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.