JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
James Diaz, MD Tickborne Viral Infections Intracranial Hyp rtension Secondary to Eosinophilic Meningitis Caused by Angiostrongylus Cantonensis
Roberto Cruz, MD, Christopher Smith, MD, Alexander Ramos, MD, Brian Copeland, MD, Paula Seal, MD, MPH
Angiostrongylus Cantonensis , a nematode, is a well-known cause of eosinophilic meningitis in endemic areas such as Southeast Asia, the Pacific Islands, and Hawaii. Nevertheless, an increasing number of cases in the southeast of the U.S. have been documented recently, specifically in Louisiana, Texas, and Florida. Infection is acquired after ingesting undercooked fresh water snails, mollusks, or undercooked vegetables contaminated by the slime from infected snails or slugs. Typical signs and symptoms include fever, general malaise, meningeal signs, headaches, photophobia, nausea and vomiting. Here we present a 23 year-old woman who presented to our emergency department with signs and symptoms consistent with intracranial hypertension, malaise, mild photophobia, and without fever, or meningeal signs. We also provide a review of the most recent literature regarding eosinophilic meningitis secondary to A. cantonensis .
CASE REPORT A 23 year-old woman presented to the emergency department at University Medical Center in New Orleans, LA in July 2017 complaining of headaches and vision changes for one week. Our neurology service was emergently consulted. She has no prior significant pastmedical history other than recent uncomplicated vaginal delivery ten months prior to presentation. She is originally from Pahn Thiet City, Vietnam but has lived in New Orleans, LA since arriving to the U.S. in 2015 and has not traveled out of the state since her arrival. She is a stay-at-home mom and denies taking over the counter medications or supplements. She mentioned her daily diet was very rich in seafood, which she usually obtains directly from local fishermen. She denied, however, eating raw, or undercooked food to her knowledge. She shops at a local Asian food market for produce. She denied any outdoor activities or travel with the exception of visiting a Louisiana State Park and campsite where she picnicked 13 days prior to her presentation. At time of admission the patient mentioned having diffuse pounding headaches for about one week. She mentioned that the headaches were worse when lying flat and improved with standing or sitting up. The severity has worsened to a 10 out of 10 on the day of admission. She also mentioned new onset horizontal diplopia, blurry vision, and pulsatile tinnitus. Upon further questioning she reported mild sensitivity to light and new onset of mild neck pain. She initially was evaluated at another emergency department nine days prior to presentation to our medical center, at which time
of nausea, vomiting, headaches, and general malaise with a subjective fever for one week. She was diagnosed with a viral illness and was discharged with supportive measures. She denied any diarrhea, abdominal pain, dysuria, or respiratory symptoms. The patient’s triage vitals were an initial blood pressure of 106/74 mm Hg and a heart rate of 62 beats per minute, and she was afebrile. The physical examwas significant for mild neck stiffness and photophobia; cranial nerve examination was significant for Frisen grade IV papilledema bilaterally with peripapillary hemorrhages on the left optic nerve located superior-nasally, 20/20 vision bilaterally, normal intraocular pressures of 16 and 15 mm Hg on right and left eye respectively, large angle esotropia in the left eye at primary gaze, and a right cranial nerve (CN) VI palsy. The rest of the neurological examination was unremarkable, with the exception of decreased sensation to touch on her left lateral thigh. Magnetic resonance imaging (MRI) of the brain with andwithout gadolinium had no abnormalities, and the MRI venogram of the head showed an intact venous system without thrombosis or stenosis. A lumbar puncture (LP) was then performed at the bedside in the left lateral decubitus position. Opening pressure (OP) was documented at 35 cm H20. After collecting 11 ml of
J La State Med Soc VOL 170 MAY/JUNE 2018 83
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