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Human angiostrongyliasis, caused by consuming the larva stage of Angiostrongylus cantonensis, is an infectious disease involving the central nervous system (CNS) and ophthalmic system. Current treatment of angiostrongyliasis involves albendazole accompanied by analgesics and corticosteroids. However, long-term use of corticosteroids may lead to significant adverse effects. In the current study, we screened through different potentially effective flavonoid compounds and identified quercetin as an effective anti-inflammatory agent in an angiostrongyliasis mouse model. Our results identified that quercetin may reverse the neurological defects in mice with angiostrongyliasis. The brain pathology and inflammatory status were also improved by albendazole-quercetin co-therapy. Further analysis showed that albendazole-quercetin co-therapy had a better therapeutic effect than albendazole or quercetin monotherapy. This therapeutic effect was achieved by inhibiting the brain inflammasome activation and apoptosis. Albendazole-quercetin co-therapy also leads to the inhibition of brain IL-5, possibly leading to improved pathology. Our results here proved that quercetin may serve as a potential adjuvant drug in treating human angiostrongyliasis., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Lam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Co-therapy with albendazole and steroid is commonly used in patients with eosinophilic meningoencephalitis caused by Angiostrongylus cantonensis infections. However, anthelminthics often worsen symptoms, possibly due to the inflammatory reaction to antigens released by dying worms. Therefore, the present study was to investigate the curative effects and probable mechanisms of the platelet-derived growth factor receptor-beta (PDGFR-β) inhibitor AG1296 (AG) and the phosphoinositide 3-kinase inhibitor (PI3K) LY294002 (LY) in A. cantonensis-induced neurovascular unit dysfunction and eosinophilic meningoencephalitis., Methods: Western blots were used to detect matrix protein degradation and the expressions of PDGFR-β/PI3K signaling pathway. The co-localization of PDGFR-β and vascular smooth muscle cells (VSMCs), and metalloproteinase-9 (MMP-9) and VSMCs on the blood vessels were measured by confocal laser scanning immunofluorescence microscopy. Sandwich enzyme-linked immunosorbent assays were used to test S100B, interleukin (IL)-6, and transforming growth factor beta in the cerebrospinal fluid to determine their possible roles in mouse resistance to A. cantonensis., Results: The results showed that AG and LY cotherapy decreased the MMP-9 activity and inflammatory reaction. Furthermore, S100B, IL-6 and eosinophil counts were reduced by inhibitor treatment. The localization of PDGFR-β and MMP-9 was observed in VSMCs. Furthermore, we showed that the degradation of the neurovascular matrix and blood-brain barrier permeability were reduced in the mouse brain., Conclusions: These findings demonstrate the potential of PDGFR-β inhibitor AG and PI3K inhibitor LY co-therapy as anti-A. cantonensis drug candidates through improved neurovascular unit dysfunction and reduced inflammatory response., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

On Hawai'i Island, an increase in human neuroangiostrongyliasis cases has been primarily associated with the accidental ingestion of Angiostrongylus cantonensis L3 in snails or slugs, or potentially, from larvae left behind in the slug's slime or feces. We evaluated more than 40 different treatments in vitro for their ability to kill A. cantonensis larvae with the goal of identifying a safe and effective fruit and vegetable wash in order to reduce the risk of exposure. Our evaluation of treatment lethality was carried out in two phases; initially using motility as an indicator of larval survival after treatment, followed by the development and application of a propidium iodide staining assay to document larval mortality. Treatments tested included common household products, consumer vegetable washes and agricultural crop washes. We found minimal larvicidal efficacy among consumer-grade fruit and vegetable washes, nor among botanical extracts such as those from ginger or garlic, nor acid solutions such as vinegar. Alkaline solutions, on the other hand, as well as oxidizers such as bleach and chlorine dioxide, did show larvicidal potential. Surfactants, a frequent ingredient in detergents that lowers surface tension, had variable results, but dodecylbenzene sulfonic acid as a 70% w/w solution in 2-propanol was very effective, both in terms of the speed and the thoroughness with which it killed A. cantonensis L3 nematodes. Thus, our results suggest promising directions for future investigation.

Angiostrongylus cantonensis is the leading cause of eosinophilic meningitis worldwide, with life-threatening complications if not managed correctly. Previous in vitro studies have utilized change in motility patterns of adult female worms to assess the efficacy of anthelmintics qualitatively. However, it is the third stage larvae (L3) that are infectious to humans. With differential staining using propidium iodide penetration as the indicator of death, we can distinguish between dead and live larvae. This assay has enabled us to quantify the in vitro efficacy of nine clinically established anthelmintics on A. cantonensis L3. All drugs were tested at a 1 mm concentration. Piperazine and niclosamide were ineffective in inducing larval death; however, albendazole sulfoxide, pyrantel pamoate, diethylcarbamazine, levamisole and praziquantel were effective as compared to unexposed controls (P < 0.05). Ivermectin and moxidectin did not induce significant levels of mortality, but they considerably reduced larval motility almost immediately. This study indicates the need for further in vivo studies to determine the optimal dose and time frame for post-infection treatment with anthelmintics that demonstrated efficacy.

