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Gnathostoma Spinigerum Was Positive

Gnathostoma Spinigerum Was Positive

Department Medicine Diagnostic Centre

Swiss TPH Winter Symposium 2017 Helminth – from Transmission to Control

Sushi Worms – Diagnostic Challenges

Beatrice Nickel -borne helminth Consumption of raw or undercooked fish

- spp. infections - spp. infections

Case 1 • 32 year old man • Admitted to hospital with severe gastric • Abdominal pain below ribs since a week, • Low-grade • Physical examination: moderate abdominal tenderness • Laboratory results: mild leucocytosis • Patient revealed to have eaten 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 / Endoscopic removal of with penetrating gastric mucosa a Roth net

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

Human parasitic infection of by • worm, Anisakis spp. (A.simplex, A.physeteris) • worm, Pseudoterranova spp. (P. decipiens) Consumption of raw or undercooked seafood containing infectious larvae Highest incidence in countries where consumption of raw or marinated fish dishes are common: • (, sushi) • Scandinavia (cod ) • Netherlands (maatjes ) • Spain (anchovies) • South America ()

Source: http://parasitewonders.blogspot.ch Life Cycle of

(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 , ulcer or even perforation. Diagnosis and Therapy Leucocytosis 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), can be effective

Source of image: David Hwang, Chonnam Med J 2012. Case 2

• 31 year old woman • Recurrent pruritic 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 -like appearance

Leroy, J., Travel Medicine and Infectious Disease (2017) Case 2

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

 Due to symptoms and the background of the patient, cutaneous was suspected  Serological test (immunoblot) for was positive

 Patient received with complete remission Gnathostomiasis Parasitic infection by of family 6 pathogenic species known Most human infections caused by: • Gnathostoma spinigerum (endemic in ) • 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:  syndrome (CLM)  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 • lesions associated with gnathostomiasis can also be caused by other helminth infections (e.g. / , 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: positive 2 = Negative control: negative 3 = patient serum: negative 4 = Positive control : negative Gnathostoma serology

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

1 = Positive control Laos: positive 1 = Positive control Peru: positive 2 = Negative control: negative 2 = Negative control: negative 3 = Patient serum: negative 3 = Patient serum: positive 4 = Positive control Peru: negative 4 = Positive control Laos: positive

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!

Acknowledgments

Swiss Tropical and Public Health Institute Team of the Diagnostic Centre Hanspeter Marti Andreas Neumayr Karin Stoll

University of Health Sciences, Vientiane, Lao PDR Youth Vonghachack

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