A 17-year-old presents to the ED after returning from vacation in Hawaii with his family. While on vacation, they went hiking on a dusty trail while barefoot, jet-skiing in the ocean where he accidentally inhaled water, spelunking, and his brother recalls one meal where he saw a live slug on his brother’s local salad and dared him to eat it (which he did).
Upon returning home 3 weeks later, he develops a severe bifrontal headache without cranial nerve deficits. Upon presentation he is noted to have 5% peripheral eosinophilia. CT scan did not reveal any focal lesions. CSF is obtained: cloudy, 20% eosinophils, normal glucose, and elevated protein. He was given albendazole empirically for treatment without improvement Over the next few days, his headache worsens and develops nausea, vomiting, and facial nerve paralysis.