1267_1268_Chochon_JON_1688 30.09.2005 08:00 Uhr Seite 1267
J Neurol (2005) 252 : 1267–1268 DOI 10.1007/s00415-005-0688-0
LETTER TO THE EDITORS thesis. Consequently, acute meningo-myelitis due to Toxocara canis was diagnosed. Although symptoms partially disappeared before any treatment, IV administration of mebendazole (800 mg per day for 10 days) was concomitant with an almost complete clinical recovery and total normalization of spinal MRI (Fig. 2).
Valérie Dauriac-Le Masson Florence Chochon Sophie Demeret Charles Pierrot-Deseilligny
Toxocara canis meningomyelitis Received: 26 July 2004 Received in revised form: 21 September 2004 Accepted: 7 October 2004 Published online: 5 October 2005
Discussion The reported infection rate with Toxocara in humans is high; 5 % of the French population had a positive serology in 1994 [10]. The infestation is usually asymptomatic, via contaminated dogs or soil, but a more marked inflammatory immune response, called “visceral larva migrans syndrome”, may occur [9, 10]. Central
Sirs: Eosinophilic meningomyelitis is rare in temperate countries. Toxocarosis is an ubiquitous parasitic infection that may lead to such neurological manifestations. Here, we report a French patient who developed meningomyelitis due to Toxocara canis, with a good recovery.
Case report
0.3 g/L of protein and 3.3 mmol/L of glucose. Hematological, biochemical, inflammatory, and immunological blood tests were normal or negative, and the number of peripheral blood eosinophils was within the normal range. HIV serology was negative. Viral polymerase chain reactions in the CSF were negative for HSV, VZV, CMV and EBV. Antibody titers against schistosomiasis, cysticercosis, hydatidosis, amoebiasis and toxoplasmosis were negative in serum. There was no cryptococcus in either the blood or CSF. No parasitic organism was detectable in either the feces or urine. However, antibody titer against Toxocara canis was positive using the ELISA method and was higher in the CSF than in serum (200 in the CSF vs 62 in the serum), suggesting intrathecal Toxocara canis antibody syn-
Fig. 2 Normalization of MRI, two months after treatment
JON 1688
A 32-year-old woman, living in Paris, was admitted to our hospital because of ascending weakness and paresthesiae in the lower limbs, associated with dysuria. One month before admission, she had thoracic pain in the left T10 dermatome, abdominal pain and diarrhea, that resolved spontaneously within a few days. Examination confirmed distal asymmetric weakness and dysesthesiae in both lower limbs, up to right T12 and left L1 dermatomes. Deep tendon reflexes were present and symmetric. Right cutaneous plantar response was in extension. There was no meningeal irritation and no rash. Spinal magnetic resonance imaging (MRI) showed intramedullar T2-weighted hyperintensity from T6 to T11, with a contrast-enhancement at level T9 (Fig. 1). CSF examination revealed 25 cells/µL with 50 % of eosinophils, 28 % of lymphocytes,
Fig. 1 Hyperintense lesion in the thoracic cord on MRI T2-weighted sequences
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nervous system involvement is rare. Some cases of epilepsy [1], encephalitis and meningo-encephalitis [5], eosinophilic meningitis [4], arachnoiditis [14], meningo-radiculitis [11], optic neuritis [6], and also meningo-myelitis [2, 3, 5, 7, 12, 13, 15], as in our patient, have been reported. However, the diagnosis of Toxocara canis meningo-myelitis should be based on a spinal syndrome, hypereosinophilia at least in the CSF, apparent hyperintense signal within the spinal cord on T2-weighted images, and most of all on a high titer of antibodies against Toxocara canis, higher in the CSF than in the serum [12]. In fact, only three cases of Toxocara canis myelopathy investigated with MRI and Toxocara antibody titers in both serum and CSF have previously been reported [3, 12, 13]. As serology remains positive for several years without any infection, the demonstration of an intrathecal synthesis of Toxocara antibody appears to be crucial to the diagnosis [15]. The use of an anti-helminthic treatment is controversial, since myelopathy is more likely to be caused by an immunological process than by abscess formation [15]. Despite absence of consensus, good results and a low rate of adverse events in humans have been
described for mebendazole at a daily dose of 20 to 25 mg/kg for 10 to 21 days [8]. Lastly, the clinical recovery and the dramatic normalization of the spinal MRI in our case and in previously reported cases of Toxocara canis myelopathy, suggest that the prognosis of this rare affection is good.
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