Babesiosis in Wisconsin: a potentially fatal disease

Babesiosis is emerging as an important tick-borne zoonosis in the United States. Most reported cases of this parasitic disease have been acquired in the Northeast. To date, only two clinical cases of Babesia microti infection acquired in the upper Midwest have been described. We report eight more cases. Most if not all of the 10 total cases probably were acquired in northwestern Wisconsin. Three cases (30% of 10) we now report were fatal and occurred in elderly patients (65-75 years old) who died after complicated hospital courses. One patient probably had had a latent Babesia infection that activated because of immunosuppression attributable to high-dose corticosteroid therapy and to splenic infarctions caused by cholesterol emboli. All three fatal cases were diagnosed incidentally and highlight the importance of considering the diagnosis of babesiosis in febrile patients who have been in babesiosis-endemic areas; examining their blood smears carefully; and treating promptly with clindamycin and quinine, and, if indicated, exchange transfusion. Medical personnel should be knowledgeable about this zoonosis, which is not limited to the northeastern United States, and is potentially serious, sometimes fatal.

Onchocerca volvulus: parasitologic and serologic responses in experimentally infected chimpanzees and mangabey monkeys

Six chimpanzees (Pan troglodytes) and six mangabey monkeys (Cercocebus atys) were inoculated with Onchocerca volvulus third-stage larvae (L3) of West African origin. Two chimpanzees each received 200, 300, or 400 L3, while three mangabeys each received either 50 or 250 L3. All six chimpanzees became microfilaria positive between 11 and 25 months postinoculation (PI), while two of the six mangabeys were skin-snip positive at 24 and 37 months PI, respectively. All chimpanzees developed antibodies to two native antigens of 14 and 22 kDa and to the recombinant antigens OV16, OC3.6, and OC9.3. Marked antibody responses were observed in the mangabey monkeys, and in general, the responses were similar to those observed in the chimpanzees. However, in the mangabeys, these responses did not generally manifest themselves until later in the infection. The results of this study suggest that in chimpanzees, the smallest inoculum used, 200 L3, was sufficient to initiate consistent infections that had parasitologic and immunologic parameters equivalent to animals inoculated with larger numbers of larvae. Similarly, inoculation of mangabey monkeys with small numbers of larvae appeared to be as likely to establish infection and induce immunologic responses as did inoculation of larger numbers of larvae. Microfilaria-positive chimpanzees and mangabey monkeys were examined by three conventional imaging techniques (X ray, ultrasound, and magnetic resonance imaging (MRI)), but no adult worms or nodules could be identified in any animal.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical, parasitologic, and immunologic observations of patients with hydrocele and elephantiasis in an area with endemic lymphatic filariasis

Hydrocele and elephantiasis, major clinical manifestations of bancroftian filariasis, are thought to share a common pathogenesis. The characteristics of 121 patients with hydrocele or elephantiasis in Leogane, Haiti, were compared: 39% of 57 men with hydrocele and 3% of 64 persons with lymphedema of the leg were microfilaria-positive (P < .001). Circulating filarial antigen, presumably from the adult worm, was detected in 15 (43%) microfilaria-negative men with hydrocele and 9 (15%) microfilaria-negative persons with leg edema (P = .004). Microfilaria-positive men had lower levels of filaria-specific IgG1 and hydroceles of significantly smaller volume and shorter duration than did microfilaria-negative men; hydrocele volume was inversely associated with microfilarial density (P = .001). In contrast, filarial antigen but not microfilariae was associated with filaria-specific IgG4 and decreased lymphocyte proliferation. Antigen status was not associated with severity of leg edema. In this filariasis-endemic area, men with hydrocele are more immunologically and parasitologically heterogeneous than are persons with elephantiasis.

Periorbital dirofilariasis

A differential diagnosis of inflammatory periocular soft tissue masses includes sarcoidosis, ruptured dermoid cyst, infectious abscess, metastatic neoplastic disease, and idiopathic pseudotumor. The authors present the case of a 42-year-old woman with a periocular inflammatory mass caused by dirofilaria of a nematode classification as Dirofilaria tenuis. The extraction of the worm was curative and the patient has been symptom-free for the ensuing 12 months. This zoonotic infection, spread by mosquito vectors from animal hosts to humans, is rarely encountered in the United States as a cause of periorbital inflammation. A history of migratory swelling and residence in, or travel to, endemic areas (the southeastern United States) should suggest the possibility of Dirofilaria infection.

