Case Report: Angiostrongylus cantonesis Myelitis in Thailand.

A 67-year-old man presented with headache, middle back pain that radiated to both legs, and paresthesia in the right leg for 1 day. He had eaten raw shrimp 1 week previously. Over the next week after admission, he developed urinary retention and weakness in both legs. The numbness in his right leg expanded to below the umbilicus. Magnetic resonance imaging of the spinal cord showed myelopathy with minimal cord swelling at T9 to the conus medullaris and a hemorrhagic lesion from T10 to T11. A complete blood count on day 28 after the onset of symptoms revealed leukocytosis without eosinophilia and no white blood cells in his cerebrospinal fluid. Results of an immunochromatographic test kit were positive for Angiostrongylus cantonesis but negative for Gnathostoma spinigerum. After a 4-week course of albendazole combined with a tapering dose of dexamethasone, he achieved nearly complete recovery.

Cerebral Toxocariasis as a Cause of Epilepsy: A Pediatric Case.

Toxocarosis is the consequence of human infection by Toxocara spp. larvae and is one of the most common ascarioses, not only in developing countries, but also in the European region, where its prevalence reaches 14%. Due to their particular behavior, children are at higher risk of this parasitic infection, whose clinical features depend on the localization of the Toxocara larvae. Neurotoxocariasis is very uncommon in children and may take different forms depending on the underlying physiopathologic process: immune reaction against the parasite antigens, vasculitis, treatment complications, or, very rarely, brain localization of Toxocara spp. larvae. The association between neurotoxocariasis and the onset of childhood epilepsy has been postulated but is still debated. Moreover, a Toxocara spp. abscess causing epileptic seizures in children has been rarely described, especially in western countries. Hereby we present a 9-year-old patient with a new diagnosis of epilepsy definitely secondary to brain abscess due to the localization of Toxocara canis larvae. Diagnosis was confirmed by neuroimaging and serological test. The successful treatment with albendazole and steroids was documented with a close and long-term clinical and neuroradiological follow-up. Our experience confirms that every case of cryptogenetic epilepsy in children deserves a neuroimaging study and, in case of cystic images, Toxocara serology is mandatory to avoid further unnecessary invasive diagnostic investigations and to set the specific drug therapy.

The metagenomic next-generation sequencing in diagnosing central nervous system angiostrongyliasis: a case report.

BACKGROUNDS: The incidence of angiostrongyliasis is increasing in recent decades due to the expanding endemic areas all over the world. Clinicians face tremendous challenge of diagnosing angiostrongyliasis because of the lack of awareness of the disease and less effective definitive laboratory tests. CASE PRESENTATION: A 27-year-old man initially manifested skin itching, emesis, myalgia and quadriparesis. With progressive weakness of four limbs and elevated protein in the cerebrospinal fluid (CSF), he was diagnosed as Guillain-Barré syndrome and treated with intravenous methylprednisolone and immunoglobulin. However, the patient deteriorated with hyperpyrexia, headache and then persistent coma. The routine tests for Angiostrongylus cantonensis (A. cantonensis) with both the CSF and the serum were all negative. In contrast, the metagenomic next-generation sequencing (mNGS) was applied with the serum sample and the CSF sample in the middle phase. The central nervous system (CNS) angiostrongyliasis was diagnosed by mNGS with the mid-phase CSF, but not the mid-phase serum. At the same time, the CSF analysis revealed eosinophils ratio up to 67%. The discovery of A. cantonensis was confirmed by PCR with CSF later. Unfortunately, the patient died of severe angiostrongyliasis. During his hospitalization, mNGS was carried out repeatedly after definitive diagnosis and targeted treatment. The DNA strictly map reads number of A. cantonensis detected by mNGS was positively correlated with the CSF opening pressure and clinical manifestations. CONCLUSIONS: The case of A. cantonensis infection highlights the benefit of mNGS as a target-free identification in disclosing the rare CNS angiostrongyliasis in the unusual season, while solid evidence from routine clinical testing was absent. The appropriate sample of mNGS should be chosen according to the life cycle of A. cantonensis. Besides, given the fact that the DNA reads number of A. cantonensis fluctuated with CSF opening pressure and clinical manifestations, whether mNGS could be applied as a marker of effectiveness of treatment is worth further exploration.

Use of Ivermectin in Neurocysticercosis: A Case Report.

