Intestinal anisakiasis in Italy: case report

Does Anisakis spp. infestation affect the proximate composition, fatty acids, and minerals contents of its host Merluccius merlucccius?

Fish play an important role in human nutrition. They are not only a great source of protein and healthy fats, but also a unique source of essential nutrients such as omega-3 fatty acids. Moreover, most fish are parasitized, and some of these parasites are able to influence the reallocation of resources in their favor and thus reduce the nutritional quality of the fish. The present study was conducted to investigate the impact of the third stage larvae (L3) of Anisakis spp. on the proximate composition, macro-minerals (potassium, calcium, and sodium), and fatty acids of European hake (Merluccius merluccius Linnaeus, 1758). In parasitized female group, our results revealed a decrease (p< 0.005) in the amount of carbohydrate by 6.5%, of calcium by 17%, and of 2 polyunsaturated fatty acids (arachidonic acid (C20: 4w-6), and eicosapentaenoic acid (C20: 5w-3) with 33% and 15% respectively. Simultaneously, an increase by 25% in the level of a single saturated fatty acid C10:0 was noticed. According to the principal component analysis, the parasitized female was wealthy of saturated fatty acids and monounsaturated fatty acids and contains less of polyunsaturated fatty acids, omega-3 fatty acids, and omega-6 fatty acids than the unparasitized female and male. No significant changes were observed in the biochemical composition of male hake, probably due to the low mean intensity of L3 larvae of Anisakis spp. in this group.

Albendazole and Mebendazole as Anti-Parasitic and Anti-Cancer Agents: an Update

The use of albendazole and mebendazole, i.e., benzimidazole broad-spectrum anthelmintics, in treatment of parasitic infections, as well as cancers, is briefly reviewed. These drugs are known to block the microtubule systems of parasites and mammalian cells leading to inhibition of glucose uptake and transport and finally cell death. Eventually they exhibit ovicidal, larvicidal, and vermicidal effects on parasites, and tumoricidal effects on hosts. Albendazole and mebendazole are most frequently prescribed for treatment of intestinal nematode infections (ascariasis, hookworm infections, trichuriasis, strongyloidiasis, and enterobiasis) and can also be used for intestinal tapeworm infections (taeniases and hymenolepiasis). However, these drugs also exhibit considerable therapeutic effects against tissue nematode/cestode infections (visceral, ocular, neural, and cutaneous larva migrans, anisakiasis, trichinosis, hepatic and intestinal capillariasis, angiostrongyliasis, gnathostomiasis, gongylonemiasis, thelaziasis, dracunculiasis, cerebral and subcutaneous cysticercosis, and echinococcosis). Albendazole is also used for treatment of filarial infections (lymphatic filariasis, onchocerciasis, loiasis, mansonellosis, and dirofilariasis) alone or in combination with other drugs, such as ivermectin or diethylcarbamazine. Albendazole was tried even for treatment of trematode (fascioliasis, clonorchiasis, opisthorchiasis, and intestinal fluke infections) and protozoan infections (giardiasis, vaginal trichomoniasis, cryptosporidiosis, and microsporidiosis). These drugs are generally safe with few side effects; however, when they are used for prolonged time (>14-28 days) or even only 1 time, liver toxicity and other side reactions may occur. In hookworms, Trichuris trichiura, possibly Ascaris lumbricoides, Wuchereria bancrofti, and Giardia sp., there are emerging issues of drug resistance. It is of particular note that albendazole and mebendazole have been repositioned as promising anti-cancer drugs. These drugs have been shown to be active in vitro and in vivo (animals) against liver, lung, ovary, prostate, colorectal, breast, head and neck cancers, and melanoma. Two clinical reports for albendazole and 2 case reports for mebendazole have revealed promising effects of these drugs in human patients having variable types of cancers. However, because of the toxicity of albendazole, for example, neutropenia due to myelosuppression, if high doses are used for a prolonged time, mebendazole is currently more popularly used than albendazole in anti-cancer clinical trials.

