Distribution of Plesiomons Shigelloides in Clinical Samples In

Home , History of seafood, Plesiomonas shigelloides

log bio y: O ro p ic e n Zoha T, Clin Microbiol 2019, 8:2 M A l

a c DOI: 10.4172/2327-5073.1000331 c

n s

l s C Clinical Microbiology: Open Access ISSN: 2327-5073

Research Article Open Access

Distribution of Plesiomons shigelloides in Clinical Samples in Various Countries: A Review Article Zoha Tavakkoli Department of Microbiology, University of Barcelona, Barcelona, Spain *Corresponding author: Zoha Tavakkoli, Department of Microbiology, Faculty of Biology, University of Barcelona, Barcelona, Spain, Tel: +0034651982299; E-mail: [email protected] Received date: April 25, 2019; Accepted date: May 03, 2019; Published date: May 10, 2019 Copyright: © 2019 Zoha T, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

P. shigelloides clearly represented in Enterobacteriaceae family. The study of Plesiomonas and knowledge about this bacterium is increasing rapidly. Plesiomonas shigelloides is as one of the pathogens that can be recognized as a more common case in patients who are infected with diarrhea. It is indicated that Plesiomonas diarrhea in most studies and clinical case reports is related to consumption of seafood or untreated water by people who travel to tropical or subtropical geographical locals. Our findings demonstrated acute clinical diarrhea of Plesiomonas with abdominal pain is more often and has a long duration of disease infected by other enteric pathogens. Still, more work needs to be done on this pathogens and needs more full investigation and its harsh effects need to be resolved.

Keywords: Plesiomonas; Gram-negative bacteria; Global pathogen; we reviewed the epidemiology of Plesiomonas shigelloides in clinical Diarrhea infection and laboratory detection of diarrheal patients by different authors in several countries and the procedure of patient's infection Introduction and also we investigated, overview and attention rate of the bacterium in various laboratories in Iran. Over the 70 years the genus of Plesiomonas, has been discovered by Ferguson and Henderson in 1947 by a single species which was named, Taxonomy P. shigelloides [1]. This aerogenic Gram-negative bacteria habitat is in an aquatic environment included freshwater ecosystem and estuaries Paracolon was one of the earliest names to describe the Gram- [2]. P. shigelloides represented in the Vibrionaseae family but currently negative anaerogenic bacilli which were associated with gastroenteritis. based on limited numbers of biochemical characteristics like as ability Many different taxa in a paracolon group of bacteria according to to ferment lactose reclassified in a family of Enterobacteriaceae that is various biochemical features including ferment lactose, possession of the only oxidase positive species in this family [3]. Over the past 2 certain somatic antigens and oxidase reaction were recognized during decades, some evidence ascribed the role of this microorganism in the the past years [11,12]. One of the members of C27 collection of form of series foodborne pathogen and etiologic operative of Paracolon bacteria that recently was named Plesiomonas, illustrated by gastroenteritis bacterial [4,5]. Additionally, some virulence candidates Ferguson and Henderson in 1947 who described the isolation from have been recognized association with microorganism pathogenicity faces of a patient with unknown clinical history and also properties including a cytotoxic hemolysin, iron acquisition systems, and resembling those of Shigella [1,13]. Thus, in many years different lipopolysaccharide. Others human infection caused by Plesiomonas proposals by numbers of scientific were published which were may are septicemia and central nervous system, eye infection and etc. presented many disagreements for the placement of this [6-8]. Almost 3 decades after the initial discovery of Plesiomonas, this microorganism in a correct genus. Shigelloides was the name organism got more attention from the investigator as a kind of human suggested by Bader in 1954 in the genus of Pseudomonas [14]. Based pathogen [4]. when they reported the existence of the microorganism on the geographical location where Ferguson and Henderson in a 62 years old woman [9]. While biochemically, the prevalence of separated this bacterium, Sakazaki and Namioka believed that the Plesiomonas connives in stool samples, nowadays Scientific and isolation should be named Michigani [15]. In 1961 Ewing and his medical information provided different molecular technologies consist colleagues proposed that because of cytochrome oxidase activity and of DNA sequencing, gene amplification, the publication of whole- flagellar morphology characterization, this microorganism should genome sequencing and many others options to determine of transfer from Pseudomonas genus to Aeromonas within the family of Plesiomonas in clinical samples as human pathogens [10]. Based on Vibrionaceae [16]. Habs and Schubert recommended new genus for various reasons include hygiene conditions, dietary habits, regional this bacteria which called Plesiomonas shigelloides [17]. According to occupations or others factors the prevalence of Plesiomonas has been the molecular analysis of bacterium by Martinez-Murica et al. reported in the higher numbers in Southeast Asia and Africa and lower indicated that P. shigeloides phylogenetically is related to Proteus [18]. rates in North America and Europe. Furthermore, with the availability Furthermore in an evaluation of Amplified Fragment Length of various diagnostic tests and increasing of patient's population Polymorphism (AFLP) P. shigelloides clearly represented in review of clinical-community samples and prevalence of Plesiomonas Enterobacteriaceae family [15]. There are some amount of phenotypic can be appropriated comparison to past viewpoints [11]. In this study, data indicate that Plesiomonas is sharing some behaviors with

