Eosinophilic meningitis

Detection of Gnathostoma spinigerum larva in the brain with complete follow-up after surgical treatment of human neurognathostomiasis

Human gnathostomiasis is a food-borne zoonotic helminthic infection widely reported in Latin America, Asia, and Southeast Asia. Consuming raw, or under-cooked fresh-water fish is the leading cause of this helminthic infection, which is clinically characterized by signs of inflammation, itching sensation, or irritation with migratory swelling. Neurological symptoms resulting from neurognathostomiasis vary, and there is scant information due to the rareness of patient brain samples. This study aimed to demonstrate the first evidence of human neurognathostomiasis by the detection of Gnathostoma spinigerum larva in patient's brain during craniotomy, supported by histopathological, immunological and proteomic evidence. Clinical symptoms were obtained from medical history and physical examination with laboratory investigations, including magnetic resonance imaging (MRI), left temporal craniotomy, histopathology of brain tissue, and Western blot analysis, were performed to elucidate the causative pathogens for diagnosis. In addition, the host-parasite interaction of the parasite invading the patient's brain was characterized through proteomics. Histopathology revealed worms with the characteristic cuticular spines of G. spinigerum which were detected and identified. These histopathological findings were consistent with a positive Western blot showing a 24-kDa reactive-band for gnathostomiasis. Proteomic analysis revealed the presence of G. spinigerum serpin and serine protease in the patient's serum. Moreover, the leucine-rich alpha-2-glycoprotein was indicated as a systemic biomarker of early brain injury related to invasion by G. spinigerum. Therefore, our study provides the initial evidence of human neurognathostomiasis due to G. spinigerum larval invasion along with successful craniotomy and proven larval detection including complete follow-up, and the disease prognosis after surgical treatment.

Acute Aseptic Meningitis Temporally Associated with Intravenous Polyclonal Immunoglobulin Therapy: A Systematic Review

An acute aseptic meningitis has been occasionally observed on intravenous polyclonal human immunoglobulin therapy. Since case reports cannot be employed to draw inferences about the relationships between immunoglobulin therapy and meningitis, we conducted a systematic review and meta-analysis of the literature. Eligible were cases, case series, and pharmacovigilance studies. We found 71 individually documented cases (36 individuals ≤ 18 years of age) of meningitis. Ninety percent of cases presented ≤ 3 days after initiating immunoglobulin therapy and recovered within ≤ 7 days (with a shorter disease duration in children: ≤ 3 days in 29 (94%) cases). In 22 (31%) instances, the authors noted a link between the onset of meningitis and a rapid intravenous infusion of immunoglobulins. Cerebrospinal fluid analysis revealed a predominantly neutrophilic (N = 46, 66%) pleocytosis. Recurrences after re-exposure were observed in eight (N = 11%) patients. Eight case series addressed the prevalence of meningitis in 4089 patients treated with immunoglobulins. A pooled prevalence of 0.6% was noted. Finally, pharmacovigilance data revealed that meningitis temporally associated with intravenous immunoglobulin therapy occurred with at least five different products. In conclusion, intravenous immunoglobulin may cause an acute aseptic meningitis. The clinical features remit rapidly after discontinuing the medication.

case of autoimmune GFAP astrocytopathy with eosinophils in the cerebrospinal fluid

Cerebrospinal fluid (CSF) eosinophilia is associated with a narrow differential, primarily including parasitic and fungal infections, neoplasm, and chemical meningitis. It has rarely been reported in neuroinflammatory conditions including as a finding of CSF cytology in two autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy cases. Here we describe a case of autoimmune GFAP astrocytopathy with classic clinical and radiographic features as well as presence of eosinophils in the CSF. This case highlights a potential association of eosinophils in the CSF with autoimmune GFAP astrocytopathy, which may suggest its inclusion in the differential diagnosis of eosinophilic meningitis, encephalitis, or myelitis.

Clinical Characteristics and Treatment Outcome of Eosinophilic Meningoencephalitis in South Indian Children: Experience From a Prospective Registry

BACKGROUND

To describe the clinical features and therapeutic outcomes of a prospective cohort of children with eosinophilic meningoencephalitis.

METHODS

Children admitted with clinical features suggestive of meningitis along with cerebrospinal fluid (CSF) eosinophilia during the period of 14 years (2008 to 2021) were included. Their baseline characteristics, epidemiologic associations, and treatment outcomes were analyzed and compared with the previous studies.

RESULTS

We identified 25 children (13 males) satisfying the inclusion criteria. The median age at presentation was 3.9 years (range 0.8 to 17 years); 68% were aged less than two years. Fourteen (56%) children had a history of exposure to snails. Most of them presented with fever, headache, irritability, lateral rectus palsy, and early papilledema. Symptoms started three to 42 days (median duration: 14 days) before admission to our center. All children had peripheral eosinophilia, which ranged from 9% to 41%. The mean CSF white blood cell count was 416/mm3 (range 50 to 1245 cells/mm3) with CSF eosinophilia ranging from 11% to 80%. Brain magnetic resonance imaging was done in 24 children and was normal in 15 (62.5%). Leptomeningeal enhancement was seen in two (8.3%) children, and other nonspecific changes were noted in seven (29.1%) children. All children recovered without any neurological deficits with a standard treatment regimen of albendazole and oral steroids. All were asymptomatic at the last follow-up. None of them had any recurrence during the follow-up period.

