LETTERS in Lanzhou, China (8). Variation may Xiaoyan Li, Jinying Chen, 9. Allander T, Tammi MT, Eriksson M, be due to different geographic and Mei Kong, Xu Su, Ming Zou, Bjerkner A, Tiveljung-Lindell A, Ander- sson B. Cloning of a human parvovirus age distributions of the virus. Anoth- Hua Zhang, and Yumin Han by molecular screening of respiratory er study reported that frequencies of Author affi liations: Tianjin Centers for tract samples. Proc Natl Acad Sci U S A. WUPyV in URTIs (6.7%) and LRTIs Disease Control and Prevention, Tianjin, 2005;102:12891–6. DOI: 10.1073/pnas. 0504666102 cases (7.1%) were comparable (10). People’s Republic of China (X. Li, M. Kong, 10. Norja P, Ubillos I, Templeton K, Sim- However, we found the incidence X. Su, M. Zou); Tianjin Medical University, monds P. No evidence for an association of WUPyV in patients with LRTIs Tianjin (X. Li, J. Chen); Tianjin Children’s between infections with WU and KI poly- (16.1%) was higher than in patients Hospital, Tianjin (H. Zhang); and Tianjin Xi- omaviruses and respiratory disease. J Clin Virol. 2007;40:307–11. DOI: 10.1016/j. with URTIs (4.4%). Among WUPyV- anshuigu Hospital, Tianjin (Y. Han) jcv.2007.09.008 infected patients with LRTIs, 71.4% were <1 year of age, which was com- References Address for correspondence: Xiaoyan Li, Tianjin parable to populations investigated in Centers for Disease Control and Prevention, other studies (2,3,6). Although ≈60% 1. Gaynor AM, Nissen MD, Whiley DM, Mackay IM, Lambert SB, Wu G, et al. Institute of Microbiology, No. 76 Hualong of outpatients with URTIs were >5 Identifi cation of a novel polyomavirus St, Hedong District, Tianjin 300011, People’s years of age, none was WUPyV posi- from patients with acute respiratory tract Republic of China; email: xiaoyanli1291@163. infections. PLoS Pathog. 2007;3:e64. tive. This fi nding suggests WUPyV com may play a major role in young chil- DOI: 10.1371/journal.ppat.0030064 2. Le BM, Demertzis LM, Wu G, Tibbets RJ, dren, especially infants, with LRTIs. Buller R, Arens MQ, et al. Clinical and Most WUPyV infection has been epidemiologic characterization of WU detected during later winter and early polyomavirus infection, St. Louis, Mis- spring (2,4,5) although other research souri. Emerg Infect Dis. 2007;13:1936–8. 3. Wattier RL, Vázquez M, Weibel C, Sha- showed no seasonal distribution (6). piro ED, Ferguson D, Landry ML, et al. We found 2 peaks, in April and De- Role of human polyomaviruses in respi- Intestinal cember 2008 (L. Xiaoyan et al., unpub. ratory tract disease in young children. , data). We also detected 1 WUPyV-in- Emerg Infect Dis. 2008;14:1766–8. DOI: 10.3201/eid1411.080394 Western Mindanao, fected case in September 2008, which 4. Neske F, Blessing K, Ullrich F, Pröttel A, suggests WUPyV could also occur in Wolfgang Kreth H, Weissbrich B. WU the Philippines summer months. polyomavirus infection in children, Ger- To the Editor: Capillariasis is Frequency of WUPyV co-infec- many. Emerg Infect Dis. 2008;14:680–1. DOI: 10.3201/eid1404.071325 caused by the foodborne tion with other pathogens varied from 5. Bialasiewicz S, Whiley DM, Lambert Capillaria philippinensis. Infection 42.1% to 79.7% (4–6). Although we SB, Jacob K, Bletchly C, Wang D, et al. causes severe and protein loss showed a co-infection rate of 71.4%, Presence of the newly discovered human resulting in dehydration, cachexia, there were 8 (28.6%) of 28 patients polyomaviruses KI and WU in Australian patients with acute respiratory tract infec- and eventually death. Infected patients with respiratory illness in whose tion. J Clin Virol. 