CUT OUT THE FIZZ

C A S E R E P O R T July Elzi
2004 Lancet   unpublished
He had a 2-week history of severe burning thoracic pain, which radiated from the right axilla in the distribution of the second to the fifth tho-racic dermatomes. He did not complain of cough or shortness of breath. He was previously healthy and was taking no medication. Of note is the fact that he had been travelling for 10 weeks in Thailand and Indonesia where he suddenly developed fever, fatigue, diarrhoea, arthralgia, headache and chest pain. He gave a history of having eaten local food
more » ... e travelling, including freshwater fish and shrimps. Stool samples showed infection with Salmonella enteritidis and Campylobacter jejuni. He was treated with azithromycin for 4 days, after which the fever resolved, but the thoracic pain worsened considerably. When the doctors examined him again he had no skin lesions, his neck was not stiff and he had hyperaesthesia along the second to fifth dermatomes. Blood tests showed a normal white cell count with 8.5% eosinophils and normal C-reactive protein. The chest radiograph was normal, but an MRI of the thoracic cord suggested myelitis in the thoracic region. A lumbar puncture gave clear, colourless cerebrospinal fluid (CSF) of normal pressure that had normal glucose and lactate, but showed a pleocytosis and increased protein. There were no microorganisms on Gram staining and no evidence of Mycobacterium tuberculosis or Cryptococcus antigen. Cultures of CSF remained sterile. Syphilis and HIV were excluded. However, the CSF leucocyte differential showed eosinophilia and eosinophilic meningitis with thoracic myelitis was diagnosed. The attending doctors then looked for a parasitic cause. Serological testing for all known helminths produced IgG specific to 4 Gnathostoma spinigerum antigens. The patient was given albendazole, 800 mg daily and prednisolone 50 mg daily for 3 weeks. He made an uncomplicated recovery and was well more than 6 months later. Eosinophilic meningitis can be caused by intracerebral TB, syphilis or lymphoma and various helminth species, including Angiostrongylus cantonensis, G. spinigerum, Toxocara canis and Paragonimus westermani. Gnathostomiasis is regarded as a re-emerging infectious disease, seen increasingly frequently in temperate regions as a result of increased travel to the tropics. The disease is potentially fatal and cats and dogs are reservoirs for adult Gnathostoma worms, passing eggs in faeces that hatch in water, so contaminating many species of fish and other vertebrates. The typical picture is one of fever, headache and rash, followed by painful radiculomyelopathy and eosinophilia. The parasite migrates around the body and penetrates the nerve root to reach the spinal cord, from where it migrates to the brain in potentially fatal cases. If not treated in time, permanent neurological deficit, paralysis and fatal subdural haemorrhage are common. This patient was fortunate that he had a good history of tropical travel, a typical clinical picture and an MRI picture of myelitis that allowed these astute doctors to diagnose his condition relatively early.
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