BACKGROUND Neurocysticercosis is a Taenia solium infection which utilizes the tapeworm as a vector and humans as a definitive host and causes development of cystic lesions in the central nervous system. The current established medical therapy is albendazole with praziquantel as a secondary agent, but results can be mixed depending on each patient and their form of neurocysticercosis. CASE REPORT We present a case pertaining to a young female patient diagnosed with single parenchymal neurocysticercosis based on clinical and diagnostic findings. This case was unique in the sense that ivermectin, another antiparasitic agent, was used as monotherapy with significant improvement in the patient's clinical presentation and radiological findings. CONCLUSIONS Despite current guidelines recommending use of albendazole with or without praziquantel for neurocysticercosis, our case (as well as 4 other cases documented in the recent past) suggest a possible use of ivermectin as potential therapy for neurocysticercosis. We recommend continued research regarding other cases of ivermectin use in similar patients and even comparison studies with albendazole with or without praziquantel in terms of efficacy and side effects in order to better treat this international endemic.

Cerebral Paragonimiasis With Hemorrhagic Stroke in a Developed Country.

Paragonimiasis is a food-borne parasitic disease caused by Paragonimus lung flukes, which are epidemic in Asia. Cerebral paragonimiasis accounts for <1% of symptomatic paragonimiasis but is the most common extrapulmonary infection. Cerebral paragonimiasis often mimics stroke and sometimes causes severe neurological sequelae. A 61-year-old woman was admitted to the hospital for severe headache. A head computed tomography scan revealed intracerebral hemorrhage with subarachnoid hemorrhage. The patient also had lesions in the lungs. She frequently ate Japanese mitten crab. Peripheral blood examination results of increased eosinophilia and immunological testing results confirmed the diagnosis of Paragonimus westermani infection. The patient was successfully treated with praziquantel as the first-line agent. Cerebral paragonimiasis is currently rare in developed countries; however, it is an important disease to consider.

Swollen eyelid reveals multiple intracranial hydatid cysts associated with a palpebral cyst.

We report a case of a hydatid cyst of the eyelid in a 12-year-old boy associated with cerebral involvement. The patient was initially treated by neurosurgeons for brain cysts. The course after an interval of two months was marked by regression of the palpebral cyst on albendazole.

Neurognathostomiasis in a young child in India: A case report.

Eosinophilc meningitis is commonly associated with Angiostrongylus and Gnathostoma infection and has largely been reported from Thailand. We present the first case report of neurognathostomaisis in a pediatric patient from India. A 3.5 year old girl presented with fever, parasthesis, behavioral changes followed by flaccid quadriparesis. Neuroimaging showed haemorrhagic radiculomyelitis with cerebrospinal fluid eosinophilia. Diagnosis of Gnathostoma infection was confirmed serologically and she was treated with anthelminthic drugs and steroids. This report emphasizes the increasing importance of central nervous system helminithic infections as an alternative diagnosis to common infections like neurotuberculosis in developing countries, even in pediatric patients. Increasing intercontinental travel and migration have increased the incidence and importance in the developed world as well.

Worms on the brain: fatal meningoencephalitis from disseminated strongyloides infection.

Severe, complicated Strongyloides infection can lead to bacterial sepsis and meningitis. We report a case of Strongyloides meningoencephalitis complicating steroid treatment for presumptive asthma. Following a patient's seizure, analysis of cerebrospinal fluid (CSF) revealed numerous Strongyloides worms (filariaform larvae). The finding of threadworms within the central nervous system (CNS) is exceptionally rare. Seven days of ivermectin therapy with subsequent lumbar puncture revealed the organisms were eradicated from the CNS. Unfortunately, the patient never recovered neurologic function and expired after supportive care was withdrawn.

Late diagnosis of central nervous system involvement associated with lethal dissemination of Strongyloides stercoralis in an advanced HIV patient from Nigeria.

Strongyloides stercoralis is a ubiquitous intestinal nematode, endemic in tropical and subtropical areas, with an unusual life cycle in which autoinfection can take place. In the immunosuppressed host, autoinfection is accelerated and larvae can spread in all organs, leading to hyperinfection syndrome or to disseminated disease. Strongyloidiasis is presently rare in Western Countries, often with delayed diagnosis due to a lack of clinical suspicion, nonspecific presentation, and low parasite intestinal output. Foreign HIV-infected patients from endemic areas are at increased risk of severe disease caused by this parasite. Here we report the case of a patient with disseminated lethal disease, whose disseminated state was missed 2 years prior to the current presentation. This emblematic case shows that intestinal parasitic infections, highly prevalent in Sub-Saharan Africa, Southeast Asia, and Latin America, are difficult to recognize but should be thoroughly investigated and excluded in high-risk patients, to prevent severe long-term lethal sequelae.

