Abstract
We report the case of a middle aged male who presented with
headache and vomiting and later diagnosed to have eosinophilic
meningitis as a complication after consumption of camel meat.
Key Words:
Eosinophilic meningitis, monitor lizard, camel
Introduction
Eosinophilic meningitis (EOM) is defined as the presence of
more than 10 eosinophils/mm3 in the cerebrospinal fluid (CSF),
and/or eosinophils accounting for more than 10 percent of CSF
leukocytes [1]. Reliable detection of eosinophils in the
CSF requires examination of centrifuged cell preparations
stained with Wright's, Giemsa, or other appropriate stains.
Eosinophils are found in the CSF in a limited number of
diseases, including certain parasitic diseases and
coccidioidal meningitis [2]. The etiologies of eosinophilic
meningitis will be reviewed here, with emphasis on the
parasitic causes of this condition.
Case Report
49 year old male presented to us with headache, fever and
vomiting since 3 days. No h/o loss of consciousness,
seizures, limb weakness. No significant medical illness
in the past. He was employed at Dubai and had a
habit of having camel meat, during festivities and other
occasions regularly. There is no h/o consumption of
drugs like Ibuprofen, Ciprofloxacin. No h/o Diabetes,
Hypertension, Tuberculosis, sexually transmitted diseases or
arthritis.
On physical examination he was conscious and oriented.
Febrile, There is no jaundice, pallor or edema. BP and
pulse were normal. Neurologically he had neck stiffness
as the only clinical sign. Other systems were
normal.
Investigations revealed total count of 12600/mm3, ESR:30mm/1st
hr, E:08%, AEC:1008, RBS, LFT, S. Electrolytes, RFT were
normal. ECG, Chest X-ray, USG Abdomen were normal.
CT Brain was normal. Peripheral blood smear showed
neutrophilia and no parasites. CSF study was done.
CSF was turbid with increased pressure, CSF protein was
236mg, Sugar : 56mg (Blood Sugar : 117mg%). Polymorphs :
5%, Lymphocytes : 50%, Eosinophils : 45%, CSF WBC: 4250.
RBC:15cells. CSF AEC : 1050cells, ADA : 10, no
xanthochromia. CSF culture and India Ink were
negative. Blood LDH : 180unit/ltr, ANA, RA Factor :
Negative, Mantoux test, HIV, VDRL : Negative, Stool RE :
Normal.
Treatment Course
Third generation cephalosporin as twice daily dose for ten
days along with intravenous Dexamethasone TID and
tapered over 10 days and later switched over to oral
predniosolone 60mg once daily. Albendazole
400mg twice daily for 2 weeks was also given [3,4].
Discussion
Eosinophilic meningitis is not a disease, it is a
manifestation which is seen in diseases like parasitic
infections, tuberculous meningitis, cryptococcal meningitis,
syphilitic meningitis, carcinomatous meningitis, rheumatoid
arthritis and HIV infection [5,7].
In this article we are highlighting on the parasitic cause of
eosinophilic meningitis. Parasites like Angiostrongylous
Cantonensis, Gnathostoma spinigerum, Schistosomiasis,
Cysticercosis, Toxocariasis, Baylisascariasis, paragonimiasis
are the most common parasites causing eosinophilic
meningitis. Less common parasites causing EOM are
Hydatidosis, Filiarisis, Strongyloidiasis and Trichinelosis
[3,7]. Apart from parasitic infections next most
commonest cause is rheumatoid arthritis. The risk factor
for EOM due to parasitic cause is bare foot walking,
eating vegetables and fruits having snail slimy tract.
It can also occur after consuming raw mollusks, [1,2] uncooked
camel meat and eating raw flesh and blood of monitor lizard
which is commonly practiced southern parts of Kerala, as
people think that raw flesh and blood of Igauna or monitor
lizard gives them strength [3]. Camel meat harbours parasites,
and eating uncooked camel meat in the form of salads can end
up in Eosinophilic meningitis.
Diagnosis is from history, clinical presentation and presence
of neck rigidity. History of consumption of raw
mollusk,monitor lizard and presence of eosinophils in
CSF[3,6] Neuroimaging and recovery of parasites from CSF
(rare), intrathecal intraglobulin assay and immunological
methods - reactivity to 31-KDa component in western blot (WB),
ELISA - PCR. Treatment includes repeated spinal taps, 2
weeks course of Albendazole (10-15mg/Kg) and 2 weeks
course of steroids (60mg/day) [3,4].
References
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Eosinophilic meningitis and its clinical relavence. Clin
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3. Parameshwaran K. Case series of Eosinophilic
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4. Liu J, Gao J, Zouc C. A case report on eosinophilic
meningitis CAUSED BY Angiostrongylis cantonensis Int J Med Sci
2011;8:510-513.
5. Ralph D Feigin, James Cherry. Feigin and Cherry's
Text Book of Pediatric Infectious Diseases, 6th edition,
Elsevier, Philadelphia, Vol 1; Chapter 34.
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meningitis. Am J Med. 2003;114(3):217.
7. Allan Ropper, Martin A Samuels. Adam and Victor Principles
of Neurology, 9th Edition, March 2009, Mc Graw-Hill
Professional.