Encephalitis in a Ghanian man

A 32-year-old Ghanian man presented on July 7, 1995, to another hospital, after noting a worm in his conjunctiva. A peripheral blood smear revealed microfilariae, and he was given diethylcarbamazine (DEC). He did not take the medication until August 12, and after two doses he became somnolent, progressively unresponsive, and was febrile to 102°F (38.9”C). He was hospitalized, found to have a white blood cell (WBC) count of 11 X 103/mm3 with 39% eosinophils (eos.), and was started on intravenous antibiotics and prednisone. A computed tomographic (CT) scan of the head was unremarkable; cerebrospinal fluid (CSF) was notable for a WBC count of 10O/l~,L; and microfilariae were seen in the CSE He continued to be lethargic and was transferred to The New York Hospital-Cornell Medical College on August 30 for further management. The patient was born in Ghana and had lived in the United States for 3 years. He lived in Gabon from 1988 to 1990, where he worked in a forested area and had many insect bites. Physical examination showed the patient to be afebrile. He had sharp fundi bilaterally, his lungs were clear to auscultation, cardiac examination revealed no murmurs, and his abdominal examination was normal. The patient was lethargic but arousable. He was oriented to name and place only and could follow only simple commands. He had normal strength and sensation, but walked with a wide-based gait and frontal release signs were noted. Babinski reflexes were not present. On admission, the WBC count was 7.2 X 103/mm3 (0.6% eos.) and CSF results were as follows: 2 WBC/yL, 51 red blood cells (RBC)/P,L, glucose 73 mg/dL, protein 47 mg/dL; no bacteria or polymorphonuclear neutrophils (PMNs) were seen on Gram stain. A CT scan of the head was unremarkable. The peripheral blood smear, from blood drawn during the day (Figure l), and CSF (Figure 2) both revealed microfilariae.