Clin Microbiol, an open access journal Volume 8 • Issue 2 • 1000331 ISSN: 2327-5073 Citation: Zoha Tavakkoli (2019) Distribution of Plesiomons shigelloides in Clinical Samples in Various Countries: A Review Article. Clin Microbiol 8: 331. doi:10.4172/2327-5073.1000331

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Enterobacteriaceae and Vibrionaceae family. Otherwise, the discussion microprobe X-ray analysis of the electron-dense pasting and Bromel is remained open because of the variety ideas of scientists. reported the bio-polar and central location of bodies which illustrated the high concentration of phosphorus and potassium [25]. Biology, habitat, and host Magnesium and silicon as well. it is found that the number, size, and Environment distribution and ecology for Plesiomonas genus is location of inclusion can bodies appertain to the cell cycle phase. based upon the various physiologic characteristics. They grow in Transmission Electron Microscopy (TEM) revealed the characteristic between 8C to 45C temperatures, therefore this bacterium is known as of typical Gram-negative bacteria with the spreading of nucleoplasm a mesophilic bacteria with the optimal temperature ranging between which are sporadic in the cytoplasm and furthermore ribosomes 35 and 39 and also maximum ranging of 40C to 45C [16,19]. However, scattered throughout the cytoplasmic matrix [24]. In recent years’ there were some reported of recovering of Plesiomonas strains from surface structures of bacteria was considered and discussed the role of Lake Vettasjarvi in Sweden, where the water temperature recorded 9C these structures in virulence. With further study, the role of the with the pH of 6.5. In addition to temperature pH rating is the growth material in the potential virulence of this organism will be established option for Plesiomonas. Primarily pH ranging for Plesiomonas growth [24]. is between 4.5 to 9 and salinities of 0% to 4%. According to these behaviors, bacterium isolated from different substrates, the first Culture condition and laboratory identification reservoir of this bacterium is the aquatic environment [16-21]. Both Plesiomonas, usually grow on enteric agar included Mac Conkey fresh and estuarine water include rivers, stream, ponds, lakes, brackish, (MAC), xylose lysine decarboxylase (XLD) or Hecton agars as Some etc are the storages of Plesiomonas, likewise the organism isolated routine non-lactose fermenter for isolation of bacteria [26-29]. from seawater and vegetables in Costa Rica [22]. Asian bacteria are the Salmonella Shigella agar may be used in identification of some strain given name to this bacterium because of the high incidence isolation of [26-30]. Like as any routine enteric pathogen test, stools samples that them in Japan and Thailand. Moreover, In recent studies, the used to test for Plesiomonas should be collected by rectal swabs and important role of Plesiomonas shigeloiedes in gastro-enteritis and refrigerated for hours. The isolation should be more facile with a 5% diarrheal cases in various African countries and also the isolation of sheep blood agar which colonies appear in gray and as nonhemolytic this bacterium in Europe from fresh water has been reported. Based after 18-24 hours incubation in 37C. It should be added ferments upon most studies and investigation Plesiomonas shigelloides can be sucrose if the organism needs sugar in the culture condition and also isolated from various environments and also recovered from different the colony of bacteria appeared green in most media. Cefsulodin hosts. And it presented us how temperature, pH, turbidity and other irgasan-Novobiocin (CIN) medium, Inositol-Brilliant Green-bile Salts characteristics can affect the source of Plesiomonas. Current studies (IBB) used as a medium for detecting of Plesiomonas in some published the concentration and existence of this taxon in various laboratories [31]. IBB medium can be used in both environmental and animal species. And also there is information that occasionally clinical specimens. Alkaline peptone water as well, used for patients reported the association of Plesiomonas with the zoonotic disease. The who needs enrichment condition in a case for a stool patient with primary habitats of P. shigeloides are freshwater and brackish as chronic diarrhea. Oxidase testing cannot use directly from enrichment estuary water; there are positive finding and distribution of environment because acid produced from carbohydrate fermentation Plesiomonas from streams, rivers, and lakes [22]. cause a false negative reaction, in a case that oxidase testing is necessary, its better use medium containing no carbohydrate. Host Otherwise, some conventional tests can divide this organism from Interestingly Plesiomonas shigelloides could be isolated from other Enterobacteriaceae, vibrionaceae and Aeromonaceae [32]. TSI Mammals, marine mammals, fish, shellfish and crustaceans, reptiles reaction, arginine dihydrolase reactions and myo-inositol fermentation and amphibians, birds which were provided in some excellent reviews and also 100% positive indole, d-glucose, and trehalose reaction are [23]. Some knowledge provided the presence of Plesiomonas in commonly for detecting of Plesiomonas from other bacteria in their Mollusks and crustaceans including shellfish, clams, oysters, shrimp, family group [33]. Molecular technique regarding PCR and gene and crab, otherwise Plesiomonas was detected from varieties numbers sequencing is able to rapid utilization compares to conventional of saltwater fish, marine fish lots, catadromous fish, according to culture method, in public health and laboratories diagnostic. Although confirmation of presence of Plesiomonas in various hosts and some other diagnostic test such as 16s rRNA and gyrB gene environments, this fact supports the suggestion that this sequencing, culture-independent diagnostic test and MOLDI-TOF MS microorganism is globally distributed in all around the world [20,24]. are accurate in identification of this genus [33-47].

