Open Access
Table 1
Clinical characteristics of the four patients with confirmed (cases 1 and 2) and probable (cases 3 and 4) Angiostrongylus costaricensis infection in Martinique. A. fulica: Achatina fulica, CRP: C-reactive protein, CSF: Cerebrospinal fluid, CT scan: Computerized axial tomography, Dx: x Days, EBV: Epstein-Barr virus, IV: intra-venous, L. aurora: Limicolaria aurora, ND: No Data.
| Case | 1 | 2 | 3 | 4 |
|---|---|---|---|---|
| Background data | ||||
| Year of diagnosis | 2000 | 2001 | 2016 | 2017 |
| Season | August, rainy season | October, rainy season | November, rainy season | February, dry season |
| Sex | M | F | F | M |
| Age | 12 months | 12 months | 14 years | 21 years |
| Area of residence (city, district) | Le Lamentin | Saint-Esprit | Le Robert | Fort-de-France |
| Living conditions | Residential area | Residential area | Residential area | ND |
| Medical history | None | None | None | None |
| Reported contact with mollusks | None, but numerous slugs of und. species in the garden | None, but numerous slugs of und. species and snails (A. fulica, L. aurora,) in the garden | None, but numerous snails (A. fulica, L. aurora) at school | ND |
| Clinical picture | ||||
| Duration of symptoms before admission | 1 month | 2 weeks | 1 month | 24 hours |
| Extra-digestive symptoms | Irritability, moderate fever (38.5 °C) > 7 days | Decreased reactivity, fever (38.0 °C)>14 days | Fever>14 days; | Fever (39.0 °C) |
| Loss of weight | 3.2% in 7 days (basal weight 9120 g) |
6% in 15 days | None | None |
| Digestive symptoms | Anorexia, emesis, right iliac fossa pain, diarrhea, trails of blood in feces, dehydration | Anorexia, right iliac fossa pain, watery diarrhea, emesis | Severe right iliac fossa pain, emesis | Abdominal pain in suprapubic region, diarrhea, emesis |
| Laboratory results | ||||
| Initial WBC (109/L) | 25.5 | 19.1 | 19.8 | 63.3 |
| Max eosinophilia (G/L (%)) |
4.25 (17) | 4.68 (19) | 9.8 (49.2) | 52.28 (82.6) |
| Initial hemoglobin (g/dL) | 9.6 | 6.8 | 15.5 | 15.5 |
| CRP (mg/L) | 95 | 94.5 | 3 | 223 |
| Liver, renal, hemostatic parameters | Normal | Normal | Normal | Normal |
| Microbiological analyses | Blood, urine, CSF cultures: negative | Negative blood culture, positive urine culture (E. coli 105 UFC/ml) | None | Blood and urine cultures: negative |
| Angiostrongylus cantonensis serology | None | None | Positive (IgG, Western-Blot) |
Positive (IgG, Western-Blot) |
| Helminth ELISA screening testa | None | None | Negative | Negative |
| Other parasitic serology | None | Schistosomiasis, toxocariasis: negative | Toxocariasis: negative | Schistosomiasis, toxocariasis: negative |
| Parasitological examination of feces | Few altered embryonated eggs of helminths & numerous Charcot Leyden crystals (D4 after surgery). | Negative, numerous Charcot Leyden crystals | Negative (3 times) | Negative (2 times) |
| Abdominal imaging & surgery | ||||
| Abdominal imagery | Ultrasound: dilated ileum, peritoneal exudate in the right iliac fossa, X-rays: distended left colic flexure (Fig. 1) | X-rays (Fig. 3): pneumoperitoneum under right hypochondria | Ultrasound: colon wall thickening, mild intraperitoneal effusion | CT scan: micronodular pulmonary pattern, peripheral lymphadenopathy. |
| Exploratory laparotomy/ laparoscopy | Laparotomy (D3): ischemic and congestive ileum, necrotic areas, mesenteric lymph node enlargement | Laparotomy (D50) | None | None |
| Surgical procedure | 18 cm long ileal resection and anastomosis | 16 cm long ileal resection (distal ileon + ileo-cecal valve) with 3 cm of healthy surgical resection margins and anastomosis | None | None |
| Histology of resected specimen | ||||
| Macroscopic aspect | Rigid, ulcerated, and hemorrhagic pattern | Surgical specimen agglutinated, necrotized, and covered with false membranes | None | None |
| Histological examination of surgical specimen | Polymorphic granulomas & eosinophilic infiltration of the intestinal mucosa, 60 to 80 μm long and mostly embryonated ovoid eggs within the granulomas with macrophages and eosinophils, thrombotic phenomena in muscular arteria caused by degenerated 140 to180-μm long A. costaricensis adults (Fig. 2A and 2B). |
Ischemic intestinal wall, granulomas with giant cells, plasmocytes and eosinophilic cells, A. costaricensis eggs (Fig. 4A), larvae (Fig. 4B) and adults in the lumen of some vessels (Fig. 4C and 4D) | None | None |
| Diagnosis & Medical care | ||||
| Diagnosis of angiostrongyliasis | Histology of resected ileal specimen (D3 after hospitalization) | Histology of resected ileal specimen (D50 after hospitalization) | Probable with positive A. cantonensis serology (D30 after hospitalization) | Probable with positive A. cantonensis serology |
| Concomitant infections | None | EBV primary infection, urinary tract infection | None | None |
| Symptomatic treatment and treatment for co-infections | After surgery: blood transfusion, proper hydration, analgesia and nutrition, antibiotics (ceftriaxone, metronidazole) | IV antibiotics for urinary tract infection (cefotaxime, netilmicin), After surgery: blood transfusion, parenteral rehydration, antipyretics, antibiotics (cefotaxime, amikacin, metronidazole) |
Acetaminophen, domperidone | Acetaminophen |
| Anthelmintic treatment | Thiabendazole 75 mg/kg/day (10 days) | Flubendazole empirical treatment (3 days) before diagnosis, thiabendazole 50 mg/kg/day (5 days) after diagnosis | Thiabendazole (5 days) |
Ivermectin (18 mg in single dose) |
| Length of hospitalization | 25 days | 2 hospitalizations 1st: 16 days 2nd: 37 days |
7 days | 10 days |
| Outcome | ||||
| Clinical improvement | 3 weeks after surgery | 3 weeks after surgery | 2 weeks after anthelmintic treatment | Regression of symptoms |
| Decline of eosinophilia | 1.41 G/L D18 after hospitalization | 1.17 G/L D71 after first hospitalization | 0.40 G/L 10 months after hospitalization | 2.0 G/L D80 after hospitalization |
| Sequelae & clinical outcome | Recovery | Recovery | Recovery | Recovery |
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