Corticosteroid treatment of eosinophilic meningitis.

The role of corticosteroids in the treatment of eosinophilic meningitis has not been definitely established. Patients given a 2-week course of prednisolone (treatment group), 60 mg/day, were compared with those given placebo (control group) in a randomized, double-blind trial. Fifty-five patients were enrolled in each group. There were significant differences between the treatment and control groups, with regard to the number of patients who still had headache after 14 days (5 vs. 25, respectively; P=.00004), the median length of time until complete disappearance of headache (5 vs. 13 days, respectively; P=.00000), and the number of patients who had repeat lumbar puncture (7 vs. 22, respectively; P=.002). Serious side effects were not detected. These results indicate that a 2-week course of prednisolone was beneficial in relieving headache in patients with eosinophilic meningitis.     

Treatment of eosinophilic meningitis with a combination of prednisolone and mebendazole

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.     

Cluster of eosinophilic meningitis attributable to Angiostrongylus cantonensis infection in French policemen troop returning from the Pacific Islands

BACKGROUND: Outbreaks of eosinophilic meningitis are reported rarely, even in regions of endemic infestation with the roundworm Angiostrongylus cantonensis, such as the Pacific Basin. We report a cluster of eosinophilic meningitis presumably attributable to A. cantonensis among French policemen returning from French Polynesia. METHODS: A retrospective cohort study among French policemen who had stayed in Tahiti was conducted using a clinical definition of eosinophilic meningitis that included severe headache within 30 days after return and eosinophilia, and who consumed locally exotic ethnic dishes with uncooked freshwater prawns. RESULTS: Five persons met the case definition for eosinophilic meningitis. Corticosteroid therapy associated with antihelminthic regimen led to improvement of symptoms in one patient. Other patients were treated with albendazole alone. All patients recovered. CONCLUSION: Among travellers at risk, the presence of severe headache and eosinophilia combined with a consistent exposure history to exotic food should alert to the possibility of A. cantonensis infestation. Travellers should be aware of the risk of infection associated with eating exotic ethnic dishes.     

Late-onset eosinophilic chronic meningitis occurring 30 years after Taenia solium infestation in a white Caucasian woman

Unlike solitary parenchymal cysts, chronic meningitis is unusual in patients with neurocysticercosis and may poorly respond to treatment. We report the case of neurocysticercosis characterized by severe headache and chronic eosinophilic meningitis occurring 30 years after infestation with Taenia solium. The patient showed considerable improvement following treatment with albendazole and prednisone.     

Treatment of angiostrongyliasis using a combination of albendazole and dexamethasone: the results of a retrospective and comparative study

As the information available on the treatment of angiostrongyliasis with a combination of albendazole and dexamethasone is limited, the efficacy of such therapy was assessed using data collected during the 2006 outbreak of angiostrongyliasis in Beijing. In a retrospective and controlled study, 35 patients treated with albendazole-dexamethasone (given 20 mg albendazole/kg and 3 mg dexamethasone daily for 7 days) were compared with 34 controls who were treated only symptomatically (with acetaminophen or other drugs). Compared with the controls, the patients given the combination were less likely to have headaches after 7 days (P = 0·038), tended to have headaches that cleared quicker (P = 0·010), and received fewer doses of acetaminophen (P = 0·036). Since no serious adverse effects were observed, a 1-week treatment with a combination of albendazole and dexamethasone appears both safe and beneficial in the treatment of angiostrongyliasis.     

Short course of prednisolone in patients with solitary cysticercus granuloma: a double blind placebo controlled study

The study was conducted to confirm the role of a short course of oral corticosteroids in patients with solitary cysticercus granuloma with seizures by a double-blind placebo-controlled study. In an open-label trial we, in past, had demonstrated a beneficial role of prednisolone. A short course of prednisolone helped in early resolution of solitary cysticercus granuloma. In this double-blind placebo-controlled randomized study, 60 patients with new-onset seizures and a single enhancing computed tomography (CT)-detected lesion of cysticercosis were randomly divided in two groups to receive either anti-epileptic monotherapy with prednisolone (n=30) or anti-epileptic monotherapy along with placebo (n=30). The patients received prednisolone, 1mg/kg/day for 10 days, followed by tapering over next 4 days. None of the patients received albendazole therapy. The patients were followed up monthly, at least for 9 months. A repeat CT scan was performed after 6 months. The data were analysed by chi-square test. The majority of patients were young. Simple partial seizure, with or without secondary generalization, was the commonest seizure type encountered. Follow-up CT scans at 6 months demonstrated non-significantly better response for prednisolone treated patients. In prednisolone group the lesion disappeared in 52% of patients and in 48% patients who received placebo. However, a significantly lesser number of prednisolone treated patients (n=12%) than controls (n=48%), had seizure recurrence. Our study suggests that short-term prednisolone therapy may not help in rapid resolution of solitary cysticercus granuloma, however, prednisolone therapy improves seizure-related prognosis.     

