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LETTER TO THE EDITOR
Year : 2022  |  Volume : 36  |  Issue : 1  |  Page : 47-48

Attempted suicide through eating Ampullarium canaliculatus: A case report of a patient with depression


Department of Psychiatry, Chi Mei Medical Center, Tainan, Taiwan

Date of Submission15-Oct-2021
Date of Decision22-Nov-2021
Date of Acceptance24-Nov-2021
Date of Web Publication26-Mar-2022

Correspondence Address:
Jin- Jia Lin
No. 442, Section 2, Shulin Street, Tainan 702
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TPSY.TPSY_7_22

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How to cite this article:
Chiang SH, Lin JJ. Attempted suicide through eating Ampullarium canaliculatus: A case report of a patient with depression. Taiwan J Psychiatry 2022;36:47-8

How to cite this URL:
Chiang SH, Lin JJ. Attempted suicide through eating Ampullarium canaliculatus: A case report of a patient with depression. Taiwan J Psychiatry [serial online] 2022 [cited 2022 May 29];36:47-8. Available from: http://www.e-tjp.org/text.asp?2022/36/1/47/341039



The major cause of eosinophilic meningitis in the Pacific Islands and Taiwan is Angiostrongylus cantonensis [1]. Most patients are infestated after eating raw or undercooked molluscan intermediate hosts and paratenic hosts that contain the infestatious third-stage larvae of the worm. Cases of patients infected by Ampullarium cantonensis snails usually resulted from accidental ingestion. But in this report, we present a case of a patient who attempted suicide through eating Ampullarium canaliculatus and was then diagnosed as eosinophilic meningoencephalitis.


  Case Report Top


A 54-year-old married female patient with depressive disorder ate four raw A. canaliculatus found in the ditch and attempted to kill herself during her work. She developed severe headache, dizziness, pain in the neck, nausea, poor intake, and general weakness 10 days later. Since she had constantly revisited the emergency department four times without telling the physician about eating raw snails until being admitted to the psychiatric ward.

After admission, the complete blood count (CBC) examination on January 25, 2020, showed an elevated eosinophil up to 17%. Then, the patient received lumbar puncture examination immediately, showing the results of elevated levels of white blood cells and total protein in the cerebrospinal fluid (CSF). Afterward, she received a follow-up lumbar puncture on January 29, 2020, showing the finding of a surge of eosinophil (up to 40%). Hence, the diagnosis of parasitic meningitis was favored (with ruling out A. cantonensis related). According to this diagnosis, she received steroid injections continuously for symptomatic treatment. During the time, she had nonspecific findings in the brain magnetic resonance imaging (MRI) study. In the following 1 year, she was admitted to the infection disease ward three times due to dizziness with vomiting and headache, and was diagnosed with recurrent eosinophilic meningitis with a possible A. cantonensis infestation. Her depressive symptoms were improved under the treatment of escitalopram 10 mg/day and flupentixol 0.5 mg/melitracen 10 mg one tablet per day for three months and then being shifted to escitalopram 10 mg/day and bupropion 300 mg/day for another six months.


  Comment Top


The typical clinical manifestations of eosinophilic meningoencephalitis include headache, fever, neck stiffness, nausea or vomiting, muscle weakness, orbital or retro-orbital pain, abdominal pain, and dizziness [2]. This lady patient, reported in this case report, suffered from typical symptoms, such as headache, neck pain with stiffness, dizziness, nausea and vomiting, but without fever, muscle weakness, orbital or retro-orbital pain, and abdominal pain. In addition to the typical manifestations, she had auditory hallucinations (voices commanding) one month after she ate A. canaliculatus. In most previous reports [3], psychotic symptoms are atypical in eosinophilic meningoencephalitis. Hong et al. have reported a case of a patient with eosinophilic meningoencephalitis manifested with auditory and visual hallucinations, bizarre, and obsessional behaviors [3]. Thus, we suggest that the complete assessment of mental status for patients of eosinophilic meningoencephalitis is important in the choice of antipsychotics and pharmacotherapy.

Eosinophilic meningoencephalitis is clinically diagnosed through a history of headaches, larval exposure within three months, and evidence of eosinophilia more than 10% of the white blood cells in the CSF [4]. A definite diagnosis of eosinophilic meningitis caused by A. cantonensis is established through detecting larvae of A. cantonensis in the CSF [2]. But to detect larvae of A. cantonensis in the CSF is difficult. The clinical presumptive diagnosis is made through having clinical symptoms of meningitis with eosinophilia and the presence of risk factors, such as a history of raw snail ingestion and the presence of serological evidence of antibodies to A. cantonensis in the serum or the CSF [2]. Our patient had clinical symptoms, history of exposure to risk factors, positive pathognomonic CBC and CSF findings (presence of eosinophil cells and proteins), suggesting to meet the diagnostic criteria.

