Angiostrongyliasis

Angiostrongyliasis is an infection by a nematode 2 Transmission

from the Angiostrongylus genus of kidney and alimen-
tary tract roundworms. For example, infection with Transmission of the parasite is usually from eating raw or
Angiostrongylus cantonensis can occur after consuming undercooked snails or other vectors. Infection is also fre-
raw Giant African land snails, great grey slugs, or other quent from ingestion of contaminated water or unwashed
mollusks. salad that may contain small snail and slugs, or have been
In humans, Angiostrongylus is the most common cause of contaminated by them. Therefore it is very important to
eosinophilic meningitis or meningoencephalitis.[1] Fre- avoid raw snails, wash and cook vegetables thoroughly,
quently the infection will resolve without treatment or se- and avoid open water sources that may be contaminated.
rious consequences, but in cases with a heavy load of par-
asites the infection can be so severe it can cause perma-
nent damage to the central nervous system or death.[2] 3 Reservoirs
Rats are the denitive host and the main reservoir for A.
1 Symptoms cantonensis, though other small mammals may also be-
come infected. While angiostrongylus can infect humans,
humans do not act as reservoirs since the worm cannot
Infection rst presents with severe abdominal pain, nau- reproduce in humans and therefore humans cannot con-
sea, vomiting, and weakness, which gradually lessens and tribute to their life cycle.[2]
progresses to fever, and then to CNS symptoms and se-
vere headache and stiness of the neck.
4 Vectors
1.1 Severe/CNS infection
A. cantonensis has many vectors, with the most com-
CNS symptoms begin with mild cognitive impairment mon being several species of snails, including the giant
and slowed reactions, and in a very severe form often African land snail (Achatina fulica) in the Pacic islands
progress to unconsciousness.[3] Patients may present with and snails of the genus Pila in Thailand and Malaysia.
neuropathic pain early in the infection. Eventually se- The golden apple snail, A. canaliculatus, is the most im-
vere infection will lead to ascending weakness, quadri- portant vector in areas of China.[3] Freshwater prawns,
paresis, areexia, respiratory failure, and muscle atrophy, crabs, or other paratenic, or transport, hosts can also act
and will lead to death if not treated. Occasionally patients as vectors.[2]
present with cranial nerve palsies, usually in nerves 7 and
8, and rarely larvae will enter ocular structures.[4] Even
with treatment, damage to the CNS may be permanent 5 Incubation period
and result in a variety of negative outcomes depending on
the location of the infection, and the patient may suer The incubation period in humans is usually from 1 week
chronic pain as a result of infection.[3] to 1 month after infection, and can be as long as 47
days.[4] This interval varies, since humans are intermedi-
ate hosts and, the life cycle does not continue predictably
1.2 Eye invasion as it would in a rat.[2]

Symptoms of eye invasion include visual impairment,

pain, keratitis, and retinal edema. Worms usually appear 6 Morphology
in the anterior chamber and vitreous and can sometimes
be removed surgically. A. cantonensis is a nematode roundworm with 3 outer
The parasite is rarely seen outside of endemic areas, and protective collagen layers, and a simple stomal opening or
in these cases patients generally have a history of travel mouth with no lips or buccal cavity leading to a fully de-
to an endemic area. veloped gastrointestinal tract.[1] Males have a small cop-