Dirofilariasis in Kuwait: first report of human infection due to Dirofilaria repens in the Arabian Gulf

Zoonotic dirofilariasis has been reported sporadically from many areas of the world but thus far, there are no such reports from the Arabian Peninsula. We present the first report of human dirofilariasis from this region in the Middle East and discuss the significance of the finding. A fixed, elongated mass in the abdominal wall of a 50-year-old Kuwaiti man was excised and a worm was identified in an abscess in tissue sections. The location of the nodule in subcutaneous tissue, the diameter of the worm in section, the multilayered cuticle with fine longitudinal ridges on the external layer, prominent internal cuticular ridges, and abundant somatic muscles suggested the diagnosis of the worm as Dirofilaria (Nochetiella) repens, a natural parasite of dogs and cats in Asia, Africa, and Europe.

Age-specific prevalence of antigenemia in a Wuchereria bancrofti-exposed population

Antigen detection assays serve as a useful adjunct to blood examinations for studies of filariasis, in terms of the diagnostic and epidemiologic information provided. We examined the utility of the Og4C3 antigen detection enzyme-linked immunosorbent assay for field studies and analyzed the distribution of Wuchereria bancrofti antigenemia in a Haitian population. Using serum samples collected following venipuncture, antigenemia levels were correlated with microfilaremia (P < 0.001). The microfilariae had a pronounced nocturnal periodicity while the sensitivity of the antigen assay was the same whether serum samples were collected during the day or at night. To determine whether the Og4C3 assay could be used in conjunction with fingerprick blood examinations, nocturnal blood surveys were conducted. Of 419 persons surveyed, 207 (49.4%) were antigen-positive with the Og4C3 assay. Serum specimens from all 121 microfilaremic individuals were antigen positive (100% sensitivity). The age prevalence of antigenemia increased from 24.5% for 1-5-year-old children to 70% for persons greater than 50 years of age. These results demonstrate that the Og4C3 assay is a sensitive tool for the detection of infection and raise questions about the expression of protective immunity in populations exposed to infection.

Differential proliferative and interleukin-10 responses to fractionated filarial antigens: preferential recognition by patients with chronic lymphatic dysfunction

To characterize filarial antigens that may be associated with the development of chronic lymphatic dysfunction in persons with lymphatic filariasis, T cell responsiveness to Brugia pahangi adult worm extracts and SDS-PAGE antigen fractions were examined among Haitians from an area in which Wuchereria bancrofti is endemic. Greater T cell proliferation and interleukin-10 (IL-10) production were observed in amicrofilaremic patients with hydrocele or elephantiasis than in amicrofilaremic or microfilaremic asymptomatic persons. Antigen fractions that stimulated the highest proliferative responses (in the 25-49 kDa range) and IL-10 production were not identical. Further separation of an immunodominant 30- to 38-kDa fraction by ion exchange high-pressure liquid chromatography identified several subfractions, including a 32-kDa protein band, that elicited T cell responses from patients with elephantiasis or hydrocele. By immunoblot, these patients also had markedly greater humoral reactivity to parasite antigens of approximately 52, 43, 32, and 30 kDa.

Cultivation and phylogenetic characterization of a newly recognized human pathogenic protozoan

An intraerythrocytic protozoan (WA1) recently isolated from a patient in Washington State was shown to be morphologically identical to Babesia microti but biologically and genetically distinct. Continuous growth of WA1 was established in stationary erythrocyte cultures. Hybridization of a chemiluminescent Babesia-specific DNA probe to Southern blots of restriction enzyme-digested genomic DNA showed that WA1 could be distinguished from other Babesia species that were antigenically cross-reactive (Babesia gibsoni and babesial parasites from desert bighorn sheep, Ovis canadensis nelsoni) or known to infect humans (B. microti, Babesia divergens, and Babesia equi), or both. A 1436-bp portion of the nuclear small subunit rRNA gene of WA1 was sequenced and analyzed. Genetic distance analysis showed that WA1 is most closely related to the canine pathogen B. gibsoni and lies within a phylogenetic cluster with Theileria species and B. equi. The methodology described will be useful for improved diagnosis and identification of human protozoal pathogens.

