Severe Neuropathic Back Pain as the Initial Presentation in Angiostrongylus cantonensis Infection: The Role of ICU Management in Overcoming Diagnostic and Analgosedation Challenges

Abstract

Introduction: Angiostrongylus cantonensis is a parasitic nematode that typically inhabits the pulmonary arteries of rats but can also reside in the central nervous systems of rats and mollusks. Humans can become infected with A. cantonensis by eating infected hosts or consuming contaminated food, especially if it is raw or undercooked. This infection can lead to various neurological symptoms, including neuropathic pain, which is often an early indication of the condition. In this report, we present a case in which the patient experienced neuropathic pain as the initial clinical manifestation of A. cantonensis infection. Case Presentation: We present a rare case of a 27-year-old female who required intensive care unit (ICU) monitoring due to heavy sedation after receiving high doses of sedative-analgesics for back pain. The patient reported experiencing severe, slow-progressing low back pain radiating to her arms and legs. The pain was described as sharp, tingling, and numbing, severely limiting her movements. To manage the pain, a combination of morphine, intermittent fentanyl, ketamine, dexmedetomidine, duloxetine, and pregabalin was administered. Consequently, the patient had to be intubated due to the effects of the analgesics. During the first two weeks in the ICU, diagnosis proved challenging as the MRI was normal and the initial lumbar puncture revealed only an eosinophilic infection. However, during a follow-up lumbar puncture, multiple parasites were discovered in the cerebrospinal fluid, which were identified as A. cantonensis. The patient remains on a ventilator as the infection has affected the spinal nerve roots, cord, meninges, and brain. We explore the crucial role of ICU care in providing both supportive and definitive treatment for this patient. Conclusions: This report underscores the critical role of the ICU in providing care for a patient with a progressively deteriorating condition without an initial definitive diagnosis. The ICU's ability to deliver optimal pain relief and sedation, advanced monitoring, and prompt therapy for deteriorating symptoms was of utmost significance. Furthermore, the multidisciplinary team in the ICU was instrumental in managing the continuum of care for the patient.