Current Management of Eosinophilic Meningitis Somsak Tiamkao, M.D. Department of Medicine Faculty of Medicine Khon Kaen University
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)