Morphology Infection • wide ranges of animals infected by are divided into enzootic or This facultative anaerobic, gram-negative, oxidase positive road epizootic. Pathological and microbiological evidence represented shape microorganism with macro-morphology illustrates different that recovery of the bacterium from animals that were healthy and colonies depending on the selective medium used. The motility occurs diseases and cause sporadic and outbreak infections in them. In with lophotrichous or monotrichous polar and lateral flagella. Colonies current data, a case of inflammation was found of a liver of young vary from flat round, 1 mm to 2 mm size with smooth edges on blood male lizard house [48]. And also was reported in grass caps, and the agar to flat, irregular edge and shape and around 1mm size when disease in rainbow trout isolated from kidneys and liver [48]. The Plesiomonas are cultured on deoxycholate agar. P. shigelloides are results showed by the increase of the temperature the rate of micro-morphological, gram-negative, motile, capsulated, flagellated mortality by infection gets in over risk. In the Basel zoo, the outbreak and non-spore forming bacilli. The single cell size is 0.7 mm to 1 m × of septicemia by was observed in King and Penguins [49]. Liver, 2.1 mm to 3 m. when the electron microscopy was used, the granules kidney, small intestine are the various internal organs for isolation regardless of bacterial growth phase detected; otherwise, an electron

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of . As we pointed before various factors such as temperature, who were an underlying medical condition such as immune- overcrowding, oxygen levels, climates conditions as well as a food compromised, thalassemia, sickle cell disease, leukemia, asplenia, source can link to the infection in animals. hemochromatosis, biliary tract disease, and cirrhosis are common • Given the current prevalence of as a global pathogen, medical factors of sepsis [104-106]. Some literature indicated bacteremia in communities determine the association of this bacterium with various case reports that detected in neonates with meningitis or diarrheal diseases [50-65]. Generally, more investigation determined meningoencephalitis patients [117]. Plesiomonas sepsis specimen, that gastroenteritis infection is more specifically than extraintestinal slightly are isolated from CSF, abscess/wound, joint fluid, pleural manifestation, which was reported less common cases in the who fluid, stool, and urine sources in patients with contamination by infected with a variety of series infection include maladies, different reservoirs [118]. Virtually, there are no much reported of Bacteremia) individual peritonitis disease [40]. As previous recovering from open wounds, only two isolation from tissue or explanation, Various risk factors are regarding to which were exudate material have been published. Surprisingly in some clinical reported in different studies, including: consumption of uncooked reports, eye disease includes endophthalmitis and keratitis by are food and seafood, foreign travel with the most common destination reported in some literature even, more that wound infection. such as Thailand, Indonesia, Vietnam, person with immune Polyarthritis, osteomyelitis, cholangitis, epididymoorchitis, compromised like as HIV patients and also consumption of peritonitis, pyosalpingitis, pancreatic and splenic abscesses are untreated water or fresh water sources in places with poor condition complication resulting from infection by [109,110]. society [66-74]. Identification of risk factors for extraintestinal • Evaluation of molecular biology represented a variety of virulence infection of is much more difficult for investigators compare to factors which are associated with pathogenicity including β- gastroenteritis disease [28]. hemolysin, enterotoxins, cholera-like toxins and a cytotoxin LPS • owadays in clinical communities, is regarding entero pathogen complex with barrier properties of the structure of LPS, somatic illnesses. Syndrome diseases are the common infection that has been antigenicity, cytotoxic activity, iron acquisition, and genetic diversity. isolated on them. Gastrointestinal infection, systematic disease and a These inconsistent data on virulence factors in the mechanism of myriad of miscellaneous infection are a group of syndrome infection pathogenicity are involving with acute gastrointestinal and which is belonging to intra-abdominal disease, soft tissue, wound extraintestinal illnesses [111-113]. infection, and ocular