Occurrence and abundance of zoonotic nematodes in snapper Chrysophrys auratus, a popular table fish from Australian and New Zealand waters

In Australia and New Zealand (NZ), snapper Chrysophrys auratus is known for delicate mild flavoured flesh and is a favoured species to serve raw as sashimi or in sushi. The diet of snapper includes a variety of intermediate hosts of larval nematodes, and as a result, snapper has potential to become highly infected with zoonotic/non-zoonotic nematodes. The aims of this study were to survey nematodes in snapper from Australia and New Zealand waters and to identify nematode species using combined morphological and molecular methods. The zoonotic potential of nematodes identified in this study are discussed. A total of 112 snapper were purchased from the Sydney fish market, New South Wales, Australia. Fish were dissected and only the visceral content and digestive tract were examined for nematode infection. Parasites were initially identified by the microscopic method as four different types belonging to the families Anisakidae (Anisakis types I & III, and Terranova type II) and Cucullanidae (Dichelyne spp.). All Anisakidae nematodes were at infective stages. Species-level identification was actualised through sequencing of the internal transcribed spacer (ITS-1, 5.8S, ITS-2) regions. The Anisakis types I & III were confirmed as Anisakis pegreffii and A. brevispiculata, respectively of which A. pegreffii is considered globally as a zoonotic nematode. The specific identification of Terranova type II and Dichelyne spp. was not possible as no comparable sequence data were available in GenBank. The phylogenetic tree clustered Anisakis types I & III with A. pegreffii and A. brevispiculata, respectively; Terranova type II sequences as a separate clade with previously identified larval and adult Terranova and Pseudoterranova species. Based on phylogenetic analyses the present Cucullanid specimens were assigned herein as Dichelyne cf. pleuronectidis, and an unknown species Dichelyne sp. 1. This study represents the first host record globally for zoonotic Anisakid nematodes in this popularly consumed table fish and a new region record for D. cf. pleuronectidis and Dichelyne sp. 1. Further investigation is required, using more comprehensive parasite detection and recovery methods, to assess the health risk these nematodes may pose to human and fish health in Australia/NZ.

World-wide prevalence of Anisakis larvae in fish and its relationship to human allergic anisakiasis: a systematic review

The infective stage of Anisakidae nematodes responsible for allergic reactions in humans is found in a variety of edible fish and cephalopods. The identification of geographical regions that are high risk for infected seafood may help prevent allergic reactions in humans. Despite an abundance of published literature which has identified anisakid larvae in an array of edible seafood as well as scattered reports of human allergic anisakiasis, the relationship between the two has not been fully explored. Therefore, a systematic spatio-temporal study was conducted to determine the prevalence of Anisakis spp. in fish from January 2000 to August 2020 firstly to explore the relationship between fish infection and cases of allergic anisakiasis and secondly to use fish infection data to map potential allergic anisakiasis 'hot spots'. A systematic literature search for original English text articles was conducted through search engines, Web of Science, Scopus, PubMed, Science Direct and Google Scholar. Out of 3228 articles which describe anisakid infection in fish, 264 were used for data extraction. Of 904 articles describing allergic anisakiasis, 37 were used for data extraction. A qualitative summary of the extracted data was performed using equal interval method (ArcMap software) in order to compare the global distribution of Anisakis-infected fish. Of the 152-identified fish hosts, five families were most commonly infected with Anisakis spp. These included Lophiidae (86.9%), Trichiuridae (77.05%), Zeidae (70.9%), Merlucciidae (67.8%) and Gadidae (56.8%). The hot spot areas for allergic anisakiasis were North and northeast of Atlantic Ocean, southwest of USA, west of Mexico, south of Chile, east of Argentina, Norway, UK and west of Iceland (confidence 99%). The highest rate of allergic anisakiasis was in Portugal and Norway with the prevalence rate of 18.45-22.50%. Allergologists should consider allergic anisakiasis as a public health issue particularly in high-risk countries where high prevalences in fish have been demonstrated.