Human infection with Angiostrongyloides cantonensis , or rat lungworm disease, manifests most commonly with neurologic symptoms that often include severe diffuse pain. While pain is reported by the majority of patients with rat lungworm disease, there are presently no published guidelines on the approach to pain management for these patients. Here we report a case of rat lungworm disease where severe refractory pain was the most prominent symptom and an intravenous lidocaine infusion was used as a successful treatment modality. Intravenous lidocaine has been shown to be safe and effective in neuropathic pain, refractory cancer pain, and peri-operative pain management. To our knowledge, this is the first case report on the use of lidocaine infusion for the management of refractory pain from rat lungworm disease, and among the first reports of any approach, to pain management for rat lungworm disease. We suggest that a lidocaine infusion protocol be considered when pain from rat lungworm disease fails to respond to first-line analgesics., (©Copyright 2020 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

A bstract: Currently, Angiostrongylus cantonensis infections are predominantly treated with albendazole. However, the use of albendazole can provoke certain neurological symptoms as a result of the immune response triggered by the dead worms. Therefore, treatment usually involves co-administration of corticosteroids to limit the inflammatory reaction. Corticosteroids play a useful role in suppressing inflammation in the brain; however, long-term usage or high dosage may make it problematic.Schisandrin B, an active ingredient from Schisandra chinensis , has been shown to have anti-inflammatory effects on the brain. This study aimed to investigate the effects and potential of schisandrin B in combination with albendazole to treat Angiostrongylus -induced meningoencephalitis. Here, we show that albendazole-schisandrin B co-treatment suppressed neuroinflammation in Angiostrongylus -infected mice and increased the survival of the mice. Accordingly, albendazole-schisandrin B co-treatment significantly inhibited inflammasome activation, pyroptosis, and apoptosis. The sensorimotor functions of the mice were also repaired after albendazole-schisandrin B treatment. Immune response was shown to shift from Th2 to Th1, which reduces inflammation and enhances immunity against A. cantonensis . Collectively, our study showed that albendazole-schisandrin B co-therapy may be used as an encouraging treatment for Angiostrongylus -induced meningoencephalitis., Competing Interests: The authors declare no conflict of interest.

Background: Angiostrongylus cantonensis infection can cause demyelination in the central nervous system, and there is no effective treatment., Methods: We used dexamethasone, Tanshinone IIA (TSIIA) and Cryptotanshinone(Two traditional Chinese medicine monomers) in combination with albendazole (AB, a standard anti-helminthic compound) to observe their therapeutic effect on demyelination in A. cantonensis -infected mice. Luxol fast blue staining and electron microscope of myelin sheath, Oligodendrocyte (OL) number and myelin basic protein (MBP) expression in brain was detected in above groups., Results: TSIIA+AB facilitated OL proliferation and significantly increased both myelin sheath thickness and the population of small-diameter axons. In addition, TSIIA treatment inhibited the expression of inflammation-related factors (interleukin [IL]-6, IL-1β, tumor necrosis factor [TNF]-α, inducible nitric oxide synthase [iNOS]) rather than inhibiting eosinophil infiltration in brain. TSIIA also decreased microglial activation and shifted their phenotype from M1 to M2., Conclusions: Taken together, these results provide evidence that TSIIA combined with AB may be an effective treatment for demyelination caused by A. cantonensis infection and other demyelinating diseases., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Steroids are commonly used in patients with eosinophilic meningitis caused by A. cantonensis infections. The mechanism steroids act on eosinophilic meningitis remains unclear. In this mouse experiments, expressions of 14-3-3 isoform β and γ proteins significantly increased in the CSF 2-3 weeks after the infection, but not increasedin the dexamethasone-treated group. Expression of 14-3-3 β, γ, ε, and θ isoforms increased in brain meninges over the 3-week period after infection and decreased due to dexamethasone treatment. In conclusion, administration of dexamethasone in mice with eosinophilic meningitis decreased expressions of 14-3-3 isoform proteins in the CSF and in brain meninges.

Angiostrongylus cantonensis is the most common cause of eosinophilic meningitis worldwide. Infection typically occurs through ingestion of undercooked molluscs or vegetables contaminated by infective larvae. Endemic regions were previously limited to southeast Asia and the Pacific basin; however, this parasite is seeing an alarming increase in global distribution with reported cases in more than 30 countries, including several states in the USA. Although infection typically results in meningitis, a broad spectrum of CNS involvement and severity is emerging as diagnostic methods (such as real-time PCR) continue to improve diagnosis. In this Grand Round, we report a case of a 20-year-old active duty US marine serving in Okinawa, Japan, afflicted with severe CNS angiostrongyliasis marked by radiculomyelitis with quadriparesis, hyperaesthesia, and urinary retention. We present this case to highlight that no clear guidelines exist for the treatment of severe CNS angiostrongyliasis and provide our consensus recommendation that treatment algorithms include use of dual corticosteroids plus anthelmintics when radicular symptoms are present. In this Grand Round we review the clinical features, epidemiology, advances to diagnostic techniques, and available data on current treatment options for CNS angiostrongyliasis. This diagnosis should be highly considered in the differential diagnosis of a patient presenting with meningeal symptoms, paraesthesia or hyperaesthesia, and CSF eosinophilia so that treatment can be started early, which is particularly important in children, because of their increased risk of severe disease and mortality. We recommend combined therapy with albendazole and prednisolone, with consideration for increased steroid dosing in severe cases., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Infection with the Rat Lungworm Angiostrongylus cantonensis is the leading cause of human eosinophilic meningoencephalitis worldwide. From its origins in southeastern Asia, the parasite was spread extensively throughout the twentieth century and is now established in many of the world's warmer regions. Its clinical effects range from mild and transient symptoms, usually headache with peripheral nerve dysfunction, to severe and permanent central nervous system (CNS) damage, occasionally fatal. The severity and prognosis of disease are determined by the larval dose, acquired by ingesting infected intermediate hosts (slugs and snails) or, less often, paratenic hosts, such as crabs, shrimps, frogs, and monitor lizards. Early diagnosis is critical for treatment and depends on clinical suspicion, for laboratory confirmation from blood and cerebrospinal fluid can be delayed and unreliable. Treatment is fraught with difficulty, compounded by conflicting published results. Corticosteroids play a useful role in suppressing early CNS inflammation, but their duration for maintenance becomes problematic in severe infections. Because most of the pathogenesis results from host immuno-inflammatory responses to migrating and dead larvae in the CNS, anthelminthic therapy remains controversial: if effective, it kills viable larvae, arresting them in the CNS and so exacerbating the pathology. In human infections, it is now clear that many larvae do leave the CNS and reach the pulmonary arteries, sometimes with clinical consequences. Pioneering life-cycle studies in rats demonstrated a "subarachnoid phase" in larval development and migration; recent autopsy findings, outlined here, show it also occurs in humans and has some bearing on treatment. One new and four previously reported cases of human infection are analyzed here, with findings indicating that anthelminthic treatment is effective only when given early and should not be commenced beyond 3 weeks after exposure to infection. In endemic areas, treatment should start as soon as this infection is suspected, even without a clear history of exposure, given the unacceptable risks of waiting for diagnostic laboratory confirmation.

