Zongli Diao

An outbreak of Angiostrongyliasis cantonensis in Beijing

Abstract An outbreak of 81 cases of angiostrongyliasis cantonensis (AC) occurred in Beijing, China, during June through September 2006. Epidemiological characteristics, clinical signs and symptoms, laboratory tests, imaging, and treatment data from the 81 AC patients were collected and analyzed. All cases had a history of eating raw freshwater snails, and acquired Angiostrongylus cantonensis as a result. The incubation period ranged from 1 to 36 days. The main symptoms were fever, severe headache, neck stiffness, and skin paresthesia. A significant increase in eosinophilia occurred in the peripheral blood of 62 cases and in cerebrospinal fluid of 64 cases; 36 patients presented a linearly enhanced abnormal signal of the leptomeninges site during a cranial MRI examination, indicative of meningitis; 18 cases had a significant nodule shadow and spot flaky ground-glass shadow on chest computerized tomography. All patients were relieved of their illness with a 7-day treatment of albendazole.

Human ocular angiostrongyliasis: a literature review.

Human ocular angiostrongyliasis caused by Angiostrongylus cantonensis infection in the eye is a very rare condition. Until now, there has been no comprehensive analysis of this disease. We searched and analysed the references found on the Internet that refer to human ocular angiostrongyliasis and reviewed the aetiology, clinical manifestations, diagnosis, epidemiology and treatment of the condition. Twenty-six references were found reporting 35 patients from 10 countries that were diagnosed with human ocular angiostrongyliasis. People are usually infected by eating raw or undercooked intermediate hosts of the parasite such as snails or contaminated vegetables. The most common symptom was visual loss. Although several treatments have been used, ocular angiostrongyliasis can still result in permanent visual impairment and may even cause blindness. As the eye is the site of infection and direct visualization is possible, ocular examination is crucial for diagnosis. The therapeutic success depended on early and complete surgical removal.

Angiostrongylus cantonensis: effect of combination therapy with albendazole and dexamethasone on Th cytokine gene expression in PBMC from patients with eosinophilic meningitis.

To determine how combination therapy with albendazole and dexamethasone changed cytokine responses in peripheral blood mononuclear cells (PBMC) in patients with eosinophilic meningitis caused by Angiostrongylus cantonensis (EOMA), we measured mRNA levels of Th2 (IL-5, IL-4 and IL-10) and Th1 (IL-2 and IFN-gamma) cytokines with reverse transcription polymerase chain reaction (RT-PCR). Forty-three patients were divided into three groups: group 1 (pre-treatment, 13 patients), group 2 (7 days post-treatment, 14 patients), and group 3 (30 days post-treatment, 16 patients). Peripheral eosinophil counts were also measured. EOMA patients showed higher levels of Th2 cytokines, including IL-5 and IL-10, and peripheral eosinophil counts, but no changes in IL-4 or Th1 cytokines. Combination therapy reduced IL-5 mRNA expression and peripheral eosinophil counts to control levels, but increased IL-10, IL-2, and IFN-gamma mRNA expression, and did not change IL-4 levels. These data suggest that systemic Th2 cytokine responses, especially IL-5, and peripheral eosinophil counts increased in EOMA patients. Combination therapy with albendazole and dexamethasone can shift the cytokine responses from Th2 to Th1 dominance, which may be a therapeutic mechanism.

Angiostrongylus cantonensis: lesions in brain and spinal cord.

