1. Abstract Angiostrongylus cantonensis, the rat lungworm, is a parasitic nematode naturally found in Southeast Asia and the Pacific Basin, in addition to Australia, Africa, the Caribbean, Hawaii and most recently in Louisiana. It is transmitted between rats and mollusks in its natural life cycle. Humans are accidental hosts by ingestion of raw or undercooked infected snails or slugs or foods contaminated by infected snails or slugs. Eosinophilic meningitis in humans is commonly caused by Angiostrongylus cantonensis. Symptoms most commonly include severe headache, malaise, nausea and vomiting, myalgias and confusion or altered mental status. History often includes ingestion of raw or undercooked seafood. This case of a non-traveling 12 month old with eosinophilic meningitis secondary to Angiostrongylus cantonensis. This presentation will discuss the work-up of eosinophilic meningitis with its rare presentation in this age group. This report will also address the literature on treatment regarding the use of albendazole only versus albendazole with corticosteroids. Eosinophilic meningitis secondary to Angiostrongylus cantonensis Stacy Nayes, MD University of Texas at Houston, Department of Pediatrics, PGY-1 Work-up and Response The initial work-up and therapy was directed at the more common causes of eosiniphilic meningitis. While labs were pending, empiric therapy was started with albendazole and prednisone for toxocara canis as this was highest on the differential with the patient’s exposure to animals., especially dogs. Pertinent lab results that were found to be negative: West Nile virus, Toxoplasma IgM, Toxocara IgG, Trichinella, Stronyloides, and fungal infections including Coccidiodes, Blastomyces and Histoplasma. Patient responded well to the albendazole and prednisone, with clinical improvement in appetite and behavior. Patient was discharged home on day 4/5 of therapy. She was readmitted two days after completing therapy with low-grade fevers, increased fussiness and patient no longer walking on her own. Labs on repeat admission were sent to the Centers of Disease Control in Atlanta. Angiostrongylus cantonensis PCR in CSF was positive. Patient was started on a longer treatment course of albendazole and prednisone. Case Report Twelve month old with no significant past medical history presented with an 11 day history of fever, Tmax of 102, decreased oral intake, increasing fussiness and decreased activity. She remained consolable with no URI symptoms, emesis or rash. Her birth history was unremarkable and she had never required any hospitalizations or urgent care visits. She had not received her 12 month vaccines as she was febrile with this illness at her one year well child check. Social history is significant for separated parents and patient spending time at two different locations. Mom lives in an apartment with no pets or smoke exposure. Dad is remarried with a 13 year old step-brother, 1 month old step-brother and multiple inside and outside dogs and cats. Physical exam: Wt: 11.5 kg (95%) Ht: 80 cm (97%) FOC: 45.5 cm (59%) T 97.3 HR 98 RR 26 BP 99/46 Gen – fussy, cries appropriately during exam, consolable HEENT – AF soft and flat, PERRL, TMs clear, MM appear dry, neck supple, no LAD RESP – CTAB, no wheezes or retractions CV – RRR, no murmur. Cap refill 3 sec Abd – soft, NT ND, normal bowel sounds GU – normal Tanner I female, no rashes or lesions Neuro – normal tone, reflexes 2 + Skin – no rashes, no jaundice Initial labs: CBC: WBC 17.9 Hb11.8 Hct 35.9 Plt 424 Diff: N 40 L 35 E 20 M 5 no bands CSF count: Glucose 30 (L), Protein 60 (H), RBC 8, WBC 568 Diff: N 0 L 39 M 35 E26 UA: 15 ketones, trace leukocyte esterase, 3-5 WBCs, negative glucose, blood, protein, nitrite Brain MRI with contrast (after a normal one obtained 9 days earlier): Leptomeningeal enhancement with diffuse nodular leptomeningeal enhancement consistent with meningitis Differential Diagnosis Most common causes of eosinophilic meningitis (all uncommon in the United States and this age): Angiostrongylus cantonesis Baylsascariasis Ghatosomiasis Toxocara canis Visceral larva migrans More common infections that may present with eosinophilic meningitis: Cysticercosis Toxoplasmosis Atypical infections: Mycobacterium TB, Coccidiomycosis Literature Review Albendazole has been shown to be highly effective against human helminthic infection while also demonstrating larvicidal and ovicidal actitivy. One study showed that albendazole when started 5-10 days after infection and continued for 21 days completely eliminated the larvae from the brains of mice. There was no noticeable damage found in cerebral hemispheres of mice after being treated and cured with albendazole. In adults with eosinophilic meningitis, a prospective, randomized, double-blind placebo controlled study showed that a two week course of albendazole had a tendency to reduce the duration of headaches. This study recommended a study comparing albendazole alone or in combination with steroids. A study in 2009 showed no significant difference in clinical outcomes between the prednisolonealone and albendazole and prednisolone together. Our patient responded well with albendazole and prednisone and made a complete clinical recovery. References 1.Parasites- Angiostrongyliasis. Centers for Disease Control and Prevention. http://www.cdc.gov/parasites/angiostrongylus/ http://www.cdc.gov/parasites/angiostrongylus/ 2.Larvicidal effect of albendazole against Angiostrongylus cantonensis in mice. American Journal of Tropical Medicine, 39(2), 1988, pp. 191-195 (87-325) 3.Comparison of Prenisolone Plus Albendazole with Prednisolone Alone for Treatment of Patients with Eosinophilic Meningitis. American Journal of Tropical Medicine, 81(3), 2009, pp 443-445. 4.Albendazole therapy for eosinophilic meningitis caused by Angiostrongylus cantonensis. Parasitol Res (2007) 100:1293-1296. Texas Pediatric Society Electronic Poster Contest Life cycle of Angiostrongylus Cantonensis