Eosinophilic meningitis in a child raising snails as pets

The rat lungworm (Angiostrongylus cantonensis) is the principal cause of eosinophilic meningitis or meningoencephalitis worldwide. It is endemic in Taiwan and the Asia Pacific area. We report the case of a 10-year-old boy who was referred to us suffering from intermittent headache, low-grade fever and blurred vision of 4-5 days' duration. He had been treated for gastroenteritis just prior to referral. The patient's history was unremarkable, except that he raised snail (Ampullarium canaliculatus) as pet at home. On physical examination, the patient's consciousness was alert and well oriented. No papilledema was found on fundal examination. The neurological examination revealed normal cranial nerve function, mild weakness of both lower limbs and normal deep tendon reflexes, but positive Babinski and Kernig signs. Laboratory findings showed peripheral eosinophilia, elevated immunoglobulin E level, cerebrospinal fluid eosinophilic pleocytosis and the presence of stage 3 A. cantonensis larvae, which confirmed the diagnosis of eosinophilic meningitis. A 2-week course of mebendazole combined the glucocorticosteroids was beneficial in relieving headache, paresthesia and the other eosinophilic meningitis symptoms in the patient.     

Chinese herbal medicine Yin-Chen-Extract as an adjunct to anthelmintic albendazole used against Angiostrongylus cantonensis-induced eosinophilic meningitis or meningoencephalitis

The effects of albendazole and Yin-Chen-Extract co-therapy on Angiostrongylus cantonensis-induced eosinophilic meningitis in BALB/c mice were evaluated. Assay indicators for the therapeutic effect include worm recovery, histopathological score of the fourth ventricle, tissue-type plasminogen activator, urokinase-type plasminogen activator, matrix metalloproteinase-9, cerebrospinal fluid total protein, leukocyte counts, and proinflammatory cytokines. As a result, albendazole and Yin-Chen-Extract co-therapy significantly decreased (P < 0.05) these factors. Although Yin-Chen-Extract may possess pharmacologic activities beneficial to the inhibition of parasite-induced inflammation, many of these hypothetical benefits await scientific testing and confirmation before application. This study suggests that the combination of Yin-Chen-Extract and albendazole has synergistic effects in managing eosinophilic meningitis or eosinophilic meningoencephalitis.     

Eosinophilic meningitis due to Angiostrongylus cantonensis in a Belgian traveller

Eosinophilic meningitis is a rare clinical entity. The most frequent cause in travellers to the tropics is infection with the rat lungworm Angiostrongylus cantonensis. In this report, we describe a case of eosinophilic meningitis due to infection with this nematode in a traveller who presented with slight headache, diarrhoea, general malaise and thoracic radicular pain after a trip through Latin America and the Fiji Islands. She responded less than optimally to repeated steroid and albendazole treatments, but finally recovered completely.     

Eosinophilic gastroenteritis： Clinical experience with 15 patients

AIM: To evaluate the clinic features of eosinophilic gastroenteritis and to examine the diagnosis, treatment, long-term outcome of this disease. METHODS: Charts with a diagnosis of eosinophilic gastroenteritis from 1984 to 2002 at Mackay Memorial Hospital were reviewed retrospectively. There were 15 patients diagnosed with eosinophilic gastroenteritis. The diagnosis was established in 13 by histologic evaluation of endoscopic biopsy or operative specimen and in 2 by radiologic imaging and the presence of eosinophilic ascites. RESULTS: All the patients had gastrointestinal symptoms and 12 (80%) had hypereosinophilia (absolute eosinophil count 1,008 to 31,360/cm3). The most common symptoms were abdominal pain and diarrhea. Five of the 15 patients had a history of allergy. Seven patients had involvement of the mucosa, 2 of muscularis, and 6 of subserosa. One with a history of seafood allergy was successfully treated with an elimination diet. Another patient improved spontaneously after fasted for several days. The remaining 13 patients were treated with oral prednisolone, 10 to 40 mg/day initially, which was then tapered. The symptoms in all the patients subsided within two weeks. Eleven of the 15 patients were followed up for more than 12 months (12 to 104 months, mean 48.7), of whom 5 had relapses after discontinuing steroids (13 episodes). Two of these patients required long-term maintenance oral prednisolone (5 to 10 mg/day). CONCLUSION: Eosinophilic gastroenteritis is a rare condition of unclear etiology characterized by relapses and remissions. Short courses of corticosteroids are the mainstay of treatment, although some patients with relapsing disease require long-term low-dose steroids.     