Good outcome with early empiric treatment of neural larva migrans due to Baylisascaris procyonis.

We report a remarkably good outcome in a 14-month-old boy with early clinical diagnosis and aggressive empirical treatment of neural larva migrans caused by the raccoon roundworm Baylisascaris procyonis. He presented with fever, meningismus, lethargy, irritability and asymmetric spastic extremity weakness. Early findings of marked blood and cerebrospinal fluid eosinophilia and of diffuse white matter signal abnormality in the brain and spinal cord on MRI suggested a parasitic encephalomyelitis. Rapid presumptive treatment with albendazole and high-dose steroids halted progression of clinical signs. The diagnosis was confirmed by 2 sequential enzyme-linked immunosorbent assay studies positive for B procyonis serum immunoglobulin G and by Western blot. Field examination with soil sampling yielded infective Baylisascaris eggs. Repeat MRI 3 months later showed atrophy and diffuse, chronic white matter abnormalities, discordant with the marked clinical improvement in this interval. At 10 months, residual neurologic deficits included subtle paraparesis and moderate language delay. This case is the first in which spinal involvement in human Baylisascaris infection was clinically suspected and confirmed by neuroimaging. Importantly, early diagnosis and aggressive treatment of Baylisascaris meningo-encephalitis and myelitis with albendazole and high-dose steroids likely contributed to the good outcome in this patient, in contrast with previous reports.

Acute neurological signs as the predominant clinical manifestation in four dogs with Angiostrongylus vasorum infections in Denmark.

Four dogs with acute neurological signs caused by haemorrhages in the central nervous system were diagnosed with Angiostrongylus vasorum infection as the underlying aetiology. Two dogs presented with brain lesions, one dog with spinal cord lesions and one with lesions in both the brain and spinal cord. Only one dog presented with concurrent signs of classical pulmonary angiostrongylosis (respiratory distress, cough), and only two dogs displayed overt clinical signs of haemorrhages. Results of coagulation assays were inconsistent. Neurological signs reflected the site of pathology and included seizures, various cranial nerve deficits, vestibular signs, proprioceptive deficits, ataxia and paraplegia. One dog died and three were euthanised due to lack of improvement despite medical treatment. This emphasises canine angiostrongylosis as a potential cause of fatal lesions of the central nervous system and the importance of including A. vasorum as a differential diagnosis in young dogs with acute neurological signs in Denmark.

Clinical manifestations of eosinophilic meningitis caused by Angiostrongylus cantonensis: 18 years' experience in a medical center in southern Taiwan.

BACKGROUND: With the improvement of public health, eosinophilic meningitis associated with Angiostrongylus cantonensis infection is now seldom reported in Taiwan. Eosinophilic meningitis typically occurred sporadically in children. This study aims to analyze the clinical manifestations and change in the contemporary epidemiology of eosinophilic meningitis in Taiwan. METHODS: This is a retrospective study of patients diagnosed with eosinophilic meningitis at Kaohsiung Veterans General Hospital, from December 1991 to September 2009. The demographic characteristics, clinical presentations, laboratory data, radiographic imaging, and treatment and clinical outcome were analyzed. A PubMed search with the keywords of eosinophilic meningitis, A cantonensis, and Taiwan was performed to retrieve cases of eosinophilic meningitis caused by A cantonensis since 1960. RESULTS: Thirty-seven patients were diagnosed to have eosinophilic meningitis during a period of 18 years. The median age was 32 years (range, 2-80 years). Ninety five percent (35/37) of the patients were adults. The median incubation period was 10.5 days (range, 3-80 days). Most of the patients presented with headache (29, 78%), fever (25, 68%), and 11(30%) had hyperesthesia. Patients with hyperesthesia had longer incubation period (55 vs. 7 days, p=0.004), lower serum immunoglobulin E levels (127.5 vs. 1295 IU/mL, p<0.001), and longer duration between symptom onset and spinal taps (14 vs. 5 days, p=0.011). Three patients presented initially with lymphocytic meningitis, and eosinophilia only appeared on a second lumbar puncture. Magnetic resonance imaging of the brain disclosed leptomeningeal enhancement (17/26, 65%) and increased signal intensity (10/26, 38%) on T2-weighted and fluid-attenuated inversion recovery images. There were eight relapses and two patients died. No sequela was noted except in one 2-year-old toddler, who had weakness of both lower limbs. CONCLUSIONS: The epidemiology of eosinophilic meningitis has changed during the past two decades in Taiwan and occurs mainly in adults in the setting of outbreaks. Hyperesthesia; repeated lumbar puncture in cases with lymphocytic meningitis of uncertain cause; and a detailed history, including food consumption, are important to establish an accurate diagnosis.

