JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
increasedWBC count in the CSF with a median of 333 cells/mm³ (18-765), and a median eosinophil differential count of 13% (0- 54).8 This study also found a CSF glucose median of 55 mg/dL (51-81), and an elevated CSF protein median of 52 mg/dL (36- 82). Of note, this study found that a significant hematologic eosinophilia was not seen until the midpoint of the clinical course. The mean eosinophil count at initial presentation was 443 +/- 90 cells/mm³ and the eosinophil count at the midpoint of the clinical course was 957 +/- 203 cells/mm³. However, a significant varying leukocytosis on a complete blood count was not noted over the clinical course.8
ormollusks. Patient did endorse eating rawvegetables from local food market, which could also have been the potential source of infection due to contamination from snails or slugs, also another potential exposure to rats or intermediate hosts could have been when she went picnicking at the state campground on the lake, particularly given the incubation period which is usually two weeks. It is important to increase awareness to practitioners about A. cantonensis in patients with eosinophilia in serum or in CSF specially if patients have exposure history, or have recently travel to endemic areas now including Louisiana, Texas, or Florida.
TREATMENTS
ACKNOWLEDGEMENTS
Eosinophilic meningitis caused by A. cantonensis is traditionally self-limiting. Mild infections do not require any medical treatment, though increased severity of infection may warrant treatment. Certain anti-helminthic medications (i.e. mebendazole, albendazole) have been used in treatments for eosinophilic meningitis, but recent studies have shown a lack of efficacy of these medications for this condition.3 It is theorized that swiftly killing the CNS larvae may promote a larger immune response, which could exacerbate meningeal irritation symptoms. However, corticosteroids have been shown to reduce meningeal inflammation and lessen the severity of the associated headache. Repeated lumbar punctures have also shown some benefit in reducing headache duration.2,3,8,14 During one study, McBride, et al., treated 86.7% (n=50) with dexamethasone and albendazole. Of all the patients, one died, though he had multiple comorbidities including disseminated salmonellosis at the age of 78. Additionally, they noted that 69.4% (n=43) of patients had some residual symptoms at discharge that were not evaluated further. PCR positivity was irrelevant in treatment outcomes.2
Maricarmen Cruz Saldana for her participation on the development of figure 1 regarding A. cantonensis life cycle.
CASE DISCUSSION
The initial presentation of right CN VI palsy, pulsatile, tinnitus, positional headaches, and papilledema were consistent with intracranial hypertension. She initially did not endorse, either light sensitivity or neck stiffness; however, upon review of symptoms, she admitted to having mild symptoms. The patient was also afebrile and meningeal signs were not elicited on physical examination; therefore, she was admitted to rule out idiopathic intracranial hypertension, and meningitis was lower in the differential. Infectious disease was consulted after LP showed a high WBC with 60% eosinophilia, it was thought that the presence of Strongyloides S . IgG was an incidental finding and unrelated to patient’s symptomatology; nevertheless, it was decided to treat with ivermectin in the setting of starting steroid therapy for A. Cantonensis to avoid a possible Strongyloides S . super infection. Headaches and papilledema responded immediately after the LP and initiation of acetazolamide. The CN VI palsy persisted until steroid therapy was initiated. This case was proven challenging due to its atypical presentation, and no known exposure history of eating raw fresh water snails,
86 La State Med Soc VOL 170 MAY/JUNE 2018
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