Clinical manifestations and outcome of patients with severe eosinophilic meningoencephalitis presumably caused by Angiostrongylus cantonensis

The clinical manifestations and outcome of patients with severe eosinophilic meningoencephalitis has never been reported. We reported 11 comatose patients with eosinophilic meningoencephalitis. Most of them presented with subacute to chronic headache and fever, followed by acute coma. Cerebrospinal fluid abnormalities were similar to alert patients with eosinophilic meningitis. None of them had received antihelmintic drug and seven patients were treated with corticosteroids. Ten patients died and one patient is still in a coma. Corticosteroids seem to be ineffective in severe eosinophilic meningitis.     

Treatment of chronic sarcoidosis with an azathioprine/prednisolone regimen.

In a few patients with chronic sarcoidosis, prolonged, unacceptably high doses of corticosteroids are required to achieve symptomatic relief. In these cases, a corticosteroid-sparing drug might be administered to allow long-term treatment without the adverse effects of corticosteroids. This study examines azathioprine as a prednisolone-sparing treatment. In an open study, the course of 11 patients with chronic sarcoidosis was analysed. In an induction phase, 2 mg azathioprine x kg body weight (BW)(-1) x day(-1) in combination with 0.6-0.8 mg prednisolone x kg BW(-1) x day(-1) were administered with prednisolone being reduced to 0.1 mg x kg BW(-1) x day(-1) within 2-3 months. This was followed by a 21-22-month maintenance phase with 2 mg azathioprine x kg BW(-1) x day(-1) and 0.1 mg prednisolone x kg BW(-1) day(-1). Clinical parameters and immunological findings of bronchoalveolar lavage (BAL) were analysed. All patients had significant symptomatic relief and improvements or resolutions of physiological, serological and radiographic findings without suffering from serious adverse effects. Nine of 11 patients completed therapy after 19-26 months, and 2/11 patients terminated therapy after 8 and 12 months, respectively. Eight patients had remissions lasting 4-73 months. Three relapses occurred after 8, 18, and 22 months. During the induction phase, BAL cell composition changed and their activity in terms of cytokine release was suppressed. This preliminary study suggests that azathioprine may be effective as a corticosteroid-sparing agent in long-term therapy of sarcoidosis, but a much larger study is necessary to give the definitive answer.     

An adult case of tuberculous meningitis]

A 36-year-old man was referred to our hospital with complaints of high fever and headache. A diagnosis of miliary tuberculosis with tuberculous meningitis was made. He was treated with isoniazid (400 mg/day), rifampicin (300 mg/day), ethambutol (750 mg/day), pyrazinamide (1.0 g/day) and prednisolone (60 mg/day). However, he lost consciousness because of hydrocephalus on the second day of hospitalization. Emergency cerebrospinal fluid drainage improved his neurological symptoms. After two months, he again complained of headache with nausea and double vision. Numerous tuberculomas were found not only in the cerebrum but also in the liver, the spleen and the retina. Recurrent hydrocephalus was treated with a V-P shunt, and combination therapy with four antituberculous agents was maintained for 18 months. He was discharged in a healthy condition, although a mild left facial palsy remained. In addition, we examined the inflammatory cytokine levels in both the CSF and the serum over the period of the patient's hospitalization. We concluded that the cytokine levels in the CSF may be associated with the progress and the prognosis of tuberculous meningitis.     

