BACKGROUND: Angiostrongyliasis cantonensis is a severe yet rare parasitic infection caused by the larvae of Angiostrongylus cantonensis. The primary characteristic feature of this foodborne illness in humans is eosinophilic meningitis. Recently, there has been a gradual increase in reported cases globally. Due to the lack of typical clinical symptoms, signs, and specific laboratory tests, early diagnosis of this disease poses significant challenges. Failure to diagnose and treat this condition promptly can result in fatalities.
METHODS: We present the case of a 13-year-old male patient who initially presented with fever and headache. The patient was preliminarily diagnosed with bacterial meningitis and received treatment with antibacterial drugs. However, the patient\'s condition worsened, and he developed progressive consciousness disturbances. Eventually, metagenomic next-generation sequencing (mNGS) testing of cerebrospinal fluid samples indicated Angiostrongylus cantonensis infection. Following treatment with albendazole and prednisone, the patient made a full recovery. We include this case report as part of a literature review to emphasize the potential applications of mNGS in the early diagnosis of Angiostrongyliasis cantonensis.
CONCLUSIONS: mNGS technology plays a crucial role in the diagnosis of angiostrongyliasis cantonensis. As this technology continues to evolve and be applied, we believe it will play an increasingly important role in diagnosing, treating, and monitoring angiostrongyliasis cantonensis.

Gliadel wafer implants (Eisai Inc., Woodcliff Lake, NJ, USA) have shown their efficacy in prolonging survival in patients with malignant gliomas. The safety of Gliadel wafers has also been reported; however, there is a certain risk of adverse events. We present a rare case of refractory cerebrospinal fluid (CSF) leakage with eosinophilic meningitis in a patient with glioblastoma who underwent tumor resection with Gliadel wafer implants. A 60-year-old man presented with a glioblastoma in the right temporal lobe. The patient underwent tumor resection with Gliadel wafer implants. During the postoperative course, the patient presented with intractable CSF leakage and the development of a pseudomeningocele. A delayed rise in blood and CSF eosinophil count (a few weeks after the primary operation) and positive drug-induced lymphocyte stimulation test (DLST) results against the Gliadel wafer led to the diagnosis of an allergic reaction to these implants. Removal of the Gliadel wafers resolved the eosinophilic reaction; however, the patient subsequently required a shunt procedure for persistent hydrocephalus. This case highlights the importance of investigating rare causes of refractory CSF leakage and hydrocephalus due to allergic reactions to Gliadel wafers. Delayed elevations of eosinophils in blood and CSF tests may lead to a diagnosis of eosinophilic meningitis. DLST against Gliadel wafers is also useful for diagnosis when it is available. To control the hydrocephalus, not only the shunt procedure but also wafer removal must be considered; however, patients with limited life expectancy are generally hesitant to undergo such additional procedures.

Angiostrongylus cantonensis is the major cause of eosinophilic meningitis worldwide. The imbalance of neurotoxic and neuroprotective metabolites in the kynurenine pathway (KP) have been suggested to contribute to the pathogenesis of central nervous system (CNS) infection. We hypothesized that KP may also be involved in parasitic eosinophilic meningitis. BALB/c mice were orally infected with 40 A. cantonensis L3, intraperitoneal dexamethasone at a dose of 500 µg/kg/day was administered from the seventh day of infection until the end of the study. The Evans blue method was used to analyze blood-brain barrier (BBB) dysfunction, and indoleamine 2,3-dioxygenase (IDO) proteins levels was measured by Western blot, immunohistochemistry (IHC), and immunofluorescence. Tryptophan and kynurenine concentrations were analyzed by IHC and liquid chromatography-tandem mass spectrometry (LC-MS/MS). The concentrations of Evans blue, IDO, tryptophan and kynurenine in the different groups of mice were compared using the nonparametric Kruskal-Wallis test. BBB dysfunction was found in mice with eosinophilic meningitis. The administration of dexamethasone significantly decreased the amount of Evans blue. An increased IDO expression was shown in Western blot, IHC and immunofluorescence following 2-3 weeks infection. Increased tryptophan and kynurenine expressions in the brain and cerebrospinal fluid (CSF) were also found in IHC and LC-MS/MS studies. The administration of dexamethasone significantly decreased the amount of IDO, tryptophan and kynurenine. In conclusion, A. cantonensis infection inducing BBB damage, then increased the influx of tryptophan into CSF. The administration of dexamethasone significantly decreased the amount of IDO, tryptophan and kynurenine.

