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Gnathostoma Spinigerum Was Positive

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Department Medicine Diagnostic Centre

Swiss TPH Winter Symposium 2017

Helminth Infection – from Transmission to Control

Sushi Worms – Diagnostic Challenges

Beatrice Nickel

Fish-borne helminth infections

Consumption of raw or undercooked fish - Anisakis spp. infections - Gnathostoma spp. infections

Case 1

• 32 year old man • Admitted to hospital with severe gastric pain • Abdominal pain below ribs since a week, vomiting • Low-grade fever • Physical examination: moderate abdominal tenderness • Laboratory results: mild leucocytosis • Patient revealed to have eaten sushi recently • Upper gastrointestinal endoscopy was performed

Carmo J, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2016-218857

Case 1

Endoscopy revealed 2-3 cm long helminth

Nematode firmly attached to / penetrating gastric mucosa
Endoscopic removal of larva with a Roth net

Carmo J, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2016-218857

Anisakiasis

Human parasitic infection of gastrointestinal tract by

• herring worm, Anisakis spp. (A.simplex, A.physeteris) • cod worm, Pseudoterranova spp. (P . d ecipiens)

Consumption of raw or undercooked seafood containing infectious larvae

Highest incidence in countries where consumption of raw or marinated fish dishes are common:

• Japan (sashimi, sushi) • Scandinavia (cod liver) • Netherlands (maatjes herrings) • Spain (anchovies) • South America (ceviche)

Source: http://parasitewonders.blogspot.ch

Life Cycle of Anisakis simplex

(L1-L2 larvae)
L3 larvae
L2 larvae

L3 larvae

Source: Adapted to Audicana et al, TRENDS in Parasitology Vol.18 No. 1 January 2002

Symptoms

Within few hours of ingestion, the larvae try to penetrate the gastric/intestinal wall

• acute gastric pain or abdominal pain • low-grade fever • nausea, vomiting • allergic reaction possible, urticaria • local inflammation

Invasion of the third-stage larvae into gut wall can lead to eosinophilic granuloma, ulcer or even perforation.

Diagnosis and Therapy

Leucocytosis Eosinophilia

Dietary history (raw fish) Endoscopy: gastroscopic examination Serological tests

• Immunoblot

length of Anisakis larvae 20-30 mm

• ELISA Removal of larvae during endoscopy with biopsy forceps If larvae can not be reached (intestinal Anisakiasis), Albendazole can be effective

Source of image: David Hwang, Chonnam Med J 2012.

Case 2

• 31 year old woman • Recurrent pruritic edema on her back and ribs • Edema resolve spontaneously within 24-48 h • Symptoms since 2 years, at least once a month • Multiple consultations and allergological investigations did not bring any results

• Laboratory results:

 Mild eosinophilia (470 µl-1), no inflammatory signs  Serological tests for parasites were negative (Trichinella, Toxocara, Filaria, Strongyloides, …)

 Stool analysis for parasites was negative

Leroy, J., Travel Medicine and Infectious Disease (2017)

Case 2

• Clinical examination

 Erythematous edema, subcutaneous cords with snake-like appearance

Leroy, J., Travel Medicine and Infectious Disease (2017)

Case 2

 The patient was from Thailand, living in France since 2 years, and frequently consumed raw fish dishes in Thailand

 Due to symptoms and the background of the patient, cutaneous gnathostomiasis was suspected

 Serological test (immunoblot) for Gnathostoma spinigerum was positive

 Patient received Ivermectin with complete remission

Gnathostomiasis

Parasitic infection by nematodes of Gnathostomatidae family 6 human pathogenic species known Most human infections caused by:

• Gnathostoma spinigerum (endemic in Asia)

• Gnathostoma binucleatum (endemic in Central and South America)

Consumption of raw or undercooked freshwater fish or parathenic hosts containing infectious L3 larvae

Larvae penetrate the intestinal wall and migrate around the body

Highest incidence in Asia, Central and South America

Gnathostoma spinigerum larva

500 µm

Images by
Françoise Brand Swiss TPH Basel

100 µm

Life Cycle of Gnathostoma spinigerum

Source: Clin. Microbiol. Rev. July 2009 vol. 22

Symptoms

Incubation period: few weeks to months • Shortly after ingestion nausea, fever, urticaria might appear • Eosinophilia • Episodic appearance of migrating edema and erythema (CLM) Symptoms may last for years The larvae can survive for many years in the human body Clinical picture:

 Cutaneous larva migrans syndrome (CLM)  Visceral larva migrans syndrome (VLM), not very frequent  Neural larva migrans syndrome (NLM), meningoencephalitis  Occular larva migrans syndrome

Diagnosis and Therapy

Dietary history (raw freshwater fish)

Eosinophilia Clinical picture, larva migrans syndrome

• Skin lesions associated with gnathostomiasis can also be caused by other helminth infections (e.g. dog/cat hookworm, Toxocara, …)

Definitive diagnosis is only possibel by identification of the larva in biopsies, but not feasible in all cases

Serology is method of choice

• Immunoblot (24 kDa band) usually antigen of G.spinigerum • Travel history is important (Asia or America)

Treatment: Ivermectin or Albendazole

Gnathostoma serology

G.spinigerum antigen (larvae from Laos)

Patient with suspected gnathostomiasis • Cutaneous larva migrans syndrome • Consumption of ceviche in Belize and
Guatemala 6 months before admission

Serodiagnostic immunoblot with antigen of

G.spinigerum was negative

1 = Positive control Laos: 2 = Negative control: 3 = patient serum:

positive

negative negative

  • negative
  • 4 = Positive control Peru:

Gnathostoma serology

  • G.spinigerum antigen (larvae from Laos)
  • G.binucleatum antigen (larvae from Ecuador)

1 = Positive control Laos: 2 = Negative control:

3 = Patient serum:

positive

1 = Positive control Peru: 2 = Negative control:

3 = Patient serum:

positive

negative

positive

positive

negative

negative

  • negative
  • 4 = Positive control Peru:
  • 4 = Positive control Laos:

Neumayr, Am. J. Trop. Med. Hyg., 95(2), 2016, pp. 413–416

Serologic tests for «Sushi Worms» at Swiss TPH

Anisakis spp. Gnathostoma spp. Angiostrongylus spp. Paragonimus spp.

Prevention of transmission

• Adequate cooking of marine seafood and freshwater fish at temperatures >60°C
• Freezing of fish and shellfish at −35°C for 15 hours or ≤ -20°C for
7 days destroys infective larvae
• Salting or marinating will not necessarily kill the parasites!

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