Eosinophilic meningitis

35F, 3 wks HA, paresthesias, ⬇️L hearing

Lived in Indonesia+Philippines past yr

LP: OP 25, 300 WBC (10%N, 60%L, 18%Eos), 5 RBC, prot 100

Altho any eos in CSF is abnl, eosinophilic meningitis is more precisely defined as presence of

Most define eos meningitis (EM): >=10 eos or >10% in CSF

🚨THREE key parasitic inf on the ddx for EosM🚨
🔸Angiostrongylus cantonensis
🔸Baylisascaris procyonis
🔸Gnathostoma spinigerum

Exhaustive list below fr our own Dr.Weller+adapted for UpToDate!

https://pubmed.ncbi.nlm.nih.gov/8368222/

Let’s briefly review these top 3. Abbreviations for the following tweets!
🗺️=Classic endemic areas, but maps included with full distribution
RF = risk factors
Tx = Treatment
CDC life cycle images included

Let's go!

Excited Excited Pikachu GIF
  1. Angiostrongylus cantonensis (rat lungworm)
    🗺️SE Asia, Pacific Basin
    🔹RF: Eat raw snail/slug, contaminated ground veggies, children play in dirt
    🔹Larvae neurotropic-migrate to neuro, ocular tissue
    🔹Severe HA, may need CSF removal for sxs
    🔹Tx: supportive(larv die over time)

2. Baylisascariasis (roundworm)
🗺️Widely in US
🔹Racoon hosts
🔹RF: ingestion of contaminated soil
🔹Migration to variety of tissues results in visceral larva migrains/ocular LM syndromes, similar to toxocariasis. EosM rare
🔹Tx: supportive vs. albendazole?

3. Gnathostomiasis
🗺️SE Asia,China,Japan
🔹RF: Eat raw fish, poultry
🔹Present:migratory cutaneous swelling, EosM, visceral mass
🔹🧠Larv penetrate/migrate up nerve➡️sudden severe radicular pain/HA➡️can cause cerebral hemorrhage
🔹Tx: Supportive. Utility CNS tx ? Cutane➡️Albend

Dx of these are difficult and primarily clinical — based on CSF eosinophilic pleocytosis +/- peripheral eosinophilia +/- exposures/the right history. Larvae are often not recovered and serologies rarely available outside of highly endemic areas

pokemon looking GIF by POKÉMON Detective Pikachu

Other parasite eggs/larv can localize w/i CNS + elicit eos pleocytosis, such as:
Cerebral, spinal schisto
Toxocariasis
Trichinosis
Neurocysticercosis
Fascioliasis
Cerebral, spinal paragonimiasis

For nonparasitic: Cocci, crypto

Noninfectious etiologies noted in tweet #2!

These infections/presentations are quite rare for us and often textbook reviews, but we know there are ID friends, @ID_fellows all over the globe on #IDTwitter. Let us know if you have tips or pearls for eosinophilic meningitis or these parasitic infections!!

pokemon GIF

Image ref:
CDC for life cycles

https://tdtmvjournal.biomedcentral.com/articles/10.1186/s40794-019-0084-x

https://wwwnc.cdc.gov/eid/article/22/12/16-0467-f1?commit=GO

Originally tweeted by BIDMC Infectious Diseases Fellowship (@BIDMC_IDFellows) on 13 August, 2020.

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