illnesses. Obviously, gastroenteritis presented • In comparison with another phenotypic method, Serology is more in 3 forms: An acute secretory gastroenteritis, bloody colitis and successful for strains dividing. Mainly two major serotyping schemes chronic or persistent diarrhea [50,75]. gastroenteritis occurred in all based on somatic and flagellar have observed in this bacterium. The ages ranging and also in some studies indicated that is a much antigenic structure of this organism was studied by Aldova and higher range in children. In Southwest Asia and Africa, Geizeras [105] a 13 O antigen and 15 H antigen [105,111]. gastroenteritis was observed by investigators. And sometimes According to the study, some of the serotypes are ubiquitous, where infection happens with others infection [51-54,76-78]. others are rare and isolated only in certain regions. By the current • Typically Secretory gastroenteritis apperceives in 50% to 88% of all investigators, 102 somatic and 51 flagellar antigens have been patients who are attending with watery diarrhea and abdominal recognized [4]. Most of the strains are originally from clinical pain, dehydration, hypokalemia and peritonism symptoms are an specimens of humans and homeothermic animal sources. It is association with secretory illness [25,51,55]. Different studies reported that in the developing countries people might be naturally indicated various duration days of acute diarrhea in patients in immunized against by drinking contaminated water. There is some hospitals [54-56,79]. Watery gastroenteritis is most often detected in cross-reactivity of different serovars of with various serovars. Thus O healthy persons and peritonism, hypokalemia and dehydration are 17 share a somatic antigen with three serovars, O11:H11, O22H3, less common symptoms of gastroenteritis cases [80-103]. A second O93:H2 cross-react with serovars a 7,8,6, serovar O23:H1a1c is most common form of gastroenteritis is dysentery colitis that is related to serovar 13, O54:H2 to 2, O57H3 to 9. In spite, 4 additional characterized by abdominal pain or tenderness and vomiting and serogroups of (O5, O14, O15, O22) have been illustrated depending also the observation of blood in patients stool [104-107]. Chronic on certain O antigenic groups of (O13, O29, O19, O28) [4,5,114]. diarrhea is a less common gastroenteritis form in which are • Some guidelines regarding the appropriate treatment of by recognized with a duration of diarrhea in 2 weeks to 2 months and antimicrobial therapy or another medical intercession that can be there is little explanation about this kind of gastroenteritis [108,109]. utilized for the treatment of moderate to severe diarrhea caused by Based upon the several publications two fatal infections related to this bacterium. In a case of gastrointestinal infection, one were described with the observation of severe diarrhea and mucus, investigator recommended azithromycin or ceftriaxone for severe dehydration and hypokalemia, septicemia and bacteremia are cases of dysentery-like diarrhea of which was treated like as involvement in infection which is almost illustrated in immune- shigellosis [115]. Quinolone therapy, tetracycline or trimethoprim- compromised patients [110-112]. commonly occurred with blood sulfamethoxazole is suggested by some authors. In some cases, the dyscrasias (thalassemia, sickle cell disease, leukemia) asplenia, band administration of oral rehydration salts or intravenous fluids may be iron overload conditions such as hemochromatosis, biliary tract recommended alone or combined with quinolone. Treatment of disease, and cirrhosis, otherwise is associated with meningitis [111]. extraintestinal infection by because of the multiples factors is A variety of virulence factors including β-hemolysis, enterotoxins, difficult. This kind of infection patients who are suffering from cholera-like toxins and a cytotoxic LPS complex have been reported others disease can be treated by quinolones, carbapenems or in association with pathogenicity [113-115]. However based on the combination of antimicrobial therapies (2 or 3 drug regimen) such molecular evaluation, represented that structure of LPS, somatic as penicillin, aminoglycoside, cephalosporin or carbapenem. antigenicity, cytotoxic activity, and genetic diversity is the Generally, it is difficult to conclude on effective treatment on patient pathogenicity factors in bacteria [102,103,116]. outcome • Based upon the different reviews, septicemia is the first clinical syndrome regarding extraintestinal infection. is detected in patients