Maternal filarial infection — A persistent risk factor for microfilaremia in offspring?

The observation that children born to mothers that are infected with Wuchereria bancrofti ore more susceptible to filarial infection than those born to uninfected mothers, raises many questions, particularly regarding immune mechanisms. In this article, Allen Hightower, Patrick Lommie and Mark Eberhard discuss these issues and their implications for the epidemiology of filarial infection.

Zoonotic Brugia infection in western Michigan

A case of zoonotic lymphatic filariasis is reported from a resident of Michigan. Numerous sections of a small, nongravid female worm, measuring approximately 65 microns in diameter, were identified in histological preparations of an excised inguinal lymph node. Based on its location, small size, thin cuticle, small number of muscle cells, and paired uterine tubes, the worm was identified as a Brugia species, undoubtedly of zoonotic origin from the local animal population. The pathological response of the host to the parasite was one of hyperplastic lymph nodes with a focal granulomatous reaction. This is the first such case to be reported from Michigan and further expands the geographical range of states in which zoonotic Brugia infection have been reported.

Babesiosis in Washington State: a new species of Babesia?

OBJECTIVE

To characterize the etiologic agent (WA1) of the first reported case of babesiosis acquired in Washington State.

DESIGN

Case report, and serologic, molecular, and epizootiologic studies.

SETTING

South-central Washington State.

PATIENT

A 41-year-old immunocompetent man with an intact spleen who developed a moderately severe case of babesiosis.

MEASUREMENTS

Serum specimens from the patient were assayed by indirect immunofluorescent antibody (IFA) testing for reactivity with seven Babesia species and with WA1, which was propagated in hamsters inoculated with his blood. A Babesia-specific, ribosomal-DNA (rDNA) probe was hybridized to Southern blots of restriction-endonuclease-digested preparations of DNA from WA1, Babesia microti, and Babesia gibsoni. Serum specimens from 83 family members and neighbors were assayed for IFA reactivity with WA1 and B. microti. Small mammals and ticks were examined for Babesia infection.

RESULTS

The patient's serum had very strong IFA reactivity with WA1, strong reactivity with B. gibsoni (which infects dogs), but only weak reactivity with B. microti. DNA hybridization patterns with the rDNA probe clearly differentiated WA1 from B. gibsoni and B. microti. Four of the patient's neighbors had IFA titers to WA1 of 256. The tick vector and animal reservoir of WA1 have not yet been identified, despite trapping 83 mammals and collecting 235 ticks.

CONCLUSIONS

WA1 is morphologically indistinguishable but antigenically and genotypically distinct from B. microti. Some patients elsewhere who were assumed to have been infected with B. microti may have been infected with WA1. Improved serodiagnostic and molecular techniques are needed for characterizing Babesia species and elucidating the epidemiology of babesiosis, an emergent zoonosis.

Trypanosomes and microfilariae in feral owl and squirrel monkeys maintained in research colonies

A group of 358 owl and squirrel monkeys imported from Colombia, Peru, and Bolivia for the U.S. Agency for International Development Malaria Vaccine Development Program was examined for trypanosomes and microfilariae. Trypanosoma rangeli, isolated by hemoculture from Aotus nancymai, Saimiri b. boliviensis, and S. b. peruviensis, accounted for 76.6% of all trypanosome infections. Trypanosoma cruzi was isolated from 25 of 194 S. b. boliviensis, including two mixed infections with T. rangeli. Identifications of trypanosomes were confirmed by blinded tests with a panel of five rRNA probes on a subsample of cultures identified morphologically. Although no trypanosomes were isolated from Aotus vociferans or A. lemurinus griseimembra, positive serologic responses to T. cruzi were observed by indirect immunofluorescence assay in all species of monkeys examined and ranged from 42.1% among S. b. peruviensis to 92.3% among A. vociferans. Among T. rangeli-infected monkeys, 43.7% were seronegative for T. cruzi. No microfilariae were found in S. b. boliviensis or A. l. griseimembra. Mansonella barbascalensis and Dipetalonema caudispina were observed in A. vociferans, M. panamensis in A. nancymai, and M. saimiri and D. caudispina in S. b. peruviensis. Such naturally occurring infections in imported animal models are potential sources of accidental transmission to animal handlers and uninfected laboratory animals and can introduce confounding variables into otherwise well-planned and well-executed studies.