CONCLUSION

We report one of the largest clinical series of children with eosinophilic meningoencephalitis from an endemic area of South India.

Case Report: Cryptococcal eosinophilic meningitis in a patient with Hodgkin lymphoma

Cryptococcal meningitis is the most common fungal meningitis in clinical practice. It primarily occurs in immunocompromised people and is typically associated with human immunodeficiency virus (HIV) infection. In rare cases, it is associated with Hodgkin lymphoma (HL). Eosinophilic meningitis (EM) is characterized by increased eosinophils in the cerebrospinal fluid (CSF) and is often caused by a parasitic infection of the central nervous system (CNS). EM caused by cryptococcal infection is rare; only four cases have been reported in the past 30 years. Here, we report a case of cryptococcal meningitis in a patient with HL who presented with an atypical eosinophil-predominant CSF cytology response. The patient's eosinophil proportion reached 91%; a proportion this high has not been reported previously and may be associated with HL. After antifungal therapy and tumor chemotherapy, the proportion of eosinophils decreased significantly. This case shows that cryptococcal meningitis and HL may be simultaneously contributing to CSF eosinophilia. HL should be considered in patients with eosinophilic cryptococcal meningitis and multiple adenopathies.

Extensive myelitis with eosinophilic meningitis after Chimeric antigen receptor T cells therapy

Immune effector cell‐associated neurotoxicity syndrome (ICANS) is a frequent adverse event after Chimeric antigen receptor T cells (CAR‐T cells). A patient treated with anti‐CD19 CAR‐T cells for a refractory mantle cell lymphoma presented at Day 8 post‐infusion with extensive myelitis. Unusual eosinophilia was disclosed in the patient's cerebrospinal fluid. After treatment with methylprednisolone and siltuximab, a decrease in clinical symptoms and magnetic resonance imaging lesions were obtained. This unprecedented presentation of eosinophilic meningitis after CAR‐T cells therapy highlights the need for a better understanding of the physiopathology of ICANS, especially to identify potentially targetable pathways.

Amyloid-β related angiitis presenting as eosinophilic meningitis: a case report

BACKGROUND

Eosinophilic meningitis is uncommon and often attributed to infectious causes.

CASE PRESENTATION

We describe a case of a 72-year-old man who presented with subacute onset eosinophilic meningitis, vasculitis, and intracranial hypertension with progressive and severe neurologic symptoms. Brain MRI demonstrated multifocal strokes and co-localized right temporo-parieto-occipital vasogenic edema, cortical superficial siderosis, and diffuse leptomeningeal enhancement. He ultimately underwent brain biopsy with immunohistochemical stains for amyloid-β and Congo red that were extensively positive in the blood vessel walls and in numerous diffuse and neuritic parenchymal confirming a diagnosis of amyloid-β related angiitis. He was treated with immunosuppression with clinical stabilization.

CONCLUSIONS

Amyloid-β related angiitis is an underrecognized cause of eosinophilic meningitis that can present fulminantly and is typically responsive to immunosuppression. The presence of eosinophils may provide additional clues to the underlying pathophysiology of amyloid-β related angiitis.

Eosinophilic meningitis following suboccipital craniotomy without bovine dural graft: illustrative case

BACKGROUND

Eosinophilic meningitis is a rare known complication after brain surgery associated with duraplasty using artificial bovine graft. However, eosinophilic meningitis after craniotomy without bovine dural graft has not been reported.

OBSERVATIONS

A 48-year-old female presented with lateral medullary infarction caused by a vertebral artery dissecting aneurysm incorporating the posterior inferior cerebellar artery (PICA). The authors performed occipital artery–PICA anastomosis and repaired the dura by primary suture without bovine graft. Thereafter, endovascular internal trapping using coils was conducted. Severe headache developed at postoperative day 17, and the patient was diagnosed with eosinophilic meningitis. After administration of a high-dose corticosteroid for 2 weeks, her symptoms and laboratory findings were improved.

LESSONS

Postoperative eosinophilic meningitis is rarely related to craniotomy without using bovine graft. Neurosurgeons should consider the possibility of eosinophilic meningitis after craniotomy without a xenogeneic dural material.

Infectious Meningitis and Encephalitis

Infectious meningitis and encephalitis are associated with significant morbidity and mortality worldwide. Acute bacterial meningitis is rapidly fatal and early recognition and institution of therapy are imperative. Viral meningitis is typically a benign self-limited illness. Chronic meningitis (defined as presenting with >4 weeks of symptoms) is most often caused by tuberculosis and fungal infection. Because the diagnostic testing for tuberculous meningitis is insensitive and cultures often take weeks to grow, therapy is often initiated empirically when the diagnosis is suspected. Human simplex virus encephalitis is the most common cause of encephalitis and requires prompt treatment with intravenous acyclovir.

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.

