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This work was supported by 8. Erker JC, Desai SM, Mushahwar IK. sp.) that had just been caught. He European Commission FP6 funded project Rapid detection of virus RNA reported no history of traveling to a by reverse transcription–polymerase chain LSHB-CT-2006-037377 and by the Chief reaction using universal oligonucleotide -endemic area. Initial Scientist Offi ce Scotland project reference primers. J Virol Methods. 1999;81:109– work-up depicted (43%), ETM/32. 13. http://dx.doi.org/10.1016/S0166-0934 and a computed tomographic scan of (99)00052-X the chest revealed left pleural effusion. 9. Li TC, Miyamura T, Takeda N. Detection Claire Crossan, Paul J. Baker, of hepatitis E virus RNA from the bivalve Two weeks later, winding, linear, John Craft, Yasu Takeuchi, Yamato-Shijimi (Corbicula japonica) in reddish lesions appeared on his back, Harry R. Dalton, . Am J Trop Med Hyg. 2007;76:170– which lasted 3 days (Figure, panel 2. A). Serologic testing for and Linda Scobie 10. Shuval H. Estimating the global burden of Author affi liations: Glasgow Caledonian thalassogenic diseases: infectious mansoni was weakly positive. Acute University, Glasgow, Scotland, UK (C. diseases caused by wastewater pollution was diagnosed, and of the marine environment. J Water Crossan, P.J. Baker, J. Craft, L. Scobie); treatment with praziquantel was Health. 2003;1:53–64. University College London, London, UK begun. In 4 weeks, all symptoms faded. (Y. Takeuchi); and European Centre for Address for correspondence: Linda Scobie, In 2009, the patient took Environment and Human Health, University Department of Life Sciences, Glasgow albendazol for helminthic of Exeter Medical School, Truro, UK (H.R. Caledonian University, Cowcaddens Rd, prophylaxis, and 3 weeks later, deep Dalton) Glasgow, G4 0BA, UK; email: linda.scobie@ migratory, swelling, reddish nodules gcu.ac.uk DOI: http://dx.doi.org/10.3201/eid1812.120924 occurred on the thorax; each lesion lasted ≈6 days, and new lesions References appeared at intervals of 1–5 days 1. Kamar N, Bendall R, Legrand-Abravanel in a somewhat linear array (Figure, F, Xia NS, Ijaz S, Izopet J, et al. Hepatitis E. panel B). By this time, hemograms Lancet. 2012;379:2477–88. http://dx.doi. displayed eosinophilia of 25%, but org/10.1016/S0140-6736(11)61849-7 a computed tomographic scan of 2. Said B, Ijaz S, Kafatos G, Booth L, Thomas HL, Walsh A, et al. Hepatitis E Autochthonous the chest showed no abnormalities. outbreak on cruise ship. Emerg Infect Results of a complete ophthalmologic Dis. 2009;15:1738–44. http://dx.doi. Gnathostomiasis, examination were unremarkable, and org/10.3201/eid1511.091094 Brazil a fecal examination was negative 3. McCreary C, Martelli F, Grierson S, for parasites. Gnathostomiasis Ostanello F, Nevel A, Banks M. Excretion To the Editor: Gnathostomiasis of hepatitis E virus by pigs of different was highly suspected on the basis is an by of ages and its presence in slurry stores in the of the clinical and epidemiologic the genus ; the main United Kingdom. Vet Rec. 2008;163:261– fi ndings and results of biopsies. 5. http://dx.doi.org/10.1136/vr.163.9.261 source of is raw freshwater Histopathologic examination re- 4. Emerson SU, Arankalle VA, Purcell RH. fi sh. In the past, gnathostomiasis was Thermal stability of hepatitis E virus. J vealed a dense superfi cial and deep regarded as restricted to certain Asian Infect Dis. 2005;192:930–3. http://dx.doi. dermal infi ltrate of eosinophils and and Central American countries, but org/10.1086/432488 neutrophils but did not show the 5. Lowther JA, Gustar NE, Powell AL, increase of migratory fl ux and changes parasite. Two samples of plasma were Hartnell RE, Lees DN. A two-year in alimentary habits have contributed systematic study to assess sent to for immunoblot in to importing cases into areas where contamination in oysters from commercial search of the diagnostic band (24-kDa the disease is not endemic (1,2). harvesting areas in the United Kingdom. antigen) of , Appl Environ Microbiol. 