Subarachnoid neurocysticercosis can be challenging to recognize, which often leads to a delay in diagnosis. We report 3 cases presenting as chronic headache disorders that highlight the unique manifestations seen with this form of neurocysticercosis and the role that the infectious diseases consultant can play in ensuring a timely diagnosis.

Metastrongyloidea includes nematodes that parasitize mammals, mainly infecting their respiratory and cardiovascular systems, and are responsible for emerging zoonosis in the world. Terrestrial mollusks are their main intermediate hosts, with few exceptions. Here we present the results of a malacological survey to know the distribution of Angiostrongylus cantonensis in Macapá, Amapá, in the Brazilian Amazon region, after the report of a case of eosinophilic meningitis in 2018. Mollusks were collected in 45 neighborhoods between March 2019 and February 2020. They were identified, parasitologically analyzed, and their nematodes parasites were identified based on the morphology and MT-CO1 sequencing. Infections of An. cantonensis were observed in Achatina fulica, Sarasinula linguaeformis and Subulina octona. These are the first records of the natural infection of the last two species by An. cantonensis in the Brazilian Amazon region. The angiostrongylid Aelurostrongylus abstrusus, which parasitizes cats, was also detected parasitizing A. fulica and Diplosolenodes occidentalis. This is also the first record of the slug D. occidentalis infected by Ae. abstrusus. The highest infection rates were recorded in neighborhoods where the environment conditions favor the proliferation of both mollusks and rodents. The results demonstrate the ample distribution of An. cantonensis in Macapá and the need for surveillance and mollusk vector control in Brazil and other countries.

Human angiostrongylosis is an emerging zoonosis caused by the larvae of three species of metastrongyloid nematodes of the genus Angiostrongylus, with Angiostrongylus cantonensis (Chen, 1935) being dominant across the world. Its obligatory heteroxenous life cycle includes rats as definitive hosts, mollusks as intermediate hosts, and amphibians and reptiles as paratenic hosts. In humans, the infection manifests as Angiostrongylus eosinophilic meningitis (AEM) or ocular form. Since there is no comprehensive study on the disease in the Indian subcontinent, our study aims at the growing incidence of angiostrongylosis in humans, alongside its clinical course and possible causes. A systematic literature search revealed 28 reports of 45 human cases from 1966 to 2022; eosinophilic meningitis accounted for 33 cases (75.5%), 12 cases were reported as ocular, 1 case was combined, and 1 case was unspecified. The presumed source of infection was reported in 5 cases only. Importantly, 22 AEM patients reported a history of eating raw monitor lizard (Varanus spp.) tissues in the past. As apex predators, monitor lizards accumulate high numbers of L3 responsible for acute illness in humans. For ocular cases, the source was not identified. Most cases were diagnosed based on nematode findings and clinical pathology (primarily eosinophilia in the cerebrospinal fluid). Only two cases were confirmed to be A. cantonensis, one by immunoblot and the other by q-PCR. Cases of angiostrongylosis have been reported in Delhi, Karnataka, Kerala, Maharashtra, Madhya Pradesh, Puducherry, Telangana, and West Bengal. With a population of more than 1.4 billion, India is one of the least studied areas for A. cantonensis. It is likely that many cases remain undetected/unreported. Since most cases have been reported from the state of Kerala, further research may focus on this region. Gastropods, amphibians, and reptiles are commonly consumed in India; however, typical preparation methods involve cooking, which kills the nematode larvae. In addition to studying rodent and mollusk hosts, monitor lizards can be used as effective sentinels. Sequence data are urgently needed to answer the question of the identity of Angiostrongylus-like metastrongylid nematodes isolated from all types of hosts. DNA-based diagnostic methods such as q-PCR and LAMP should be included in clinical diagnosis of suspected cases and in studies of genetic diversity and species identity of nematodes tentatively identified as A. cantonensis.

Angiostrongylus cantonensis is a metastrongyloid nematode and the etiologic agent of angiostrongyliasis, a disease characterized by eosinophilic meningitis. This emerging zoonotic parasite has undergone great expansion, including in some regions of Europe and America. In the Canary Islands, the parasite was first discovered parasitizing Rattus rattus on the island of Tenerife in 2010. To date, the distribution of this parasite in the Canary Islands has been restricted to the northern zone and the main cities of Tenerife. Using molecular tools for the sentinel species present in the Canary Islands, this study confirmed the presence of the nematode on two other islands in the Canary Archipelago: La Gomera and Gran Canaria. Furthermore, this emerging parasite was detected, besides in the common definitive host R. rattus, in wild Mus musculus and Felis catus and in four terrestrial gastropod species, Limacus flavus, Milax gagates, Insulivitrina emmersoni, and Insulivitrina oromii, two of them endemic to La Gomera, for the first time, increasing the number of non-definitive host species. This study reinforces the expansion character of A. cantonensis and highlights the importance of knowledge about sentinel species for identifying new transmission locations that help prevent and control the transmission of the parasite and, thus, prevent public health problems.