Survival and development of larval Onchocerca volvulus in diffusion chambers implanted in primate and rodent hosts

Third-stage larvae (L3) of Onchocerca volvulus were implanted in diffusion chambers in chimpanzees, mangabey monkeys, rhesus monkeys, squirrel monkeys, and inbred strains of mice, jirds, and rats for 3-63 days. At different times during the experimental period, larvae were recovered and assessed for their viability and development. Survival and growth rates were equal regardless of whether the implanted larvae were fresh or cryopreserved. Survival and growth rates of the larvae did not differ among the primate and rodent hosts tested, with the exception of squirrel monkeys and rats, which were resistant to infection. Molting from L3 to fourth-stage larvae began on day 3 and continued through day 14 in the primates and rodents. The primate and rodent models developed in the present study will be useful for the study of the immunology and chemotherapy of onchocerciasis.

Preliminary evaluation of recombinant Onchocerca volvulus antigens for serodiagnosis of onchocerciasis

Serodiagnostic assays for onchocerciasis based on native antigens are hampered by the scarcity of antigen, and they suffer from poor specificity. The present study was designed to evaluate the diagnostic utility of recently described recombinant Onchocerca volvulus antigens OC 3.6 and OC 9.3 in enzyme immunoassays. The recombinant proteins were expressed as glutathione S-transferase fusions and were tested in several enzyme immunoassay formats to measure immunoglobulin G (IgG) and IgG4 antibodies with sera from patients with onchocerciasis in Nigeria and with various types of control sera. The best results were obtained by measuring IgG4 antibodies to the fusion proteins. Forty of 42 (95%) serum specimens from patients with onchocerciasis were reactive with OC 3.6; the reactivity with OC 9.3 was 81%. Results obtained with sera from experimentally infected chimpanzees suggest that OC 3.6 might be especially useful for detecting prepatent infections in humans, while OC 9.3 mainly detects mature, patent infections. Sera from individuals in Nigeria and the United States residing in areas nonendemic for onchocerciasis were uniformly nonreactive with these antigens in IgG and IgG4 assays, as were sera from patients with bancroftian filariasis, brugian filariasis, loiasis, ascariasis, schistomiasis, and dracunculiasis. These results suggest that enzyme immunoassays based on the recombinant antigens OC 3.6 and OC 9.3 are useful for the diagnosis of onchocerciasis.

Heterogeneity in filarial-specific immune responsiveness among patients with lymphatic obstruction

The relationship between chronic obstructive disease and antifilarial immune responsiveness was studied in the Haitian community of Leogane, where Wuchereria bancrofti is endemic. Differences in sex ratios and in the prevalence of microfilaremia were observed between patients with hydrocele and those with lymphedema or elephantiasis of the lower limb. Only 2 of 84 patients with limb involvement (74 women, 10 men) were microfilaremic compared with 25 of 42 men with hydrocele. Microfilaria-positive men with hydrocele had significantly lower IgG2 and proliferative responses to filarial antigen than did amicrofilaremic men with hydrocele or individuals with lymphedema or elephantiasis. Parasite-specific cellular responses of amicrofilaremic individuals with obstructive disease were greater, although not significantly so, than those of amicrofilaremic asymptomatic members of the community. These results are compatible with the hypothesis that development of obstructive disease of the lymphatics has an immune component in amicrofilaremic persons.

