eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Gnathostomiasis

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Updated: Jan 22, 2009

Introduction

Background

Gnathostomiasis is a rare infection that most often results from ingestion of the third-stage larvae of the nematode Gnathostoma spinigerum, although several other species also cause human disease. The larvae may be found in raw or undercooked meat (eg, freshwater fish, chicken, snails, frogs, pigs) or in contaminated water. Rarely, larvae penetrate the skin of individuals who are exposed to contaminated meat or water.

Any organ system can be involved, but the most common manifestation of infection is localized, intermittent, migratory swelling in the skin and subcutaneous tissues. Such swelling may be painful, pruritic, and/or erythematous. Angiostrongylus cantonensis and Gnathostoma species are common causes of parasitic eosinophilic meningitis, which results from their random migration into the CNS.¹ Infection is typically associated with peripheral eosinophilia, in which the eosinophils may exceed 50% of the circulating WBCs. The classic triad of infection is intermittent migratory swelling, eosinophilia, and travel to endemic areas (mainly Southeast Asia).²

Pathophysiology

Definitive hosts for Gnathostoma species include dogs, cats, tigers, leopards, lions, mink, opossums, raccoons, and otters, in which the adult worms live in a tumor in the gastric wall. Eggs leave an aperture in the tumor that opens on the stomach lumen and pass into water in the feces. After approximately one week, the eggs develop into larvae, which hatch and are then ingested by the first intermediate host, minute crustaceans of the genus Cyclops. Larvae penetrate the gastric wall of the copepods, migrate through the body cavity, and mature into second-stage and early third-stage larval forms. The copepods are ingested by the second intermediate hosts or definitive hosts (eg, fish, frogs, snakes, chicken, pigs), in which they again penetrate the gastric wall, migrate into muscles, and mature into advanced third-stage larvae before encysting.

When flesh from these hosts is eaten, the larvae excyst in the stomach, penetrate the gastric wall, migrate through the liver, and travel to the connective tissue and muscles. After 4 weeks, they return to the gastric wall to form the tumor, where they mature into adults in 6-8 months. At 8-12 months after initial ingestion, the worms mate, and eggs begin to pass into the feces of the host.

Humans become infected when they ingest third-stage larvae in raw or undercooked meat of the definitive host or when they drink, work in, or bathe in water contaminated with larvae or infested copepods. Cases of probable prenatal transmission in humans have occurred as well. In humans, the larvae do not return to the stomach wall, but rather, they migrate randomly throughout the body for as long as 10-12 years. For this reason, eggs are rarely, if ever, found in human feces.

Within 24-48 hours of ingestion, larvae invade the gastric and/or intestinal wall, resulting in eosinophilia and local symptoms. They migrate to and through the liver. Their migration through the body begins 3-4 weeks to several years after ingestion. Typically, episodes last 1-2 weeks. Over time, episodes are often less frequent, less intense, and shorter. Disease is thought to result from mechanical damage to tissues caused by gnathostome migration; gnathostome production and/or the action of toxins that resemble those of acetylcholine, hyaluronidase, protease, and hemolysin; and the host's response to the infestation.

Frequency

United States

Human cases of gnathostomiasis acquired in the United States have not been reported and it remains rare in individuals who are exposed abroad.

International

Gnathostomiasis is an uncommon disease, even in endemic areas of Southeast Asia (including Japan, Korea, Laos, Malaysia, Taiwan, and Thailand) and Latin America (mainly Mexico and Ecuador), although its incidence appears to be increasing, possibly because of changing dietary habits. It is most common in Thailand and Japan. In Thailand, it is the most common parasitic infection of the CNS. In Thailand, 6% of subarachnoid hemorrhages in adults and 18% of those in infants and children are due to gnathostomiasis.

Mortality/Morbidity

Gnathostomiasis can persist 10-12 years and may cause significant morbidity because of its propensity to involve any part of the body. Random invasion of the CNS, which is the major cause of mortality, may lead to death in 8-25% of patients or long-term sequelae in 30% of patients with CNS involvement.

