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Research Article

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
a

Helminth ELISA screening test simultaneously detects seven different species of tissue helminths (Toxocara sp., Trichinella sp., Echinococcus sp., Fasciola sp., Filaria, Schistosoma sp. and Strongyloides sp.).

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