Page 4 of 10 Distribution and Result banana prawns; they found very low levels of this microorganism in both groups. P. shigelloides isolated from 15 different fish species by P. shigelloides with a worldwide distribution is known as a kind of Jagger [104]. P. shigelloides also was recovered in 23% of marine fish global pathogen. Most epidemiological information and investigations lots by Herrera et al. and Joh et al. [79] studied on the bacterial regarded that Plesiomonas shigelloides can be surrounded as a pathogen and their flora in the waters in Korean eel farms, they found diarrheal disease in human infection [119,120]. Therefore our 2.2% existence of Plesiomonas among 183 bacterial isolates from 621 knowledge conducted, Identification of Plesiomonas from clinical farm-cultured sick eels [128]. Nadirah and colleagues [99] samples have been reviewed as like as geographical sources. In documented the concentration of Plesiomonas in ranging from 1013 to addition, epidemiologic reports potentially illustrated that 1016 CFU in red hybrid tilapia. Plesiomonas is one of the most extraintestinal disease is less common than enteritis and also systemic common bacteria recovered from dolphins and also recovered from including of maladies such as bacteremia, peritonitis, and faces of 53% of live and dead otters in California Sea and one hepatobiliary disease had a smaller number of case reports in American sea lion mouth [129,130]. Plesiomonas shigelloides infection. Our study has documented the distribution of illnesses cases in different countries. Few reports of Clinical samples distribution and Iran Plesiomonas USA, Japan, Cuba, and Netherland of outbreaks were noticed in the literature [121-124]. In tropical and subtropical regions of the world distribution studies where warmer temperatures appear higher numbers of Plesiomonas in In various clinical and epidemiologic studies, Plesiomonas fresh water sources and increased illness rates, such as Bangladesh, shigelloides has been indicated as an enteric pathogen, it is regarded India, Malaysia, Thailand, China, Romania, Taiwan, Germany, that various investigations conducted epidemiologic data of bacterial Australia, Kenya, Mexico, Nigeria, Madagascar, Peru and some gastroenteritis in human infections and they represented that temperate countries as Canada, Spain, Czechoslovakia, Finland, extraintestinal are less common than enteritis in a case report of Sweden and South Africa. Some scientist believed that diarrheal illness sporadic and epidemic diarrheal disease. Holmberg and his related to Plesiomonas shigelloides may occur in greater numbers in collaborations [131] implicated that 31 Plesiomonas shigelloides reform nations conditions compared to the industrialized isolated from the United States while other investigation indicated environment. Consequently, in Southeast Asia and Africa higher isolation of P. shigelloiedes in <0.1% of the asymptomatic individual. reports and in North America and Europe, lower reports number of In a study by a group of medical microbiology in the United States, Plesiomonas has been regarded with considering of different reasons British Colombia and Vancouver in 1989 was determined the clinical like as hygiene conditions, dietary habits, regional occupations, and characters, epidemiology and effect of antimicrobial therapy on P. some others factors [125-128]. shigelloides diarrhea. Between August 1986 and December 1987 stool As we explained before varieties of ecological conditions can effect specimens of patients were collected to metropolitan clinical in Plesiomonas infection, as our previous literate the microorganism is laboratories and also some additional specimens to British Colombia mesophilic with a temperature ranging of 8C and 45C. Based on the provincial health laboratories. Clinical and epidemiological condition, various reports have been determined for infection of information was rolled up by patients interviewing or with observing Plesiomonas in streams, rivers, and lakes. Carlos Gonzales and the symptoms of their enteric pathogen and also after 1 to 12 months. colleagues worked on the occurrence of Plesiomonas in fresh water The information included: age, sex, presence of diarrhea, nature of from six lakes located in North of the polar circle in the north of stools, abdominal pain, urgency or tenesmus, fever, duration of Sweden [114]. They determined the existence of nine samples of symptoms, duration of illness. Stools specimens were cultured on Plesiomonas from one of six lakes and their results were illustrated that various media. During the 18 months study, 25 P. shigelloides were this microorganism can occur in aquatic environments where the isolated from 17820 out patient’s stools specimens in metropolitan temperature conditions are extremely low for a long period. Study clinical laboratories. 12 P. shigelloides infected were identified after an done by Farmer and co-workers, reported the range of 10 CFU/100 ml analysis of stool specimens in the provincial health laboratories. Most concentrations in a German river to 10,000 CFU/100 ml in a Florida of the strains were isolated from Hekton enteric and sorbitol estuarine [58]. Miller and Koburger reported several Plesiomonas MacConkey agars. of P. shigelloides infection 27 tests adequate for recovering cases from varieties of water sources [119]. Arial et al. they detecting other enteric pathogens, 30% (8) of them were positive for recovered Plesiomonas from Tama River during the warmer month of infection. Other infections were included Campylobacter sp., Shigella the year by using the Salmonella-Shigella and Deoxycholate Hydrogen sp., Salmonella sp., Yersinia sp., in 19 patients only P. shigelloides were Sulfide Lactos agars which analyzed 350 water samples and isolated detected and no others entering pathogen. Medium age of patients was from 8.9% to 22.4% of sampling sites [127]. Giobotti et al. [87] isolated 30 years old and 71% noticed with a history of tropical travel to 70 freshwater samples from seven different sources along the Cambe southwest Asia (45%), Central America (45%), Africa (10%), 8 patients stream that the isolation was performed in MacConkey agar with accumulated their infection locally in British Colombia, which all had incubation in 37C for 24 hours and they isolated two Plesiomonas a history of seafood consumption. All patients of P. shigelloides had samples among all samples. In Nilofar stream of Bursa in Turkey, diarrhea that 78% were in medical attention in 2 weeks and only 39% investigators found 30 Plesiomonas isolation from 36 samples around of controlled patients had an acute illness. The present findings 83%. The Plesiomonas also was isolated from river water in Slovakia suggested that P. shigelloides is traveler diarrhea and as a and Sweden. One study in the Philippine was examined brackish water gastrointestinal pathogen and showed that the organism may be a ponds that could found 6.6% Plesiomonas positive sample water. more common cause of diarrhea that is currently recognized. In Plesiomonas also was presented after a tsunami hit southern in India British, Colombia indicated that travel diarrhea was related to in 2004. The different publication has been looked at the isolation of consumption of seafood or untreated water and study patients had Plesiomonas from various animal species and also in a number of more acute illnesses compare to control patients. shellfish such as clams, oyster, shrimp, and crab. Dr. Mackay and team, they illustrated the concentration of Plesiomonas in wild and cultured