2008;41:63–8. DOI: may also have borborygmi, abdominal specimens we detected only 1 virus, 10.1016/j.jcv.2007.11.001 pain, weight loss, anorexia, vomiting, WUPyV. No WUPyV was detected 6. Payungporn S, Chieochansin T, Thongmee and bipedal (1). in samples from 43 control patients, C, Samransamruajkit R, Theamboolers A, Poovorawan Y. Prevalence and molecu- C. philippinensis was fi rst report- whereas in patients with LRTIs and lar characterization of WU/KI polyoma- ed in 1963 in Bacarra, Ilocos Norte URTIs, infection rates were 16.1% viruses isolated from pediatric patients Province in the northern Philippines and 4.4%, respectively. These fi nd- with respiratory disease in Thailand. Virus (2). Since then, additional endemic ings suggest WUPyV may be a po- Res. 2008;135:230–6. DOI: 10.1016/j. virusres.2008.03.018 foci of C. philippinensis have been tential pathogenic agent in children 7. Dalianis T, Ramqvist T, Andreasson K, identifi ed. The most recent focus is in with acute respiratory tract infections. Kean JM, Garcea RLKI. WU and Merkel Monkayo, Compostela Valley, in the More comprehensive case–control in- cell polyomaviruses: a new era for hu- southern Philippines (3). In the past vestigations are needed to determine man polyomavirus research. Semin Can- cer Biol. 2009;19:270–5. DOI: 10.1016/j. several years, suspected unconfi rmed the association of WUPyV infections semcancer.2009.04.001 cases have been reported from Zam- with respiratory diseases. 8. Yuan XH, Jin Y, Xie ZP, Gao HC, Xu ZQ, Zheng LS, et al. Prevalence of human KI boanga del Norte Province in western and WU polyomaviruses in children with Mindanao. In 1999, an epidemic of This work was supported by Tianjin acute respiratory tract infection in China. gastroenteritis in Piñan Municipality Municipal Science and Technology Com- J Clin Microbiol. 2008;46:3522–5. DOI: was reported; it resulted in 42 deaths. 10.1128/JCM.01301-08 mission (grant no. 07SYSYSF05100). The team of the De-

736 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 4, April 2010 LETTERS partment of Health Regional Offi ce A total of 24 persons in Katipu- holds have water connections (level conducted stool examinations and sus- nan were interviewed regarding his- III). Fifty-seven percent of households pected the presence of Capillaria ova tory of capillariasis and their eating have access to communal faucets in symptomatic patients (4). In No- habits. Fourteen residents reported (level II), and 31% have access only vember 2007, several deaths caused having eaten kinilaw (raw freshwater to rivers or springs (9). Therefore, in- by chronic diarrhea were reported in fi sh soaked in vinegar and garnished creased access to toilets and safe water Siayan Municipality. These deaths with salt, ginger, and lime). Seven of is needed. Local ordinances concern- were attributed to capillariasis, but the persons interviewed had a diagno- ing ownership and use of toilets must their cause was never confi rmed (5). sis of capillariasis, and 6 had >1 rela- be strictly enforced, and evaluation In February 2008, we obtained tive with a diagnosis of capillariasis. and rehabilitation of existing toilet and 205 stool specimens from residents of All of the previously diagnosed case- water systems must be conducted. Katipunan who had a history of diar- patients were treated with In spite of efforts concerning in- rhea of >2 weeks duration and abdom- (400 mg tablets). Most patients were formation, education, and communi- inal disturbance. These samples were instructed to take 1 tablet 1×/day for cation on capillariasis, many residents processed by using the formalin–ether 20 days; others were instructed to take continue to eat raw or poorly cooked concentration technique (6) and ex- 1 tablet 2×/day for 5 or 10 days. freshwater fi sh. Concurrent infection amined by expert microscopists. One The drug of choice for treating among household members, includ- hundred fi fty-one (73.3%) persons patients with capillariasis is mebenda- ing those in younger age groups, was were infected with >1 organism; 67 zole, 200 mg 2×/day for 20–30 days. observed in this study. These fi ndings (32.5%) had 1 parasitic infection and An alternative treatment is albenda- result from the fact that consumption 84 (40.8%) had multiple parasitic in- zole, 400 mg 1×/day for 10 days (7,8). of kinilaw has become widely accept- fections. Ninety-one (44.2%) persons Variations in the treatment regimen ed and is consumed as a viand (choice had >1 soil-transmitted helminth in- used for patients with capillariasis at food) by families. Thus, information, fection, and 93 (45.2%) had >1 pro- the study site suggest a need to train education, and communication cam- tozoan infection. Ten (4.9%) persons health professionals on the diagnosis, paigns must be intensifi ed. A promis- were confi rmed to have Capillaria treatment, and