A 64 y.o. white male, a frequent traveler to the Philippines, presented to the emergency room with aphasia and right sided weakness and incoordination.
A church minister, the patient had made many prior trips to the Philippines in connection with church missionary work. He had returned from his most recent two month trip to the Philippines two weeks previously. Nine months before his ER presentation he had been seen for fatigue and had 25% eosinophilia on peripheral smear. Examination of stools for O&P were negative 3 months prior to his acute neurologic illness.
His Philippine church mission was on the island of Mindanao where he engaged in proselytizing and in various projects intended to improve the living circumstances of the local people.
His family said that he had had numerous insect bites, consumed local foods, and had not had travel related immunizations. He had not taken anti-malarial prophylaxis.
His past medical history was unremarkable and he took no medications on a regular basis (although he did take herbal and naturopathic remedies). He was married and had no history of high risk sexual behaviour.
On examination he was afebrile with normal vital signs. He was noted to be aphasic and to have right upper extremity weakness and incoordination. Laboratory data included WBC 10.1 with 80% segs, 10% lymphs (no significant eosinophilia). Electrolytes, LFTs, and CXR were normal.
An MRI scan was performed and showed a mass in the left fronto-parietal area (see images at left). Moderate mass effect was evident with compression of the lateral ventricle.
In the emergency room he was evaluated by a neurosurgeon who was concerned about likely high grade glioma. The patient was placed on corticosteroids to reduce brain edema and underwent brain biopsy several days later.
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