Strongyloides stercoralis hyperinfection: difficulties in diagnosis and treatment.

Immunocompromised patients who are infected with Strongyloides stercoralis may develop a potentially fatal auto-infection syndrome characterised by non-specific pulmonary and gastrointestinal symptoms and Gram negative sepsis. We present the case of one such patient who underwent a negative laparotomy for a presumed intra-abdominal surgical catastrophe with a subsequent protracted stay on the intensive care unit. Once the diagnosis of strongyloidiasis was made, the patient was successfully treated with subcutaneous antihelminthic drugs. With appropriate screening for and eradication of strongyloides in those with immune compromise, or in those about to start immunosuppressive therapy, potentially fatal episodes of hyperinfection could be avoided. In the absence of screening, severe strongyloidiasis should be suspected in immunosuppressed individuals who have travelled to or resided in an endemic area and present with the characteristic features. Awareness of the signs of hyperinfection amongst those involved in acute care could prevent unnecessary morbidity and mortality in these patients.

Ascariasis-associated worm encephalopathy in a young child.

Infestation with Ascaris lumbricoides in children has a varied manifestation, but encephalopathy is a very rare presentation. This report describes a case of ascariasis-associated encephalopathy in a child. An 18-month-old boy was admitted with altered sensorium. He had a history of vomiting and was passing Ascaris worms in the vomitus. The cerebrospinal fluid analysis did not reveal any abnormality. The patient was treated with an antihelminthic drug and he recovered completely. Worm encephalopathy should be considered as a differential diagnosis for unexplained encephalopathy in tropical areas.

Multiple brain hemorrhages and hematomas associated with ectopic fascioliasis in brain and eye.

BACKGROUND: Fascioliasis is a parasitic infection caused by Fasciola hepatica. Human beings can be infected accidentally by an ingestion of the metacercariae; and the parasite exists almost persistently in the bile ducts, but rarely in other organs. We report an interesting case of ectopic fascioliasis in both the brain and the right eye of a school-aged boy, which was associated with 2 unruptured intracranial aneurysms. To our knowledge, no case report such as this has been found in the medical literature. CASE DESCRIPTION: After an ingestion of Potamon denticulata (a fresh crab) for 4 months, a 10-year-old boy presented with neurologic manifestations caused by 5 episodes of intracranial hemorrhages and hematomas. The boy simultaneously suffered repeated affliction in the right eye accompanied by headache, vomiting, ophthalmalgia, exophthalmos, and abducens nerve palsy. Digital subtraction angiography revealed 2 unruptured intracranial aneurysms. The definitive diagnosis of this case had been confirmed by an observation of the parasite moving out of the patient's swelling conjunctiva and by the results of the laboratory tests. The patient was treated with praziquantel and completely recovered. The 2 aneurysms were not surgically treated but underwent a long-term follow-up. The follow-up DSA revealed that one aneurysm disappeared but the other remained unchanged. CONCLUSIONS: Multiple brain hemorrhages and hematomas can be associated with ectopic fascioliasis in brain and eyes. An intracranial infection occasionally caused by F hepatica or other parasites can be indicated by a fever of unknown origin, eosinophilia, and iterative intracranial hemorrhages. Ingestion of P denticulata may be an uncommon transmission route of fascioliasis. Fascioliasis can be successfully treated.

Neurotoxocarosis.

Infection of humans with embryonated eggs of Toxocara canis (larva migrans) remains asymptomatic, or results in covert or common toxocarosis, visceral larva migrans syndrome, or ophthalmologic and neurologic impairment. Though neurological manifestations of Toxocara canis larvae are rare, toxocarosis remains an important differential diagnosis of various neurological disorders. Manifestations of the central nervous system are dementia, meningo-encephalitis, myelitis, cerebral vasculitis, epilepsy, or optic neuritis. Manifestations of the peripheral nervous system comprise radiculitis, affection of cranial nerves, or musculo-skeletal involvement. If toxocarosis is neglected, ignored, or refused as a differential of these abnormalities, it may be easily overlooked for years. Early recognition and treatment of the infection is, however, of paramount importance since it reduces morbidity and mortality and the risk of secondary superinfection. Like the visceral manifestations, neurological manifestations of toxocarosis are treated by benzimidazole components, most frequently albendazole, corticosteroids, or diethylcarbamazine. If detected and treated early, the prognosis of neurological manifestations of toxocarosis is favourable.