follow-up of cases, and ing approach is through collaboration infections. The distribution of organ- on disease prevention and control. with other agencies. For example, the isms observed is shown in the Table. Guidelines on proper laboratory tech- Department of Education in the Philip- Among the 10 persons who had niques for diagnosis of capillariasis; pines may become involved in dissem- capillariasis, 8 were from Baran- treatment protocols and supportive ination of information on capillariasis gay (smallest adminstrative region) measures; and protocols for detection, to students and in early detection and Matam, 1 from Barangay Dabiak, and follow-up, and treatment for relapse treatment of infected school children. 1 from Barangay Carupay, a nearby cases must be developed. barangay. Six cases were in male pa- Rates of infection with protozoans Acknowledgments tients and 4 were in female patients. and soil-transmitted helminths at the We thank the National Center for Dis- Ages of infected persons ranged from 5 study site are high, which indicate fe- ease Prevention and Control, the National to 54 years (mean 29.2 years, SD 17.1 cal contamination of food and water. A Epidemiological Center, and the Center years). Three of the reported case-pa- review of records from the Katipunan for Health Development for Western Min- tients (a 5-year-old boy, an 8-year old rural health unit indicated that 76% of danao of the Department of Health, the boy, and a 48-year-old woman) were households in this municipality have local government units of the province of from the same household. access to toilets. Only 11% of house- Zamboanga del Norte, and the municipal- ity of Katipunan for technical assistance Table. Parasites detected in Katipunan, Zamboanga del Norte, the Philippines, and logistics support; Johnson and John- February 2008* Parasite No. (%) son Philippines, Inc., for providing partial 64 (31.1) support for conducting fi eld work; and Entamoeba coli 49 (23.8) Joanne Ramirez and Edward Castelo for 46 (22.3) assistance with the fi eld work. Endolimax nana 14 (19.9) 34 (16.5) Vicente Y. Belizario Jr, Blastocystis hominis 21 (10.2) Francis Isidore G. Totañes, Giardia lamblia 19 (0.2) Winifreda U. de Leon, Entamoeba histolytica 14 (6.8) Julius R. Migriño Jr, Capillaria philippinensis 10 (4.9) *A total of 205 parasites were detected by using the formalin–ether concentration technique. and Lino Y. Macasaet

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 4, April 2010 737 LETTERS

Author affi liations: University of the Philip- Buruli Ulcer 738-Techapp.pdf). At the start of treat- pines–National Institutes of Health, Manila, ment, the patient had a large ulcer on the Philippines (V.Y. Belizario Jr, F.I.G. To- Lesions in HIV- the right leg and thigh, a nodule 2 tañes, J.R. Migriño Jr); University of the Positive Patient cm in diameter on the left thigh, and Philippines College of Public Health, Ma- a plaque 8 cm in diameter on the left nila (W.U. de Leon); and National Center To the Editor: Mycobacterium thigh. After 2 weeks of treatment, the for Disease Prevention and Control, Manila ulcerans disease (Buruli ulcer) is a size of the large ulcer had increased. (L.Y. Macasaet) neglected and emerging tropical dis- After 4 weeks, the nodule became an ease (1). It often leads to extensive ulcer 6 cm in diameter, and the plaque DOI: 10.3201/eid1604.080483 destruction of skin and soft tissue with became a large ulcer 15 cm in diameter the formation of large ulcers (2). In with a satellite ulcer 2 cm in diameter. References 2004, the World Health Organization After 8 weeks, we observed enlarge- 1. Cross J, Belizario VY Jr. Capillariasis. In: (WHO) recommended the combina- ment of all lesions and the appearance Murrel KD, Fried B, editors. Food-borne tion treatment of rifampin/streptomy- of an ulcer on the left wrist. Treatment parasitic zoonoses, fi sh and plant-borne cin for patients with this disease (3). was continued for an additional 4 parasites. Vol. 11. In: Black S, Seed RJ, According to WHO, development of editors. World class parasites. New York: weeks (total 12 weeks). Radiologic in- Springer Science and Business Media, new antimicrobial drug treatment is vestigation did not disclose any bone LLC; 2007. p. 209–32. one of the major advances since the destruction. 