# Central Nervous System Infection by Free-Living Nematode Cephalobus cubaensis in a Human Host in Africa

## TL;DR

A rare case of central nervous system infection by a free-living nematode Cephalobus cubaensis in an immunocompetent human in Africa is reported, leading to fatal outcomes.

## Contribution

This is the first documented case of Cephalobus cubaensis causing a fatal central nervous system infection in a human.

## Key findings

- The nematode Cephalobus cubaensis was identified in brain and ear canal samples using PCR and sequencing.
- The infection was linked to a prior bacterial otitis externa that allowed nematode colonization.
- The patient's condition worsened despite anthelminthic treatment, resulting in death from bronchopneumonia.

## Abstract

Background: Human central nervous system infections due to free-living nematodes, although extremely rare, are usually fatal. Immunodeficiency has not been a feature of most of these cases, unlike the situation pertaining to disseminated Strongyloides stercoralis infection. Case report: An elderly immunocompetent man presented with a history of tinnitus and otalgia, progressing to central nervous system involvement with confusion, weakness, and other neurological signs. Examination revealed a unilateral external auditory canal soft tissue mass and radiological evidence of ipsilateral temporal bone destruction and brain parenchymal disease. A biopsy of the ear canal mass revealed the presence of an unidentified nematode species, and treatment with anthelminthics was started. The patient’s clinical condition deteriorated and he died shortly after admission to the intensive care unit. The immediate cause of death was bronchopneumonia. During the autopsy, an extensive involvement of the right middle cranial fossa was found, with destruction of the squamous and petrous parts of the temporal bone. Results: We identified adult, larval, and egg stages of a free-living nematode in the antemortem external auditory canal tissue mass and the post-mortem brain samples. Polymerase chain reaction assays, with Sanger and whole-genome sequencing, identified Cephalobus cubaensis. This is a free-living species not previously known to be pathogenic to humans, although nematodes of the same genus have caused mastitis in horses. Conclusions: Microscopic appearance and the invasive behaviour of the pathogen evoked a putative diagnosis of Halicephalobus gingivalis, the most frequently reported free-living nematode infecting humans. However, this nematode’s size and anatomical features, and the clinical presentation and duration of illness, prompted the consideration of an alternative species. We speculate that an initial bacterial otitis externa provided the opportunity for colonization by the nematode from an environmental source and subsequent invasion.