paratenic hosts of A. cantonensis and investigates their role in causing human neuroangiostrongyliasis worldwide. A literature review was conducted by searching PubMed, JSTOR and Scopus, pooling additional information from sources accumulated over many years by RHC, and snowball searching. The review identified 138 relevant articles published between 1962 and 2022. Freshwater prawns/shrimp, crayfish, crabs, flatworms, fish, sea snakes, frogs, toads, newts, lizards, centipedes, cattle, pigs and snails were reported to act as paratenic hosts in various regions including South and Southeast Asia, Pacific islands, the USA and the Caribbean, as well as experimentally. Human cases of neuroangiostrongyliasis have been reported from the 1960s onwards, linked, sometimes speculatively, to consumption of freshwater prawns/shrimp, crabs, flatworms, fish, frogs, toads, lizards and centipedes. The potential of paratenic hosts to cause neuroangiostrongyliasis depends on whether they are eaten, how frequently they are consumed, the preparation method, including whether eaten raw or undercooked, and whether they are consumed intentionally or accidentally. It also depends on infection prevalence in the host populations and probably on how high the parasite load is in the consumed hosts. To prevent human infections, it is crucial to interrupt the transmission of rat lungworm to humans, from both intermediate hosts and frequently consumed paratenic hosts, by adhering to safe food preparation protocols. Educating the general public and the medical community about this largely neglected tropical/subtropical disease is key.

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Neuroangiostrongyliasis, an emerging parasitic disease of humans and wildlife.

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Caused by the nematode Angiostrongylus cantonensis (rat lungworm).

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Infection primarily via ingestion of stage 3 larvae of the parasite.

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People eat raw intermediate or paratenic hosts infected with stage 3 larvae.

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Comprehensive review of paratenic hosts’ role in neuroangiostrongyliasis globally.

Trade and Deforestation Predict Rat Lungworm Disease, an Invasive-Driven Zoonosis, at Global and Regional Scales

The introduction of non-native species and deforestation are both important drivers of environmental change that can also facilitate the geographic spread of zoonotic pathogens and increase disease risk in humans. With ongoing trends in globalization and land-use conversions, introduced species and deforestation are ever more likely to pose threats to human health. Here, we used rat lungworm disease, an emerging zoonotic disease caused by Angiostrongylus cantonensis and maintained by invasive rats and snails, to explore how these two forms of environmental change can impact zoonotic disease risk. We used logistic regressions to examine the role of global trade in the introduction of A. cantonensis at a country level and used model estimates to predict the probability of introduction as a function of trade. We then used hurdle-based regression models to examine the association between deforestation and rat lungworm disease in two regions where A. cantonensis is already established: Hawaii and Thailand. At the global scale, we found the trade of horticultural products to be an important driver in the spread of A. cantonensis and that the majority of countries at high risk of future A. cantonensis introduction are islands. At country scales, we found deforestation to increase the per-capita risk of A. cantonensis exposure in Hawaii and Thailand. Our study provides a preliminary view of the associations between species introductions, deforestation, and risk of A. cantonensis exposure in people. Better understanding how these two widespread and overlapping forms of environmental change affect human health can inform international biosecurity protocols, invasive species management, and land-use policies.

Clinical Efficacy and Safety of Albendazole and Other Benzimidazole Anthelmintics for Rat Lungworm Disease (Neuroangiostrongyliasis): A Systematic Analysis of Clinical Reports and Animal Studies

The safety and efficacy of benzimidazole anthelmintics for the treatment of rat lungworm disease (neuroangiostrongyliasis) have been questioned regardless of numerous experimental animal studies and clinical reports. In this review, 40 of these experimental animal studies and 104 clinical reports are compiled with a focus on albendazole. Among the 144 articles involving an estimated 1034 patients and 2561 animals, 4.1% were inconclusive or vague regarding the use of benzimidazoles. Of the remaining 138 articles, 90.5% found benzimidazoles to be safe and effective (885 patients, 2530 animals), 4.3% as safe but ineffective (73 patients, 3 animals), and 5.0% caused adverse reactions (7 patients, 28 animals). Among those clinical reports that described a confirmed diagnosis of neuroangiostrongyliasis in which albendazole monotherapy was used, 100% reported high efficacy (743 patients, 479 animals). In those where albendazole-corticosteroid co-therapy was used, 97.87% reported it to be effective (323 patients, 130 animals).

