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LETTER TO EDITOR
Year : 2018  |  Volume : 66  |  Issue : 4  |  Page : 1166

Eosinophilic meningitis caused by consumption of meat of monitor lizard (Varanus bengalensis)


Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India

Date of Web Publication18-Jul-2018

Correspondence Address:
Dr. Abdoul Hamide
Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.237031

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How to cite this article:
Johny J, Kumar A, Kolar VV, Hamide A. Eosinophilic meningitis caused by consumption of meat of monitor lizard (Varanus bengalensis). Neurol India 2018;66:1166

How to cite this URL:
Johny J, Kumar A, Kolar VV, Hamide A. Eosinophilic meningitis caused by consumption of meat of monitor lizard (Varanus bengalensis). Neurol India [serial online] 2018 [cited 2018 Aug 17];66:1166. Available from: http://www.neurologyindia.com/text.asp?2018/66/4/1166/237031




Sir,

A 31-year old lady presented to the emergency services with chief complaints of high-grade fever, headache, and vomiting for 10 days. No history of seizures, trauma, or ear discharge was present. On examination, she was febrile, drowsy, disoriented with normal vital parameters. There was papilledema, signs of meningeal irritation without focal neurological deficits. Contrast-enhanced computed tomography of the brain was normal. Pyogenic meningitis was suspected, lumbar puncture was performed, and inj. ceftriaxone 2 g intravenous (i.v.) q 12h was started. The total leucocyte count was 11400/μL, with 35% eosinophils and an absolute eosinophil count of 4012/μL. Cerebrospinal fluid (CSF) analysis revealed 780 cells/mm 3, with 60% eosinophils; protein level of 112 mg/dL; and, glucose level of 86 mg/dL, with a corresponding blood glucose level of 128 mg/dL. Diagnosis of eosinophilic meningitis was made. The magnetic resonance imaging of brain was normal.

After revisiting the history, she was reported to have consumed meat of monitor lizard 10 days prior to the development of symptoms. As monitor lizard is the paratenic host of Angiostrongylus cantonensis, it was presumed to be the causative agent. She was started on inj. dexamethasone 8 mg i.v. q 6h. By the second day of steroid therapy, patient's fever and headache had subsided and her sensorium had improved. Steroid therapy was continued for 15 days. Repeat CSF analysis on the 12th day of admission revealed an acellular picture with normal protein level. At follow-up visits, the patient was normal.

Eosinophilic meningitis is defined as the presence of at least 10 eosinophils/mm 3 in the CSF or 10% of CSF leukocytes.[1]A. cantonensis is the commonest agent. Its principal host is rat, which carries the first-stage larvae, and the intermediate hosts are snails and slugs, which carry the infective third-stage larvae. Monitor lizards, prawns, and fish are paratenic hosts. In many parts of the world, the meat, especially the liver of monitor lizard, is consumed as an aphrodisiac.[2],[3]

A. cantonensis causes central nervous system damage by direct mechanical and toxic injury.[2],[3] The clinical presentations include an excruciating headache (>90%), fever, paresthesia and vomiting, followed by signs of meningitis. Infection with Gnathostoma spinigerum, the second commonest agent, presents with intracerebral hemorrhage or myelitis.[4]

With nonavailability of serological tests, the diagnosis of A. cantonensis-induced meningitis in our case was based on the temporal association of the clinical manifestations with the consumption of meat of monitor lizard and the development of eosinophilic meningitis, which responded to steroid therapy.

In conclusion, eosinophilic meningitis is rare; however, dietary history, as well as a high eosinophil count in blood and CSF are important clues to the diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shah I, Barot S, Madvariya M. Eosinophilic meningitis: A case series and review of literature of Angiostrongylus cantonensis and Gnathostoma spinigerum. Indian J Med Microbiol 2015;33:154-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Parameswaran K. Case series of eosinophilic meningoencephalitis from South India. Ann Indian Acad Neurol 2006;9:217-22.  Back to cited text no. 2
  [Full text]  
3.
Eamsobhana P. Eosinophilic meningitis caused by Angiostrongylus cantonensis – A neglected disease with escalating importance. Trop Biomed 2014;31:569-78.  Back to cited text no. 3
    
4.
Kanpittaya J, Sawanyawisuth K, Intapan PM, Khotsri P, Chotmongkol V, Maleewong W. A comparative study of neuroimaging features between human neuro-gnathostomiasis and angiostrongyliasis. Neurol Sci 2012;33:893-8.  Back to cited text no. 4
    




 

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