Angiostrongylus cantonensis, the rat lungworm, is the most common infectious cause of eosinophilic meningoencephalitis worldwide. This parasite is endemic to Southeast Asia and the Pacific Islands, and its global distribution is increasing. We report A. cantonensis meningoencephalitis in a 12-month-old boy in Tennessee, USA, who had not traveled outside of southwestern Tennessee or northwestern Mississippi.

Background: Angiostrongylus cantonensis (A. cantonensis) infection can lead to optic neuritis, retinal inflammation, damage to ganglion cells, demyelination of optic nerve and visual impairment. Combined therapy of albendazole and dexamethasone is a common treatment for the disease in the clinic, but it plays no role in vision recovery. Therefore, it has been necessary to explore alternative therapies to treat this disease. Previous studies reported the neuro-productive effects of two constituents of Danshen (a Chinese herb)-tanshinone II-A (TSII-A) and cryptotanshinone (CPT), and this study aims to evaluate the impacts of TSII-A or CPT combined with albendazole on optic neuritis caused by A. cantonensis infection in a murine model., Methods: To assess the effects of TSII-A or CPT combined with albendazole on optic neuritis due to the infection, mice were divided into six groups, including the normal control group, infection group and four treatment groups (albendazole group, albendazole combined with dexamethasone group, albendazole combined with CPT group and albendazole combined with TSII-A group). The infection group and treatment groups were infected with A. cantonensis and the treatment groups received interventions from 14 dpi (days post infection), respectively. At 21 dpi, the visual acuity of mice in each group was examined by visual evoked potential (VEP). The pathologic alteration of the retina and optic nerve were observed by hematoxylin and eosin (H&E) staining and transmission electronic microscopy (TEM)., Results: Infection of A. cantonensis caused prolonged VEP latency, obvious inflammatory cell infiltration in the retina, damaged retinal ganglions and retinal swelling, followed by optic nerve fibre demyelination and a decreasing number of axons at 21 dpi. In treatment groups, albendazole could not alleviate the above symptoms; albendazole combined with dexamethasone lessened the inflammation of the retina, but was futile for the other changes; however, albendazole combined with CPT and albendazole combined with TSII-A showed obvious effects on the recovery of prolonged VEP latency, destruction and reduction of ganglion cells, optic nerve demyelination and axon loss. Compared with albendazole-CPT compound, albendazole combined with TSII-A was more effective., Conclusions: The current study demonstrates that albendazole combined with TSII-A plays a more effective role in treating optic neuritis caused by A. cantonensis in mice than with dexamethasone, as applied in conventional treatment, indicating that albendazole combined with TSII-A might be an alternate therapy for this parasitic disease in the clinic.

Angiostrongylus cantonensis is a parasitic pathogen whose forth-stage larvae (L4) parasitize in the central nervous system (CNS) of the human cause severe eosinophilic encephalitis or meningoencephalitis. Previous study indicated an impressive anthelmintic efficacy of tribendimidine (TBD) against CNS parasitized L4 of A. cantonensis. Tegument of the larvae is the first physical barrier to protect them from attack by the host immune system. In the present study, tegumental and hypodermic alterations were observed by scanning electron microscopy and transmission electron microscopy after administration of TBD. During treatment of TBD in vivo, L4 presented wizened side sensor, disappearance of mastoids and longitudinal grain, prominent surface coat, heterogeneous tegumental layers, incompact hypodermic cell junctions, blurred myotube, and small scale of vacuole in a basal layer. After incubation with TBD in vitro, L4 exhibited a swollen side sensor and mastoids disappearance in head end. Abundant tegumental blebs and obvious deformation of both cross-grain and longitudinal grain were detected on the surface, and shrinkage of all tegumental layers, chaotic cell junction, turbid muscle cell, disappearance of myotubes, and vacuole-like changes were visible under the electron microscope. The results implied the potential mechanism of the anthelmintic effect of tribendimidine against L4 of A. cantonensis by direct damages to tegumental and hypodermic.

Angiostrongylus cantonensis (A. cantonensis) infection causes eosinophilic meningitis in humans. Eosinophilia and a Th2-type immune response are the crucial immune mechanisms for eosinophilic meningitis. CD4+CD25+ regulatory T cells (Treg) are involved in the pathogenesis of A. cantonensis. Diammonium glycyrrhizinate (DG) is a compound related to glycyrrhizin (GL), a triterpene glycoside extracted from liquorice root. We investigated the curative effects and probable mechanisms of therapy involving a combination of albendazole and DG in BALB/c mice infected with A. cantonensis, and compared these with therapy involving albendazole and dexamethasone. We analysed survival time, body weight, signs, eosinophil numbers, immunoglobulin E (IgE), interleukin-5 (IL-5), and eotaxin concentrations, numbers and Foxp3 expression of CD4+CD25+ Treg, worm recovery and histopathology. The present results demonstrated that the combination of albendazole and DG could increase survival time more efficiently and relieve neurological dysfunction; decrease weight loss, eosinophil numbers, concentrations of IgE, IL-5 and eotaxin, the number and expression of Foxp3 of CD4+CD25+ Treg; and improve worm recovery and histopathology changes in treated animals, compared with the combination of albendazole and dexamethasone. The observations presented here suggest that the albendazole and dexamethasone combination could be replaced by the combination of albendazole and DG.