The MRI findings in CNS infection with A. cantonensis are nonspecific, ranging from normal to leptomeningeal enhancement, ventriculomegaly, punctate area of abnormal enhancement, and hyperintense signal lesions on T2-weighted images [5]. These abnormal signs can be found in more severe cases. But MRI findings in our patient were nonspecific. She had only paranasal sinusitis but without any evidence of abnormal enhancing lesions in her MRI study.

According to the suggestions by Morassutti et al. [4], the treatment of eosinophilic meningoencephalitis consists primarily of reducing the inflammatory response and relieving pain. Administration of oral corticosteroids has been adopted in most hospitals in areas where the disease is most prevalent. But intravenous administration of corticosteroids may be necessary when the patient is unconscious. Moreover, supportive treatment is important to maintain patients' hydration, and analgesic drugs should be given for pain relief. Repeated lumbar punctures are needed to decrease intracranial pressure, thereby reducing pain symptoms. The effectiveness of anthelmintic drugs for the treatment of eosinophilic meningoencephalitis remains unclear. In this case report, our patient received supportive care (pain control and hydration) with steroids and antibiotics. Her having received repeated lumbar punctures was for the purpose of examination only, but not for reducing the intracranial pressure.

Eosinophilic meningitis is a rare, underrecognized clinical entity with a distinct differential diagnosis. Our patient may be the first case in Taiwan who attempted suicide through eating A. cantonensis snails. A detailed history of risk factors and a second lumbar puncture of lymphocytic meningitis of uncertain cause are crucial for an accurate diagnosis [2]. She went to the emergency department several times due to headache and nausea and missed the possible diagnosis of eosinophilic meningitis due to a lack of detailed related history. She was finally admitted to the psychiatry ward due to depression and somatic complaints and then was transferred to the infection disease ward under the impression of psychotic symptoms after a detailed history of eating raw A. canaliculatus.

Another notable aspect of our patient was the presence of psychotic symptoms. She complained of auditory hallucinations off and on after eating raw A. canaliculatus. Therefore, clinicians should keep the psychotic symptoms in mind if the patient has a history of eating A. canaliculatus. Although psychotic symptoms might not be specific in patients with eosinophilic meningoencephalitis, antipsychotics should be given if psychotic symptoms are shown.

Based on report in this case, we suggest that the psychiatrist should pay attention to possible eosinophilic meningitis if a depressed patient who had suicide attempt through eating A. canaliculatus, develop some somatic complaints such as headache, fever, neck stiffness, nausea or vomiting, muscle weakness, orbital or retro-orbital pain, abdominal pain, and dizziness. Clinicians should arrange further studies such as CBC and differential count, CSF study, lumbar puncture, and brain MRI to diagnose eosinophilic meningitis.

In summary, a detailed history of raw food consumption, laboratory tests, and a second lumbar puncture is important to establish an accurate diagnosis. Clinicians should be vigilant regarding the potential presence of psychotic symptoms in cases of eosinophilic meningoencephalitis [3]. (The study was approved for publication by the institutional review board of Chi Mei Medical Center (study protocol number = IRB Serial No. 11009-006 and date of approval = September 30, 2021) without the need of obtaining signed informed consent from the patient).


  Financial Support and Sponsorship Top


None.

[TAG:2]Conflicts of Interest[/TAG:2]

The authors declare no potential conflicts of interest in publishing this report.



 
  References Top

1.
Tsai HC, Chen YS, Yen CM: Human parasitic meningitis caused by Angiostrongylus cantonensis infection in Taiwan. Hawaii J Med Public Health 2013; 72: 26-7.  Back to cited text no. 1
    
2.
Tseng YT, Tsai HC, Sy CL, et al.: Clinical manifestations of eosinophilic meningitis caused by Angiostrongylus cantonensis: 18 years' experience in a medical center in southern Taiwan. J Microbiol Immunol Infect 2011; 44: 382-9.  Back to cited text no. 2
    
3.
Hong DS, Bernstein M, Smith C, et al.: Eosinophilic meningoencephalitis: Psychiatric presentation and treatment. Int J Psychiatry Med 2008; 38: 287-95.  Back to cited text no. 3
    
4.
Morassutti AL, Thiengo SC, Fernandez M, et al.: Eosinophilic meningitis caused by Angiostrongylus cantonensis: an emergent disease in Brazil. Mem Inst Oswaldo Cruz 2014; 109: 399-407.  Back to cited text no. 4
    
5.
Tsai HC, Liu YC, Kunin CM, et al.: Eosinophilic meningitis caused by Angiostrongylus cantonensis associated with eating raw snails: Correlation of brain magnetic resonance imaging scans with clinical findings. Am J Trop Med Hyg 2003; 68: 281-5.  Back to cited text no. 5
    




 

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