A Critical Appraisal of Global Testing Protocols for Zoonotic Parasites in Imported Seafood Applied to Seafood Safety in Australia

It is not suggested that any country is intentionally exporting seafood which does not comply with Codex seafood-safety guidelines/codes/standards. However, with an open access resource such as fisheries, there is vast potential for errors to occur along convoluted supply chains, spanning multiple countries, which may negatively impact the safety of edible seafood products imported into Australia. Australian importation policy and inspection procedures are founded upon a bedrock of trust in the integrity, reliability and safety of the global seafood supply chain. In order for seafood imported to Australia to be considered safe the non-mandatory international health standards, governed by Codex Alimentarius, for seafood must be predicated upon the most efficacious methods and stringently governed by each exporting provenance. Currently, tests for zoonotic parasites are not applied to imported edible seafood products on arrival into Australia. Therefore, this critical analysis is aimed at discussing the effectiveness of current testing protocols for zoonotic parasites in edible seafood advised by Codex Alimentarius which may impact the safety of the product imported into Australia.

Human anisakiasis in Italy: a retrospective epidemiological study over two decades

A retrospective analysis on human anisakiasis in Italy since its first description in 1996 was performed by conducting a literature search. Inclusion criteria based on the presence of a larva and on parasite identification were applied. Epidemiological data and clinical features were analysed. Particular attention was paid to the source of infection. In total, 73 cases were included in the analysis, while 34 were excluded. Cases were reported from eight Italian regions, most frequently Abruzzo, Apulia and Latium. The parasite was detected by endoscopy (51.4%) or laparotomy (48.6%). The site of infection was intestinal (42.5%), gastric (43.8%), oesophageal (1.4%) or ectopic (12.3%). Most of the parasites (71.0%) were identified as Anisakis sp. or A. simplex (s.l.). However, when molecular methods were used (21 cases), A. pegreffii was always identified. In most of the patients (65.7%), the source of infection was raw or undercooked anchovies, followed by "anchovies or sardines" (15.1%), generic "raw seafood" (15.1%), and sardines (1.4%). In only 2 cases (2.7%), the source was not available. This is the first systematic analysis of Italian cases of anisakiasis. The main conclusions derived from the results are: i) attention should be given to the history, in particular when raw marinated anchovies, proven to be the main source of human anisakiasis in Italy, are consumed; ii) in order to assess correct epidemiological data, a confirmed and specific etiological identification should always be sought.

Molecular Epidemiology of Anisakis and Anisakiasis: An Ecological and Evolutionary Road Map

This review addresses the biodiversity, biology, distribution, ecology, epidemiology, and consumer health significance of the so far known species of Anisakis, both in their natural hosts and in human accidental host populations, worldwide. These key aspects of the Anisakis species' biology are highlighted, since we consider them as main driving forces behind which most of the research in this field has been carried out over the past decade. From a public health perspective, the human disease caused by Anisakis species (anisakiasis) appears to be considerably underreported and underestimated in many countries or regions around the globe. Indeed, when considering the importance of marine fish species as part of the everyday diet in many coastal communities around the globe, there still exist significant knowledge gaps as to local epidemiological and ecological drivers of the transmission of Anisakis spp. to humans. We further identify some key knowledge gaps related to Anisakis species epidemiology in both natural and accidental hosts, to be filled in light of new 'omic' technologies yet to be fully developed. Moreover, we suggest that future Anisakis research takes a 'holistic' approach by integrating genetic, ecological, immunobiological, and environmental factors, thus allowing proper assessment of the epidemiology of Anisakis spp. in their natural hosts, in human populations, and in the marine ecosystem, in both space and time.

Distinguishing gastric anisakiasis from non-anisakiasis using unenhanced computed tomography

PURPOSE

This study aimed to assess the diagnostic performance of unenhanced computed tomography (CT) for distinguishing gastric anisakiasis from non-anisakiasis gastric conditions and the reproducibility of CT findings.

METHODS

Fifty-six anisakiasis and 74 non-anisakiasis cases with gastric wall thickening on urgent observation using unenhanced CT were included. Using a κ analysis, two radiologists independently assessed the reproducibility of CT findings, including "circumferential gastric wall thickening," "gastric wall thickening extending more than two segments," "bulky and low-density gastric wall thickening," "increase in peri-gastric fat density," and "ascites." An anisakiasis diagnostic score (ADS) was developed for this study and was used to quantitatively evaluate the CT findings. An anisakiasis diagnostic prediction (ADP) with an appropriate cutoff value was used to further evaluate the ADS. Two radiologists reassessed the findings in consensus to determine the sensitivity, specificity, and accuracy of the CT findings, including the ADP and ADS area under the curve (AUC).