2. Chitwood MB, Velasquez C, Salazar NG. establishment of the Global Buruli The patient was positive for HIV Capillaria philippinensis (Nematoda: Ulcer Initiative (1). Treatment with Trichinellida) from intestine of man in the by the Determine HIV-1/2 test (Ab- Philippines. J Parasitol. 1968;54:368–71. rifampin/streptomycin for >4 weeks bott Laboratories, Dainabot Co. Ltd., DOI: 10.2307/3276953 can inhibit the growth of M. ulcerans Tokyo, Japan), the Uni-Gold HIV 3. Belizario VY Jr, de Leon WU, Esparar in preulcerative lesions (4). In other test (Trinity Biotech PLC, Bray, Ire- DG, Galang JM, Fantone J, Verdadero C. patients, despite 4 weeks of treatment, Compostela Valley: a new endemic focus land), and the Genie II HIV-1/HIV-2 for Capillariasis philippinensis. South- lesions may deteriorate. Whether this test (Bio-Rad, Marnes-la-Coquette, east Asian J Trop Med Public Health. treatment is less effi cacious in persons France). Results of PCR for M. ulcer- 2000;31:478–81. with HIV infection is unknown. ans and Ziehl-Neelsen staining were 4. Icao C. Capillariasis report. Interagency In August 2008, a 35-year-old Conference on Capillariasis in Zamboan- positive for all specimens obtained ga del Norte. 2008 Feb 21. Dipolog City man was referred to the Medical Cen- during the 8 weeks of initial treat- (the Philippines): Zamboanga del Norte tre of the Democratic Republic of ment. The patient died 2 weeks after Provincial Health Offi ce; 2008. Congo for assessment of chronic ul- treatment ended, just when antiretro- 5. Alipala J. Philippine Daily Inquirer. 70 cers. Lesions had appeared 12 months dead in parasite infection; whole Zambo viral treatment had been scheduled to village affl icted [cited 2008 Feb 27]. earlier when the patient was living in begin. http://services.inquirer.net/print/print. Kafufu/Luremo, a new focus of Buruli Although the patient did not re- php?article_id=103456 ulcer in Angola (5). Tissue specimens spond clinically to treatment with 6. World Health Organization. Training man- were subjected to Ziehl-Neelsen stain- ual on the diagnosis of intestinal parasites; rifampin/streptomycin, whether the 2004. Geneva: The Organization [cited ing, culture, and PCR. All results were treatment also failed microbiological- 2008 Mar 7]. http://www.who.int/worm- positive for M. ulcerans. Histopatho- ly is more diffi cult to prove. Results of control/documents/benchaids/en/training- logic analysis of formalin-fi xed tissue PCRs performed during treatment re- manual_sip98–2.pdf confi rmed the diagnosis of active Bu- 7. Abramowicz M. Drugs for parasitic infec- mained positive. However, PCR does tions. The Medical Letter. 2004;46:e1– ruli ulcer. We treated the patient with not differentiate between living and e12. a combination of rifampin (10 mg/kg/ dead M. ulcerans bacteria. Therefore, 8. World Health Organization. WHO model day, orally) and streptomycin (15 mg/ our positive results suggest, but do not prescribing information: drugs used in kg/day, by intramuscular injection). parasitic diseases, 2nd ed. Geneva: The prove, treatment failure. The positive Organization; 1995. Wound dressings containing an aque- culture after 2 weeks of treatment also 9. Katipunan Rural Health Unit. Annual re- ous solution of chloramine/metron- suggests treatment failure but cultures port for 2007. Katipunan, Zamboanga del idazole/nitrofurantoine were changed obtained at 4 and 8 weeks were con- Norte (the Philippines): The Unit; 2007. daily (6). For logistic reasons, surgery taminated. However, culturing M. ul- (large excision) under general anes- Address for correspondence: Vicente Y. cerans bacteria is diffi cult, especially thesia was not possible. if samples must be transported (7). Belizario Jr, University of the Philippines– Characteristics of the patient are National Institutes of Health, Pedro Gil St, Patients with Buruli ulcer may shown in the online Technical Appen- also be infected with HIV. In a study Ermita 1000 Manila, the Philippines; email: dix (www.cdc.gov/EID/content/16/4/ [email protected] conducted during January 2002–Au-

738 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 4, April 2010