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Angiostrongylus spp

Angiostrongylus cantonensis
And
Angiostrongylus costaricensis
 TAXONOMY

 Class : Nematoda
 Ordo : strongylida
 Family : metastrongyloidea
 Genus : Angiostrongylus
 Around 19 species are recognized worldwide .
 Two species infect humans widely:
1. Angiostrongylus cantonensis (Chen, 1935, in
Canton ) causes eosinophilic meningitis
2. Angiostrongylus costaricensis (Morera &
Céspedes, 1971, in Costa Rica) causes abdominal
angiostrongyliasis, especially a problem in South
America
 Angiostrongylus cantonensis and Angiostrongylus
costaricensis are parasitic worms of rats.
 A.cantonensis also called the rat lungworm, the
adult worms reside in the arterioles of the lung
of the definitive host
 Angiostrongylus (Parastrongylus) costaricensis is
similar, except that the adult worms reside in
the arterioles of the ileocecal area of the
definitive host
 Definitive Host
A.cantonensis ; Rattus norwegicus,
A.costaricensis : cotton rat
 Transmission ; Humans contract the disease by
ingestion of third-stage larvae in insufficiently
cooked intermediate hosts: mollusks and
crustaceans for A. cantonensis; the slug,
Vaginulus plebius, for A. costaricensis.
 Other animals that become infected such as
freshwater shrimp, land crabs, frogs, and
planarians of the genus Platydemus, are
transport hosts / paratenic hosts that are
not required for reproduction of the parasite but
might be able to transmit infection to humans if
eaten raw or undercooked.
 Humans are accidental hosts who do not
transmit infection to others.
Epidemiology
It is likely that the parasite has been spread by
rats transported on ships and by the
introduction of mollusks such as the giant
African land snail (Achatina fulica)/ bekicot.
In addition, the semi-slug Parmarion
martensi (native of Southeast Asia)has spread
in regions of Hawaii and is found to often be
infected with A. cantonensis, and the freshwater
snail Pomacea canaliculata (native of South
America) has been introduced into Taiwan and
China and has been implicated in outbreaks of
disease in those countries.
• Angiostrongylus cantonensis infects humans in
Southeast Asia, Hawaii, the Pacific Islands
(Tahiti, Samoa, Cook Islands), the Philippines,
Taiwan, parts of China, the Caribbean, and
Madagascar
• A. costaricensis is prevalent in Central and
South America, notably Costa Rica, where
approximately 300 cases are reported annually
• Outbreaks of human angiostrongyliasis have
involved a few to hundreds of persons; over
2,800 cases have been reported in the
literature from approximately 30 countries.
In Asia the highest numbers of
human cases are found in Taiwan,
Thailand, and in the Pacific Islands.
The lowest numbers of human
infections are found Vietnam,
Malaysia, Indonesia, Japan,Cuba.
 The demographics of patients most frequently
affected vary with country.
In Tahiti, adults are affected more
frequently than children, and the sexes have
equal rates of infection
in Thailand, males are nearly three times
as likely to become infected as females and the
majority of cases occur in individuals who are
between the ages of twenty and thirty-nine.
in Taiwan, the vast majority of cases, eighty
percent, are children under the age of twelve who
play with or eat raw Giant Africa Land Snails
during the months of high rainfall when they are
most abundant.
Risk factors
ingestion
of raw or undercooked infected snails or slugs;
or pieces of snails and slugs accidentally chopped up
in vegetables, vegetable juices, or salads;
or foods contaminated by the slime of infected snails
or slugs.
of raw or undercooked transport hosts/ paratenic host
(freshwater shrimp, land crabs, frogs, etc. ).
In addition, contamination of the hands during the
preparation of uncooked infected snails or slugs could lead
to ingestion of the parasite.
Morphology
 Adult
- male ; slender worms that can grow to be 25 mm, d :
0,26 mm, post ; bursa copulatrix and a pair of spiculae (
l : 2mm )
- female : l : 21-25 mm, d : 0,30-0,36 mm, with
characteristic red (gut) and white (uterine tubules)
spiral appearance / barber pole app.
 First stage larvae are, on average, 0.27mm long and
0.014mm wide, while third stage larvae have mean
dimensions of 0.557mm long and 0.025mm wide.
 Adult worms of A. cantonensis live in the
pulmonary arteries of rats. The females
lay eggs that hatch, yielding first-stage
larvae, in the terminal branches of the
pulmonary arteries. The first-stage larvae
migrate to the pharynx, are swallowed,
and passed in the feces. They penetrate,
or are ingested by, an intermediate host
(snail or slug). After two molts, third-
stage larvae are produced, which are
infective to mammalian hosts.
 When the mollusk is ingested by the
definitive host, the third-stage larvae
migrate to the brain where they develop
into young adults. The young adults
return to the venous system and then the
pulmonary arteries where they become
sexually mature. Of note, various animals
act as paratenic (transport) hosts: after
ingesting the infected snails, they carry
the third-stage larvae which can resume
their development when the paratenic
host is ingested by a definitive host.
 Humans can acquire the infection by eating raw or
undercooked snails or slugs infected with the parasite;
they may also acquire the infection by eating raw
produce that contains a small snail or slug, or part of
one.
 There is some question whether or not larvae can exit
the infected mollusks in slime (which may be infective
to humans if ingested, for example, on produce). The
disease can also be acquired by ingestion of
contaminated or infected paratenic animals (crabs,
freshwater shrimps). In humans, juvenile worms
migrate to the brain, or rarely in the lungs, where the
worms ultimately die.
 The life cycle of Angiostrongylus
(Parastrongylus) costaricensis is similar,
except that the adult worms reside in the
arterioles of the ileocecal area of the definitive
host. In humans, A. costaricensis often reaches
sexual maturity and release eggs into the
intestinal tissues. The eggs and larvae
degenerate and cause intense local
inflammatory reactions and do not appear to
be shed in the stool.
Angiostrongylus cantonensis
 The incubation period of A.
cantonensis averages 1 to 3 weeks, but
has ranged from 1 day to greater than 6
weeks. Illness from A.cantonensis usually
lasts between 2-8 weeks but can last
longer. People present with symptoms of
bacterial meningitis, such as nausea,
vomiting, neck stiffness, and headaches
that are often global and severe.
Additionally, abnormal sensations of the
arms and legs can occur.
 Sometimes the eyes can be affected. When patients are
tested for bacterial meningitis by taking a sample of the
fluid that surrounds the brain, the fluid does not show
high levels of the cells that help fight off bacterial
infections (polymorphonuclear leukocytes) as one might
expect. Instead, another cell type called eosinophils are
found (this is called eosinophilic meningitis), though
these cells may be absent early and late in the course of
disease. Most infections of A. cantonensis resolve
spontaneously over time without specific treatment
because the parasite cannot survive for long in the
human body. However, serious complications can rarely
occur, leading to neurologic dysfunction or death.
Angiostrongylus costaricensis
 The incubation period is not specifically known, but is
thought to usually range from several weeks to several
months, possibly even up to 1 year. A. costaricensis is
usually found in the intestine (especially the ileocecal
region) and can cause abdominal pain, fever, nausea
and vomiting. Abdominal findings can often mimic
appendicitis, and infection is identified after surgical
removal of the appendix. In rare cases, the larvae enter
the mesenteric arteries found in the abdominal cavity
where they mature into adults and can cause arteritis,
infarction, thrombosis, and gastrointestinal
hemorrhage.
 Eggs produced by adult worms lodge in
capillaries and cause an inflammatory
reaction as they degenerate. The immune
system’s response to the adults, larvae,
and eggs can result in a massive
eosinophilic inflammatory reaction, with
eosinophilic invasion of the intestinal
wall and eosinophilic vasculitis.
Intestinal obstruction and perforation
can occur, and deaths have been
reported. Recurrent episodes of illness
may occur over several months. Most
cases resolve spontaneousl
Diagnosis
 Angiostrongylus cantonensis
Diagnosing A. cantonensis infections can be difficult, in
part because there are no readily available blood tests.
Important clues that could lead to the diagnosis of
infection are a history of travel to where the parasite is
known to be found and ingestion of raw or undercooked
snails, slugs, or possibly transport hosts (such as frogs,
fresh water shrimp or land crabs) in those areas. A high
level of eosinophils, a blood cell that can be elevated in
the presence of a parasite, in the blood or in the fluid
that surrounds the brain can be another important clue.
Persons worried that they might be infected should
consult their health care provider.
 Laboratory Diagnosis
 In eosinophilic meningitis with A. cantonensis, the
cerebrospinal fluid (CSF) is abnormal (elevated
pressure, proteins, and leukocytes; eosinophilia). On
rare occasions, larvae have been found in the CSF. In
abdominal angiostrongyliasis with A. costaricensis,
eggs and larvae can be identified in biopsy specimens.
 Molecular Diagnosis

