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Molecular Characterisation of Airport Malaria: Four Cases in France During Summer 1999

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Molecular Characterisation of Airport Malaria: Four Cases in France During Summer 1999 Article available at http://www.parasite-journal.org or http://dx.doi.org/10.1051/parasite/2002092187 MOLECULAR CHARACTERISATION OF AIRPORT MALARIA: FOUR CASES IN FRANCE DURING SUMMER 1999 JAFARI S.*, DURAND R.*, LUSINA D.** & LE BRAS J.* Summary: Résumé : CARACTÉRISATION MOLÉCULAIRE DE QUATRE CAS DE Four airport malaria cases have been observed in the vicinity of PALUDISME D'AÉROPORT OBTENUS EN FRANCE AU COURS DE L'ÉTÉ 1999 the Roissy-Char!es-de-Gaulle International Airport, Paris, France. Quatre cas de paludisme d'aéroport ont été observés au voisinage These cases were geographically very close to each other and de l'aéroport Roissy-Charles de Gaulle de Paris. Ces cas, clustered in a short period of time during the summer of 1999. regroupés sur une courte période de l'été 1999, étaient The phenotype and genotype of the Plasmodium falciparum géographiquement très proches. Le phénotype et le génotype des isolates obtained from these patients were determined in order to isolats de Plasmodium falciparum de ces patients ont été déterminés know whether a single mosquito could have infected more than dans le but de savoir si un seul moustique a pu infecter plus d'un one subject. The genomic characterisation of isolates was sujet. Le génotypage des isolats a été effectué au moyen de l'étude performed using the polymorphic markers merozoite surface des marqueurs polymorphes merozoite surface protein 1 (Msp 1 ) et protein 1 (Mspl) and merozoite surface protein2 (Msp2) genes, merozoite surface protein 2 (Msp2), des répétitions K et ɷ du gène the K and ɷ repeats domains of cg2 and the dihydrofolate cg2, et du génotype de la dihydrofolate réductase (DHFR). Les reductase (DHFR) genotypes. Results showed identical genotypes résultats ont montré un profil moléculaire identique pour les isolats for isolates 1, 2 and 4 whereas the genotype of isolate 3 differed 1, 2 et 4 et un génotpye différent pour l'isolat 3 à un locus. at one locus. The molecular analysis was consistent with the L'analyse moléculaire est en accord avec l'hypothèse d'une hypothesis that all patients could have been bitten by the same contamination par le même moustique des cas 1, 2, 3 et 4. mosquito and that patient 3, may have received a different clone Cependant, le cas 3 pourrait avoir reçu un clone différent et une and an additional species. In vitro susceptibility data did not espèce associée. L'étude de la sensibilité in vitro n'a pu infirmer ni confirm or rule out this hypothesis because isolates had the same confirmer cette hypothèse dans la mesure où les isolats ont présenté profile of susceptibility to the tested drugs. le même profil de sensibilité aux antipaludiques testés. KEY WORDS : airport malaria, Plasmodium falciparum, Plasmodium malariae, MOTS CLÉS : paludisme d'aéroport, Plasmodium falciparum, Plasmodium genotyping, in vitro susceptibility. malariae, génotypage, sensibilité in vitro. INTRODUCTION falciparum. The man died and the woman recovered spontaneously. Since then, 73 other cases of airport malaria have been reported in Western Europe, 28 of irport malaria is acquired through the bite of which occurred in France (Lusina et al, 2000). A an infective Anopheles mosquito transported review of the history of the cases shows that airport Aby aeroplanes from endemic areas (Giacomini, malaria mostly occurred simultaneously in more than 1998; Guillet et al., 1998). The first two cases were one individual in the same area (Isaacson, 1989). In retrospectively reported in a French illegitimate couple many cases, the members of the same family living in in 1969 (Doby & Guiguen, 1981). The man and the close proximity to an international airport were woman lived in the same street near the Bourget air­ involved as were personnel working on airstrips or in port. They had no compatible travel history; they did air terminals (Bouvier et al., 1990; Majori et al, 1990; not receive a recent blood transfusion and did not take Giacomini et al, 1997 ; Van Den Ende et al, 1998).The intravenous drugs. Both were infected by Plasmodium hypothesis of one mosquito biting more than one person has already been suggested in a previous * Centre National de Référence pour la Chimiosensibilité du Palu­ review (Isaacson, 1989). A phenotypic and a limited disme, Assistance Publique-Hôpitaux de Paris. Laboratoire de Para­ molecular study of P. falciparum isolates was also sitologic Hôpital Bichat-Claude Bernard, 46, Rue Henri Huchard. consistent with this hypothesis for two cases observed 75877 Paris cedex 18, France. ** Laboratoire de Biologie Médicale, Centre Hospitalier Robert Bal­ in 1994 (Eldin de Pécoulas et al, 1996). Evidence that langer, 93602 Aulnay-sous-Bois, France. a same mosquito may lead to several airport malaria Correspondence: S. Jafari, Laboratoire de Parasitologic Hôpital cases could have practical implications in terms of alert Bichat-Claude Bernard. 