Comparative studies on the efficacy of three anthelminthics on treatment of human strongyloidiasis in Okinawa, Japan

A study was undertaken to compare the efficacy of three drugs in the treatment of uncomplicated strongyloidiasis in Okinawa, Japan. Two hundred and eleven patients with confirmed Strongyloides stercoralis infection were given either ivermectin, 6 mg in a single dose, albendazole, 400 mg/day for 3 days or pyrvinium pamoate, 5 mg/kg/day for 3 days. For each treatment, the same regimen was repeated once 2 weeks later. Efficacy was evaluated at 2 weeks, 6 months and 12 months after the second course of treatment. Each follow-up examination included a parasitological examination of z stool specimens, using the agar-plate culture method. Coprological cure was obtained in 65 of the 67 patients treated with ivermectin (97.0%), in 65 of the 84 patients treated with albendazole (77.4%) and only in 14 of the 60 patients who were given pyrvinium pamoate (23.3%). The cure rates were lower in males and in the patients with concurrent HTLV-1 infection. An epidemiological feature of Strongyloides infection in recent Okinawa might allow workers to evaluate the exact efficacy of the treatment for an extended period, over a year, without the possibility of reinfection from the environment.     

HPA-axis effects of nebulised fluticasone propionate compared with oral prednisolone in childhood asthma

The aim of this study was to compare the effect of 7 days nebulised fluticasone propionate (FP) with oral prednisolone on 24-h urinary-free cortisol excretion, systemic exposure and safety. This was a randomised, double-blind, double-dummy, two-way crossover study. Thirty-one children (19 male, 12 female, mean age 8 years) with stable asthma were randomly assigned to 7 days treatment with either FP Nebules (2 x 0.5 mg/2 ml bd) or prednisolone tablets once daily (2 mg/kg/day for 4 days [maximum 40 mg] followed by 1 mg/kg/day or half the original dose for 3 days [maximum 20 mg]). After a 2-4 week washout period, patients received the second treatment for 7 days, followed by a 2-week follow-up visit. The primary outcome measure was 24-h urinary-free cortisol concentrations corrected for creatinine. Nebulised FP (1 mg bd) had significantly less effect on 24-h urinary-free cortisol excretion than oral prednisolone (8.9 ng/ml for FP and 5.0 ng/ml for prednisolone, P = 0.001). Systemic exposure to FP was also low. In conclusion, FP Nebules had significantly less effect on hypothalamic-pituitary-adrenal axis function than oral prednisolone in asthmatic children when used at doses recommended for the treatment of an acute exacerbation of asthma.     

Maintenance of remission with leflunomide in Wegener's granulomatosis

OBJECTIVE: To investigate the safety and efficacy of leflunomide plus low-dose prednisolone for the maintenance of remission in Wegener's granulomatosis (WG). METHODS: This was a Phase II, single-centre, open-label clinical investigation of patients with generalized WG treated with leflunomide after the induction of complete (n = 4) or partial (n = 16) remission by cyclophosphamide/prednisolone combination therapy. Leflunomide treatment was initiated at 20 mg/day and increased to 30 mg/day after 12 weeks and, in patients with partial remission, to 40 mg/day after 24 weeks. Concomitant low-dose prednisolone (< or =10 mg/day) was allowed during the study. In addition to the frequency of relapse, treatment efficacy was assessed by the standard measures of disease activity/extent. RESULTS: A total of 20 patients were enrolled in the trial. During a treatment period of up to 2.5 yr (median 1.75 yr, range 1-2.5 yr), one patient had a major relapse and required retreatment with cyclophosphamide/prednisolone. Eight patients had minor relapses that were successfully treated by dose increases to 40 mg/day leflunomide. Disease activity remained unchanged for the duration of the study. The most frequently reported adverse events were mild respiratory infection (40%), arthralgia (35%) and hypertension (35%); dry skin, nail disorder and diarrhoea were each reported by 30% of patients. Despite the aggressive pretreatment with cyclophosphamide, adverse events with leflunomide treatment at the higher dose (30-40 mg/day) were comparable with those seen with the standard dose (20 mg/day) for rheumatoid arthritis patients. CONCLUSION: Leflunomide appears to be safe and well tolerated for the maintenance of complete or partial remission of WG. The results of this pilot study encourage further controlled trials comparing leflunomide with alternative remission maintenance therapies.     

The effect of different doses of prednisolone in the treatment of childhood ITP

The result of treatment of children with ITP, who received either 0.5, 1 or 2 mg/kg per day of prednisolone showed that 1 mg/kg per day gave the best response, the least failure rate and the duration of treatment was not different compared to 2 mg/kg per day. It was concluded that the proper dosage of the prednisolone given to these children should be 1 mg/kg per day. However the number of the patients in the study were rather small further clinical studies and treatment with 1 mg/kg and 2 mg/kg per day of prednisolone in childhood ITP are warranted.     