RESULTS

Considering reproducibility, a substantial agreement (0.6 < κ < 0.8) was achieved for all findings except "circumferential gastric wall thickening" (κ = 0.499), whereas for diagnostic performance, all findings except ascites were significantly more frequent among the anisakiasis cases. "Bulky and low-density gastric wall thickening" had the highest sensitivity (98%), whereas "gastric wall thickening extending more than two segments" had the highest specificity (80%). The ADP sensitivity, specificity, and accuracy were 91%, 84%, and 87%, respectively. The AUC was 0.902 (p < 0.05).

CONCLUSIONS

Unenhanced CT findings are useful for distinguishing anisakiasis from non-anisakiasis gastric conditions with sufficient reproducibility.

Geographic and host size variations as indicators of Anisakis pegreffii infection in European pilchard (Sardina pilchardus) from the Mediterranean Sea: Food safety implications

European pilchards are traditionally eaten marinated or salted in the Mediterranean countries often without thermal processing or gutting due to small size. Since ingestion of live third stage Anisakis larvae represents a causing agent in the onset of anisakiasis, the aim of our study was to assess prevalence and intensity of Anisakis infection in European pilchards originating from different Mediterranean regions in a three-year sampling period (2013-2015). A total of 1564 specimens of European pilchard collected from two geographically distinct sampling regions (western Mediterranean and Adriatic Sea) were examined using the UV-Press method, which utilises the fluorescence of frozen anisakids in flattened and subsequently frozen fillets and viscera. A subsample of 67 isolated larvae was identified as A. pegreffii by diagnostic allozyme markers and sequence analyses of the mtDNA cox2 locus. The overall prevalence in pilchards was 12.2% (range 0-44.9% for different sampling points) and mean intensity 1.8. More importantly, we have observed an overall larval prevalence of 1.5% in fillets. The highest prevalence (44.9%) was recorded in pilchards caught in western parts of the Mediterranean. As fish host size was a significant predictor of parasite abundance, it should be highlighted that these pilchards were also the largest (mean total length 173.2mm); on average >2cm larger than the rest of the samples. Other isolated nematode species included Hysterothylacium sp. in viscera, showing almost a double of A. pegreffii prevalence, 20.1%. In summary, our study demonstrates that the presence of A. pegreffii in European pilchards from the Mediterranean Sea is highly influenced by both geographic and host size variation. This implies that, before future risk management measures are developed, these variables should be assessed in order to minimize public health concerns.

Reviewing biodiversity and epidemiological aspects of anisakid nematodes from the North-east Atlantic Ocean

This review provides an inventory of the biodiversity of the anisakid species identified so far from fish and marine mammals of the NE Atlantic Ocean. The paper reviews and discusses various taxonomical and epidemiological aspects related to biodiversity assessment, with emphasis on: (1) taxa recognized as 'biological species' based on molecular/genetic markers; (2) current molecular/genetic approaches to identify the species at different developmental stages; (3) ecological data related to the actual geographical distribution and definitive host preferences of the species; (4) their distribution in various, commercially important fish species in northern European waters; (5) their possible occurrence in farmed fish; and, finally, (6) an update of their zoonotic potential as causative agents of anisakidosis in humans.

Prevalence and Mean Intensity of Anisakidae Parasite in Seafood Caught in the Mediterranean Sea Focusing on Fish Species at Risk of Being Raw-consumed. A Meta Analysis and Systematic Review

OBJECTIVE

To assess the prevalence and mean intensity of anisakids in seafood caught in the Mediterranean Sea, focusing on fish species at risk of being raw-consumed.

DESIGN

Systematic review and meta-analysis of studies published from 1960-2012.