46. Rue Henri Huchard. 75877 Paris cedex 18, procedures and management of the relatives or col­ France. Tel.: +33 (0)1 40 25 78 97 - Fax: +33 (0)1 40 25 67 63. E-mail: [email protected] leagues of a patient. 187 Four recent airport malaria cases have been observed Msp1 and msp2 PCR products were then sequenced in the vicinity of the Roissy-Charles de Gaulle Inter­ using an ABI PRISM® 310 Genetic Analyser and an ABI national Airport, Paris, France (Lusina et al, 2000). PRISM® Big Dye Terminator Cycle sequencing KitR These cases were geographically very close to each (Perkin-Elmer Cetus). The genomic characterisation of other and clustered in a short period of time during isolates was completed by the study of the cg2 and the summer of 1999. The phenotype and genotype the dihydrofolate reductase (DHFR) genotypes. The K of the P. falciparum isolates obtained from these and ɷ repeats domains of cg2 were amplified as pre­ patients were determined in order to know whether viously described (Durand et al, 1999). Size poly­ a single mosquito could have infected more than one morphisms of PCR products were resolved on a 2.5 % subject. agarose gel stained with ethidium bromide. The deter­ mination of the nature of DHFR codon 108 was per­ formed by PCR followed by restriction fragment length polymorphism (PCR-RFLP) (Eldin de Pécoulas et al, MATERIALS AND METHODS 1995). The in vitro susceptibility to chloroquine, qui­ nine and halofantrine of isolates was determined on enous blood samples were collected in EDTA patient parasitized red blood cells within three days of Vacutainer® tubes (Becton Dickinson, USA) and sampling using the semi-microtest method (Le Bras & Vmaintained at 4° C. The microscopic observa­ Deloron, 1983). The 50 % inhibitory concentration tion of thin blood smears showed that all patients were (IC50) of tritiated hypoxanthine uptake was calculated infected with P. falciparum ; one case (patient 3) pre­ by non-linear regression analysis. The in vitro sus­ sented another malaria episode due to P. malariae ceptibility to chloroquine was defined as IC50 < 80 nM. 33 days after the initial P. falciparum infection. Threshold values for susceptibility to quinine and halo­ Patient 1, a 30-year old man, was admitted to hospital fantrine were defined respectively as IC50 < 800 nM and on 27 July 1999. He had developed fever with cough IC50 < 6 nM. and diarrhoea from 20 July. Blood smears showed 33.500 parasitized red blood cells/µl (parasitemia of 0.8 %). Patient 1 recovered rapidly after quinine IV treatment. Patient 2, a 29-year old woman, was RESULTS admitted on 5 August, having suffered from a fever for six clays. Blood smears showed 209.000 parasitized red T he data obtained for isolates 1, 2 and 3 reflected blood cells/pl (parasitemia of 5.5 %). Patient 2 received in vitro resistance to chloroquine and suscepti- quinine IV and recovered. Patient 3, a 43-year old man, bility to quinine and halofantrine (Table I). The was hospitalised on 11 August, having suffered from semi-microtest was a failure for the fourth isolate due a fever for a week. Blood smears showed 86.000 para­ to the delayed shipment of the sample. sitized red blood cells/µl (parasitemia of 2 %). The out­ Msp1 and msp2 PCR products showed an identical pro­ come was favourable under quinine IV treatment for file on the agarose gel in all the cases. All isolates were all the four patients. Patient 3 developed a new malaria polyclonal as two bands were observed (one of the episode which was clue to P. malariae as mentioned bands appeared with a higher intensity) on the msp1 before. Patient 4, a 25-year old woman, consulted a and msp2 profiles. Results of DNA sequencing sum­ physician on 30 July for digestive problems with fever. marized in the Table I showed identity in block 2 A viral infection was misdiagnosed and patient 4 was repeat region of msp1 gene which belonged to the K1 hospitalised on 28 August for fever and vomiting. A allelic family for all the four isolates while the poly­ pancytopenia was observed, blood smears showed a morphic central domain of msp2 gene showed iden­ parasitemia of 5 %. Patient 4 received quinine IV and tity in isolates 1, 2 and 4 which belonged to the recovered. The clinical presentation and epidemiolo­ 3D7/CAMP allelic family with seven repeats of the gical aspects of these cases have been reported in hexanucleotide GGTGCT in block 2 (Smythe et al., details elsewhere (Lusina et al, 2000). 1993). The polymorphic central domain of msp2 in iso­ Genomic DNA extraction was performed as previously late 3 was a subtype of the 3D7/CAMP allelic family described (Durand et al., 1997). The amplifications of with eight repeats of the hexanucleotide GGTGCT in block 2 of merozoite surface protein 1 (Msp1) and block 2.
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