Race

No predilection has been reported.

Sex

No predilection has been reported, except in cases in which occupational or dietary exposure is related to gender roles.

Age

No predilection has been reported, except in cases affected by factors related to occupational or dietary exposure.

Clinical

History

In patients with gnathostomiasis, mild malaise, fever, urticaria, anorexia, nausea, vomiting, diarrhea, and epigastric pain may occur as the larvae migrate through the gastric and/or intestinal wall. Right upper quadrant pain may accompany the liver-migration phase of the illness. Further symptoms depend on the subsequent migration of the larvae.

• Skin and soft tissue - One or more areas involved with tenderness or swelling; creeping eruptions; pain, pruritus, and erythema; nodules or boils
• Pulmonary - Cough, chest pain, dyspnea, and/or hemoptysis; coughing up of worm
• GI - May mimic appendicitis, cholecystitis, or an intestinal mass lesion
• Genitourinary - Hematuria
• Ophthalmologic - Decreased visual acuity, blindness, pain, and/or photophobia
• Otologic - Decreased hearing and/or tinnitus
• CNS
  • Radiculomyelitis (most common), radiculomyeloencephalitis, encephalitis, and/or meningitis may result. Condition may mimic or cause subarachnoid hemorrhage.
  • Agonizing neuritic pain followed by paralysis or decreased sensorium over a few days is typical.
  • Migration of focal neurologic symptoms and signs (eg, cranial nerve palsies, paralysis of an extremity, urinary retention) is typical. With eosinophilic meningitis caused by A cantonensis, CNS depression, low-grade fevers, headache, and nonfocal neurologic symptoms and signs (except for occasional cranial nerve VII or VIII involvement) are more typical.

Physical

Physical examination findings depend on the area of the body into which the larvae migrate. Single or multiple regions may be involved.

• Skin and soft tissue
  • Panniculitis
  • Intense, nonpitting edema
  • Creeping eruptions
  • Subcutaneous nodules or abscesses
• Pulmonary
  • Lobar consolidation or collapse
  • Pleural effusions
  • Pneumothorax
  • Hydropneumothorax
• GI
  • Tender right upper quadrant, mid epigastrium, and/or right lower quadrant
  • Right lower quadrant mass
• Ophthalmologic
  • Uveitis
  • Iritis
  • Intraocular hemorrhage
  • Increased intraocular pressure
  • Retinal scarring/detachment
• CNS
  • Fever, stiff neck, and/or photophobia
  • Evidence of increased intracranial pressure
  • Migratory focal neurologic findings
  • Paralysis, cranial nerve involvement, and/or urinary retention

Causes

• Travel to or from an endemic area
  • Southeast Asia, especially Thailand and Japan
  • Latin America, especially Mexico and Ecuador
  • Australia
  • Asia and the Middle East
• Dietary/occupational exposure or ingestion
  • Raw or undercooked freshwater fish (ceviche in Mexico and South America, sashimi in Japan, sum-fak in Thailand)
  • Other raw or undercooked flesh
  • Contaminated water

Differential Diagnoses

Other Problems to Be Considered

Angiostrongylus cantonensis
Baylisascaris procyonis
Cysticercus cellulosae
Encephalitis
Eosinophilia-myalgia syndrome
Loa loa
Pentastomiasis
Sparganosis
Subarachnoid hemorrhage

Workup

Laboratory Studies

The following studies are indicated in gnathostomiasis:

• CBC count
  • Eosinophilia may be present, particularly during the active phases of larval migration. Eosinophils may exceed 50% of the circulating WBCs.
  • Findings may reveal leukocytosis.
• Urinalysis
  • Rarely, microscopic hematuria is present.
  • The worm may be found.
• Serology
  • Enzyme-linked immunosorbent assay (ELISA) and the Western blot are promising diagnostic tests.
  • These tests are not widely available in the United States and many other countries.