Infectious Causes of Eosinophilic Meningitis in Korean Patients: A Single-Institution Retrospective Chart Review from 2004 to 2018

Eosinophilic meningitis is defined as the presence of more than 10 eosinophils per μl in the cerebrospinal fluid (CSF), or eosinophils accounting for more than 10% of CSF leukocytes in patients with acute meningitis. Parasites are the most common cause of eosinophilic meningitis worldwide, but there is limited research on patients in Korea. Patients diagnosed with eosinophilic meningitis between January 2004 and June 2018 at a tertiary hospital in Seoul, Korea were retrospectively reviewed. The etiology and clinical characteristics of each patient were identified. Of the 22 patients included in the study, 11 (50%) had parasitic causes, of whom 8 (36%) were diagnosed as neurocysticercosis and 3 (14%) as Toxocara meningitis. Four (18%) patients were diagnosed with fungal meningitis, and underlying immunodeficiency was found in 2 of these patients. The etiology of another 4 (18%) patients was suspected to be tuberculosis, which is endemic in Korea. Viral and bacterial meningitis were relatively rare causes of eosinophilic meningitis, accounting for 2 (9%) and 1 (5%) patients, respectively. One patient with neurocysticercosis and 1 patient with fungal meningitis died, and 5 (23%) had neurologic sequelae. Parasite infections, especially neurocysticercosis and toxocariasis, were the most common cause of eosinophilic meningitis in Korean patients. Fungal meningitis, while relatively rare, is often aggressive and must be considered when searching for the cause of eosinophilic meningitis.

Fermenting Bread Dough as a Cheap, Effective, Nontoxic, and Generic Attractant for Pest Snails and Slugs

Simple Summary

Snails and slugs are key pests of crops but control options are limited with an overreliance on molluscicides, which have variable efficacy. Thus, there is an urgent need to improve the performance of these pesticides, and one option is to identify more efficacious attractants for incorporation into baits and/or use in traps. Our results showed that a simple bread dough (flour, water, and yeast) was highly attractive to six invasive pest gastropod species in both laboratory and field trials in Hawaii, Oregon, and Montana. The dough remained attractive for at least 8 days and was significantly more attractive than a widely used toxic bait (Deadline^® M-Ps™). Given its simplicity, low cost, and the ready availability of its ingredients, the dough has potential to be used in developing countries where access to commercial molluscicides is limited by cost. In addition, a premixed dry formulation of flour and yeast, where water simply needs to be added to activate the bait, would likely have an indefinite shelf life and be readily shippable, both highly desirable properties for an operational lure. Thus, bread dough constitutes a nontoxic, generic, and effective tool that could be used in the detection and management of pest gastropods worldwide.

Abstract

Invasive slugs and snails are among the most damaging pests of agriculture in temperate and tropical regions of the world. Control options, however, are limited and there is a heavy reliance on chemical molluscicides of variable efficacy. There is an ongoing need to improve management methods. Here, we show that a simple fermenting bread dough formulation (flour, water, and yeast) was effective in attracting pest mollusk species in laboratory tests, and in multiple replicated field trials in Hawaii, Oregon, and Montana. The dough attracted substantially more terrestrial pest gastropods, including invasive species of major economic importance such as Cornu aspersum, Deroceras reticulatum, Ambigolimax valentianus, Xerolenta obvia, Lissachatina fulica, and Parmarion martensi, than water controls. The dough remained attractive for at least 8 days and was significantly more attractive than a widely used metaldehyde-based bait, Deadline^® M-Ps™. Thus, fermenting bread dough represents a nontoxic, generic, and effective tool to aid in managing pest gastropod infestations, either using baited traps or in attract-and-kill approaches. Given its simplicity, low cost, and the ready availability of its ingredients, the dough also has potential to be used in developing countries where access to commercial molluscicide baits is limited by cost.

Meningitis patients with Angiostrongylus cantonensis may present without eosinophilia in the cerebrospinal fluid in northern Vietnam

Background

Eosinophilic meningitis (EM) is a rare clinical syndrome caused by both infectious and noninfectious diseases. In tropical pacific countries, Angiostrongylus cantonensis is the most common cause. However, the EM definition varies in the literature, and its relation to parasitic meningitis (PM) remains unclear.

Methodology/Principal findings

Adult and adolescent patients of 13 years old or above with suspected central nervous system (CNS) infections with abnormal CSF findings were prospectively enrolled at a tertiary referral hospital in Hanoi, Vietnam from June 2012 to May 2014. Patients with EM or suspected PM (EM/PM) were defined by the presence of either ≥10% eosinophils or an absolute eosinophil cell counts of ≥10/mm³ in the CSF or blood eosinophilia (>16% of WBCs) without CSF eosinophils. In total 679 patients were enrolled: 7 (1.03%) had ≥10% CSF eosinophilia, 20 (2.95%) had ≥10/mm³ CSF eosinophilia, and 7 (1.03%) had >16% blood eosinophilia. The patients with ≥10% CSF eosinophilia were significantly younger (p = 0.017), had a lower body temperature (p = 0.036) than patients with ≥10/mm³ CSF eosinophilia among whom bacterial pathogens were detected in 72.2% (13/18) of those who were tested by culture and/or PCR. In contrast, the characteristics of the patients with >16% blood eosinophilia resembled those of patients with ≥10% CSF eosinophilia. We further conducted serological tests and real-time PCR to identify A. cantonensis. Serology or real-time PCR was positive in 3 (42.8%) patients with ≥10% CSF eosinophilia and 6 (85.7%) patients with >16% blood eosinophilia without CSF eosinophils but none of patients with ≥10/mm³ CSF eosinophilia.