Galectin plays an important role in host-parasite interactions. In this study, we identified a novel gene encoding galectin-10 (AcGal-10) from the cDNA library of Angiostrongylus cantonensis and characterized its biological role in the parasite. Sequence and phylogeny analysis showed that AcGal-10 is related to other galectin family members with the conserved loci (H(84)-D(86)-R(88)-V(96)-N(98)-W(105)-E(108)-R(110)). The mRNA level of AcGal-10 was expressed in reactive oxygen stress radicals. We have identified two proteins of A. cantonensis galectin-10 gene, one of which was reported (AcGAL10-W) and the others is AcGAL-10-M. In addition, recombinant AcGal-10 (rAcGal-10) was constructed into the pGEX-4T-1 plasmid, purified, and finally confirmed by SDS-PAGE and LC-MS. Hemagglutination assay showed that the minimum concentration of rAcGAL10-W and rAcGAL10-M required for the hemagglutination of BALB/c mice erythrocyte was 25 μg/mL, and the carbohydrate-binding ability showed no difference between rAcGAL10-W and rAcGAL10-M. The mRNA levels of AcGal-10 were indeed expressed higher after stimulation with H(2)O(2) and recombinant A. cantonensis galectin-10. A mutation of AcGal-10 was also found, but there was no significant difference compared with the wild type. Furthermore, we also confirmed that recombinant AcGal-10 plays a role in the activation of the microglia. In conclusion, the report here showed that AcGal-10 may be an important molecule related to infection of A. cantonensis.

Angiostrongyliasis, also known as eosinophils meningitis, is caused by Angiostrongylus cantonensis parasites in the human central nervous system. Currently, the drug of choice for treatment of angiostrongyliasis is albendazole, but dead worm lysis causes severe inflammatory response, which leads to central nervous system damage. Tribendimidine, a broad-spectrum anti-helmintic drug developed in China, is a derivative of amidantel. This study was designed to test the efficacy of tribendimidine against A. cantonensis in mice. We treated 65 infected female BALB/c mice with tribendimidine or albendazole by oral route. We observed that tribendimidine at doses of 50, 100 and 200 mg/kg/day was effective, and the worm reduction rates were 54.8 %,77.4 %, and 100 % compared with the control group. In addition, the therapeutic effect of early tribendimidine treatment (7 days post-infection [PI]) was better than the late treatment (14 days PI), in comparison with the albendazole group (20 mg/kg/day). The index of therapeutic efficacy included body weight, neurological function, survival time, worm reduction, mRNA levels of proinflammatory cytokines in brain tissue, histopathological examination and electron microscopy scanning. The results showed that tribendimidine could kill the larvae of A. cantonensis in the mice model, and the worm's body wall was observed to be damaged. After treatment with tribendimidine, the survival conditions such as body weight and neurological function were improved, and brain inflammation was reduced in infected mice. This study showed a strong efficacy of tribendimidine against A. cantonensis and provided suitable alternative treatments to further explore its potential use in treatment of human angiostrongyliasis.

Angiostrongylus cantonensis (A. cantonensis) is the most common cause of parasitic eosinophilic meningitis worldwide. By using an animal model of BALB/c mice infected with A. cantonensis, previous studies indicated that the anthelmintic drug, albendazole, could kill A. cantonensis larvae and prevent further infection. However, the dead larvae will induce severe immune responses targeting at brain tissues. To alleviate the detrimental effects caused by the dead larvae, we administered curcumin, a traditional anti-inflammatory agent, as a complementary treatment in addition to albendazole therapy, to determine whether curcumin could be beneficial for treatment. The results showed that although curcumin treatment alone did not reduce worm number, combined treatment by albendazole and curcumin helped to reduce eosinophil count in the cerebrospinal fluid, better than using albendazole alone. This alleviating effect did not affect albendazole treatment alone, since histological analysis showed similar worm eradication with or without addition of curcumin. Nevertheless, curcumin treatment alone and combined albendazole-curcumin treatment did not inhibit MMP-9 expression in the brain tissue. In conclusion, curcumin, when used as a complementary treatment to albendazole, could help to alleviate eosinophilic meningitis through suppression of eosinophil count in the cerebrospinal fluid.

To investigate the pepsin-activated infective (third-stage) larvae of Angiostrongylus cantonensis at the transcriptomic level, 1496 ESTs were generated from a cDNA library and clustered into 161 contigs and 757 singletons. Among these unigenes, 54.5% had significant sequence homology with known proteins. The most abundantly expressed transcripts were cathepsin B-like cysteine protease 1 and 2, metalloprotease I, metalloprotease 1 precursor, and extracellular superoxide dismutase. Protein complex was the most common Gene Ontology classification within the 'cellular component' category, embryonic development ending in birth or egg hatching within 'biological process', and protein binding within 'molecular function'. Moreover, 280 clusters were mapped to 158 KEGG pathways and 134 had unique EC numbers. These findings suggest that treatment with pepsin-HCl not only digests the tissues of the snail host but also activates the infective larvae., (Copyright © 2011 Elsevier B.V. All rights reserved.)