Imaging Studies

• Plain radiography - Pulmonary or GI findings
• Xerography - Rarely helps in localizing a soft tissue worm
• CT
  • CT rarely helps in localizing a soft tissue worm.
  • In CNS disease, CT may reveal evidence of intracranial hemorrhage, obstructive hydrocephalus, or meningeal inflammation in one half of the cases.

Other Tests

• Sputum examination may reveal a worm.

Procedures

• Surgical excision and/or resection rarely help in making the diagnosis by revealing the larvae in the skin, subcutaneous tissue, gingivae, or wounds.
• Lumbar puncture may be helpful.
  • Pleocytosis (20-1430 WBCs, but typically <500, with a mean of 250)
  • Eosinophilia (5-94%, with a mean of 38%)
  • Xanthochromia, some RBCs

Histologic Findings

• When found, larvae are 2.5-12.5 mm by 0.4-1.2 mm. In tissue, eosinophils predominate, with the presence of fibroblasts, histiocytes, and foreign-body giant cells; this finding may suggest an eosinophilic granuloma.
• In the CNS, migratory tracts may be present with perivascular infiltration of eosinophils, plasma cells, and lymphocytes. Unlike eosinophilic meningitis due to A cantonensis, no CNS granulomata or parasite fragments are observed.

Treatment

Medical Care

The clinical presentation and course of gnathostomiasis dictate the appropriate measures.

Surgical Care

The only definitive treatment is surgical removal of the worm, which is possible only when it is accessible.

Consultations

Consultation with infectious diseases and other appropriate specialists, as dictated by the clinical circumstances, is reasonable.

Medication

Although surgical removal, when possible, is the treatment of choice in gnathostomiasis, albendazole appears to have an increasing role in complementing surgical intervention.³ Ivermectin in a single dose is better tolerated than albendazole but may be less effective.⁴ Mebendazole, which was formerly used, had variable results and significant toxicities and should no longer be used. Adjunctive corticosteroid therapy may have a role in the treatment of CNS disease.

Anthelmintics

These agents are the drugs of choice when surgical treatment is not possible or successful. Parasite biochemical pathways are different from the human host, thus toxicity is directed to the parasite, egg, or larvae. The mechanism of action varies within the drug class. Antiparasitic actions may include the following:

• Inhibition of microtubules that causes irreversible block of glucose uptake
• Tubulin polymerization inhibition
• Depolarizing neuromuscular blockade
• Cholinesterase inhibition
• Increased cell membrane permeability, resulting in intracellular calcium loss
• Vacuolization of the schistosome tegument
• Increased cell membrane permeability to chloride ions via chloride channels alteration

Albendazole (Albenza)

The first DOC for treating gnathostomiasis. A synthetic nitroimidazole that binds to tubulin, inhibits microtubule assembly, decreases glucose absorption, and inhibits fumarate reductase in the parasite. Poorly soluble in water, it is well absorbed when taken with a fatty meal. Concentration in the cerebrospinal fluid reaches 40% of that in the serum.

Dosing

Adult

400 mg PO qd/bid for 21 d

Pediatric

Not established; 15 mg/kg/d PO divided bid/tid for 21 d may be appropriate; not to exceed 800 mg/d

Interactions

Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Alopecia, reversible bone marrow suppression, or hepatocellular injury may occur after prolonged high-dose therapy

Thiabendazole (Mintezol)

A synthetic benzimidazole that should be used only when albendazole is not available because of its toxicities and questionable efficacy. Its mechanism of action is thought to be similar to that of albendazole.

Dosing

Adult

50 mg/kg/d PO divided q12h for 5 d; not to exceed 3 g/d

Pediatric

Administer as in adults

Interactions

May elevate serum levels of theophylline, increasing toxicity (monitor serum levels and reduce dose prn)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Clinical experience in children <30 lb is limited; nausea, vomiting, and vertigo occur in as many as 50% of patients; may cause rash, hypersensitivity, erythema multiforme, leukopenia, and hallucinations; caution in renal or hepatic impairment

Ivermectin (Mectizan, Stromectol)

Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing cell death. Half-life is 16 h; metabolized in liver.