1
2 9 TREATMENT

ulatory bursa at the posterior. Females have a barber intracranial pressure and eosiniphil counts should rise.
pole shape down the middle of the body, which is cre- Increased levels of eosinophils in the CSF is a trademark
ated by the twisting together of the intestine and uterine of the eosiniphilic meningitis.[3]
tubules. The worms are long and slender - males are 15.9
19 mm in length, and females are 2125 mm in length.[5]
8.2 Brain imaging
Brain lesions, with invasion of both gray and white matter,
7 Life cycle can be seen on a CT or MRI. However MRI ndings tend
to be inconclusive, and usually include nonspecic lesions
The adult form of A. cantonensis resides in the pulmonary and ventricular enlargement. Sometimes a hemorrhage,
arteries of rodents, where it reproduces. After the eggs probably produced by migrating worms, is present and of
hatch in the arteries, larvae migrate up the pharynx and diagnostic value.
are then swallowed again by the rodent and passed in the
stool. These rst stage larvae then penetrate or are swal-
lowed by snail intermediate hosts, where they transform 8.3 Serology
into second stage larvae and then into third stage infective
larvae. Humans and rats acquire the infection when they In patients with elevated eosiniphils, serology can be used
ingest contaminated snails or paratenic (transport) hosts to conrm a diagnosis of Angiostrongylias rather than in-
including prawns, crabs, and frogs, or raw vegetables con- fection with another parasite.[1] There are a number of
taining material from these intermediate and paratenic immunoassays that can aid in diagnosis, however sero-
hosts. After passing through the gastrointestinal tract, the logic testing is available in few labs in the endemic area,
worms enter circulation.[4] In rats, the larvae then migrate and is frequently too non-specic. Some cross reactivity
to the meninges and develop for about a month before has been reported between A. cantonensis and trichinosis,
migrating to the pulmonary arteries, where they fully de- making diagnosis less specic.
velop into adults.[2]
The most denitive diagnosis always arises from the iden-
Humans are incidental hosts; the larvae cannot reproduce tication of larvae found in the CSF or eye, however due
in humans and therefore humans do not contribute to the to this rarity a clinical diagnosis based on the above tests
A. cantonensis life cycle. In humans, the circulating lar- is most likely.
vae migrate to the meninges, but do not move on to the
lungs. Sometimes the larvae will develop into the adult
form in the brain and CSF, but they quickly die, incit-
ing the inammatory reaction that causes symptoms of
9 Treatment
infection.[2]
Treatment of angiostrongyliasis is not well dened, but
most strategies include a combination of anti - parasitics
to kill the worms, steroids to limit inammation as the
8 Diagnosis worms die, and pain medication to manage the symptoms
of meningitis.
Diagnosis of Angiostrongyliasis is complicated due to the
diculty of presenting the angiostrongylus larvae them-
selves, and will usually be made based on the presence of 9.1 Anti-helminthics
eosiniphilic meningitis and history of exposure to snail
hosts. Eosiniphilic meningitis is generally characterized Anti-helminthics are often used to kill o the worms,
as a meningitis with >10 eosiniphils/L in the CSF or at however in some cases this may cause patients to worsen
least 10% eosiniphils in the total CSF leukocyte count.[4] due to toxins released by the dying worms. Albenda-
Occasionally worms found in the cerebrospinal uid or zole, ivermectin, mebendazol, and pyrantel are all com-
surgically removed from the eye can be identied in or- monly used, though albendazole is usually the drug of
der to diagnose Angiostrongyliasis. choice. Studies have shown that anti-helminthic drugs
may shorten the course of the disease and relieve symp-
toms. Therefore anti-helminthics are generally recom-
8.1 Lumbar puncture mended, but should be administered gradually so as to
limit the inammatory reaction.[3]
Lumbar puncture should always be done is cases of sus-
pected meningitis. In cases of eosiniphilc meningitis it
will rarely produce worms even when they are present in 9.2 Anti-inammatories
the CSF, because they tend to cling to the end of nerves.
Larvae are present in the CSF in only 1.9-10% of cases.[3] Anti-helminthics should generally be paired with corti-
However, as a case of eosiniphilic meningitis progresses, costeroids in severe infections to limit the inammatory
11.1 Recommendations for individuals
reaction to the dying parasites. Studies suggest that a
two-week regimen of a combination of mebedizole and
prednisolone signicantly shortened the course of the dis-
