An outbreak of eosinophilic meningitis caused by Angiostrongylus cantonensis in travelers returning from the Caribbean

Background. Outbreaks of eosinophilic meningitis caused by the roundworm Angiostrongylus cantonensis are rarely reported, even in regions of endemic infection such as Southeast Asia and the Pacific Basin. We report an outbreak of A. cantonensis meningitis among travelers returning from the Caribbean. Methods. We conducted a retrospective cohort study among 23 young adults who had traveled to Jamaica. We used a clinical definition of eosinophilic meningitis that included headache that began within 35 days after the trip plus at least one of the following: neck pain, nuchal rigidity, altered cutaneous sensations, photophobia, or visual disturbances. Results. Twelve travelers met the case definition for eosinophilic meningitis. The symptoms began a median of 11 days (range, 6 to 31) after their return to the United States. Eosinophilia was eventually documented in all nine patients who were hospitalized, although on initial evaluation, it was present in the peripheral blood of only four of the nine (44 percent) and in the cerebrospinal fluid of five (56 percent). Repeated lumbar punctures and corticosteroid therapy led to improvement in symptoms in two of three patients with severe headache, and intracranial pressure decreased during corticosteroid therapy in all three. Consumption of one meal (P = 0.001) and of a Caesar salad at that meal (P = 0.007) were strongly associated with eosinophilic meningitis. Antibodies against an A. cantonensis-specific 31-kD antigen were detected in convalescent-phase serum samples from 11 patients. Conclusions. Among travelers at risk, the presence of headache, elevated intracranial pressure, and pleocytosis, with or without eosinophilia, particularly in association with paresthesias or hyperesthesias, should alert clinicians to the possibility of A. cantonensis infection.