The anthelminthic efficacy of some differently obtained extracts of several plants was tested in vivo in laboratory animals and in vitro. The extracts were obtained by ethanolic, methanolic, aqueous, or chloroform, respectively, acetonitrile polyethylenglycol (PEG) and/or propylencarbonate (PC) elution at room temperature or at 37°C. The plants used were bulbs of onions, garlic, chives, coconut, birch tree, ananas, cistrose, banana, chicory, date palm fruit, fig, pumpkin, and neem tree seeds. The worm systems tested both in vivo and in vitro were Trichuris muris and Angiostrongylus cantonensis but only in vivo Toxocara cati. The tests clearly showed that the different extraction methods eluted different components and different mass amounts, which had different efficacies against the above-cited worms. In vitro effects against A. cantonensis and T.muris were best with aqueous extracts, followed by chloroform extracts. The other plant extracts showed only low or no effects on A. cantonensis in vitro. In the case of T. muris, best results were obtained in vivo and in vitro with PEG/PC extracts of the onion followed by the aqueous extract of coconut. The complete elimination of worms in the in vivo experiments with T. muris was obtained when infected mice were treated with a 1:1 mixture of extracts of coconut and onion being produced by elutions with a mixture of 1:1 PEG and PC and fed daily for 8 days. T. cati in a naturally infected cat was eliminated by daily oral application of 6 ml coco's fluid for 5 days. This study shows that a broad spectrum of plants has anti-nematodal activities, the intensity of which, however, depends on the mode of extraction. This implicates that, if results should be really comparable, the same extraction methods at the same temperatures have to be used. Furthermore, efficacy in in vitro systems does not guarantee as good--if at all--efficacy in vivo.

Angiostrongylus cantonensis infection causes eosinophilic meningitis in humans. Baicalein is a flavonoid originally isolated from the roots of Scutellaria baicalensis Georgi. In this study we evaluated the efficacy of the combination of albendazole and baicalein for treating eosinophilic meningitis in BALB/c mice. Therapeutic efficacy included the survival time, body weight, neurological function, leucocyte and eosinophil counts, eotaxin concentration, matrix metalloproteinase-9 (MMP-9) activity, larval recovery and histopathological examination. The results showed that the combination of albendazole and baicalein was more effective than either drug administered singly. Combination therapy increased the survival time, decreased body weight loss, neurological dysfunction, leucocyte response, eotaxin concentration and MMP-9 activity. Our results suggest that the combination of albendazole and baicalein may exhibit synergistic beneficial effects in the treatment of eosinophilic meningitis induced by A. cantonensis.

Eosinophilic meningitis caused by Angiostrongylus cantonensis is an emerging infectious disease. It is the most common form of human angiostrongyliasis. The diagnosis is made by clinical criteria including the presence of cerebrospinal fluid eosinophils and a history of exposure to A. cantonensis larvae, e.g., from raw freshwater snails or contaminated vegetables. Among various treatment options, corticosteroid is the only effective treatment.

In this study, we investigated the anthelmintic activity of [6]-gingerol, [10]-shogaol, [10]-gingerol, [6]-shogaol and hexahydrocurcumin, a constituent isolate from the roots of ginger (Zingiber officinale), for the parasite Angiostrongylus cantonensis. This study found that the above constituents killed A. cantonensis larvae or reduced their spontaneous movements in a time- and dose-dependent manner. The larvicidal effect or ability to halt spontaneous parasite movement of [10]-shogaol, [6]-gingerol, [10]-gingerol, [6]-shogaol and hexahydrocurcumin at various concentrations was reached from 24 to 72 h, respectively. Further investigation to determine minimal effective doses of [10]-gingerol and hexahydrocurcumin revealed [10]-gingerol to have a greater maximum larvicidal effect and loss of spontaneous movements than hexahydrocurcumin, mebendazole and albendazole. These constituents of ginger showed effects against DPPH and peroxyl radical under larvicidal effect. Together, these findings suggest that these constituents of ginger might be used as larvicidal agents against A. cantonensis., (2010 Elsevier B.V. All rights reserved.)

The effect of the food flavoring of 'koi-hoi', a popular Thai snail dish, on the viability and infectivity of Angiostrongylus (=Parastrongylus) cantonensis third-stage larvae was assessed in a mouse model. Groups of 50 each of actively moving, non-motile coiled, and extended larvae were obtained from experimentally infected snail meat, after one-hour exposure to standard 'koi-hoi' flavoring. These larvae and groups of 50 unexposed moving larvae (control) were individually fed to each group of three experimental BALB/c mice. The effect on Angiostrongylus worm burden was measured after 3 weeks of infection. Infectivity of the motile larvae after exposure to 'koi-hoi' food flavoring was 38 + or - 5.29%. This was highly significantly lower than the infectivity (62 + or - 7.21%) of the control (unexposed) third-stage larvae (chi(2) = 17.28, P < 0.001). In the non-motile larvae resulting from exposure to the food flavoring, no adult worm was recovered from the extended larvae, indicating that they were no longer alive and unable to cause infection. A small proportion (3.33 + or - 2.31%) of the coiled larvae developed into young adult worms, indicating that mobility alone is not a definitive indicator of viability. The present study confirms that the food flavoring components of 'koi-hoi' dish adversely affect the viability and infectivity of A. cantonensis larvae. Exposure of the third-stage larvae to 'koi-hoi' food flavoring resulted in decreased viability and eventually death. Prolonged treatment with food flavoring to inactivate/immobilize and then kill the infective, third-stage larvae of A. cantonensis in snail meat prior to consumption may be one of the possible economical means of reducing human infection., (Copyright 2009 Elsevier B.V. All rights reserved.)

To determine how combination therapy with albendazole and dexamethasone changed cytokine responses in peripheral blood mononuclear cells (PBMC) in patients with eosinophilic meningitis caused by Angiostrongylus cantonensis (EOMA), we measured mRNA levels of Th2 (IL-5, IL-4 and IL-10) and Th1 (IL-2 and IFN-gamma) cytokines with reverse transcription polymerase chain reaction (RT-PCR). Forty-three patients were divided into three groups: group 1 (pre-treatment, 13 patients), group 2 (7 days post-treatment, 14 patients), and group 3 (30 days post-treatment, 16 patients). Peripheral eosinophil counts were also measured. EOMA patients showed higher levels of Th2 cytokines, including IL-5 and IL-10, and peripheral eosinophil counts, but no changes in IL-4 or Th1 cytokines. Combination therapy reduced IL-5 mRNA expression and peripheral eosinophil counts to control levels, but increased IL-10, IL-2, and IFN-gamma mRNA expression, and did not change IL-4 levels. These data suggest that systemic Th2 cytokine responses, especially IL-5, and peripheral eosinophil counts increased in EOMA patients. Combination therapy with albendazole and dexamethasone can shift the cytokine responses from Th2 to Th1 dominance, which may be a therapeutic mechanism.

