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Travelers' Eosinophilic Meningitis: Caribbean Source Outbreak

Investigation of an outbreak of eosinophilic meningitis reveals that A. cantonensis, the leading cause of EM worldwide, is present in Jamaica.

Angiostrongylus cantonensis is the principal infectious cause of eosinophilic meningitis (EM). This rat lungworm causes human disease primarily in Southeast Asia and the Pacific basin, where larvae can infect edible intermediate or transport hosts such as prawns, fish, frogs, and snails; these hosts can, in turn, contaminate produce such as lettuce. A. cantonensis has rarely caused EM in the Western Hemisphere. This report describes an EM outbreak in adult U.S. travelers shortly after they returned from Jamaica in April 2000. Retrospective analyses were performed on a 23-person travel group after 2 members were hospitalized with EM, defined as headache plus at least 1 other finding (neck pain or rigidity, photophobia, visual disturbances, hyperesthesias, or paresthesias) occurring within 35 days after completing travel.

Twelve travelers (52%) had EM; 9 were hospitalized. Disease onset began a median of 11 days after their return (range, 6-31 days). Only 2 patients developed fever. All hospitalized patients eventually demonstrated eosinophilia, but initially 5 patients (56%) had cerebrospinal fluid (CSF) eosinophilia, and 4 patients (44%) had peripheral blood eosinophilia. Nine patients reported hyperesthesias or paresthesias. Two of the 3 patients with most severe headaches improved following corticosteroid therapy and repeated lumbar punctures, and CSF pressures declined in all 3. All patients recovered, although headaches lasted for up to 2 months in 2 cases. Convalescent sera from 11 patients contained antibodies to a 31-kD antigen of A. cantonensis, absent in the 11 healthy travelers. Retrospective analysis linked EM to 1 meal (P=0.001) containing Caesar salad (P=0.007).

Comment: Although A. cantonensis was not identified directly in CSF of these EM patients, their clinical and serologic data are clear and convincing. A. cantonensis infection can occur in the Caribbean, and this organism has recently been identified in rats and snails in Jamaica (JWID Mar 8 2002, and Emerg Infect Dis Mar 2002). Clues to this infection in the Western Hemisphere include Caribbean travel, persistent headache, meningitis with the unusual associated findings of paresthesias or hyperesthesias, and a lymphocytic pleocytosis eventually revealing eosinophilia.

— Neil R. Blacklow, MD

Published in Journal Watch Infectious Diseases March 8, 2002

Citation(s):

Slom TJ et al. An outbreak of eosinophilic meningitis caused by Angiostrongylus cantonensis in travelers returning from the Caribbean. N Engl J Med 2002 Feb 28; 346:668-75.

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