Mansonella ozzardi: the course of patency in experimentally-infected patas monkeys

Twenty-five of 30 patas monkeys (Erythrocebus patas) inoculated with varying numbers (35 to 135) of third-stage larvae of Mansonella ozzardi developed patent infections in an average of 163 days. There was no correlation between the size of the inoculum and the length of the prepatent period. Ten of the monkeys were monitored thereafter by regular blood examination for extended periods of time in order to characterize the onset, course and duration of patency. Typically, with the onset of patency, microfilaremias increased steadily, peaking at about 20 weeks and then decreased slowly stabilizing at low levels for up to 48 weeks. Thereafter microfilariae disappeared from the blood and occasionally reappeared in scanty numbers. Laparotomies and followup studies indicated that the spleen was involved in the suppression of peripheral microfilaremia as had been observed earlier in patas monkeys infected with Loa loa. In ten monkeys splenectomized after the initial "wave" of microfilaremia, it was observed that (a) 30% of the animals remained amicrofilaremic, (b) another 30% reestablished patent infections but microfilaremias were lower than presplenectomy levels, and (c) in the remaining 40%, levels of microfilaremia equaled or exceeded pre-splenectomy levels. Patent infections persisted for up to 212 weeks. One monkey splenectomized prior to inoculation with 87 larvae developed a patent infection with microfilaremia which persisted for 156 weeks. Three monkeys with low and high levels of microfilaremia bled at four hour intervals over a 28 hour period showed no evidence of periodicity in the microfilaria.(ABSTRACT TRUNCATED AT 250 WORDS)

Transplacental transmission of Wuchereria bancrofti in Haitian women

To document the occurrence of transplacental transmission of microfilariae and to determine how frequently it occurred, umbilical cord blood samples and placental tissues were collected from 22 microfilaria-positive women in an area with endemic Wuchereria bancrofti. Microfilaria (mf) counts in the women ranged from 1 to 3,820 mf/ml. Microfilariae were detected in 2 placenta samples and a single cord blood sample. The positive cord blood sample and 1 of the positive placenta samples came from the same woman; no microfilariae were found in a finger prick sample taken from the infant 3 wk after delivery. Our results suggest that microfilariae cross the placenta in less than 10% of pregnancies of microfilaria-positive mothers. Furthermore, the microfilaria count of the mother does not seem to influence directly whether microfilariae are present in the placental blood pool. Although actual transfer of microfilariae to the fetus may occur infrequently, exposure to parasite antigens occurs with much greater frequency. The effect of in utero exposure to either microfilariae or parasite antigens may render newborns tolerant and explain why children born to infected mothers are almost 3 times more likely to become infected than are children born to uninfected women.

Comparative efficacy of clearing-dose and single high-dose ivermectin and diethylcarbamazine against Wuchereria bancrofti microfilaremia

To compare the efficacy and tolerability of various combinations of low- and high-dose ivermectin and diethylcarbamazine (DEC), 59 persons with Wuchereria bancrofti microfilaremia were enrolled in a double-blinded six-arm clinical trial in Leogane, Haiti. On day 1, study participants were treated with low clearing doses of ivermectin, DEC, or placebo; on day 5 they received 200-400 micrograms/kg of ivermectin or 6 mg/kg of DEC. Adverse reactions, which were generally mild, occurred more frequently with ivermectin than with DEC. One year after treatment, the geometric mean microfilarial density returned to 0.9% of pretreatment levels for persons who received a total of 420 micrograms/kg of ivermectin. This rate was significantly lower than 5.6% for persons who were treated with 220 micrograms/kg of ivermectin (P = 0.02) and 9.3% for those receiving 6 or 7 mg/kg of DEC (P = 0.006). Persons treated with a clearing dose of ivermectin followed by 6 mg/kg of DEC also had low microfilarial densities (1.7% of pretreatment levels), suggesting an additive or synergistic effect of the two drugs. The addition of a clearing dose neither reduced the severity of adverse reactions nor improved the efficacy of high-dose ivermectin. Community-based intervention trials are now warranted to determine the feasibility and effectiveness of mass chemotherapy with single high-dose ivermectin for the prevention and control of lymphatic filariasis.

Strianema venezuelensis gen. et sp. n. (Filarioidea: Onchocercidae) from Venezuelan armadillos (Dasypus spp.)

