Chaundra and Shea Rodrigues are the 31-year-old parents of Z.R., their 13-month-old son. They live in Hilo, Hawai’i. On December 31, 2019, the plaintiffs went to the Island Naturals Market & Deli, located at 1221 Kilauea Ave, Hilo, Hawai’i, for lunch. They purchased two avocado sandwiches, comprised of sourdough bread, lettuce, onion, avocado, and a pickle on the side. Plaintiff Chaunda gave some of the avocado from her sandwich to her son, Z.R. After consuming approximately half her sandwich, Plaintiff Chaunda took another bite and felt something unusual in her mouth. She removed the item from her mouth and discovered it was as slug. She inspected the rest of her sandwich and found the other part of the slug still inside. The realization of what she had consumed caused her to vomit.
Plaintiff Chaunda was aware of the risk of rat lungworm so she contacted a local hospital who told her that there was little they could do until symptoms manifested. Upset at the thought that she would simply have to “wait and see,” plaintiff Chaunda eventually went to Hilo Medical Center Emergency Department on January 1, 2020, where she was treated for two hours and prescribed albendazole. Plaintiffs Shea and Z.R. also sought medical attention due to their exposure to the rat lung worm parasite. Plaintiff Z.R. received treatment at Hilo Urgent Care on January 2, 2020, and Plaintiff Shea received treatment from Sarah Strong, N.D., on January 3, 2020.
Plaintiff Chaunda took the remaining slug pieces from her sandwich to the Jarvi Lab at the University of Hawai’i at Hilo’s Daniel K. Inouye College of Pharmacy on January 2, 2020, to determine her and her family’s risk of developing angiostrongyliasis. The reported that the slug Plaintiff Chaunda partially consumed tested positive for the rat lungworm parasite, Angiostrongylus cantonesis. Presently, Plaintiff Chaunda has been experiencing increased tension and pressure between her shoulders and in the lower/lumbar portion of her spine. Because they are still well within the incubation period, the plaintiffs remain anxious about whether they will develop angiostrongilyasis in the coming weeks as a result of their exposure to an infected intermediate host.
About Angiostrongyliasis, a/k/a Rat Lungworm
Angiostrongyliasis, also known as rat lungworm, is a disease that affects the brain and spinal cord. It is caused by a parasitic nematode (roundworm parasite) called Angiostrongylus cantonesis. The adult form of A. cantonesis is only found in rodents. However, infected rodents can pass larvae of the worm in their feces. Snails, slugs, and certain other animals (including freshwater shrimp, land crabs, and frogs) can become infected by ingesting this larvae; these are considered intermediate hosts.
Humans can become infected with A. cantonensis if they eat (intentionally or otherwise) a raw or undercooked infected intermediate host, thereby ingesting the parasite. Sometimes, people can become infected by eating raw produce that contains a small infected snail or slug, or part of one. It is currently not known for certain whether the slime left by infected snails and slugs are able to cause infection.
Infection with A. cantonesis can case a rare type of meningitis, eosinophilic meningitis, and according to the CDC, A. cantonesis is the most common cause of human eosinophilic meningitis. Some infected individuals do not have any symptoms or only have mild symptoms. In other infected persons, the symptoms can be much more severe.
Symptoms usually begin 1 to 3 weeks after exposure to the parasite but have been known to range anywhere from 1 day to as long as 6 weeks after exposure. When symptoms are present, they can include severe headache and stiffness of the neck, tingling or painful feelings in the skin or extremities, low-grade fever, nausea, and vomiting. Sometimes, a temporary paralysis of the face may also be present, as well as light sensitivity. Although it varies from case to case, symptoms usually last between 2-8 weeks.
There are no readily available blood tests for angiostrongyliasis. In Hawai’i, cases can be diagnosed with a polymerase chain reaction (PCR) test, performed by the State Laboratories Division that detects A. cantonesis DNA in a patient’s cerebrospinal fluid (CSF) or other tissue. Most often, however, a diagnosis is based on a patient’s exposure history—such as if they have a history of travel to areas where the parasite is known to be found or history of ingestion of raw or undercooked snails, slugs, or other animals known to carry the parasite—and their clinical signs and symptoms consistent with angiostronyliasis, as well as laboratory finding of eosinophils (a special type of white blood cell) in their CSF. There is no reliable diagnostic test available to detect infections of angiostrongyliasis.
There is no specific treatment for angiostrongyliasis. In 2018, the Hawai’i Governor’s Joint Task Force on Rat Lungworm Disease published preliminary evidence-based clinical guidelines for the diagnosis and treatment of neuroangiostrongyliasis. The preliminary guidelines call for a complete neurologic examination; a detailed history of possible exposure to snails/slugs, rats, or other things suggesting a risk for infection; and a lumbar puncture, or spinal tap, to diagnose the disease and relieve headaches caused by the disease. Because the parasites cannot grow or reproduce in humans and will die eventually, causing inflammation, steroids should be given as early as possible to reduce inflammation. Anti-parasitic drugs, such as albendazole, may be helpful, although there is limited evidence of this in humans. If albendazole is used, it must be combined with steroids to treat any possible increase in inflammation caused by dying worms. Persons with symptoms should consult their healthcare provider for more information.
Rat Lungworm History in Hawai’i
Angiostrongyliasis first became a reportable illness to the Hawai’i Department of Health (HDOH) in 2007, meaning that clinicians are required to report patients with eosinophilic meningitis, and laboratories are required to provide cerebrospinal fluid results for such patients. When suspected cases are reported, disease investigators work closely with the patients to carefully examine where they live, work, recreate, or may have traveled in order to identify how they may have become infected.
Since tracking of angiostrongyliasis began in 2007, there have been 46 laboratory-confirmed cases and 37 probable cases, resulting in a total of 83 cases statewide reported to the HDOH. Two adult deaths related to the disease have been reported, one in 2012 and the other in 2015. Between 2006 and 2016, the HDOH recorded between one and 11 cases of angiostrongyliasis per year. In 2017, there was a total of 18 laboratory-confirmed cases— meaning lumbar puncture samples tested positive for the parasite—and three probable cases—meaning persons had symptoms and history consistent with an infection, but there was no laboratory confirmation.
Historically, a majority of cases occurred on Ohau. However, since 2004, most cases have appeared on Hawai’i island. In 2017, out of the 18 confirmed and 3 probable cases reported, 11 confirmed cases and 2 probable cases of angiostrongyliasis were from Hawai’i Island.