Chronic eosinophilic pneumonia: treatment with inhaled corticosteroids

BACKGROUND: Chronic eosinophilic pneumonia (CEP) is highly sensitive to systemic corticosteroids, but frequently relapses if the dose is tapered or treatment discontinued. Long-term usage of systemic corticosteroids may cause side effects. Alternative treatments are therefore desired. OBJECTIVES: We evaluated the response of CEP to monotherapy with inhaled corticosteroids (ICS). METHODS: Four patients who had CEP without spontaneous resolution were studied. Patients received inhaled beclomethasone dipropionate (BDP) at a dose of 0.8 mg/day in 1 patient and 1.6 mg/day in 3 patients for 2 weeks. Treatment was continued if a patient showed improvement in at least 1 of the following indices: radiological findings, symptoms, and blood eosinophilia. RESULTS: After the initial 2 weeks of treatment with BDP, the blood eosinophil count increased in 2 patients and decreased in 2. Symptoms worsened in 2 and improved in 2. Infiltrates on chest radiography increased in 3 and showed little change in 1. In the 2 patients with worsening of all 3 outcome indices, oral prednisolone was started; the indices improved. In the remaining 2 patients, BDP alone was continued. One patient had worsening of CEP after 2 months of treatment, and another had relapse of CEP at 3.5 years while receiving 1.6 mg/day of BDP. All patients thus finally had worsening or relapse of CEP during treatment with BDP. CONCLUSIONS: ICS may not be effective when given as monotherapy in patients with CEP.     

Advanced ovarian cancer: long-term results of treatment with intensive cisplatin-based chemotherapy of brief duration

Study Objective: To determine the efficacy of a 6-month course of combination chemotherapy with hexamethylmelamine, cyclophosphamide, doxorubicin, and cisplatin (H-CAP) in the treatment of advanced ovarian carcinoma. Design: Prospective, non-randomized, single-institution trial with a 6-month course of chemotherapy, followed by second-look laparotomy for restaging. Minimum follow-up after completion of therapy is 83 months. Patients: Fifty-five patients with advanced (stage III or IV), intermediate- or high-grade epithelial carcinoma of the ovary. Twenty patients had limited residual tumor (3 cm or less maximal tumor diameter) after initial cytoreductive surgery; 35 had extensive residual disease. Interventions: All patients received chemotherapy with hexamethylmelamine (150 mg/m2 body surface area orally on days 1 to 14), cyclophosphamide (350 mg/m2 intravenously on days 1 and 8), doxorubicin (20 mg/m2 intravenously on days 1 and 8), and cisplatin (60 mg/m2 intravenously on day 1). Courses were repeated at 4-week intervals; 41 patients (75%) received six courses; 10 patients received five courses, 3 patients received four courses, and 1 patients received three courses. Forty-seven patients underwent second-look laparotomy after completion of therapy; 8 had their disease restaged clinically. Results: Fifty-three of fifty-five patients (96%) had either partial or complete response to treatment. Nineteen of forty-seven patients who had a second-look laparotomy had a surgically documented complete response; 17 of these 19 patients began chemotherapy with limited residual tumor. Ten patients (18%) remain disease-free 83 to 108 months after therapy, whereas three additional patients died of other diseases without clinical evidence of recurrent ovarian cancer. Nine of twenty patients who began chemotherapy with limited residual tumor remain disease-free, as compared to only 1 of 35 patients with more extensive tumor (P less than 0.001). All long-term, disease-free survivors had surgically documented complete response at second-look laparotomy. Conclusions: Treatment with cisplatin-based combination chemotherapy after aggressive cytoreductive surgery should be considered standard treatment for advanced ovarian carcinoma. Our intensive, 6-month course of treatment produced results comparable to those previously reported with prolonged treatment.     

Double-dose ivermectin vs albendazole for the treatment of gnathostomiasis

A comparative study was performed for the treatment of gnathostomiasis patients with ivermectin 0.2 mg/kg for 2 days in 15 patients vs albendazole 400 mg twice daily for 21 days in 14 patients. The ivermectin and albendazole gave cure rates of 100% and 78.5%, respectively, however the difference was not statistically significant between the two drugs (Fisher's exact, p=0.0996). One year after treatment, the patients who had no migratory swellings and a drop in ELISA titers or a negative immunoblot test were considered to be cured. The side effect of ivermectin for two days was dizziness. The side effects of albendazole were nausea, dizziness, and an increased alkaline phosphatase.