Name of Parasite: Parastrongylus cantonensis

Common names/ other names: Rat lungworm, Angiostrongylus cantonensis

I. MORPHOLOGY
A. cantonensis is a nematode roundworm with 3 outer protective collagen layers, and a simple
stomal opening with no lips or buccal cavity leading to a fully developed gastrointestinal tract.
Males have a small copulatory bursa at the posterior. Females have a “barber pole” shape down
the middle of the body, which is created by the twisting together of the intestine and uterine
tubules. The worms are long and slender - males are 15.9-19 mm in length, and females are 21-
25 mm in length

Adult male (top) and female (bottom) A. cantonensis worms. Note copulatory bursa at posterior
of male, and characteristic “barber pole” spiral in female.

II. LIFE CYCLE

The adult form of A. cantonensis resides in the pulmonary arteries of rodents, where it
reproduces. After the eggs hatch in the arteries, larvae migrate up the pharynx and are then
swallowed again by the rodent and passed in the stool. These first stage larvae then penetrate or
are swallowed by snail intermediate hosts, where they transform into second stage larvae and
then into third stage infective larvae. Humans and rats acquire the infection when they ingest
contaminated snails or paratenic (transport) hosts including prawns, crabs, and frogs, or raw
vegetables containing material from these intermediate and paratenic hosts. After passing
through the gastrointestinal tract, the worms enter circulation. In rats, the larvae then migrate to
the meninges and develop for about a month before migrating to the pulmonary arteries, where
they fully develop into adults.
Humans are incidental hosts; the larvae cannot reproduce in humans and therefore humans do not
contribute to the A. cantonensis life cycle. In humans, the circulating larvae 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, inciting the inflammatory reaction that causes
symptoms of infection.

III. MODE OF TRANSMISSION

Transmission is based on food-borne routes, ingestion of raw or insufficiently cooked
contaminated mollusks, crustacean, or other hosts; or ingestion of vegetables contaminated with
infectious larvae.

IV. PATHOLOGY & SYMPTOMATOLOGY

Symptomatic treatment is indicated for symptoms such as nausea, vomiting, headache, and in
some cases, chronic pain due to nerve damage or muscle atrophy. Repeat lumbar puncture may
be required to lower intracranial pressure and relieve headaches.
V. LABORATORY DIAGNOSIS
Diagnosis of the human infection caused by A. costaricensis can be
made by examining biopsied or surgical specimens and confirming the presence of
the parasites or their eggs. Graeff-Teixeira et al. (1991) established histopathological patterns for
diagnosis. Also, an enzyme-linked immunosorbent assay (ELISA)
was developed that demonstrated a sensitivity of 86% and a specificity of 83% when
used with sera adsorbed with Ascaris suum antigens (Graeff-Teixeira et al., 1997).
ANGIOSTRONGYLIASIS 229
In endemic areas, meningitis or meningoencephalitis caused by A. cantonensis is
suspected in the presence of the characteristic signs of eosinophilia in the blood and
eosinophilic pleocytosis of the cerebrospinal fluid. In places such as Thailand,
where infection of the central nervous system caused by Gnathostoma spinigerum
has a high prevalence, the two diseases must be differentiated. Punyagupta et al.
(1990) indicate that gnathostomiasis causes sharp pain in the nerve roots, signs of
cerebral and spinal disease, and yellowish or bloody cerebrospinal fluid. Although
most reports indicate that only in a few cases can the parasite be found in patients’
cerebrospinal fluid or eyes, Hwang and Chen (1991) reported having recovered it by
lumbar puncture in 41.5% of 84 pediatric cases. Serologic tests are useful for confirming the
presumptive diagnosis (Legrand and Angibaud, 1998). Two varieties of
ELISA have shown a specificity of 100%, but sensitivity of just 50% to 60%
(Eamsobhana et al., 1997).

VI. TREATMENT
Treatment of angiostrongylus is not well defined, but most strategies include a combination of
anti - parasitics to kill the worms, steroids to limit inflammation as the worms die, and pain meds
to manage the symptoms of meningoencephalitis.
Anti-Helminthics
Anti-helminthics are often used to kill off the worms, however in some cases this may cause
patients to worsen due to toxins released by the dying worms. Albendazole, ivermectin,
mebendazol, and pyrantel are all commonly used, though albendazole is usually the drug of
choice. Studies have shown that anti-helminthic drugs may shorten the course of the disease and
relieve symptoms. Therefore anti-helminthics are generally recommended, but should be
administered gradually so as to limit the inflammatory reaction.
Anti-Inflammatories
Anti-helminthics should generally be paired with corticosteroids in severe infections to limit
the inflammatory reaction to the dying parasites. Studies suggest that a two week regimen of a
combination of mebedizole and prednisolone significantly shortened the course of the disease
and length of associated headaches without observed harmful side effects [8]. Other studies
suggest that albendazole may be more favorable, because it may be less like to incite an
inflammatory reaction. The Chinese herbal medicine long-dan-xie-gan-tan (LDGXT) has also
been shown to have a similar anti-inflammatory effect, and in mild cases may be used alone to
relieve symptoms while infection resolves itself.
VII. PREVENTION AND CONTROL

While human angiostrongyliasis is not very prevalent, except in a few

areas of high endemicity, prophylaxis is important because there is no known therapeutic
treatment for the infection. Theoretically, angiostrongyliasis could be controlled by reducing
rodent and mollusk populations, though practical application
seems doubtful. Preventive measures for individuals consist of thoroughly washing
vegetables, and hands after garden or field work; not eating raw or undercooked
mollusks and crustaceans; and not drinking water that may be unhygienic.
Experiments have shown that incubation of infective A. costaricensis larvae for 12
hours at 5°C in 1.5% sodium hypochlorite kills all the larvae. Incubation in saturated
sodium chloride or in commercial vinegar reduced the number of larvae but failed
to prevent the infection in mice (Zanini and Graeff-Teixeira, 1995).