Current Management of

Eosinophilic Meningitis
Somsak Tiamkao, M.D.
Department of Medicine
Faculty of Medicine
Khon Kaen University

Topics
Clinical manifestations
Diagnosis
Immunodiagnosis
Current management

Eosinophilic Meningitis (EoM)

CSF eosinophil > 10 %
Wet smear or Wrights stain

EoM is not a disease

Parasitic infestration
Tuberculous meningitis
Cryptococcal meningitis
Syphilitic meningitis
Carcinomatous meningitis
Rheumatoid arthritis
HIV infection

Parasitic infestration

Epidemiology
Angiostrongyliasis
Thailand (NE)
Taiwan
Asia pacific
US
Oct Feb.

Gnathostomiasis
Japan
Thailand

Presenting symptoms
Angiostrongyliasis
Headache
(meningitis)
Ocular
GI ??

Gnathostomiasis
Cutaneous
(migratory swelling,
larva migran)
Neuro.
(SAH,ICH,myelitis,
meningitis,radicular
pain,)
Ocular

Diagnosis
Angiostrongyliasis & Gnathostomiasis
Definite : larva, immunodiagnosis
Clinical diagnosis*

Clinical dx. of A. cantonensis

Duration of headache
Character of headache
Incubation period
Without history of raw snail

Physical signs
80
70
60

50
40
30
20
10
0
fever

stiffneck

Jitpimolmard

eosinophilia

Chotmongkol

Sawanyawisuth

Laboratory findings
CSF analysis
Serology
CT & MRI

CSF

Parasite ?

CSF analysis
Angiostrongyliasis
OP > 30 cm H2O ~ 40 %
WBC < 5,000 cells/mm3
CSF protein < 500 mg/dl
CSF sugar > 50 %
Some cases CSF sugar < 50 %

Gnathostomiasis
Xanthochromia
WBC < 1,000 cells/mm3

Serology
Ab or Ag detection
Immunoblotting or Western blot
Indication
Study
Questionable cases

Lab : Depart. Parasitology, KKU

0-4336-3432

www.eosinophilic-meningitis.worldmedic.com

Angiostrongyliasis

Immunoblotting : Ab detection
29 kDa diagnostic band
Sensitivity : 56-100%
Specificity : 95-100%

IMMUNOBLOTTING
Antibody against 29 KDa of A.cantonensis
MW marker (KDa)

29 KDa

P: positive control; N: negative control; T: tested serum

IMMUNOBLOTTING

Antibody against 24 KDa of G.spinigerum

24 KDa

1-9 : Gnathostomiasis sera

MRI : angiostrongyliasis

Kanpittaya, et al. AJNR 2000

MRI in gnathostomiasis
Tract ?

Sawanyawisuth K, Tiamkao S, et al. AJNR, 2004

MRI : cauda equina gnathostomiasis

Prior to treatment
Sawanyawisuth K, Tiamkao S, et al. (submitting)

9 months F/U

CT : Gnathostomiasis

Treatment
A. cantonensis
Anti parasite
Lumbar puncture
Corticosteroids

Albendazole 15 MKD
16.2

mean duration of headache

(day)

18

P < 0.05

16
14
12

8.9

10
8
6
4
2
0
albendazole

Jitpimolmard, et al (submitting)

placebo

Lumbar puncture
9

8.23

8
7

VAS

6
5
3.02

4
3
2
1
0

Sawanyawisuth, et al (submitting)

Corticosteroids
Prednisolone
4*3, 2 weeks
RCT

Corticosteroids 2 weeks
P = 0.00004

P = 0.00000
25
()

()

25
20
15
10

5
0

steroid

placebo

Chotmongkol, et al, CID, 2000.

13

14
12
10
8
6

4
2
0

steroid

placebo

Corticosteroid 1 & 2 weeks

mean duration of headache
(day)

4.78

4
3
2
1
0
1 wk

Sawanyawisuth, et al. (submitting)

2 wks.

Corticosteroid 1 week
Relapsed ~ 15 %
Mostly less severe (VAS)

Side effect of corticosteroid

No serious side effect :
UGIB, severe hyperglycemia

Suggestions
Lumbar puncture in case of suspicious
Prednisolone 4*3
1 week : close follow up, advice
2 weeks : without taper off

Albendazole 15 MKD (option)

Ongoing study
Predictive factor & duration of headache
Severe cases : combine steroid &
albendazole

Eosinophilic meningoencephalitis
Supportive treatment
Corticosteroids : equivocal
Prognosis

Treatment
Gnathostomiasis
Cutaneous : Albendazole 800 mg/d, 21 days
Ivermectin 0.2 MKD single dose
CNS : no definite treatment
F/U : eosinophilia ( 6 months)
: ELISA Ig G (12 months)

Summary
Prevention
Angiostrongyliasis
EoM : Prednisolone (1 or 2 weeks +/albendazole) and Lumbar puncture
Eo. Meningoencephalitis : supportive Rx.
Gnathostomiasis
Cutaneous : Albendazole 800 mg,21 days
Neurological : supportive Rx. (albendazole or
steroid may be beneficial)