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During the 2004-2008 the pathogenicity of P. shigelloides in all age Thailand from October 2001 till October 2002, Ladaporn Bodhidata et groups were estimated in the province in 22 remote communities of al. [123] collected 236 stool specimens of children age 3 months to 5 North-western Ecuador. Institutional review board commission in the years were collected. With standard microbiology methods, 10% were University of California, Berkeley, University of Michigan, Trinity identified as Plesiomonas with susceptibility testing by disk diffusion College and the University of San Fransisco. 2,936 fecal samples were [107]. Tseng HK et al. [126] collected a total of 111 cases of isolated from all ages persons include: <1 (6%=168), 1-4 years old Plesiomonas shigelloides infection in a medical center of Northern (20%=597), 5-12 years (26% 753), >13 years (46%=1362) and 2%=56 Taiwan between the age ranges of 22 days to 72 years was collected. persons who missed their birth. In order to 775 cases and 2161 One third 39.11% were found in young persons with no differences controls, 253 (8.6%) P. shigelloides were isolated. 11.4% of case- between men and women in the high peak in the summer season with patients with diarrhea were represented by P. shigelloides. Risk Ratios 96% diarrhea, 55% fever, abdominal pain 71%. Between September (RRs) and bootstrapped (Cis) for P. shigelloides infection was 2007 and March 2008, Jean Marie et al. [112] in Dakar Senegal in an estimated at 95%. Single infection with P. shigelloides was not institution in an urban area among 176 children age 1 month to 5 years associated with diarrhea (RR 1.5, 95% CI 0.9-2.2) as a result of this who were assayed by conventional methods and PCR only 2% of investigation P. shigelloides with a single infection increase risk for a samples were found as Plesiomonas shigelloides.In a study named CDS diarrheal disease that is determined this microorganism play a minor from 13 states of health department laboratories, 28 strains of role in the pathogen. In the co-infection analysis, P. shigelloides can be Plesiomonas shigelloides were recovered from stools without any other pathogenic in the presence of another pathogen. Finally, the present infections. Consumption of uncooked shellfish, notably oysters and study showed that the P. shigelloides based on crude risk ratio is raw shrimp were the different factors associated with Plesiomonas pathogenic. Therefore the data suggested that multi pathogenic infection. Thirteen of 14 patients ate oysters from the Gulf of Mexico infection may play a role in the pathogenesis of diarrhea infection. or the Caribbean. Epidemiologic data from several studies of Plesiomonas from Southeast Asia illustrated between 5% to 15.4% of In an extensive review in Southeast China, the prevalence of P. patients who recently consumed seafood. A study by Ashish Anil Sule shigelloides infection was illustrated Chen and collaborates [120]. on Plesiomonas gastroenteritis in young healthy patients, three persons R Cooper and Geradine Brown from the Department of have been several well-documented outbreaks of diarrheal disease bacteriology in South Australia isolated a Shigella-like bacterium and associated with the microorganism in Japan, China, Cameroon [114]. drew their attention to this species [130]. Based on the observation CDS study found that foreign travel is a second major factor in they focused on this species, from March 1963 to September 1967 P. Palesiomonas gastroenteritis infection that they isolated 7 of 9 patients shigelloides was isolated from faeces of 38 patients. In 1963 and 1964 traveling to Mexico. In a study on Bacterial pathogen spectrum of one case, seven cases in 1965 and 1966 and also 23 cases in the first acute diarrheal outpatients in an urbanized rural district in Southwest nine months of 1967 occurred. In the colder month of July to October China, by Zhou Y and colleagues [57] fecal specimens of acute no cases were observed while in the hotter months of January to April diarrhea cases and relevant epidemiological information were collected most cases occurred. from 797 patients, that 198 samples (24.8%) were positive in pathogen isolation, and 223 strains were isolated [124]. The order of isolation In 1973 between 5-13 August at the Youth Activity Centre of rates from high to low was DEC, Aeromonas, P. shigelloides, Toyono in Osaka and the outbreak of diarrhea was occurred. Among Salmonella, Shigella, and Vibrio. P. shigelloides were cultured in 2141 persons, 978 cases were suffered from acute diarrhea. The main Alkaline Peptone Water (APW) and selected on Thiosulfate Citrate symptoms were 88% diarrhea, 82% abdominal pain, 22% fever, and Bile Sucrose (TCBS) agar and MacKenzie (Mac) and the rate of 13% headache. The stools were watery and with mucous. During the 12 Plesiomonas was estimated at 2.5%. and 13 August, stool specimens from 124 patients were collected for the bacteriological study. 21 samples were obtained during the acute In the CDS investigation reports Thailand, Indonesia, and Vietnam phase of diarrhea incubated in SS agar for overnight and biochemical are the most common places where the Plesiomonas isolated from characterization of their cultures reported that they were P. travelers. Consequently, by the different research about the prevalence shigelloides. On 21 October 1974, 35 employers in Moriguchi city near of Plesiomonas illnesses, it is difficult to detect which risk factors like the central area of Osaka were involved with acute diarrhea with the as social, geographic, or medical are associated with Plesiomonas clinical features of 92% diarrhea, 63% lassitude and 54% abdominal infection. Some reports determined a common risk factor linked to pain. And diarrhea occurred as a mild, watery. 24 of those patients Plesiomonas and some medical centers over a number of years have were recovered from acute diarrhea. Faecal specimens for examination been reported one or more risk factors for intestinal or extraintestinal were available in 8 patients that P. shigelloides was isolated in three Plesiomonas infection. Finally, national health investigation has been patients. In the first epidemic P. shigelloides isolated from only 16.9% determined Plesiomonas infection has a specific risk factor. In our of all specimens, if the organism is related to the etiological agent, this review of different studies of Plesiomonas shigelloides in Iran, we rate can be low in this isolation. determined that this microorganism is not a normal bacterium in clinical diagnosis and various investigation groups. And otherwise we In Hong Kong, TL Wong et al. [121] the occurrence of Plesiomonas got reports of various clinical laboratories from different cities Tehran shigelloides infection by epidemiological and clinical data. A total of and north of Iran to ask about the diagnosis test of Plesiomonas in 197 Plesiomonas shigelloides isolates were determined from 188 diarrhea patients to detect of this bacterium but they didn’t have the patients, that 167 (85 males and 82 females) samples were available for culture medium of Plesio and no information about the culture and analyzing. 35 samples (21%) had a history to travel out of Hong Kong another diagnostic testing. Because the people don’t have to travel the which 21 (12.6%) consumed seafood or uncooked food and 39 (23.4%) countries that are more involved with Plesiomonas and also they don’t had underlying medical conditions. 165 (98.8%) had symptoms of consume seafood as much as other countries, so they don’t focus on Plesiomonas shigelloides infection. 9 (5.4%) had chronic diarrhea, this bacterium in diarrhea patients. So we found only 2 studies abut watery and bloody diarrhea was discharged by 122 (73.1%) and 42 Plesiomonas infection in Iran, one about fish infection and one clinical (25%) of patients. In a case-control study of diarrheal disease in