Dosing

Adult

150-200 mcg/kg/d PO as single dose

Pediatric

<5 years: Not established
>5 years: Administer as in adults

Interactions

May interact with other ligand-gated chloride channels, such as those gated by GABA

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Treat mothers who intend to breastfeed only when risk of delayed treatment outweighs possible risks to the newborn caused by ivermectin excretion in milk
Repeat courses of therapy may be required in immunocompromised patients
May cause nausea, vomiting, and mild CNS depression; may cause drowsiness

Corticosteroids

These agents may have an ancillary role in reducing inflammation associated with CNS gnathostomiasis.

Dexamethasone (Decadron, Dexone)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Dosing

Adult

Loading dose: 10 mg IV
Maintenance dose: 4 mg IV q6h; not to exceed 16 mg/d

Pediatric

Loading dose: 1-2 mg/kg IV
Maintenance dose: 1-1.5 mg/kg/d divided q4-6h IV; not to exceed 16 mg/d

Interactions

Effects decrease with coadministration of barbiturates phenytoin and rifampin; decreases effect of salicylates and vaccines; coadministration may increase albendazole levels by 50%

Contraindications

Documented hypersensitivity; active bacterial or fungal infection

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use

Follow-up

Further Inpatient Care

• The need for inpatient care of patients with gnathostomiasis depends on the clinical presentation of the infection.

Further Outpatient Care

• Most patients are treated on an outpatient basis, as the clinical circumstances dictate, except in cases with complications or CNS involvement.

Transfer

• The need for transfer depends on the availability of necessary services and specialists.

Deterrence/Prevention

• Emphasize the need to avoid exposure.
• Ingestion of raw and undercooked food should be avoided in endemic areas.
• Freezing meat at -20°C for 3-5 days kills the larvae.
• Marinating meat in vinegar for 6 hours or in soy sauce for 12 hours kills the larvae.
• Lime juice does not kill the larvae, even with prolonged exposure.
• Contaminated water should be boiled for 5 minutes before use.
• Gloves should be worn or the hands should be washed frequently if exposure to possibly contaminated water or flesh is likely.

Complications

• In Thailand, 6% of subarachnoid hemorrhages in adults and 18% of those in infants and children are due to gnathostomiasis.
• Pneumonia, sepsis, paralysis, and/or long-term neurologic sequelae are possible.

Prognosis

• Gnathostomiasis is seldom fatal, except in CNS disease.
• Long-term morbidity is possible because of tissue injury during migration.
• With CNS disease, the mortality rate is 8-25%; one third of survivors have long-term sequelae.

Miscellaneous

Medicolegal Pitfalls

• Epidemiology is the key to the diagnosis of gnathostomiasis.
  • Obtain the patient's travel and dietary history.
  • Ask about significant exposures.
• Failure to consider the diagnosis in the appropriate clinical setting is a pitfall.

Special Concerns

• Pregnancy
  • Three documented cases of intrauterine transmission of gnathostomiasis have been reported.
  • The use of antiparasitic agents is contraindicated in pregnancy.

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Keywords

gnathostomiasis, CNS infection, chokofishi, consular disease, encephalitis, eosinophilia, eosinophilic meningitis, eosinophilic myeloencephalitis, Gnathostoma binucleatum, G binucleatum, G doloresi, G hispidum, G nipponicum, G procyonis, G spinigerum, hematuria, hydropneumothorax, intraocular hemorrhage, iritis, meningitis, nodular (migratory) eosinophilic panniculitis, panniculitis, parasitic infection, photophobia, pleural effusions, pneumothorax, radiculomyelitis, radiculomyeloencephalitis, Shanghai rheumatism, Tau-cheed, tinnitus, urticaria, uveitis, Woodbury bug, Yangtze River edema

Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Medical Editor

Glenn J Fennelly, MD, MPH, Director, Division of Pediatric Infectious Diseases, Jacobi Medical Center; Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine
Glenn J Fennelly, MD, MPH is a member of the following medical societies: Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Martin Weisse, MD, Program Director, Associate Professor, Department of Pediatrics, West Virginia University
Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

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