Eosinophilic meningitis in New Caledonia: The role of Angiostrongylus cantonensis?

INTRODUCTION

Eosinophilic meningitis is a rare form of meningitis with sequelae or death occurring in approximately 2-3% of cases. The most frequent etiological agent is the parasite Angiostrongylus cantonensis. The aim of this study was to characterize New Caledonian cases and to assess the extent to which of A. cantonensis was involved.

MATERIAL AND METHODS

We performed a retrospective study of all cases of eosinophilic meningitis (EM) admitted to the Territorial Hospital of New Caledonia, from 2004 to 2019. We performed a descriptive and a multivariate analysis to identify association of variables with severe and fatal cases (or cases with sequelae).

CONCLUSION

Angiostrongyliasis was confirmed as being responsible for 17 of the 92 reported EM cases in New Caledonia from 2004 to 2019 with most being young adults and non-walking infants, and with two peaks of incidence one during the dry season and one during the rainy season. Considering the high incidence and regularity of cases, the potential reservoirs should be identified to target prevention campaigns.

Biomphalaria glabrata infected with Angiostrongylus cantonensis: Proteomic changes in the snail host

Angiostrongylus cantonensis is the main cause of human eosinophilic meningitis. Humans are accidental hosts, becoming infected due to ingestion of raw intermediate (snails and slugs) or paratenic hosts. Once ingested, the larvae migrate towards the brain where they die, causing the disease. To develop better mollusk control strategies, it is important to first understand what happens in the snail during infection, therefore our purpose was to characterize proteomic, metabolic and immunologic changes in Biomphalaria glabrata 24 h after infection with A. cantonensis. For this purpose, proteins were extracted from infected and uninfected snails and analyzed through mass spectrometry. Hemolymph was also collected, the number of hemocytes was counted and urea, nitric oxide, calcium, glycogen levels as well as alanine and aspartate aminotransferases activities were assessed. The cephalopodal region and gonad-digestive gland complex were dissected and their glycogen content was measured. After infection with A. cantonensis, we observed an increase of hemocytes and granulocytes as well as an increase in hemoglobin type 2 proteins. Temptin-like protein was also found up-regulated in infected snails. Several proteins with structural function (such as myosin heavy chain - striated muscle - like and protein LOC106059779 with ADAM/reprosolin domain) were also differentially expressed, suggesting loss/damage of internal tissues. Increase in phosphoglycerate mutase indicates an increase in glycolysis, possible to compensate the increase in energetic needs. Consequently, there is a decrease in glycogen reserves, particularly in the gonad - digestive gland complex.

Guidelines for the diagnosis and treatment of neuroangiostrongyliasis: updated recommendations

A subcommittee of the Hawaii Governor's Joint Task Force on Rat Lungworm Disease developed preliminary guidelines for the diagnosis and treatment of neuroangiostrongyliasis (NAS) in 2018 (Guidelines, 2018). This paper reviews the main points of those guidelines and provides updates in areas where our understanding of the disease has increased. The diagnosis of NAS is described, including confirmation of infection by real-time polymerase chain reaction (RTi-PCR) to detect parasite DNA in the central nervous system (CNS). The treatment literature is reviewed with recommendations for the use of corticosteroids and the anthelminthic drug albendazole. Long-term sequelae of NAS are discussed and recommendations for future research are proposed.

First cases of Angiostrongylus cantonensis infection reported in Martinique, 2002-2017

Neuroangiostrongyliasis is a parasitic disease caused by the accidental ingestion of the nematode Angiostrongylus cantonensis in its larval form. Human infection can lead to eosinophilic meningitis, sometimes complicated by life-threatening radiculomyelitis or encephalitis. Although some cases have been reported from other Caribbean Islands, no cases have been diagnosed in Martinique so far. Here, we report the first eight laboratory-confirmed cases of neuroangiostrongyliasis on the island of Martinique, French West Indies, between 1 January 2002 and 31 December 2017. One case was fatal and five resulted in neurological sequelae. The medical community should consider the risk of A. cantonensis infection in patients living in or returning from Martinique.

