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Disease

Humans are a paratenic (intermediate) host, meaning that infection by larval stages of the parasite can occur but the parasite does not complete its lifecycle in the host. In paratenic hosts, adult worms do not develop in the intestine, and eggs will not be observed in the feces. The clinical presentation of baylisascariasis depends on the number and the location of larvae in the body. The infecting dose of larvae may be related to the disease presentation; when large numbers of embryonated eggs are ingested, larvae may be more likely to penetrate the central nervous system, causing neural larva migrans. Death or permanent disability is a common outcome of neural larva migrans due to Baylisascaris.

Non-specific signs and symptoms may appear as soon as one week post-infection and include but are not limited to nausea, fever, and lethargy. Specific clinical presentations vary depending on the dose and location of migrating larvae in the body.

Neural larva migrans often presents as acute eosinophilic meningoencephalitis. Signs and symptoms may develop within 2 to 4 weeks after ingestion of large numbers of infective eggs and include weakness, incoordination, ataxia, irritability, weakness, seizures, altered mental status, stupor, and/or coma. Once symptoms and signs of neurologic disease are detected, significant pathology generally is already present.
Ocular larva migrans may present as diffuse unilateral subacute neuroretinitis. photophobia, retinitis, and/or blindness (typically unilateral). This manifestation can occur with neural larva migrans or alone.
Visceral larva migrans may be associated with macular rash, abdominal pain, hepatomegaly, and pneumonitis. Larvae can cause inflammatory reactions in organs and tissue damage. Skin infection and inflammation have been reported.

Of note, a number of other parasitic nematode infections may cause similar signs and symptoms, such as infection with larvae of Toxocara spp. and Angiostrongylus spp. The pathogenesis of this disease is similar to that of Toxocara infection. However, the clinical course often is more severe because, unlike Toxocara, Baylisascaris larvae are larger and continue to molt and increase in size, resulting in extensive reaction and damage in the CNS, heart, and other internal organs.

Consider Baylisascaris infection in persons with severe developmental disabilities or pica/geophagia and sudden onset of eosinophilic encephalitis. A history of exposure to raccoons or their feces is highly suggestive but not necessary.

Diagnosis

Diagnosis of baylisascariasis can be difficult. Diagnostic findings include eosinophilic pleocytosis, peripheral eosinophilia, deep white matter abnormalities on MRI, and positive Baylisascaris antibody titers on serologic testing of CSF and serum. Neuroimaging and encephalography may assist with identifying neural larva migrans. Ocular examinations may reveal a migrating larva, larval tracks, or lesions consistent with presence of a nematode larva in the eye.

Examination of tissue biopsies and morphological identification of larvae may be helpful, but depending on the number of larva it may be problematic to acquire an effective sample (one with a cross-section of a larva). Larvae can become encapsulated within granulomas.

There is no commercially available serological test for baylisascariasis. However, CSF or serum may be tested for antibodies at CDC if the index of suspicion is high in cases of clinical disease. Serological testing for other nematode infections should be considered and may help to diagnose other causes of larva migrans if Baylisascaris serology is negative. Please contact CDC if for more information about baylisascariasis testing.

Treatment

In cases where suspicion of exposure is high, immediate treatment with albendazole (25-50 mg/kg per day by mouth for 10 – 20 days) may be appropriate. Treatment is successful when administered soon after exposure to abort the migration of larvae. Indications for immediate treatment may include known oral exposure to raccoon feces, presence of Baylisascaris eggs in the feces of the implicated animal or animals, and suspected oral exposure to raccoon feces in an area where the prevalence of raccoon infection is known to be high. Treatment should be initiated as soon as possible after ingestion of infectious material, ideally within three days. If albendazole is not immediately available, mebendazole or ivermectin may be used in the interim.

For clinical baylisascariasis, treatment with albendazole, at the dose given above, with concurrent corticosteroids to help reduce the inflammatory reaction is indicated to attempt to control the disease.

* Oral albendazole is available for human use in the United States.

* Oral mebendazole is available for human use in the United States.

* Oral ivermectin is available for human use in the United States.

This information is provided as an informational resource for licensed health care providers as guidance only. It is not intended as a substitute for professional judgment.

Albendazole

Albendazole is pregnancy category C. Data on the use of albendazole in pregnant women are limited, though the available evidence suggests no difference in congenital abnormalities in the children of women who were accidentally treated with albendazole during mass prevention campaigns compared with those who were not. In mass prevention campaigns for which the World Health Organization (WHO) has determined that the benefit of treatment outweighs the risk, WHO allows use of albendazole in the 2nd and 3rd trimesters of pregnancy. However, the risk of treatment in pregnant women who are known to have an infection needs to be balanced with the risk of disease progression in the absence of treatment.

Pregnancy Category C: Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal, or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.

It is not known whether albendazole is excreted in human milk. Albendazole should be used with caution in breastfeeding women.

The safety of albendazole in children less than 6 years old is not certain. Studies of the use of albendazole in children as young as one year old suggest that its use is safe. According to WHO guidelines for mass prevention campaigns, albendazole can be used in children as young as 1 year old. Many children less than 6 years old have been treated in these campaigns with albendazole, albeit at a reduced dose.

Mebendazole

Mebendazole is in pregnancy category C. Data on the use of mebendazole in pregnant women are limited. The available evidence suggests no difference in congenital anomalies in the children of women who were treated with mebendazole during mass treatment programs compared with those who were not. In mass treatment programs for which the World Health Organization (WHO) has determined that the benefit of treatment outweighs the risk, WHO allows use of mebendazole in the 2nd and 3rd trimesters of pregnancy. The risk of treatment in pregnant women who are known to have an infection needs to be balanced with the risk of disease progression in the absence of treatment.

It is not known whether mebendazole is excreted in breast milk. The WHO classifies mebendazole as compatible with breastfeeding and allows the use of mebendazole in lactating women.

The safety of mebendazole in children has not been established. There is limited data in children age 2 years and younger. Mebendazole is listed as an intestinal antihelminthic medicine on the WHO Model List of Essential Medicines for Children, intended for the use of children up to 12 years of age.

Ivermectin

Ivermectin is pregnancy category C. Data on the use of ivermectin in pregnant women are limited, though the available evidence suggests no difference in congenital abnormalities in the children of women who were accidentally treated during mass prevention campaigns with ivermectin compared with those who were not. The World Health Organization (WHO) excludes pregnant women from mass prevention campaigns that use ivermectin. However, the risk of treatment in pregnant women who are known to have an infection needs to be balanced with the risk of disease progression in the absence of treatment.

Ivermectin is excreted in low concentrations in human milk. Ivermectin should be used in breast-feeding women only when the risk to the infant is outweighed by the risk of disease progress in the mother in the absence of treatment.

The safety of ivermectin in children who weigh less than 15kg has not been demonstrated. According to the WHO guidelines for mass prevention campaigns, children who are at least 90 cm tall can be treated safely with ivermectin. The WHO growth standard curves show that this height is reached by 50% of boys by the time they are 28 months old and by 50% of girls by the time they are 30 months old, many children less than 3 years old been safely treated with ivermectin in mass prevention campaigns, albeit at a reduced dose.

Page last reviewed: August 28, 2019

Content source: Global Health, Division of Parasitic Diseases and Malaria