Eosinophilic Meningitis due to Angiostrongylus cantonensis in Europe

Abstract Objectives To describe and analyse the epidemiological and clinical characteristics of imported human angiostrongyliasis in Europe. Methods We performed a systematic literature review of cases of human angiostrongyliasis in Europe. We searched seven databases, extracted epidemiological and clinical characteristics from included records and performed simple summary statistics on extracted data. Results We identified 22 cases reported between 1988-2019 mainly from French Polynesia, Southeast Asia and The Caribbean Islands. The dominant suspected mode of transmission was ingestion of prawns, shrimp or salad. For patients with data, 90% had a history of headache, often lasting, and half had paresthesia. 89% had eosinophilia, 93% had cerebrospinal fluid (CSF) eosinophilia and 92% had elevated CSF protein. Central nervous system (CNS) imaging was normal in most cases. Two thirds received albendazole or mebendazole treatment, although this is not currently recommended. Conclusions We have increased previous numbers to 22 reported cases in total since 1988. Angiostrongyliasis should generally be suspected in patients with a lasting headache who have returned from Southeast Asia, China, The Caribbean Islands, Australia or French Polynesia, as well as parts of North America and Tenerife, Spain, though one autochtonous case from mainland Europe has also been reported. A dietary history should focus on prawns, shrimp and salad, whilst also including slugs and snails, and other paratenic hosts where relevant. The clinical diagnosis is supported by the presence of blood eosinophilia, CSF eosinophilia and elevated CSF protein. Definitive laboratory diagnosis should be sought out, and CNS imaging should be used to support, not to rule out the diagnosis. The most up to date evidence should always be consulted before initiating treatment. Current recommendations include analgesics, corticosteroids and periodic removal of CSF for symptom relief, while antihelminthic treatment is debated.