STUDY SELECTION

Main criteria for the inclusion of studies were as follows: Findings of anisakid larvae, in both muscles and viscera; fish species for human consumption caught in the Mediterranean Sea; prevalence and mean intensity data for each species; and sample size equal to or more than 40 fishes.

RESULTS

Twelve studies were identified. Among these, four studies considered the following three fish species that are often consumed raw or preserved lightly, or not cooked thoroughly: anchovy, pilchard, and Atlantic mackerel.

DATA SYNTHESIS

All pooled analyses were based on the random-effect model. Anisakids prevalence in fish muscle was 0.64% (P < 0.0001), in viscera it was 1.34% (P < 0.0001), and overall prevalence was 0.95% (P < 0.0001). Mean intensity in muscle was 2.31 (P = 0.0083), in viscera it was 1.55 (P = 0.0174), and overall it was 1.81 (P < 0.0005). Heterogeneity indices (I(2)) were significantly high with the exception of viscera mean intensity.

CONCLUSIONS

Anchovy, pilchard, and Atlantic mackerel have a low prevalence and mean intensity of anisakidae larvae in both viscera and muscles. Mean Intensity was also low.

Evolution of the Anisakis risk management in the European and Italian context

Due to the social and legislative implications, the presence of Anisakis spp. larvae in fishery products has become a concern for both the consumers and the official Control Authorities. The issuance of a large number of provisions, aimed at better managing fish products intended to be consumed raw or almost raw and the associated risks, resulted in a very complicate legal framework. In this work, we analyzed the evolution of the normative through an overview on the local and international legislations, focusing on issues that are of practical interest for Food Business Operators (FBOs) in the fishery chain. In addition, we performed a survey across the Department of Prevention of the Italian Local Health Authorities (LHA) and the main fish markets in Italy to collect the operating procedures and the monitoring plans. Overall, we found many differences, due to the absence of a national reference standard for the management of the Anisakis risk. From this examination, it turns clear that only a participation of all the involved institutions, a strategy of synergistic interventions, as well as a correct training of FBOs, can result in an effective risk management and a proper risk communication, which should overcome states of confusion and unnecessary negative impacts on the economy.

First molecular identification of the zoonotic parasite Anisakis pegreffii (Nematoda: Anisakidae) in a paraffin-embedded granuloma taken from a case of human intestinal anisakiasis in Italy

BACKGROUND

Anisakiasis is an important fish-borne zoonosis provoked by larval stages of nematodes belonging to the genus Anisakis. The detection and identification of human infections is difficult. This is due to: a) the low specificity of the clinical features and symptomatology related to human infections; b) the paucity of diagnostic features of larvae found in granulomatous lesions characteristic of "invasive anisakiasis"; and c) the lack morphological characters diagnostic at the specific level when larvae of Anisakis are detected. Thus, molecular-based diagnostic approaches are warranted.

METHOD

We have developed a PCR method that amplifies the DNA of Anisakis spp. in fixed paraffin-embedded tissues. This method was applied to a granuloma removed from a human case of intestinal anisakiasis in Italy. Specific primers of the mtDNA cox2 gene were used and sequence analysis was performed according to the procedures already established for species of Anisakis.

RESULTS

The sequence obtained (629 bp) was compared with those of the other species of Anisakis which have so far been genetically characterized and with sequences obtained from larval stages of Anisakis collected from the Mediterranean fish Engraulis encrasicolus. This enabled the genetic identification of the larva in the human tissue as A. pegreffii. This is the first instance of human intestinal anisakiasis diagnosed using PCR of DNA purified from a fixed eosinophilic granuloma embedded in paraffin.

CONCLUSION

The case of human anisakiasis presented reinforces the pathological significance of the species A. pegreffii to humans. The molecular/genetic methodological approach based on mtDNA cox2 sequence analysis, described here, can allow easy and rapid identification of Anisakis spp. in formalin-fixed and paraffin embedded tissues removed from cases of either gastric or intestinal human anisakiasis.

