Eosinophilic meningoencephalitis caused by Angiostrongylus cantonesis

Abstract

A 67-year-old man presented with fatigue, myalgia and progressive drowsiness for 10 days and finally slipped into a coma. Neurological examinations showed mild neck stiffness, increased deep tendon reflex in his four limbs and bilateral positive Babinski's sign. Blood count analysis showed 15 530 leukocytes/μl with 22.2% eosinophils. His cerebrospinal fluid (CSF) contained 550 leukocytes/μl with 74% eosinophils, glucose of 62 mg/dl (normal range: 40–80 mg/dl) and protein of 150 mg/dl (normal range: 15–45 mg/dl). The serum and CSF surveys for bacteria, herpes simplex virus, cytomegalovirus, amoeba, fungus and tuberculosis were all negative. An electroencephalogram (EEG) showed diffuse cortical dysfunction particularly involving the bilateral frontoparietal lobes. The chest X-ray was unremarkable. Magnetic resonance imaging (MRI) of the brain showed abnormal hyperintensity in the sulcal CSF spaces on T2-fluid-attenuated inversion recovery (T2-FLAIR) images, suggestive of meningitis. Also noted were multifocal disoriented linear and nodular T2-hyperintense lesions in the bilateral cerebral white matter (Figure 1). 99mTc-ethylene …