Rat lung worm disease (RLWD) is endemic to Hawai\'i, and cases of severe RLWD with long-term sequelae have been reported in Hawai\'i. However, there are limited data on clinical features of the RLWD survivors with the long-term sequelae. The authors conducted a survey to report on clinical characteristics of RLWD survivors with the long-term sequelae. Four RLWD survivors had severe RLWD with persistent, neurological symptoms for years after RLWD. In conclusion, long-term sequelae of severe RLWD exist. The most common long-term consequence among participants was severe skin pain, which may relate to damage of the nerves or spinal cord.

Angiostrongylus cantonensis is the main causative agent for eosinophilic meningoencephalitis in humans. Larvae are rarely found in the cerebral spinal fluid (CSF). Consequently, serology and DNA detection represent important diagnostic tools. However, interpretation of the results obtained from these tools requires that more extensive accuracy studies be conducted. The aim of the present study is to update guidelines for diagnosis and case definitions of neuroangiostrongyliasis (NA) as provided by a working group of a recently established International Network on Angiostrongyliasis. A literature review, a discussion regarding criteria and diagnostic categories, recommendations issued by health authorities in China and an expert panel in Hawaii (USA), and the experience of Thailand were considered. Classification of NA cases and corresponding criteria are proposed as follows: minor (exposure history, positive serology, and blood eosinophilia); major (headache or other neurological signs or symptoms, CSF eosinophilia); and confirmatory (parasite detection in tissues, ocular chambers, or CSF, or DNA detection by PCR and sequencing). In addition, diagnostic categories or suspected, probable, and confirmatory are proposed. Updated guidelines should improve clinical study design, epidemiological surveillance, and the proper characterization of biological samples. Moreover, the latter will further facilitate accuracy studies of diagnostic tools for NA to provide better detection and treatment.

An ample variety of parasitic associations are found between mollusks and nematodes, in which the mollusks may act as intermediate, paratenic or definitive hosts. Some free-living nematodes, in particular those of the order Rhabditida, are also found frequently in terrestrial mollusks. The present study reviews the results of the parasitological testing on samples of terrestrial mollusks conducted at the Brazilian National Reference Laboratory for Schistosomiasis and Malacology between 2008 and 2021. The samples were supplied primarily by the public health authorities from the different regions of Brazil, but also by research institutions and general population. The mollusks were processed individually and the obtained larvae were identified from their morphology and, whenever necessary, by molecular analysis. A total of 1,919 service orders were registered during the period, including 19,758 mollusk specimens collected from 23 of the 26 Brazilian states, as well as the Federal District, totalizing 145 municipalities. There was a marked predominance of the synanthropic species that are widely distributed in Brazil-Achatina fulica (87.08%), Bulimulus tenuissimus (4.18%), Bradybaena similaris (2.06%), and Sarasinula linguaeformis (1.50%). Of the 16,750 terrestrial mollusks examined, nematodes were recorded in 1,308 service orders, with the predominance of the superfamily Metastrongyloidea, in 616 service orders. They included Angiostrongylus cantonensis, rat lungworm, which was found in 252 samples, and Aelurostrongylus abstrusus in 145 samples. Free-living nematodes were found in 952 samples, Ancylostoma caninum and Cruzia tentaculata (previously identified as Strongyluris sp.) in one and 275 samples, respectively, and other parasites in 210 samples (not identified). The results highlight the diversity of the associations between nematodes and terrestrial mollusks in Brazil, in particular invasive and synanthropic species, with emphasis on the giant African land snail, Achatina fulica. They demonstrate the prominent role of this species of mollusk in the transmission of medically-important nematodes, which affect the health of both humans and animals, in particular eosinophilic meningitis, which is caused by Angiostrongylus cantonensis. This reinforces the need for more studies, and justify the growing demand for information as well as parasitological diagnosis of this mollusk, given its wide distribution in Brazil and its impact as an urban pest.