Images in Clinical Medicine

Gnathostomiasis — Neuroimaging of Larval Migration

Pasiri Sithinamsuwan, M.D., and Parnsiri Chairangsaris, M.D.

N Engl J Med 2005; 353:188July 14, 2005

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Article

An 18-year-old man presented with symptoms that evolved over the course of three days and included fever, radicular back pain, vertigo, ataxia, headache, and left-sided hemiparesis. He reported that he had had skin swellings in a migratory pattern during the preceding month. His diet typically consisted of raw fish. A complete blood count showed 7100 white cells per cubic millimeter with 33 percent eosinophils. A computed tomographic scan of the brain showed diffuse swelling. A magnetic resonance image of the brain revealed multiple worm-like lesions in both hemispheres and the cerebellum (arrows, Panels A and B), which did not enhance with the administration of gadolinium. A lumbar puncture revealed an opening pressure of 250 mm of water, the presence of xanthochromia, a white-cell count of 3000 cells per cubic millimeter with 70 percent eosinophils, a protein level of 51 mg per deciliter, and a glucose level of 5.1 mmol per liter. An immunoblot assay of a sample of cerebrospinal fluid was positive for gnathostomiasis. Treatment with albendazole was not given because of concern that severe brain edema might develop if the worms were to die suddenly. Prednisolone was given at a dosage of 60 mg per day for seven days. The patient improved within two weeks, and he was discharged with mild left-sided hemiparesis. At six months after discharge, he had residual mild spasticity of the left leg but no weakness. Gnathostomiasis is typically caused by Gnathostoma spinigerum and is most commonly seen in Southeast Asia. The clinical symptoms are related to the mechanical disruption that is associated with the larval migration.

Pasiri Sithinamsuwan, M.D.
Parnsiri Chairangsaris, M.D.
Pramongkutklao Hospital, Bangkok, Thailand 10400

Citing Articles (5)

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   Jaturat Kanpittaya, Kittisak Sawanyawisuth, Pewpan M. Intapan, Piyarat Khotsri, Verajit Chotmongkol, Wanchai Maleewong. (2011) A comparative study of neuroimaging features between human neuro-gnathostomiasis and angiostrongyliasis. Neurological Sciences
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   Juri Katchanov, Yukifumi Nawa. (2010) Helminthic invasion of the central nervous system: Many roads lead to Rome. Parasitology International 59:4, 491-496
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   Anna M. Checkley, Peter L. Chiodini, David H. Dockrell, Imelda Bates, Guy E. Thwaites, Helen L. Booth, Michael Brown, Stephen G. Wright, Alison D. Grant, David C. Mabey, Christopher J.M. Whitty, Frances Sanderson. (2010) Eosinophilia in returning travellers and migrants from the tropics: UK recommendations for investigation and initial management. Journal of Infection 60:1, 1-20
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   James H. Diaz. (2010) Recently Reemerging Helminthic Infections Causing Eosinophilic Meningoencephalitis: Neuroangiostrongyliasis, Baylisascariasis, and~Gnathostomiasis. Journal of Neuroparasitology 1, 1-14
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   James H. Diaz. (2009) Recognizing and Reducing the Risks of Helminthic Eosinophilic Meningitis in Travelers: Differential Diagnosis, Disease Management, Prevention, and Control. Journal of Travel Medicine 16:4, 267-275
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