Human infection with the rat lungworm Angiostrongylus cantonensis (Parastrongylus cantonensis) in Thailand, especially in the northeastern region, is associated with the habit of eating koi-hoi, which contains raw snail meat. Infection results from the snails being carriers of the larval parasite. The present study was conducted to assess the effect of food flavorings in koi-hoi, alcohol, and exposure time of the two variable on the infective larvae of A. cantonensis. Infected Biomphalaria glabrata snails were used for koi-hoi preparation. Raw snail meat was mixed with koi-hoi flavoring and left at room temperature for various time periods ranging from 5 to 60 minutes. At a predetermined time, two pieces of snail meat were removed at random and examined for viability (as determined by motility) of the parasitic third-stage larvae. At the same time, two random pieces of snail meat were removed and treated with 10 mL of a local 40% alcoholic drink for 30 minutes before examination of larval viability. Exposure of infected snail meat for 10 minutes or more to koi-hoi food flavoring resulted in significantly more nonmotile (dying or dead) larvae. Addition of the local alcoholic drink after exposure to the flavoring exerted an additional killing effect on the larvae. Despite long exposure time, both the koi-hoi flavoring and addition of alcoholic drink were not completely effective in killing the infective larvae in the snail meat. Thorough cooking of the food intended for human consumption should still be practiced.

Eosinophilic meningitis in humans is commonly caused by the nematode Angiostrongylus cantonensis. A severe headache is the most common presenting symptom. A prospective, randomized, double-blind, placebo, controlled study was conducted to determine if albendazole was efficacious in relieving such headaches. Seventy-one patients (36 and 35 in the treatment and control groups) were enrolled in the study. Five patients (two and three in the treatment and control groups) were excluded from the study because of being lost to follow-up, and the clinical data were incomplete. Therefore, 34 and 32 patients in the treatment and control groups were studied, respectively. Albendazole was administered at 15 mg/kg/day or identical placebo for 2 weeks. The number of patients with persistent headaches after 2 weeks was 7 and 13 in the albendazole and placebo groups (p = 0.08), respectively. The mean duration of a headache was 8.9 and 16.2 days in the albendazole and placebo groups, respectively (p = 0.05). No serious drug events were observed. A 2-week course of albendazole appeared to reduce the duration of headache in eosinophilic meningitis.

Angiostrongylus cantonensis is the major cause of human eosinophilic meningoencephalitis. ICR mice were infected orally with 35 infective larvae and sacrificed at 4-14 days, 25 days or 32 days post infection (dpi) for pathological and immunocytochemical examinations. In the non-treated group, no apoptosis signal was found in the meninges or parenchyma of the brains (4-14 dpi). Only a few apoptotic cells were noticed at 25 dpi (3%) and 32 dpi (10%). In the groups, the animals were given a single dose of mebendazole (20 mg/kg, per os at various times) or injections of interleukin 12 (IL-12) (10 ng/daily, intraperitoneally), all the animals were sacrificed at 14 dpi; the number of apoptotic cells was increased (17-21%). In the group that received a single dose of mebendazole (4 dpi) in combination with IL-12 injections (4-13 dpi), mild meningitis was observed, and most of the infiltrated inflammatory cells were in the apoptotic program (55%). Taken together, apoptosis of the inflammatory cells (most were eosinophils) could be induced when the infected mice were treated with mebendazole or/and IL-12.

Angiostrongylus cantonensis can invade the central nervous system, leading to human eosinophilic meningitis or eosinophilic meningoencephalitis. Curcumin is a natural product which has the effects of anti-inflammation, anti-oxidation and anti-carcinogensis, while the administration of curcumin has been reported to possibly relieve the symptoms of meningitis. The present study tested the potential efficacy of curcumin in A. cantonensis-induced eosinophilic meningitis of BALB/c mice. Assay indicators for the therapeutic effect included the larvicidal effect, eosinophil counts and matrix metalloproteinase-9 (MMP-9) activity in angiostrongyliasis. Eosinophils were mildly reduced in treatment groups compared with infected-untreated mice. However, there were no significant differences in larvicidal effects or MMP-9 activity. This study suggests that anti-inflammatory treatment with curcumin alone has low efficacy, but the treatment does not interfere with MMP-9 expression and is not useful for larvicidal effects. The possible reasons include low curcumin across the blood-brain barrier and also those larvae that survive stimulate MMP-9 production, which promotes blood-brain barrier damage, with leukocytes then crossing the blood-brain barrier to cause meningitis. Further studies will be required to test these possibilities.

To study the efficacy of the combination of prednisolone and mebendazole for the treatment of eosinophilic meningitis, we conducted a pilot study among Thai patients with eosinophilic meningitis. Patients were given a two-week course of prednisolone, 60 mg/day, and mebendazole, 10 mg/kg/day. The primary observation parameter was the number of patients who still had headaches after the two-week course of treatment. Forty-one patients were enrolled in the study. Four (10%) patients still had headaches after the two-week course of treatment and the median length of time until complete disappearance of headaches was three days. Serious side effects were not detected. Treatment for two weeks with the combination regimen of prednisolone and mebendazole is safe and beneficial in relieving headaches in patients with eosinophilic meningitis.