Conclusions

The etiology of PM in northern Vietnam is A. cantonensis. The eosinophil percentage is a more reliable predictor of parasitic EM than absolute eosinophil count in the CSF. Patients with PM may present with a high percentage of eosinophils in the peripheral blood but not in the CSF.

Eosinophilic meningitis (EM) is a rare meningitis accompanied by eosinophils in the CSF and caused by multiple etiologies. Angiostrongylus cantonensis, which is a rat lungworm parasite, is the most common cause in tropical Asia. Previous papers have defined EM as CSF eosinophils ≥10% or CSF eosinophils ≥10/mm³. However, the relationship of EM to parasitic meningitis (PM) remains unclear. This prospective study enrolled 679 patients with suspected CNS infection who were admitted to a tertiary referral hospital in Hanoi, Vietnam from June 2012 to May 2014. The characteristics of patients with ≥10% CSF eosinophilia resembled those of patients with >16% blood eosinophilia without CSF eosinophils, whereas those of patients with ≥10/mm³ CSF eosinophilia were comparable with those of patients with typical bacterial meningitis. Serology or real-time PCR for A. cantonensis was positive in 3 out of 7 patients with ≥10% CSF eosinophilia and 6 out of 7 patients with > 16% blood eosinophilia without CSF eosinophils but none of patients with ≥10/mm³ CSF eosinophilia. The percentage, in contrast to the absolute eosinophil count in CSF, is reliable for predicting parasitic EM. Patients with PM may present with eosinophilia in the peripheral blood but not in the CSF.

Eosinophilic meningitis outbreak related to religious practice

Three patients with eosinophilic meningitis (EoM) were investigated in two hospitals in Porto Alegre, Southern Brazil. These patients had a common exposure after the ingestion of raw mollusks in a religious ritual. Two of them had an uncommon presentation with intense lower distal extremities pain and small fiber neuropathy as defined by an electroneuromyography (ENMG) study. All three patients were positive for Angiostrongylus cantonensis serology and recovered after antihelminthic and anti-inflammatory treatment. Increased awareness of A. cantonensis infection is important to avoid new infections and to improved recognition and handling of cerebral angiostrongyliasis.

Case Report: Subarachnoid Hemorrhage and Eosinophilic Meningitis due to Disseminated Fascioliasis

Human infection with the trematode Fasciola occurs with a worldwide prevalence of up to 17 million. Sheep and cattle are the normal host. Infection typically results in hepatobiliary disease, but extrahepatic manifestations are occasionally reported. Here, we present the case of a previously healthy 31-year-old Kurdish woman, admitted to hospital with a subarachnoid hemorrhage, eosinophilic meningitis, and lung and liver disease. A diagnosis of Fasciola infection was made based on strongly positive serology in blood and cerebrospinal fluid. The patient improved following treatment with triclabendazole and prednisolone.

First case report of eosinophilic meningitis associated with cerebral toxoplasmosis in an HIV-positive patient

Cerebral toxoplasmosis is the most common cause of focal brain lesion in people living with HIV (PLWH) and usually causes multifocal encephalitis with little or no meningeal involvement. Classically, only subtle cerebrospinal fluid (CSF) abnormalities are described. There are no prior case reports in the literature on eosinophilic meningitis associated with cerebral toxoplasmosis in PLWH. We report on an HIV-positive man from Brazil who presented to the emergency department with headache, nausea, vomiting, and hemiparesis. He had a T-CD4+ lymphocyte count of 145 cells/mm3, and antiretroviral failure was identified. Brain computed tomography showed a contrast-enhancing lesion with mild mass effect and trimethoprim–sulfamethoxazole and dexamethasone were started. Examination of CSF showed 194 cells/mm3 (74% eosinophils, 18% lymphocytes, 4% monocytes, and 2% neutrophils), protein = 83 mg/dL, and glucose = 49 mg/dL. Detection of Toxoplasma gondii on CSF by polymerase chain reaction confirmed the diagnosis of cerebral toxoplasmosis. An exhaustive laboratorial investigation excluded other possible etiologies. After 14 days, the patient showed complete resolution of neurological and CSF alterations and substantial improvement in the brain lesion and was discharged home. We suggest that eosinophilic meningitis should be included in the spectrum of manifestations of HIV-related cerebral toxoplasmosis, especially in countries with high prevalence of toxoplasmosis in the general population.

Eosinophilic meningitis due to Angiostrongylus cantonensis in Europe

OBJECTIVES

To describe and analyse the epidemiological and clinical characteristics of imported human angiostrongyliasis in Europe.

METHODS

A systematic literature review of cases of human angiostrongyliasis in Europe was performed. Seven databases were searched. The epidemiological and clinical characteristics were extracted from included records and simple summary statistics were performed on extracted data.