 PCR assay for the specific detection of A. cantonensis


in human CSF specimens.
 No specific molecular tests are available for A.
costaricensis. A conventional PCR followed by DNA
sequencing can be performed for A. costaricensis on a
case-by case basis. Acceptable specimen type is tissue
biopsies.
 Management and Therapy

Despite the fact that there is no specific therapy for the


Angiostrongyliasis because of its short course, there are
a number of treatments for symptoms.

• analgesics and corticosteroids: alleviate radicular


symptoms and headache
• spinal tap: reduces intracranial pressure and
associated headache
• general and neurologic care: for patients suffering
from complications such as infections
• thiabendazole: anthelminthic drug determined to
have insignificant effect on clinical course of
angiostrongyliasis
• mebendazole: 100mg, twice daily for five days for
anthelminthic treatment
Prevention & Control
 Prevention of A. cantonensis infections involves
educating persons residing in or traveling to areas
where the parasite is found about not ingesting raw or
undercooked snails and slugs, freshwater shrimp, land
crabs, frogs, and monitor lizards, or potentially
contaminated vegetables, or vegetable juice. Removing
snails, slugs, and rats found near houses and gardens
should also help reduce risk. Thoroughly washing hands
and utensils after preparing raw snails or slugs is also
recommended. Vegetables should be thoroughly washed
if eaten raw.