Angiostrongyliasis is one of the common causes leading to eosinophilic meningitis. Tissue-type plasminogen activator (tPA) and urokinase-type plasminogen activator (uPA) may play a role in the pathogenesis. Administration of steroid drugs has been reported to possibly relieve the symptoms of eosinophilic meningitis. This study evaluates the curative effects of albendazole-dexamethasone co-therapy on eosinophilic meningitis in BALB/c mice. Assay indicators for the therapeutic effect include worm recovery, histopathological score of meningitis, tPA, uPA, total protein, and leukocyte counts. The results show that the albendazole-dexamethasone co-therapy significantly decreased (P<0.05) these factors after treatment on day 5 post-inoculation (PI), in contrast to treatment on 15 PI. Thus, the timing of medication is important and is closely related to the anthelmintic efficacy of a drug. At the same dosage and days post-infection, the earlier administration shows better results. This study showed that albendazole-dexamethasone co-therapy is an effective approach for the treatment of parasitic meningitis.

Angiostrongylus cantonensis causes a form of parasitic meningitis in humans. Albendazole kills the nematode larvae staying in the brain. However, the dead larvae are capable of evoking a severe inflammatory response resulting in the brain damage. Matrix metalloproteinase 9 (MMP-9) is associated with the development of meningitis and with the immune inflammatory reaction. Presently, we studied the combination effects of albendazole and GM6001 (a MMP-9 inhibitor) against angiostrongyliasis in BALB/c mice. Co-administration of drugs produced marked effects; to kill the infecting larvae and to block MMP-9 activity. The combination treatment reduced MMP-9 activity by 89.2% in cerebrospinal fluid. The numbers of inflammatory cells increased significantly upon establishment of infection, but subsided upon co-treatment. Significantly fewer larvae were recovered from treated mice than from untreated, infected mice. The present results strongly suggest that co-therapy with albendazole and GM6001 may be an useful approach for the treatment of human angiostrongyliasis.

Matrix metalloproteinase 9 (MMP-9) is involved in the pathogenesis of parasitic meningitis caused by the nematode Angiostrongylus cantonensis. The present study evaluated the efficacy of albendazole therapy in BALB/c mice infected with the third stage larvae of this nematode. Albendazole showed a pronounced larvicidal activity. Eosinophil numbers significantly increased in infected mice but decreased upon administration of albendazole. Densitometric scanning indicated that albendazole reduced gelatinolytic activity detected by gelatin-substrate zymography. In the cerebrospinal fluid, albendazole reduced the lytic area intensity of the 94 kDa MMP-9 band by 46.5% within 7 days, and by 51.5% by day 14. Examination of brain tissue revealed a similar pattern of decrease (48.6% by day 7, and 53.9% by day 14). Albendazole may thus be an effective compound for the treatment of angiostrongyliasis through its larvicidal activity and facilitation of an improved inflammatory response via the reduction of MMP-9 activity., (Copyright 2004 Springer-Verlag)

Abdominal angiostrongyliasis is a zoonotic infection produced by a metastrongylid intra-arterial nematode, Angiostrongylus costaricensis. Human accidental infection may result in abdominal lesions and treatment with anti-helminthics is contra-indicated because of potential higher morbidity with excitement or death of worms inside vessels. To evaluate the effect of mebendazole on localization of the worms, male Swiss mice, 5 week-old, were infected with 10 third stage larvae per animal. Twelve infected mice were treated with oral mebendazol, at 5 mg/kg/day, for 5 consecutive days, begining 22 days after inoculation. As control groups, 12 infected but non-treated mice and other 12 non-infected and non-treated mice were studied. The findings at necropsy were, respectively for the treated (T) and control (C) groups: 92% and 80% of the worms were inside the cecal mesenteric arterial branch; 8% and 10% were located inside the aorta. Only in the group C some worms (10%) were found inside the portal vein or splenic artery. These data indicate that treatment with mebendazole does not lead to distal or ectopic migration of A. costaricensis worms.

Our previous in vivo studies on angiostrongyliasis showed that PF1022A had stronger killing effects against female adults than against males. No killing effects were observed against young adult worms in the central nervous system. To characterize the former in vivo action of PF1022A, in vitro effects of PF1022A on the motility of Angiostrongylus cantonensis were studied directly. Few differences in the efficacy were observed between male and female worms, but dose- and time-dependent inhibition was observed in adults treated with PF1022A at 10(-7)-10(-11) g/ml. PF1022A was slightly less effect we against young-adult worms than against adult worms. Minor effects of PF1022A were observed on the third-stage larvae. These results suggest that selectivity against adult females in vivo could be attributable to non-neuropharmacological mechanisms and that PF1022A does not pass through the blood-brain barrier in host animals.

In vitro effects of VD-99-11 were examined using adult Angiostrongylus cantonensis and isolated frog rectus. In A. cantonensis, paralysis was elicited by VD-99-11 at 10(-9)-10(-6) g/ml. The paralysis caused by VD-99-11 (10(-8) g/ml) was antagonized by picrotoxin or bicuculline but not by phentolamine. A relationship between VD-99-11 and gabergic antagonists was observed in worm preparations contracted by eserine or pyrantel: VD-99-11 at higher concentrations (3x10(-6) g/ml) caused a marked contraction. In worm preparations contracted with eserine or pyrantel, the only additional contraction induced by VD-99-11 (5x10(-6) g/ml) was antagonized by strychnine. In experiments on the guanidine (2.5x10(-3) M)-induced twitch responses in isolated frog rectus, marked stimulation was caused by VD-99-11 (3-5x10(-6) g/ml). The stimulated responses induced by VD-99-11 were antagonized by tetrodotoxin, D-tubocurarine, strychnine, and hemicholinium-3, respectively. These results suggest that VD-99-11 seems superior to milbemycin D, milbemycin oxime, and ivermectin in some aspects, such as in vitro potency, though this new substance is similar to these drugs in having two different actions on the gabergic mechanism at lower concentrations and on the cholinergic mechanism at higher concentrations.