RESULTS

Twenty-two cases reported between 1988 and 2019 were identified. They were mainly from French Polynesia, Southeast Asia, and the Caribbean Islands. The dominant suspected mode of transmission was ingestion of prawns, shrimp, or salad. For patients with data, 90% had a history of headache, often lasting, and half had paresthesia. Eighty-nine percent had eosinophilia, 93% had cerebrospinal fluid (CSF) eosinophilia, and 92% had elevated CSF protein. Central nervous system (CNS) imaging was normal in most cases. Two-thirds received albendazole or mebendazole treatment, although this is not currently recommended.

CONCLUSIONS

We have increased previous numbers to 22 reported cases in total since 1988. Angiostrongyliasis should generally be suspected in patients with a lasting headache who have returned from Southeast Asia, China, the Caribbean Islands, Australia, or French Polynesia, as well as parts of North America and Tenerife, Spain, although one autochthonous case from mainland Europe has also been reported. A dietary history should focus on prawns, shrimp, and salad, whilst also including slugs and snails and other paratenic hosts where relevant. The clinical diagnosis is supported by the presence of blood eosinophilia, CSF eosinophilia, and elevated CSF protein. A definitive laboratory diagnosis should be sought, and CNS imaging should be used to support, not to rule out the diagnosis. The most up-to-date evidence should always be consulted before initiating treatment. Current recommendations include analgesics, corticosteroids, and periodic removal of CSF for symptom relief, while antihelminthic treatment is debated.

A new synthetic lure for management of the invasive giant African snail, Lissachatina fulica

Synthetic chemical lures mimicking pheromones or food attractants are essential tools in eradication programs for invasive species. However, their uses in programs aiming to control or eradicate terrestrial gastropods are largely unexplored. The goal of this study was to find a synthetic attractant that could aid in the eradication or management of the giant African snail (Lissachatina fulica). Field studies in Hawaii showed that a commercial papaya-flavored oil attracted snails. Analysis of the odor profile of the oil identified a total of 22 chemicals, which comprised > 98% of the volatile compounds emitted by the oil. A synthetic blend was reconstructed that mirrored the release rates of the papaya oil odors. In laboratory and field bioassays, the reconstructed blend, applied to cotton wicks as water and canola oil or water and mineral emulsions, attracted more snails than the water and oil emulsion control wicks. Field studies in Hawaii and Florida showed that the reconstructed blend in an oil emulsion was not attractive to non-target species such as butterflies or bees. The snails were attracted from distances > 1 m and entered traps baited with the attractant emulsion. When tested in the South Florida giant African snail eradication program, direct ground application of the reconstructed papaya-flavored oil emulsion increased the number of snails killed by over 87% compared to water emulsion controls. Integrating tactics using the synthetic papaya oil attractant into control measures should increase the effectiveness of eradication and management programs.

A Case Report of Slug Ingestion Causing Eosinophilic Meningitis, Papilledema, and Pronounced Motor Weakness in a US Marine

Angiostrongyliasis is the most common cause of eosinophilic meningitis worldwide and is primarily characterized by eosinophilic meningitis, meningoencephalitis, or myelitis. It is caused by ingestion of the nematode Angiostrongylus cantonensis, the rat lungworm (or apple snail). The most common route of infection is by ingestion of parts of the intermediate hosts like mollusks or food contaminated with infective third stage larvae. Following ingestion, the larvae migrate through the intestinal walls into the bloodstream and further into the central nervous system where they cause meningo-encephalo-myelitis and can have a variety of ocular manifestations. We present a case of a Caucasian United States Marine who suffered severe meningo-encephalo-myelitis with papilledema following ingestion of a raw Giant African Snail (Lissachatina lutica) while stationed in Japan. He developed eosinophilic meningoencephalitis, polyneuropathy, motor weakness, and papilledema. We describe the unique clinical features of this disease in our patient.

A case report of Coccidioides posadasii meningoencephalitis in an immunocompetent host

Background

Coccidioides spp. are dimorphic fungi endemic to Central America, regions of South America and southwestern USA. Two species cause most human disease: Coccidioides immitis (primarily California isolates) and Coccidioides posadasii. Coccidioidomycosis is typically acquired through inhalation of soil or dust containing spores. Coccidioidal meningitis (CM), most common in the immunocompromised host, can also affect immunocompetent hosts.

Case presentation

We report a case of C. posadasii meningoencephalitis in a previously healthy 42-year-old Caucasian male who returned to Canada after spending time working in New Mexico. He presented with a 3-week history of headache, malaise and low-grade fevers. He developed progressive confusion and decreasing level of consciousness following hospitalization. Evidence of hydrocephalus and leptomeningeal enhancement was demonstrated on magnetic resonance imaging (MRI) of his brain. Serologic and PCR testing of the patient's CSF confirmed Coccidioides posadasii. Despite appropriate antifungal therapy he continues to have significant short-term memory deficits and has not returned to his full baseline functional status.

Conclusions

Travel to endemic regions can result in disease secondary to Coccidioides spp. and requires physicians in non-endemic areas to have a high index of suspicion. Effective therapeutic options have reduced the mortality rate of CM, however, it is still associated with significant morbidity and requires life-long therapy.