A 13-year-old boy had a one-month history of left upper limb numbness and headache, and a 20-day history of intermittent fever. He had eaten an inadequately cooked Pomacea canaliculata, an intermediate host of Angiostrongylus cantonensis, 35 days earlier. Blood count analysis showed 7.52 × 109 leukocytes/L with 18.3% eosinophils (0.5–5%). A lumbar puncture showed clear cerebrospinal fluid without erythrocytes (80 × 106 cells/L), 45% lymphocytes and 54% eosinophils; the opening pressure was 150 mm of H2O. Results of tests for circulating antigens of Angiostrongylus cantonensis were positive. Magnetic resonance imaging of the brain showed an enhancement in sagittal T1-weighted images (Figure 1). Magnetic resonance imaging of the spine showed a contrast-enhanced nodule in sagittal T1-weighted images after administration of gadolinilum (Figure 2). Consequently, a diagnosis of angiostrongyliasis was made, and the patient was treated with albendazole and dexamethasone. Symptoms of headache and intermittent fever resolved within 20 days, but left upper limb numbness remained. This symptom disappeared with time. Brain and spinal cord lesions were completely resolved at a one-year follow-up. Figure 1. Magnetic resonance imaging of the brain of the patient, showing multiple lesions in sagittal T1-weighted images after administration of gadolinilum. Figure 2. Spinal magnetic resonance imaging of the spine of the patient, showing a contrast-enhanced nodule in sagittal T1-weighted images after administration of gadolinilum.

Treatment of angiostrongyliasis using a combination of albendazole and dexamethasone: the results of a retrospective and comparative study

Abstract As the information available on the treatment of angiostrongyliasis with a combination of albendazole and dexamethasone is limited, the efficacy of such therapy was assessed using data collected during the 2006 outbreak of angiostrongyliasis in Beijing. In a retrospective and controlled study, 35 patients treated with albendazole–dexamethasone (given 20 mg albendazole/kg and 3 mg dexamethasone daily for 7 days) were compared with 34 controls who were treated only symptomatically (with acetaminophen or other drugs). Compared with the controls, the patients given the combination were less likely to have headaches after 7 days (P = 0·038), tended to have headaches that cleared quicker (P = 0·010), and received fewer doses of acetaminophen (P = 0·036). Since no serious adverse effects were observed, a 1‐week treatment with a combination of albendazole and dexamethasone appears both safe and beneficial in the treatment of angiostrongyliasis.

The identification of risk factors for critically ill patients with acute fever and formulation of activation criteria to alert outpatient clinic doctors

RATIONALE, AIMS AND OBJECTIVES Acute fever is the most common early clinical symptom of many critical illnesses with a high mortality rate. It is necessary to identify patients with severe acute fever early and accurately. The aim of this study is to identify risk factors for critically ill outpatients with acute fever and formulate activation criteria of adult fever state score (AFSS) to alert outpatient clinic doctors. METHODS Retrospectively, 357 adult patients with acute fever were divided into two groups: 180 patients with a severe state and 177 patients with a mild state. Logistic regression was used to determine risk factors for the severe state. Risk factors were weighted and an AFSS was formulated. A receiver operating characteristic (ROC) analysis of weighted cumulative scores was performed to evaluate the diagnostic accuracy of AFSS, and the kappa test was used to confirm diagnostic reliability. A χ(2) -test for trend was applied to determine the relevance between AFSS and admission rate and in-hospital mortality. A Kruskal-Wallis test was used to examine the relationship between AFSS and length of stay. RESULTS Risk factors for state included: old age, long fever course, past medical history, abnormal temperature, abnormal respiratory rate, abnormal heart rate, abnormal mean arterial pressure and abnormal peripheral white blood cell count. The area under the ROC curve of AFSS was 0.964 and ≥8 points predicted severe state; the Kappa value was 0.801. With an increase in score, there was an increase in admission rate, mortality rate and length of stay. The forecast performance of AFSS was superior to the modified early warning score. CONCLUSIONS The AFSS has high diagnostic accuracy and reliability for the early identification of patients with severe acute fever.