We examined the effects of PF1022A, newly developing in Japan, on adult Angiostrongylus cantonensis in the pulmonary arteries of rats. Following five and ten successive oral doses at 10 mg/kg per day, the first-stage larvae in rat faeces disappeared completely at 2 weeks after treatment. The treatment completely killed the female worms, but not the male worms. However, numbers of male worms were also decreased after the administration of either five successive oral doses at 10 mg/kg per day for four courses or five successive intraperitoneal doses at 0.5 mg/kg per day. Next, we examined the effects of PF1022A on larval A. cantonensis migrating into the central nervous system (CNS) of rats. Following five successive oral doses at 5 or 10 mg/kg per day and five successive intraperitoneal doses at 0.5 mg/kg per day, lesser killing effects were observed on male as well as female worms. On the basis of these results it is apparent that PF1022A will become a promising anthelmintic available as treatment for tissue-dwelling as well as intestinal nematodes.

Levamisole, in dosages of 2.5, 5, 10, and 25 mg/kg/day, was given orally by orogastric tube beginning 5, 10, 15, and 20 days after the infection of ICR mice with 50 third-stage larvae of Angiostrongylus cantonensis. Medication was given for 7, 14 or 21 consecutive days. The mice in each group were sacrificed 3 days after cessation of treatment and the brains were examined for parasites. Complete anthelmintic effects could be obtained when treatment was started 10 days post-infection with dosages as low as 2.5 mg/kg/day for 21 consecutive days. Over 90% worm reduction was achieved in the two-week treatment group with medication beginning 5 days after infection at diverse dosages. High dose were given in the treatment groups beginning 15 days post-infection. When the commencement of medication was delayed to 20 days post-infection, worm reduction rates were around 50% in spite of long periods and/or high dosages of medication.

Effects of levamisole, orally administered at 1, 3, 5 or 7 successive daily doses of 30 mg/kg, on the number of first-stage larvae of Angiostrongylus cantonensis released in the faeces of treated rats were examined. First-stage larval counts (larvae per gram of faeces per female worm recovered, LPG/female) were conspicuously reduced 1 day after administration in all treated groups. In the group treated with a single dose, the larval counts increased 2 days after administration, but no larvae could be detected in the other treated groups. Histological observations of lung tissues of the host showed the degenerative changes in the reproductive system of the worms. These results suggest that levamisole affects the larval output of A. cantonensis through a direct paralyzing action and an indirect mode of action including inhibition in energy metabolism.

Male BALB/c mice were infected with Angiostrongylus cantonensis and at various times p.i. treated with cyclosporin A (CsA) either for 5 days continuously or intermittently, or for 12-16 days on alternate days. They were monitored for peripheral blood eosinophilia and at necropsy examined for CSF and bone marrow eosinophilia, and worm recovery. CsA treatment provoked a transient inhibition of peripheral blood eosinophilia in all groups examined, followed by rebounding eosinophilia. There was no significant difference in bone marrow and CSF eosinophilia between CsA- and vehicle-treated groups. Mice treated with CsA on alternate days yielded lower intracranial worm recovery with small-sized worms at days 7, 21 and 30 p.i. than vehicle-treated groups did. No significant reduction in worm recovery was noted in mice treated for 5 days either continuously or intermittently, although worms, especially female ones, harvested from groups treated with CsA from days--1 to 3 or from days 13 to 17 were significantly smaller than those from vehicle-treated groups. CsA-treatment suppressed blastogenic responses of spleen cells against Con A or worm antigen at days 7 and 21 p.i. In vitro treatment of the 3rd stage larvae with CsA did not adversely influence survival of A. cantonensis in mice. These data indicate that CsA exerts anti-parasitic effects against A. cantonensis in mice.

Attempts have been made to increase the survival rate of third-stage larvae of Parastrongylus cantonensis during cryopreservation. Parasites were obtained from experimentally infected snails, Biomphalaria glabrata. The maximum non-toxic concentrations of cryoprotectants dimethyl sulphoxide (DMSO) and glycerol were determined as 10% v/v in NCTC 109 medium. Different pre-cooling times and serum additives were assayed to determine their effects on the viability of larvae. Larvae pre-cooled at -20 degrees C for 15-20 minutes before transfer to -70 degrees C had the optimum survival rate. The presence of serum was essential for further cooling to -196 degrees C. There were no differences between native and heat-inactivated sera on the larval viability. The survival of larvae recovered after storage at -196 degrees C was higher in sera collected from the rat, man, or fetal calf than in sera collected from the mouse, dog, or horse. Viability assessed by mouse-infections showed that thawed larvae retained infectivity for susceptible hosts, but it was significantly lower than that of unfrozen control worms.

Two kinds of benzimidazoles, flubendazole and mebendazole were each administered at 10 mg/kg to rats harbouring the developing larvae of the rat lungworm, Angiostrongylus cantonensis 3 or 10 days post-infection and to those harbouring the adult worms 70 days post-infection. Almost all of the larvae were eliminated from the rats mediated 3 days post-infection. The larvicidal effects of the drugs administered 10 days post-infection were not so high as those 3 days post-infection. However, the growth of larvae in rats medicated 10 days post-infection were significantly inhibited as judged from their length, width and weight except the length of the larvae in rats given mebendazole. An inhibition of their growth was also demonstrated by the observation that no first-stage larvae were released from the rats medicated 10 days post-infection and examined 66 days post-infection at which the first-stage larvae were released from non-medicated rats. On the other hand, when the drugs were administered 70 days post-infection, no effects were seen on the number, body size and weight of recovered worms, and the release of the first-stage larvae. A sound conclusion was drawn that the developing larvae are more sensitive to the drugs than the adult worms.