Page 6 of 10 reports. The study done by Morteza Sattari and his colleagues [116] for in the freshwater reservoir. As we described in our results in a national the characterization of Plesiomonas shigelloides and Aeromonas from epidemiologic study of 13 states of health department laboratories, 28 raised fish, they collected 78 samples from 8 fish raised polls and Plesiomonas strains were recovered from stools and without any other studied hemolytic, enterotoxin production, motility and antibiotic infection that was associated with consumption of uncooked shellfish, resistance [98]. Furthermore, they isolated 5.19% Plesiomonas oyster and raw shrimp. In addition to seafood consumption, foreign shigelloides, 15.38% Aeromonas hydrophila and other bacteria with travel is a second risk factor of Plesiomonas gastroenteritis infection 50% and 62.3% enterotoxin positive for Plesiomonas and Aeromonas [151-153]. It is also pointed out that the most common destination of respectively. They indicated that Plesiomonas and Aeromonas are able travelers infected by Plesiomonas was reported, Mexico, Kansai to produce a variety of potential virulence markers which may be Airport, Thailand, Indonesia, and Vietnam. In previous studies by Shah involved in pathogenicity. In a study done by Mohammad Hossein N and colleagues, [94] the highest frequency of Plesiomonas cases were Salari and Fatemeh Hakimian [101] on entero pathogen bacteria found from South and Southeast Asia and the lowest were related to samples from under 5 years old children that were associated with Latin America and the Caribbean. Another risk factor of Plesiomonas diarrhea, detected only one Plesiomonas shigelloides infection case diarrhea is the consumption of untreated water in low socioeconomic among 558 diarrhea samples. Based upon our study Plesiomonas or poor condition regions that are linked to tropical and subtropical shigelloides received little attention from Iran and they have few climate and temperature in lakes and rivers [28,29,35]. In many cases reports of infection of this bacterium and otherwise, in reports of of Plesiomonas are observed in patients who are suffering from one or various clinical laboratories in Iran, it is recognized that they don’t more underlying medical illnesses like as immune-compromised or have normal test and medium in the laboratory for Plesiomonas secondary medical sequelae include cancer, cirrhosis, HIV, blood- detection. borne dyscrasias (sickle cell anemia and thalassemia) [4,34,38,108,109,110,111,112]. In several cases reported that transmit Discussion ion of Plesio infection can occur from mother to child during the birth process [154-159]. Based on different authors studies, travelers' diarrhea is the most frequent health problem in people who travels to various geographical In summary, our study presented that Plesiomonas shigelloides is as environments with the different sanitary condition, which estimated one of the pathogens that can be recognized as a more common case in between 13% to 60% [130-134]. Diarrhea in travelers can be occurred patients who are infected with diarrhea. It is indicated that by watery stools with or without other symptoms, or as unformed Plesiomonas diarrhea in most studies and clinical case reports is stools by abdominal pain, tenesmus, vomiting, nausea, fever, and related to consumption of seafood or untreated water by people who prostration. Wide range of infectious organisms include EAEC, ETEC, travel to tropical or subtropical geographical locals. Our findings Shigella spp., Campylobacter spp., Vibrio spp., Aeromonas spp., demonstrated acute clinical diarrhea of Plesiomonas with abdominal Salmonella spp., and Plesiomonas spp., are discussed as bacteria caused pain is more often and has a long duration of disease infected by other traveler diarrhea [135-137]. Recently several surveys indicated that enteric pathogens. And finally in the study of Iran case report and various aspects of the biology of Plesiomonas shigelloides as a member collecting information of various clinical and environmental of the Enterobacteriaceae family received limited attention from laboratories we found only two Plesiomonas research in this country scientific and medical information [138-140]. This bacterium is as a that it implicates that this bacterium is an organism with little potential enteric pathogen of humans and various extraintestinal attention from different research groups or in diagnosis clinical infections and has demonstrated that the organism can show laboratories in Iran [160-163]. symptoms of infection with other enteric pathogens [141-143]. A study done by Geizer and Arai, [119] it was estimated the rate carrier of Conclusion Plesiomonas in a healthy individual between 0.0078% and 0.26%, but it The various data of case-control research and outbreak disease might change depends on geographic local and population [140]. supported that Plesiomonas shigelloides is a potential enteropathogen. Escobar [102] in Ecuador documented the prevalence rate of single Our knowledge of biology and epidemiology of P. shigelloides over the infection by Plesiomonas in range of 11.4% to <5% that was less than past 2 decades regarded that sanitary condition, dietary choices and the community rang [141,142]. Some other authors mentioned that environmental factors may play an important role in the global this microorganism is associated with other enteric pathogens. In pathogenicity of this microorganism. However the study of association with the epidemic of diarrhea illness, Plesiomonas Plesiomonas and knowledge about this bacterium is increasing every shigelloides rating increased and the bacterium isolation rate varied day but still, some question includes the relationship between this from 0.2% to 15% in symptomatic patients [144]. The study by Kevin C pathogen bacterium and geographic location and also an association of [45] on clinical features, epidemiology and treatment of Plesiomonas Plesiomonas with other enteric pathogens are resolved and need more in 1986, suggested that the bacteria are a traveler’s diarrhea and the fully investigated. author indicated that the organism causes secretory most common and invasive diarrhea as less commonly [143]. They found that 76% of patients infected by Plesiomonas showed symptoms for more than 2 References weeks and 32% more than 4 weeks. It showed that the duration of 1. Abbott SL, Kokka, RP, Janda JM (1991) Laboratory investigations on the symptoms in patients infected by other organism is lower (<0.05). low pathogenic potential of Plesiomonas shigelloides. J Clin Microbiol 29: Generally, diarrhea in patients infected by Plesiomonas is an 148-153. association with acute illness with abdominal pain and colitis. And the 2. Ahmad M, Aggarwal M, Ahmed A (1998) Bloody diarrhea caused by organism can have effected in all ages group in both males and females. Plesiomonas shigelloides proctitis in a human immunodeficiency virus- Otherwise is affiliated with consumption of seafood and untreated infected patient. Clin Infect Dis 27: 657. water [145-150]. Most data mentioned that in the warmer tropical and subtropical regions of the world, higher numbers of Plesiomonas exist

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