A new filaria, Strianema venezuelensis gen. et sp. n., is described from armadillos in Venezuela. The adults inhabit the subcutaneous tissues and the microfilariae are found in the skin and occasionally the blood. The adults, which are of small size (males 9.6 to 13.8 mm in length by 57 to 63 microns in diameter, females 18.3 to 26.3 mm in length by 95 to 120 microns in diameter), have a distinctly striated cuticle. This filaria resembles most closely the genus Cercopithifilaria, from which it can be distinguished by the absence of a buccal capsule or pre-esophageal ring, and 11 to 13 pair of caudal papillae, three or four pair of which are separated as a group anterior to the cloaca. The species, S. venezuelensis, can be distinguished from the three other species of filariae described from armadillos by the undivided esophagus, number and distribution of caudal papillae in the male, size and shape of the spicules, and the distinctive microfilaria. The microfilaria, which averages 280 microns in length, has a unique, slender, almost filamentous tail.

Albendazole in the treatment of onchocerciasis: double-blind clinical trial in Venezuela

A double-blind clinical trial was conducted in Monagas State, Venezuela to assess the tolerance and efficacy of albendazole in the therapy of Onchocerca volvulus infection. Forty-nine patients (26 treated and 23 controls) received a 10-day course of albendazole (400 mg/day) or a placebo. Consistent with the excellent tolerance observed, albendazole did not kill microfilariae. However, analysis of changes in microfilarial densities (mf/mg of skin) over one year showed that albendazole was active against O. volvulus, presumably by interfering with embryogenesis. The nature, degree, and duration of this effect remain to be determined.

Identification of surrogate rodent hosts for larval Onchocerca lienalis and induction of protective immunity in a model system

The objectives of this project were to screen a variety of inbred rodent species and strains to determine their usefulness as surrogate hosts for the study of the early larval development of Onchocerca lienalis and then to use a selected model to study the induction of protective immunity. In the primary screen, 6 strains of mice, 5 strains of rats, jirds, and multimammate rats were tested. Animals were infected with fresh O. lienalis by subcutaneous implantation of third-stage larvae (L3) contained in diffusion chambers covered with 5.0-microns pore-size membranes. After 7 days the chambers were recovered, and larval viability and growth were assessed. Approximately one-half of inoculated larvae were recovered alive regardless of the host tested. Larvae were implanted in CBA/J and DBA/2J mice in chambers covered with membranes that prevented host cells from entering; survival and growth rates of the larvae were not altered by the absence of cells from the chambers. Cryopreserved larvae were implanted in chambers with 5.0-microns pore-size membranes in CBA/J and DBA/2J mice and Wistar Furth rats for 3-28 days. No statistically significant difference was seen in the larval recoveries on days 3-28 in all 3 hosts. Statistically significant increases in length were seen in the 3 strains from day 3 to day 14, after which growth appeared to cease. Molting from L3 to fourth-stage larvae was observed in all 3 hosts beginning on day 3, with most larvae completing the molt by day 7.(ABSTRACT TRUNCATED AT 250 WORDS)

Kinetics of circulating human IgG4 after diethylcarbamazine and ivermectin treatment of bancroftian filariasis

Patent filarial infections are associated with elevated levels of parasite-specific IgG4. This study investigated the shifts of filarial-specific human IgG and IgG4 antibodies after diethylcarbamazine and ivermectin treatment of bancroftian filariasis. Thirty adult Haitians were treated first with a 1-mg clearing dose of ivermectin and then with either one or two 200-micrograms/kg doses of ivermectin or with 12 daily 6-mg/kg doses of diethylcarbamazine. Posttreatment levels of antifilarial IgG4 were dependent on both treatment group and time of follow-up. IgG4 increased markedly to a maximum by day 30 in all treatment groups and then began to decrease; the greatest decrease was among diethylcarbamazine-treated patients. Posttreatment microfilaremia was inversely correlated with the decrease in IgG4; thus, shifts in IgG4 were associated with treatment response for all groups. Antifilarial IgG levels were not correlated with drug treatment and did not change to the same degree as did IgG4 responses.