Diagnostic importance of eosinophilic meningitis in HIV-positive and HIV-negative patients

The presence of eosinophils in the cerebrospinal fluid (CSF) should always be considered abnormal. This study aimed to evaluate the causes of eosinophils in the CSF of patients who are HIV positive and HIV negative. This is the first study of eosinophils in the CSF of patients who are HIV-positive. This was a retrospective study of CSF reports from 1996 to 2005, patients were selected based on the presence of eosinophils in the CSF. We analyzed 20,008 CSF reports; eosinophils were present in 5%. The median and interquartile range (IQR) of eosinophils was 2% (1%, 4%). Eosinophilic meningitis (CSF eosinophils ≥ 10%) was present in 12% of the samples. The main etiologies were infectious diseases as follows: neurocysticercosis, Cryptococcus sp. meningitis, and acute bacterial meningitis. In HIV-positive cases, all causes were by infectious disease, the main pathogen being Cryptococcus sp. The probability of neurocysticercosis in a patient from an endemic region who is HIV-negative and has CSF eosinophils more than 10% was five times higher compared to a person without eosinophilic meningitis. There was a weak positive correlation between CSF eosinophils and increased serum eosinophils. Among the HIV-negative cases, the most frequent non-infectious causes were cerebrovascular syndromes, of these hemorrhage (91.5%). In the HIV-positive group, there were no cases of non-infectious cerebral disease. CSF eosinophils are suggestive of disease. The causes must be investigated, considering the most prevalent infectious diseases in the region.

Severe CNS angiostrongyliasis in a young marine: a case report and literature review

Angiostrongylus cantonensis is the most common cause of eosinophilic meningitis worldwide. Infection typically occurs through ingestion of undercooked molluscs or vegetables contaminated by infective larvae. Endemic regions were previously limited to southeast Asia and the Pacific basin; however, this parasite is seeing an alarming increase in global distribution with reported cases in more than 30 countries, including several states in the USA. Although infection typically results in meningitis, a broad spectrum of CNS involvement and severity is emerging as diagnostic methods (such as real-time PCR) continue to improve diagnosis. In this Grand Round, we report a case of a 20-year-old active duty US marine serving in Okinawa, Japan, afflicted with severe CNS angiostrongyliasis marked by radiculomyelitis with quadriparesis, hyperaesthesia, and urinary retention. We present this case to highlight that no clear guidelines exist for the treatment of severe CNS angiostrongyliasis and provide our consensus recommendation that treatment algorithms include use of dual corticosteroids plus anthelmintics when radicular symptoms are present. In this Grand Round we review the clinical features, epidemiology, advances to diagnostic techniques, and available data on current treatment options for CNS angiostrongyliasis. This diagnosis should be highly considered in the differential diagnosis of a patient presenting with meningeal symptoms, paraesthesia or hyperaesthesia, and CSF eosinophilia so that treatment can be started early, which is particularly important in children, because of their increased risk of severe disease and mortality. We recommend combined therapy with albendazole and prednisolone, with consideration for increased steroid dosing in severe cases.

Pharmacological Management of Severe Neuropathic Pain in a Case of Eosinophilic Meningitis Related to Angiostrongylus cantonensis

Angiostrongylus cantonensis, the rat lungworm, is the most common infectious cause of eosinophilic meningitis and can be fatal. The parasite can be found throughout Southeast Asia and Pacific Islands and the global distribution is expanding. We present the case of a fourteen-year-old female who had previously traveled to Hawaii and developed severe neuropathic pain related to A. cantonensis infection refractory to gabapentin and pregabalin monotherapy, who was eventually managed with an ultralow dose ketamine infusion, methadone, and serotonin-norepinephrine reuptake inhibitor.

The helminth community of a population of Rattus norvegicus from an urban Brazilian slum and the threat of zoonotic diseases

Urban slums provide suitable conditions for infestation by rats, which harbour and shed a wide diversity of zoonotic pathogens including helminths. We aimed to identify risk factors associated with the probability and intensity of infection of helminths of the digestive tract in an urban slum population of Rattus norvegicus. Among 299 rats, eleven species/groups of helminths were identified, of which Strongyloides sp., Nippostrongylus brasiliensis and, the human pathogen, Angiostrongylus cantonensis were the most frequent (97, 41 and 39%, respectively). Sex interactions highlighted behavioural differences between males and females, as eg males were more likely to be infected with N. brasiliensis where rat signs were present, and males presented more intense infections of Strongyloides sp. Moreover, rats in poor body condition had higher intensities of N. brasiliensis. We describe a high global richness of parasites in R. norvegicus, including five species known to cause disease in humans. Among these, A. cantonensis was found in high prevalence and it was ubiquitous in the study area - knowledge which is of public health importance. A variety of environmental, demographic and body condition variables were associated with helminth species infection of rats, suggesting a comparable variety of risk factors for humans.

Autochthonous Case of Eosinophilic Meningitis Caused by Angiostrongylus cantonensis, France, 2016

We report a case of a 54-year-old Moroccan woman living in France diagnosed with eosinophilic meningitis caused by Angiostrongylus cantonensis. Diagnosis was based on clinical symptoms and confirmed by testing of serum and cerebrospinal fluid samples. Physicians should consider the risk for A. cantonensis infection outside of endemic areas.

Eosinophilic Meningitis Due to Infection With Paragonimus kellicotti

Paragonimus kellicotti is an emerging pathogen in the United States with 19 previously reported cases, most in Missouri. Pulmonary symptoms with eosinophilia are most common, though 1 case did involve the central nervous system with few symptoms. We describe the first 2 cases of eosinophilic meningitis due to Paragonimus kellicotti.