Experimental challenge of Anisakis simplex sensu stricto and Anisakis pegreffii (Nematoda: Anisakidae) in rainbow trout and olive flounder

The third-stage larvae of Anisakis simplex sensu lato (s.l.) are found in many marine fishes. To ensure food safety, it is important to determine whether these larvae are present in the body muscle of commercial fish species. However, there is little information regarding the tissue specificity of Anisakis and two of its sibling species, A. simplex sensu stricto (s.s.) and Anisakis pegreffii, that are common in marine fish in Japanese waters. We orally challenged rainbow trout (Oncorhynchus mykiss (Walbaum)), and olive flounder (Paralichthys olivaceus (Temminck and Schlegel)) with L3 larvae of these two sibling species and monitored infection for 5weeks. In rainbow trout, A. simplex s.s., but not A. pegreffii larvae, migrated into the body muscle. A small number of freely moving A. pegreffii larvae were recovered within the body cavity. In olive flounder, A. simplex s.s. larvae were found in both the body cavity and body muscle. A. pegreffii larvae were found only in the body cavity and primarily encapsulated in lumps. Our results indicate that there are differences in the sites of infection and host specificity between the two sibling species of A. simplex s.l.

Anisakis simplex: from obscure infectious worm to inducer of immune hypersensitivity

Infection of humans with the nematode worm parasite Anisakis simplex was first described in the 1960s in association with the consumption of raw or undercooked fish. During the 1990s it was realized that even the ingestion of dead worms in food fish can cause severe hypersensitivity reactions, that these may be more prevalent than infection itself, and that this outcome could be associated with food preparations previously considered safe. Not only may allergic symptoms arise from infection by the parasites ("gastroallergic anisakiasis"), but true anaphylactic reactions can also occur following exposure to allergens from dead worms by food-borne, airborne, or skin contact routes. This review discusses A. simplex pathogenesis in humans, covering immune hypersensitivity reactions both in the context of a living infection and in terms of exposure to its allergens by other routes. Over the last 20 years, several studies have concentrated on A. simplex antigen characterization and innate as well as adaptive immune response to this parasite. Molecular characterization of Anisakis allergens and isolation of their encoding cDNAs is now an active field of research that should provide improved diagnostic tools in addition to tools with which to enhance our understanding of pathogenesis and controversial aspects of A. simplex allergy. We also discuss the potential relevance of parasite products such as allergens, proteinases, and proteinase inhibitors and the activation of basophils, eosinophils, and mast cells in the induction of A. simplex-related immune hypersensitivity states induced by exposure to the parasite, dead or alive.

Anisakis simplex: analysis of expressed sequence tags (ESTs) of third-stage larva

This study analyzed the expressed sequence tags (ESTs) of the third-stage larvae of Anisakis simplex, in an attempt to gain further insight into its genomic expression patterns. An A. simplex cDNA library was constructed using the Uni-ZAP XR expression vector. A total of 493 clones (insert DNA>400 bp) were sequenced out of 580 clones selected randomly from a cDNA library of the A. simplex third-stage larva. After BLAST search analyses, 154 (31.2%) ESTs were found to have very low similarity, or no match at all to any of the proteins and gene sequences in the published databases. Most matched clones (98 clones, 20.0%) were determined to be highly homologous with the genes or proteins of Caenorhabditis elegans. Ten (2.0%) ESTs matched the genes isolated from humans, and 21 (4.3%) ESTs matched with the previously reported A. simplex genes or proteins. Eighty-nine clones (18.0%) matched a total of 14 genera and 17 species of human parasites. These 339 ESTs identified could be grouped into 13 categories: allergens or antigens (4.1%), growth- and cell division-related proteins (3.2%), heat shock proteins or molecular chaperones (1.8%), membrane proteins (5.6%), metabolism-associated proteins (24.2%), mitochondrial proteins (9.4%), nuclear proteins (2.4%), proteases and protease inhibitors (3.5%), signal transduction proteins (2.4%), structural proteins (7.4%), transcription and translation machinery-associated proteins (20.1%), transporters and receptor proteins (3.8%), and other protein types (12.1%). The genetic information of Anisakis determined in this study might prove to be quite helpful in elucidating the pathogenetic mechanisms of anisakidosis, and might be useful in the development of therapeutic reagents specific to anisakidosis.