Current Management of Eosinophilic Meningitis

Somsak Tiamkao, M.D.Department of Medicine

Faculty of MedicineKhon Kaen University

Topics

• Clinical manifestations• Diagnosis• Immunodiagnosis• Current management

Eosinophilic Meningitis (EoM)

• CSF eosinophil > 10 %• Wet smear or Wright’s 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,radicularpain,…)• 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

0

10

20

30

40

50

60

70

80 %

fever stiffneck eosinophilia

Jitpimolmard Chotmongkol Sawanyawisuth

Laboratory findings

CSF analysisSerologyCT & 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, KKU0-4336-3432

• www.eosinophilic-meningitis.worldmedic.com

Angiostrongyliasis

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

IMMUNOBLOTTINGAntibody against 29 KDa of A.cantonensis

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

MW marker (KDa)

29 KDa

IMMUNOBLOTTINGAntibody 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 9 months F/U

Sawanyawisuth K, Tiamkao S, et al. (submitting)

CT : Gnathostomiasis

Treatment

• A. cantonensis–Anti parasite –Lumbar puncture–Corticosteroids

Albendazole 15 MKD

8.9

16.2

02468

1012141618

mea

n du

ratio

n of

hea

dach

e (d

ay)

albendazole placebo

Jitpimolmard, et al (submitting)

P < 0.05

Lumbar puncture

8.23

3.02

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VAS

กอนเจาะหลัง หลังเจาะหลัง

Sawanyawisuth, et al (submitting)

Corticosteroids

• Prednisolone 4*3, 2 weeks

• RCT

Corticosteroids 2 weeks

5

25

0

5

10

15

20

25

จํานวนผูที่ยังปวด

ศีรษะหลังรักษา

(คน

)

steroid placebo

5

13

0

2

4

6

8

10

12

14

ระยะเวลาที่ปวดศีรษะ

(วัน

)

steroid placebo

Chotmongkol, et al, CID, 2000.

P = 0.00004 P = 0.00000

Corticosteroid 1 & 2 weeks

4.78 5

0

1

2

3

4

5

mea

n du

ratio

n of

hea

dach

e (d

ay)

1 wk 2 wks.

Sawanyawisuth, et al. (submitting)

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)