ease and length of associated headaches without observed
harmful side eects.[6] Other studies suggest that alben-
dazole may be more favorable, because it may be less like
to incite an inammatory reaction.[7] The Chinese herbal
medicine long-dan-xie-gan-tan (LDGXT) has also been
shown to have a similar anti inammatory eect, and in
mild cases may be used alone to relieve symptoms while
infection resolves itself.[7]
9.3 Symptomatic treatment
Symptomatic treatment is indicated for symptoms such as
nausea, vomiting, headache, and in some cases, chronic
pain due to nerve damage or muscle atrophy.
10 Epidemiology
A. cantonensis and its vectors are endemic to Southeast
Asia and the Pacic Basin.[1] The infection is becoming
increasingly important as globalization allows it to spread
to more and more locations, and as more travelers en-
counter the parasites. The parasites probably travel ef-
fectively through rats traveling as stowaways on ships, and
through the introduction of snail vectors outside endemic
areas.
Although mostly found in Asia and the Pacic where
asymptomatic infection can be as high as 88%, human
cases have been reported in the Caribbean, where as
much as 25% of the population may be infected. In the
United States, cases have been reported in Hawaii, which
is in the endemic area [5]. The infection is now endemic
in wildlife and a few human cases have also been reported
in areas where the parasite was not originally endemic,
such as New Orleans and Egypt.
The disease has also arrived in Brazil, where there were
34 conrmed cases from 2006 to 2014, including one
death.[8] The giant African land snail, which can be a vec-
tor of the parasite, has been introduced to Brazil as an
invasive species and is spreading the disease. There may
be more undiagnosed cases, as Brazilian physicians are
not familiar with the eosinophilic meningitis associated
to angiostrongyliasis and misdiagnose it as bacterial or
viral.[8]
11 Public health and prevention
There are many public health strategies that can drasti-
cally limit the transmission of A. cantonensis by limiting
contact with infected vectors. Vector control may be pos-
sible, but has not been very successful in the past. Edu-
cation to prevent the introduction of rats or snail vectors
3
outside endemic areas is important to limit the spread of
the disease.[9] There are no vaccines in development for
angiostrongyliasis.
11.1 Recommendations for individuals
To avoid infection when in endemic areas, travelers
should:
Avoid consumption of uncooked vectors, such as
snails and freshwater prawns
Avoid drinking water from open sources, which may
have been contaminated by vectors
Prevent young children from playing with or eating
live snails
12 References
[1] Baheti NN & Sreedharan M et al (2008). Eosinophilic
meningitis and an ocular worm in a patient from Kerala,
south India J. Neurol. Neurosurg. Psychiatry 79 (271).
[2] David, John T. and Petri, William A Jr. Markell and
Voges Medical Parasitology. St. Louis, MO: El Sevier,
2006.
[3] Hua Li, Feng Xu, Jin-Bao Gu and Xiao-Guang Chen
(2008). Case Report: A Severe Eosinophilic Menin-
goencephalitis Caused by Infection of Angiostrongylus
cantonensis. Am. J. Trop. Med. Hyg., 79(4): 568570.
[4] L. Ramirez-Avila (2009). Eosinophilic Meningitis due
to Angiostrongylus and Gnathostoma Species. Emerging
Infections, 48: 322-327.
[5] Syed, Soa. Mulcrone, Renee Sherman; O'Connor,
Barry, eds. Angiostrongylus cantonensis. Animal Di-
versity Web. Retrieved 2017-04-04.
[6] V Chotmongkol and K Sawadpanitch et al. (2006).
Treatment of Eosiniphilic Meningitis with a Combina-
tion of Prednisolone and Mebendazole. Am. J. Trop.
Med. Hyg., 74(6): 11221124.
[7] SC Lai, KM Chen, YH Chang and HH Lee (2008).
Comparative ecacies of albendazole and the Chi-
nese herbal medicine long-dan-xie-gan-tan, used alone
or in combination, in the treatment of experimental
eosinophilic meningitis induced by Angiostrongylus can-
tonensis. Annals of Tropical Medicine & Parasitology,
102(2): 143150.
[8] Thom, Clarissa (2014-08-04). Meningite transmitida
por parasita avana no Brasil [Meningitis transmitted by
parasite increases in Brazil]. O Estado de S. Paulo (in Por-
tuguese). Retrieved 2014-08-04.
[9] JE Alicata (1991). The Discovery of Angiostrongylus
Cantonensis as a Cause of Human Eosiniphilc Meningi-
tis. Parasitology Today, 7(6): 151-153.
4 13 EXTERNAL LINKS

13 External links
Parasites - Angiostrongyliasis (also known as An-
giostrongylus Infection)". CDC. 2015-12-28. Re-
trieved 2017-04-04.

DPDx - Angiostrongyliasis. CDC. 2016-10-17.

Retrieved 2017-04-04. Tabs for Parasite Biology,
Image Gallery, Laboratory Diagnosis, and Treat-
ment Information.
 5

14 Text and image sources, contributors, and licenses

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