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.

Angiostrongylus cantonensis: a review of its distribution, molecular biology and clinical significance as a human pathogen

Angiostrongylus cantonensis is a metastrongyloid nematode found widely in the Asia-Pacific region, and the aetiological agent of angiostrongyliasis; a disease characterized by eosinophilic meningitis. Rattus rats are definitive hosts of A. cantonensis, while intermediate hosts include terrestrial and aquatic molluscs. Humans are dead-end hosts that usually become infected upon ingestion of infected molluscs. A presumptive diagnosis is often made based on clinical features, a history of mollusc consumption, eosinophilic pleocytosis in cerebral spinal fluid, and advanced imaging such as computed tomography. Serological tests are available for angiostrongyliasis, though many tests are still under development. While there is no treatment consensus, therapy often includes a combination of anthelmintics and corticosteroids. Angiostrongyliasis is relatively rare, but is often associated with morbidity and sometimes mortality. Recent reports suggest the parasites' range is increasing, leading to fatalities in regions previously considered Angiostrongylus-free, and sometimes, delayed diagnosis in newly invaded regions. Increased awareness of angiostrongyliasis would facilitate rapid diagnosis and improved clinical outcomes. This paper summarizes knowledge on the parasites' life cycle, clinical aspects and epidemiology. The molecular biology of Angiostrongylus spp. is also discussed. Attention is paid to the significance of angiostrongyliasis in Australia, given the recent severe cases reported from the Sydney region.

The Increase of Exotic Zoonotic Helminth Infections: The Impact of Urbanization, Climate Change and Globalization

Zoonotic parasitic diseases are increasingly impacting human populations due to the effects of globalization, urbanization and climate change. Here we review the recent literature on the most important helminth zoonoses, including reports of incidence and prevalence. We discuss those helminth diseases which are increasing in endemic areas and consider their geographical spread into new regions within the framework of globalization, urbanization and climate change to determine the effect these variables are having on disease incidence, transmission and the associated challenges presented for public health initiatives, including control and elimination.

Preliminary expression profile of cytokines in brain tissue of BALB/c mice with Angiostrongylus cantonensis infection

Background

Angiostrongylus cantonensis (A. cantonensis) infection can result in increased risk of eosinophilic meningitis. Accumulation of eosinophils and inflammation can result in the A. cantonensis infection playing an important role in brain tissue injury during this pathological process. However, underlying mechanisms regarding the transcriptomic responses during brain tissue injury caused by A. cantonensis infection are yet to be elucidated. This study is aimed at identifying some genomic and transcriptomic factors influencing the accumulation of eosinophils and inflammation in the mouse brain infected with A. cantonensis.

Methods

An infected mouse model was prepared based on our laboratory experimental process, and then the mouse brain RNA Libraries were constructed for deep Sequencing with Illumina Genome Analyzer. The raw data was processed with a bioinformatics’ pipeline including Refseq genes expression analysis using cufflinks, annotation and classification of RNAs, lncRNA prediction as well as analysis of co-expression network. The analysis of Refseq data provides the measure of the presence and prevalence of transcripts from known and previously unknown genes.

Results

This study showed that Cys-Cys (CC) type chemokines such as CCL2, CCL8, CCL1, CCL24, CCL11, CCL7, CCL12 and CCL5 were elevated significantly at the late phase of infection. The up-regulation of CCL2 indicated that the worm of A. cantonensis had migrated into the mouse brain at an early infection phase. CCL2 could be induced in the brain injury during migration and CCL2 might play a major role in the neuropathic pain caused by A. cantonensis infection. The up-regulated expression of IL-4, IL-5, IL-10, and IL-13 showed Th2 cell predominance in immunopathological reactions at late infection phase in response to infection by A. cantonensis. These different cytokines can modulate and inhibit each other and function as a network with the specific potential to drive brain eosinophilic inflammation. The increase of ATF-3 expression at 21 dpi suggested the injury of neuronal cells at late phase of infection. 1217 new potential lncRNA were candidates of interest for further research.

Conclusions

These cytokine networks play an important role in the development of central nervous system inflammation caused by A. cantonensis infection.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-015-0939-6) contains supplementary material, which is available to authorized users.