The identification of risk factors for infectious patients with acute fever and formulation of activation criteria to alert outpatient clinic doctors: Early warning infectiosity score

RATIONALE, AIMS AND OBJECTIVES Acute fever is the most common clinical symptom for infectious diseases. It is necessary to identify risk factors for infectious patients with acute fever and formulate activation criteria of early warning infectiosity score system (EWIS) to alert outpatient clinic doctors. METHODS Logistic regression analysis was used to determine risk factors for infectious diseases from the clinical data of 758 patients with acute fever. Risk factors were weighted and an EWIS was formulated. A receiver operator characteristic (ROC) analysis of weighted cumulative scores was performed to evaluate the diagnostic accuracy of EWIS, and the Kappa test used to confirm diagnostic reliability. A χ(2) -test for trend was applied to determine the relevance between EWIS and incidence of infectious diseases. RESULTS Risk factors for infections included conjunctival hyperaemia, rash, diarrhoea, increased alanine aminotransferase, splenomegaly and abnormal percentage of peripheral neutrophils (NE%). Risk factors were weighted and tabulated. The areas under the ROC curves of the EWIS was 0.929 and ≥ 4 points predicted infectious diseases, and the Kappa values were 0.750. As the score increased, the incidence of infectious diseases increased. The areas under the ROC curves of the EWIS predicting on single viral and bacterial infectious diseases were 0.961 and 0.896, and the Kappa values were 0.807 and 0.701, respectively. CONCLUSIONS Risk factors for infections have been identified, quantified and formulated into a table of EWIS that have high diagnostic accuracy and reliability for the early identification of contagious diseases.

Identification of Factors Associated with Clinically Severe Angiostrongyliasis

Angiostrongyliasis is a globally distributed parasitic disease. Early and accurate identification of patients with severe infection is required. In this retrospective study, 81 patients with angiostrongyliasis were divided into two groups: 24 patients with severe disease and 57 with mild disease. Logistic regression analysis was used to determine the factors associated with severe disease. Receiver operating characteristic (ROC) analysis, κ tests, and χ(2) tests were performed. The factors analyzed included: headache (P = 0.013), abnormal cerebrospinal fluid pressure (P = 0.013), and abnormal peripheral blood eosinophil count (P = 0.007). The area under the ROC curve for the activation criteria for angiostrongyliasis (ACA) was 0.914, with a score of ≥ 7 points predicting a severe state; the κ value was 0.744. The incidence of severe angiostrongyliasis increased with increasing score. ACA is a useful tool with high accuracy and reliability for predicting the severity of angiostrongyliasis.

Myelitis Caused by Infection of Angiostrongylus cantonensis

A 32-year-old man presented to our hospital on July 5, 2006, after the onset of headache, paresthesias of the left upper limb for 10 days, and weakness for 7 days before admission. He had eaten an inadequately cooked Pomacea canaliculata 20 days previously. Laboratory testing indicated a normal white blood cell count of 6,700/mm3 with mild eosinophilia of 7.8% (523/mm3). A lumbar puncture test showed an opening pressure of 220 mm H2O and 160 cells with 23% eosinophils, and cerebrospinal fluid (CSF) cultures were negative. We detected the circulating antigens (CAg) of Angiostrongylus cantonensis by double antibody sandwich enzyme-linked immunosorbent assay (ELISA), and they tested positive. This method had a high sensitivity (86.4%), and no cross-reactions with sera from patients with many other parasites were observed.1 Therefore, the result was helpful for diagnosis. Spinal magnetic resonance imaging (MRI) showed a lesion with high signal intensity in the cervical spinal cord on both sagittal and transverse T2-weighted imaging (T2WI) (Figures 1 and ​and2)2) at 9 days after admission. Figure 1. A lesion in the cervical spinal cord presented as hyperintense on a sagittal T2WI. Figure 2. A lesion in the cervical spinal cord presented as hyperintense on a transverse T2WI. On the basis of history, clinical presentation, and examinations, a diagnosis of angiostrongyliasis was made,2 and the patient was treated with a combination of albendazole and dexamethasone. Symptoms of headache and paresthesia resolved within 14 days, and spinal-cord lesions completely resolved by a 1-month follow-up (Figures 3 and ​and44). Figure 3. The abnormally high signal on a sagittal T2WI completely disappeared. Figure 4. The abnormally high signal on a sagittal T2WI completely disappeared.