Chronic Eosinophilic Meningoencephalitis by Prototheca Wickerhamii in an Immunocompetent Boy

Human protothecosis is mainly a cutaneous infection caused by the Prototheca species. Prototheca wickerhamii is an established pathogen of eosinophilic meningoencephalitis in dogs, but no eosinophilic pleocytosis of the cerebrospinal fluid has been reported in human cases of meningitis. Herein, we report a case of chronic protothecosis manifesting eosinophilic meningoencephalitis in an immunocompetent boy.

Eosinophilic meningitis triggered by implanted Gliadel wafers: case report

Although carmustine (Gliadel) wafers improve local tumor control and extend the overall survival in patients with malignant glioma, adverse effects have been documented. The authors report the first case of eosinophilic meningitis triggered by the placement of Gliadel wafers. A 61-year-old man with a history of alimentary allergy and glioblastoma in the right frontal lobe underwent resection followed by the implantation of Gliadel wafers. Three weeks later he suffered the sudden onset of headache, vomiting, and progressive consciousness disturbance. Computed tomography revealed enlargement of the ventricular system and subdural space on the side of the tumor. His CSF leukocyte count increased up to 3990 cells/mm³; 95% of the cells were eosinophilic granulocytes (EGs), suggesting eosinophilic meningitis. Laboratory examination showed the patient to have various elevated allergy indicators. The administration of corticosteroids failed to improve his condition. Despite the insertion of a lumbar drain his symptoms failed to improve. He underwent a second surgical intervention to remove the Gliadel wafers. Histologically, EGs had assembled around the wafers. Eosinophilic infiltrate was present in the brain parenchyma around small vessels. After ventriculoperitoneal shunting his course was favorable. A drug lymphocyte stimulation test against the Gliadel wafers failed to demonstrate a positive reaction; polifeprosan, the wafer matrix without 1,3-bis(2-chloroethyl)-1-nitrosourea, yielded a positive reaction. These findings strongly suggest that although extremely rare, polifeprosan (the wafer matrix) can elicit an allergic reaction. When eosinophilic meningitis is suspected after the implantation of Gliadel wafers, their immediate removal should be considered.

Eosinophilic meningitis: a case series and review of literature of Angiostrongylus cantonensis and Gnathostoma spinigerum

Eosinophilic meningitis is defined as the presence of >10 eosinophils/μL in cerebrospinal fluid (CSF) or at least 10% eosinophils in the total CSF leukocyte count. Eosinophilic meningitis has been reported in two case series and two case reports in India till date and has not been reported in children below 15 years of age. We present two children with eosinophilic meningitis with peripheral eosinophilia and the proposed etiologic agents based on the clinical setting and their response to antihelminthic agents.

[A case of myelitis with eosinophilia of the cerebrospinal fluid]

A 25-year-old woman developed numbness of the right flank two weeks after a one-month stay in Thailand and Laos, which are known as areas of angiostrongylosis cantonensis infections. The signs were numbness, pain sense disorder, and vibration sense disorder on the region of the 6th to 12th dermatome. On a MRI T(2) weighted image (T(2)WI), signal hyperintensity in a longitudinal spinal lesion was seen. In the cerebrospinal fluid (CSF), eosinophils were detected. The patient was diagnosed with eosinophilic meningitis and myelitis, and then treated with intravenous methylprednisolone. This improved her signs, CSF and MRI findings. She took no drugs, did not have any allergies, any vasculitis, or neuromyelitis optica spectrum disorders. Although anti-parasite antibodies were not identified, she was probably infected by angiostrongylus cantonensis from her history and examinations.

Magnetic resonance imaging of infectious meningitis and ventriculitis in adults

Magnetic resonance imaging findings of meningitis are usually nonspecific with respect to the causative pathogen because the brain response to these insults is similar in most cases. In this article, we will use a few representative cases to describe the characteristic magnetic resonance findings of meningitis and its complications, including ventriculitis.

Central nervous system manifestations of Angiostrongylus cantonensis infection

Over 20 species of Angiostrongylus have been described from around the world, but only Angiostrongylus cantonensis has been confirmed to cause central nervous system disease in humans. A neurotropic parasite that matures in the pulmonary arteries of rats, A. cantonensis is the most common cause of eosinophilic meningitis in southern Asia and the Pacific and Caribbean islands. The parasite can also cause encephalitis/encephalomyelitis and rarely ocular angiostrongyliasis. The present paper reviews the life cycle, epidemiology, pathogenesis, clinical features, diagnosis, treatment, prevention and prognosis of A. cantonesis infection. Emphasis is given on the spectrum of central nervous system manifestations and disease pathogenesis.

Communicating hydrocephalus following eosinophilic meningitis is pathogenic for chronic Viliuisk encephalomyelitis in Northeastern Siberia

BACKGROUND

Viliuisk encephalomyelitis (VE) is an endemic neurological disease in Northeast Siberia and generally considered to be a chronic encephalomyelitis of unknown origin actually spreading in the Sakha (Yakutian) Republic.