2012;78:5812–7. We report a case of autochthonous resulting in high titers. Albendazol, 6. Baker K, Morris J, McCarthy N, Saldana gnasthostomiasis in Brazil. L, Lowther J, Collinson A, et al. An 800 mg/day for 21 days, and a A 37-year-old man from Rio de outbreak of norovirus infection linked to single dose of , 0.2 mg/ Janeiro sought medical attention in oyster consumption at a UK restaurant, kg, were administered and, despite February 2010. J Public Health (Oxf). 2005 because of low , , initial improvement, the disease 2011;33:205–11. abdominal tenderness, and in 7. McLeod C, Hay B, Grant C, Greening G, relapsed, requiring a second cycle of the left shoulder. The symptoms Day D. Inactivation and elimination of the medications. No signs of disease started 15 days after a recreational human enteric viruses by Pacifi c oysters. occurred during 2 years of follow-up. J Appl Microbiol. 2009;107:1809–18. trip to Tocantins, where he practiced Gnathostomiasis is found http://dx.doi.org/10.1111/j.1365- sport fi shing and ate sashimi- 2672.2009.04373.x mostly in Japan and Thailand. In the style freshwater raw fi sh (Cichla Americas, most cases occur in Mexico

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 12, December 2012 2087 LETTERS

(3). Gnathostomiasis was previously the , which may in a linear array. History of traveling to reported in Brazil, but the patient was result in death (5). If left untreated, gnathostomiasis-endemic areas is not infected in (4). gnathostomiasis may remit and recur strictly necessary, considering recent Four species are known to cause several times until death of the larvae reports of gnathostomiasis acquisition disease in , and G. spinigerum ≈12 years after infection. in previously unaffected regions (10). is the most frequent cause. Adult The rate of detection of larvae parasites live in the stomach of in skin biopsy specimens varies Thiago Jeunon de Sousa Vargas, defi nitive hosts (, , and other from 24% to 34%, and the diagnosis Sabrina Kahler, Cassio Dib, fi sh-eating mammals), and are frequently needs confi rmation by Marcio Barroso Cavaliere, eliminated in feces. These hatch and serologic testing (3). Immunoblot is and Maria Auxiliadora release the fi rst-stage larvae in fresh highly sensitive and specifi c and is Jeunon-Sousa water; larvae are ingested by the fi rst regarded as the most valuable ancillary Author affi liations: ID–Investigação em intermediate , a , and technique (1,6). The diagnosis in the Dermatologia, Rio de Janeiro, Brazil (T. develop into second-stage larvae. patient reported here had a 4-year Jeunon de Sousa Vargas, M.A. Jeunon- are ingested by the second delay, despite investigation in several Sousa); Hospital Federal de Bonsucesso, intermediate hosts (fi sh, eels, , renowned institutions. Rio de Janeiro (T. Jeunon de Sousa Vargas, , and reptiles), and larvae mature The treatment of choice is S. Kahler, C. Dib); and Colégio Brasileiro to the third stage. When eaten by an albendazol, 800 mg/day for 21 de Cirurgiões, Rio de Janeiro (M. Barroso appropriate defi nitive host, third-stage days, but ivermectin, 0.2 mg/kg in a Cavaliere) larvae evolve to adults and fi nally single dose or for 2 subsequent days, DOI: http://dx.doi.org/10.3201/eid1812.120367 reach the stomach of their host. is an alternative (7). More than 1 Third-stage larvae cannot mature treatment cycle might be required References in humans and keep migrating in skin, (8). promotes outward subcutaneous tissue, or other organs. migration of the larvae to the dermis, 1. Herman JS, Chiodini PL. Gnathostomiasis, Initial signs and symptoms are fever, and we believe that the low doses used another emerging imported disease. Clin Microbiol Rev. 2009;22:484–92. http:// anorexia, nausea, , diarrhea, for helminths by the patient reported dx.doi.org/10.1128/CMR.00003-09 malaise, urticaria, and epigastric here might have activated quiescent 2. Moore DAJ, McCroddan J, Dekumyoy pain. Eosinophilia is frequent. After larvae and triggered new lesions (9). P, Chiodini PL. Gnathostomiasis: an 2–4 weeks, larvae migrate to skin or A high index of suspicion is emerging imported disease. Emerg Infect Dis. 2003;9:647–50. http://dx.doi. subcutaneous tissue, causing winding necessary to diagnose this disease org/10.3201/eid0906.020625 linear erythematous lesions or in areas where it is not endemic. 3. Diaz Camacho SP, Zazueta Ramos M, migratory swelling nodules. Cutaneous Gnathostomiasis must be suspected Ponce Torrecillas E, Osuna Ramirez gnathostomiasis is the most common in a patient who has a history of I, Castro Velazquez R, Flores Gaxiola A, et al. Clinical manifestations and form of disease. The larvae also can eating raw freshwater fi sh, persistent immunodiagnosis of gnathostomiasis in migrate to lungs; genitourinary tract; eosinophilia, and migrans–like Culiacan, Mexico. Am J Trop Med Hyg. digestive tract; ears; eyes; and rarely, lesions and/or migratory deep nodules 1998;59:908–15.

Figure. Gnathostomiasis in a 37-year-old man, Brazil. A) Evanescent winding, linear, reddish lesions on the back in 2005. B) Deep migratory reddish nodules (arrows) on the lateral thorax, occurring in 2009 after treatment with albendazol for helmintic prophylaxis.

2088 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 12, December 2012 LETTERS

4. Dani CMC, Mota FK, Sanchonette VP, Zoonotic We tested for the presence of DNA Maceira JP, Maia APC. Gnathostomiasis from spotted fever group Rickettsia in Brazil: case report. An Bras Dermatol. Transmission of 2009;84:400–4. http://dx.doi.org/10.1590/ spp., Anaplasma spp., Francisella S0365-05962009000400012 Pathogens by tularensis, and Babesia spp. in 147 I. 5. Katchanov J, Sawanyawisuth Ixodes ricinus ricinus ticks collected from roe deer K, Chotmongkol V, Nawa Y. and goats at 2 sites in eastern Romania: Neurognathostomiasis, a neglected Ticks, Romania parasitosis of the central nervous system. Bacau (46°35′0″N, 26°55′0″E) and Emerg Infect Dis. 2011;17:1174–80. To the Editor: The Ixodes ricinus Galati (45°26′22″N, 28°2′4″E). http://dx.doi.org/10.3201/eid1707.101433 tick is a predominant vector of a large Specimens were tested by PCR, using 6. Intapan PM, Khotsri P, Kanpittaya J, specifi c primers for each pathogen or Chotmongkol V, Sawanyawisuth K, variety of pathogens of veterinary and Maleewong W. Immunoblot diagnostic medical consequence in Europe (1). group of pathogens, as described (4). test for neurognathostomiasis. Am J Trop The most prevalent I. ricinus–borne Sequences obtained from Eurofi ns Med Hyg. 2004;83:927–9. http://dx.doi. infection of persons in Europe is Lyme MWG Operon (Ebersberg, Germany) org/10.4269/ajtmh.2010.10-0113 were identifi ed by using BLAST 7. Nontasut P, Claesson BA, Dekumyoy borreliosis, a multisystemic disorder P, Pakdee W, Chullawichit S. Double- caused by spirochetes of the Borrelia (www.ncbi.nlm.nih.gov/BLAST) and dose ivermectin vs albendazole for the burgdorferi sensu lato complex (2). compared with sequences available treatment of gnathostomiasis. Southeast Persons bitten by ticks can also become in GenBank. Asian J Trop Med Public Health. DNA from Rickettsia spp. was 2005;36:650–2. infected with many other pathogens, 8. Strady C, Dekumyoy P, Rigolet CM, Danis such as bacteria (Anaplasma spp., detected in 20 (13.6%) ticks. Sequence M, Bricaire F, Caumes E. Long-term Francisella spp., Coxiella burnetii, analyses revealed that 9 (6.1%) follow-up of imported gnathostomiasis Bartonella spp., Rickettsiae spp., and sequences were related to the R. shows frequent treatment failure. Am J monacensis strain IRd/Serbia glta gene Trop Med Hyg. 2009;80:33–5. Neoerhlichia mikurensis); parasites 9. Suntharasamai P, Riganti M, Chittamas (Babesia spp., Theileria spp.); and (99%–100% nt similarity) (GenBank S, Desakorn V. Albendazole stimulates arboviruses (tick-borne accession no. GQ925820) and 11 outward migration of Gnathostoma virus, Crimean-Congo hemorrhagic (7.48%) were related to R. helvetica spinigerum to the dermis in man. gltA gene (99%–100% nt similarity) Southeast Asian J Trop Med Public fever virus, and Eyach virus) (1). Health. 1992;23:716–22. Symptoms induced by such pathogens (GenBank accession no. AM418450). 10. Herman JS, Wall EC, van Tulleken C, are often diverse and nonspecifi c, DNA from Anaplasma spp. was Godfrey-Faussett P, Bailey RL, Chiodini complicating accurate diagnosis of the identifi ed in 33 (22.4%) ticks. Analysis PL. Gnathostomiasis acquired by British revealed that 30 of the 33 amplifi ed tourists in Botswana. Emerg Infect Dis. disease. 2009;15:594–7. http://dx.doi.org/10.3201/ In Romania, cases of Lyme fragments showed 100% identity to eid1504.081646 disease and tick-borne encephalitis the 16S rDNA gene of a symbiont (caused by tick-borne encephalitis in the family Anaplasmataceae, Address for correspondence: Thiago Jeunon virus) have been identifi ed (3). Candidatus Midichloria mitochondrii de Sousa Vargas, Hospital Federal de However, little is known about the (GenBank accession no. EU780455), Bonsucesso—Dermatology and Anatomical public health impact of these diseases, and the remaining 3 were related to Pathology, Av. Londres 616, Bonsucesso Rio de and none of the other tick-borne known pathogenic species identifi ed Janeiro, Rio de Janeiro CEP:21041-030, Brazil; pathogens present in Europe have in Romania: 2 (1.4%) exhibited email: [email protected] been reported as causes of infection 100% identity to Anaplasma in Romania. Although I. ricinus is the phagocytophilum (GenBank accession most abundant and widespread tick in no. EU982548), and 1 (0.7%) showed Romania (3), the public health impact 99% similarity to Ehrlichia muris of I. ricinus–borne disease is likely (GenBank accession no. GU358691). to be underestimated. Therefore, the Francisella tularensis–specifi c DNA fi rst step in evaluating the distribution was amplifi ed from 4 DNA extracts of these potential pathogens is to (2.7%). All 4 sequences were identical establish their presence in ticks from and shared 99% similarity with the F. previously unexplored areas. tularensis peptidyl-propyl cis-trans We conducted a study to identify isomerase gene (GenBank accession the main tick-borne bacterial and no. CP003048). Babesia spp.–specifi c parasitic human pathogens known DNA was amplifi ed in 1 DNA extract to be present in Europe but not (0.7%), and it shared 99% sequence previously detected in Romania. identity with the Babesia sp. EU1 18S

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