07 eosinophilic meningitis
TRANSCRIPT
Current Management of Eosinophilic Meningitis
Somsak Tiamkao, M.D.Department of Medicine
Faculty of MedicineKhon Kaen University
Topics
• Clinical manifestations• Diagnosis• Immunodiagnosis• Current management
Eosinophilic Meningitis (EoM)
• CSF eosinophil > 10 %• Wet smear or Wright’s stain
EoM is not a disease
• Parasitic infestration • Tuberculous meningitis• Cryptococcal meningitis• Syphilitic meningitis• Carcinomatous meningitis• Rheumatoid arthritis• HIV infection
Parasitic infestration
Epidemiology
• Angiostrongyliasis– Thailand (NE)– Taiwan
• Asia pacific• US
– Oct – Feb.
• Gnathostomiasis–Japan–Thailand
Presenting symptoms
• Angiostrongyliasis–Headache
(meningitis)• Ocular• GI ??
• Gnathostomiasis– Cutaneous(migratory swelling,larva migran)
– Neuro.(SAH,ICH,myelitis,
meningitis,radicularpain,…)• Ocular
Diagnosis
• Angiostrongyliasis & Gnathostomiasis–Definite : larva, immunodiagnosis–Clinical diagnosis*
Clinical dx. of A. cantonensis
• Duration of headache• Character of headache• Incubation period• Without history of raw snail
Physical signs
0
10
20
30
40
50
60
70
80 %
fever stiffneck eosinophilia
Jitpimolmard Chotmongkol Sawanyawisuth
Laboratory findings
CSF analysisSerologyCT & MRI
CSF
Parasite ?
CSF analysis
• Angiostrongyliasis– OP > 30 cm H2O ~ 40 %– WBC < 5,000 cells/mm3
– CSF protein < 500 mg/dl– CSF sugar > 50 % – Some cases CSF sugar < 50 %
• Gnathostomiasis– Xanthochromia– WBC < 1,000 cells/mm3
Serology
• Ab or Ag detection• Immunoblotting or Western blot• Indication
– Study – Questionable cases
• Lab : Depart. Parasitology, KKU0-4336-3432
• www.eosinophilic-meningitis.worldmedic.com
Angiostrongyliasis
• Immunoblotting : Ab detection • 29 kDa diagnostic band• Sensitivity : 56-100%• Specificity : 95-100%
IMMUNOBLOTTINGAntibody against 29 KDa of A.cantonensis
P: positive control; N: negative control; T: tested serum
MW marker (KDa)
29 KDa
IMMUNOBLOTTINGAntibody against 24 KDa of G.spinigerum
24 KDa
1-9 : Gnathostomiasis sera
MRI : angiostrongyliasis
Kanpittaya, et al. AJNR 2000
MRI in gnathostomiasis
Tract ?
Sawanyawisuth K, Tiamkao S, et al. AJNR, 2004
MRI : cauda equina gnathostomiasis
Prior to treatment 9 months F/U
Sawanyawisuth K, Tiamkao S, et al. (submitting)
CT : Gnathostomiasis
Treatment
• A. cantonensis–Anti parasite –Lumbar puncture–Corticosteroids
Albendazole 15 MKD
8.9
16.2
02468
1012141618
mea
n du
ratio
n of
hea
dach
e (d
ay)
albendazole placebo
Jitpimolmard, et al (submitting)
P < 0.05
Lumbar puncture
8.23
3.02
0123456789
VAS
กอนเจาะหลัง หลังเจาะหลัง
Sawanyawisuth, et al (submitting)
Corticosteroids
• Prednisolone 4*3, 2 weeks
• RCT
Corticosteroids 2 weeks
5
25
0
5
10
15
20
25
จํานวนผูที่ยังปวด
ศีรษะหลังรักษา
(คน
)
steroid placebo
5
13
0
2
4
6
8
10
12
14
ระยะเวลาที่ปวดศีรษะ
(วัน
)
steroid placebo
Chotmongkol, et al, CID, 2000.
P = 0.00004 P = 0.00000
Corticosteroid 1 & 2 weeks
4.78 5
0
1
2
3
4
5
mea
n du
ratio
n of
hea
dach
e (d
ay)
1 wk 2 wks.
Sawanyawisuth, et al. (submitting)
Corticosteroid 1 week
• Relapsed ~ 15 %
• Mostly less severe (VAS)
Side effect of corticosteroid
• No serious side effect : UGIB, severe hyperglycemia
Suggestions
• Lumbar puncture in case of suspicious• Prednisolone 4*3
– 1 week : close follow up, advice– 2 weeks : without taper off
• Albendazole 15 MKD (option)
Ongoing study
• Predictive factor & duration of headache• Severe cases : combine steroid &
albendazole
Eosinophilic meningoencephalitis
• Supportive treatment• Corticosteroids : equivocal• Prognosis
Treatment
• Gnathostomiasis– Cutaneous : Albendazole 800 mg/d, 21 days
Ivermectin 0.2 MKD single dose– CNS : no definite treatment– F/U : eosinophilia ( 6 months)
: ELISA Ig G (12 months)
Summary• Prevention• Angiostrongyliasis
– EoM : Prednisolone (1 or 2 weeks +/-albendazole) and Lumbar puncture
– Eo. Meningoencephalitis : supportive Rx.• Gnathostomiasis
– Cutaneous : Albendazole 800 mg,21 days– Neurological : supportive Rx. (albendazole or
steroid may be beneficial)