METHODOLOGY AND PRINCIPLE FINDINGS

In search for the pathophysiology and causative agent of VE, we performed a cross-sectional study on clinical, serological and neuroimaging data on chronic VE patients during two medical expeditions to three villages within the Viliuiski river basin in the Republic of Sakha in 2000 and to the capital Yakutsk in 2006. The severity of the core clinical picture with predominant sensory ataxia, gait apraxia, lower limb spasticity, cognitive impairment and bladder dysfunction correlated with the degree of MRI findings showing enlargement of inner ventricular spaces as in communicating hydrocephalus. Laboratory studies revealed transient eosinophilia during the preceding acute meningitis-like phase, but no ongoing inflammatory process in the CSF. We found immune reactions against Toxocara canis in the majority of chronic VE patients but rarely in controls (P = 0.025; Fisher's exact test). Histological analysis of subacute to subchronic VE brain samples showed eosinophilic infiltrations with no signs of persistent Toxocara canis infection.

CONCLUSIONS AND SIGNIFICANCE

Our data showed that pressure by the communicating hydrocephalus as a mechanical factor is the major pathogenic mechanism in chronic VE, most likely triggered by eosinophilic meningitis. There are no signs for an ongoing inflammatory process in chronic VE. The past eosinophilic reaction in VE might be caused by Toxocara ssp. infection and might therefore represent the first hint for an initial cause leading to the development of chronic VE. Our data provide a framework for future studies and potential therapeutic interventions for this enigmatic epidemic neurological disease potentially spreading in Sakha Republic.

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

INTRODUCTION

In endemic areas, eosinophilic meningitis is mainly caused by Angiostrongylus cantonensis. We describe a series of this poorly-known condition.

METHODS

Retrospective cohort study (2000-2012) including all patients diagnosed with eosinophilic meningitis in French Polynesia.

RESULTS

Forty-two patients (males: 61.9%, age: 22 (IQR 17-32)) were diagnosed with a serologically proven (n=13) or probable A. cantonensis meningitis, mostly during the dry season (66.6%) and following the consumption of or prolonged contact with an intermediate/paratenic host (64.3%). No differential diagnosis was found in probable cases, in whom serological tests were performed earlier (7.5 days (6.5-10)) compared to positive patients (7.5 (6.5-10) versus 11 (7-30) days, p=0.02). The most commonly reported symptom was headache (92.8%). Fever (7.1%) and biological inflammatory syndrome (14.3%) were rare. Blood eosinophil count was 1200/mm(3) (900-2548). Cerebrospinal fluid (CSF) analysis disclosed a protein level of 0.9 g/L (0.7-1.1), a CSF/plasma glucose ratio of 0.50 (0.40-0.55), and 500 leucocytes/mm(3) (292-725; eosinophils: 42.0% (29.5-60); lymphocytes: 46.5% (32.5-59.0)). Thirteen cases (31.0%) were severe, with 11 focal neurological deficits. A delayed hospital referral (OR 1.13, p=0.05) was associated with severity.

CONCLUSIONS

A. cantonensis meningitis must be evocated in young patients with meningitic syndrome, severe headache, and CSF inflammation with predominance of eosinophils.

[Case of recurrent encephalomyelitis associated with eosinophilia in CSF]

We report a 30-year-old man with recurrent eosinophilic encephalomyelitis. He had a history of childhood asthma and allergic rhinitis. A half year before admission, when he suffered from a headache, a few lesions were indicated by brain MRI at another hospital. From a month before admission, he noticed gait disturbance, sensory impairment, difficulty in micturition, and constipation. Neurological examination revealed moderate muscle weakness in the feet, hypoesthesia below Th6, and bladder-bowel disturbance including impotence. Lumbar T(2) weigthed MRI showed a severe swelling and a hyperintense lesion at the conus medullaris. Brain MRI revealed several asymptomatic white matter lesions. Eosinophilia was documented in the cerebrospinal fluid (CSF) but not in the peripheral blood. Clinical symptoms and MRI findings were remarkably improved after steroid pulse therapy. Note that eosinophils in the CSF were also decreased after the treatment with apoptosis-like cells. We thought that CSF eosinophilia was the core pathogenic feature of this case, but clinical settings that provoke CSF eosinophilia such as parasites and other infectious agents, neuromyelitis optica, atopic myelitis, eosinophilic leukemia and hypereosinophilic syndrome could be ruled out. The remarkable responses to steroids without any additional therapy, compatible with idiopathic eosinophilic syndromes, confirmed that this was a case of idiopathic eosinophilic recurrent encephalomyelitis.

Rapid progression and brain atrophy in anti-AMPA receptor encephalitis

Anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor encephalitis is an anti-neuronal surface antigen autoimmune encephalitis that is rarely reported. Our study evaluated the first known patient who developed anti-AMPA receptor encephalitis during pregnancy. Initial brain MRI revealed bilateral limbic encephalitis. However, rapid brain atrophy on MRI with extensive hypometabolism of cerebral cortices, caudate nuclei and brain stem hypoperfusion on (18)F-FDG PET developed when clinically progressed. IgG index of serial CSF studies reflected the clinical improvements after plasmapheresis and plasma exchange. The clinical spectrum of anti-AMPA receptor encephalitis may be expanded from limited limbic involvement to extended central nervous system.