Trichinosis with ventilatory failure and persistent myocarditis

Egyptian propolis and selenium nanoparticles against murine trichinosis: a novel therapeutic insight

Trichinosis is a serious zoonotic disease that causes human morbidity and mortality. New effective natural remedies with minimal side effects that are well tolerated are needed to treat both enteral and parenteral trichinosis. This study evaluated the efficacy of selenium (Se), Se nanoparticles (SeNPs) and Egyptian propolis compared with albendazole as antiparasitic, anti-inflammatory and anti-angiogenic agents for treating murine trichinosis. We used parasitological, histopathological and immunohistochemical assays, as well as scanning electron microscopy, to examine adult worms. Overall, 80 Swiss albino male mice were divided into eight groups, with ten mice in each group, as follows: negative control, positive control, albendazole, propolis, Se, combination of propolis and Se, SeNPs and combination of SeNPs and propolis. Mice were slaughtered seven and 35 days after infection to examine the intestinal and muscular phases, respectively. This study demonstrated the efficacy of the combination of SeNPs and propolis. As revealed by electron microscopy, this combination caused damage to the adult worm cuticle. Additionally, compared with albendazole, it resulted in a significant reduction in adult worm and total larval counts; moreover, it caused a decrease in the number of larvae deposited in muscles, with a highly significant decrease in the inflammatory cell infiltrate around the larvae and a considerable decrease in the expression of the angiogenic marker vascular endothelial growth factor in muscles. In conclusion, the combination of SeNPs and propolis had antiparasitic, anti-inflammatory and anti-angiogenic effects on trichinosis. Consequently, this combination could be used as a natural alternative therapy to albendazole for treating trichinosis.

Trichinella spiralis-associated myocarditis mimicking acute myocardial infarction

BACKGROUND

Trichinellosis is a parasitic infection caused by nematodes of the genus Trichinella, and its principal mode of transmission is the consumption of raw or undercooked contaminated meat. Cardiac involvement in trichinellosis is unusual, yet it represents the most frequent cause of death. Here, we report a case in which Trichinella spiralis-associated myocarditis simulated a myocardial infarction.

CASE PRESENTATION

A 35-year-old African man with no previous medical history was admitted to the emergency department for acute substernal discomfort at rest described as a pressure with no radiation. The electrocardiogram performed upon admission showed non-specific alterations of repolarization. Blood biology revealed high levels of troponin T and predominant eosinophilic leukocytosis. A transthoracic echocardiography was carried out and found a significant left ventricular concentric hypertrophy with a preserved ejection fraction. The septal and inferior walls, as well as the endocardium were hyperechogenic. The patient was hospitalized for eosinophilic myocarditis. The cause of hypereosinophilia was investigated, and a Trichinella spiralis serology came back strongly positive. A diagnosis of Trichinella spiralis associated-myocarditis was made.The patient was treated with albendazole-prednisolone dual therapy with favorable clinical and biological outcomes.

CONCLUSION

The clinical suspicion of trichinellosis is based on suggestive epidemiology associated with the typical clinical presentation and the presence of eosinophilia. Eosinophilic myocarditis is a severe complication of trichinellosis which can result in death due to rhythm disorders. Chest pain, increase in troponins, and electrocardiographic abnormalities are all elements that can mimic a myocardial infarction and mislead clinicians.Abbreviations: ANCA: Anti-Neutrophil Cytoplasmic Antibodies; ANA: Anti-Nuclear Antibodies; ECDC: European Centre for Disease Prevention and Control; ECG: Electrocardiogram; ELISA: Enzyme-Linked ImmunoSorbent Assay; EMF: Endomyocardial Fibrosis; ES: Excretory-Secretory; ICT: International Commission on Trichinellosis; MRI: Magnetic Resonance Imaging.

'Curved tunnel' sign on MRI: a typical radiological feature in hepatic trichinellosis

PURPOSE

To summarize the clinical and radiological features of hepatic trichinellosis.

METHODS

Patients diagnosed with trichinellosis and liver involvement in our institution since 2011 were included retrospectively. Then, qualified patients were divided into a seropositive group and a clinically diagnosed group. Preoperative liver CT and/or MRI images were evaluated independently by two radiologists. The correlations between the radiological and pathological features were evaluated by a radiologist and a pathologist. Independent t-tests were carried out to assess clinical data between groups and those reported in the previous literature. Values of P less than 0.05 were considered statistically significant.

RESULTS

Eventually, ten patients were enrolled, five in each group. All patients recovered successfully after surgical (n = 8) or conservative treatment (n = 2). The clinical, radiological, and pathological features were highly consistent between the two groups. All patients were under 60 years of age (48.0 ± 7.9 years in the seropositive group, 48.6 ± 10.1 years in the clinically diagnosed group), and they were older than those previously reported in the literature (30.5 ± 17 years, n  =  31; P = 0.032 and 0.028). Eosinophilia was found in four patients, and all were mildly increased (˂ 1.5 × 10⁹/L). Lesions in all patients were in the right lobe of the liver, and nine of them showed a characteristic 'curved tunnel' sign on DCE-MRI images. None of the patients had signs or evidence of extrahepatic infection.

CONCLUSION

The 'curved tunnel' sign on MRI is a typical radiological feature in hepatic trichinellosis.

Biomolecular Changes and Cortical Neurodegenerative Lesions in Trichinella Spiralis Infected BALB/c Mice: A Preliminary Study Elucidating a Potential Relationship Between Systemic Helminthic Infections and Idiopathic Parkinson's

Idiopathic Parkinson's (IP) is a neurodegenerative disease that is suspected to be due to exposure to infections during early life. Toxoplasmosishas been the only suspected parasitic infection in IP (Celik et al., 2010). Recently, some non-central nervous system bacterial and viral infections have been incriminated in IP (Çamcı & Oğuz, 2016). So in the current study, we tried to explore if the systemic inflammatory reactions triggered by some helminths like Trichinella spiralis can induce Parkinsonian lesions in the brain, especially that the cerebral complications have been reported in 10-20% of Trichinella spiralis infected patients . An experimental study was designed to assess the neurodegenerative and biomolecular changes that may occur in Trichinella spiralis infected BALB/C mice in comparison to rotenone induced PD model and apparently healthy ones. The motor affection was significantly lesser in the Trichinella infected mice than the Parkinson's model, but when the catalepsy score was calculated (through the grid and bar tests) it was found to be significantly higher in the infected mice than in the healthy ones. A significant increase in the blood advanced oxidative protein products (AOPP), IFN-γ, TGF-β, and brain DNA fragmentation was also detected in the Trichinella spiralis infected mice. After histopathological examination, a significant increase in the cortical apoptotic neurons and Lewy's body were observed in the Trichinella infected and the rotenone induced Parkinson's model sections. A significant decrease in the immunohistochemical expression of the tyrosine hydroxylase expression in the brain sections and the ELISA measured dopamine level in the brain homogenate was also reported in the infected mice group. This study findings may collectively suggest that the systemic inflammatory reactions and the oxidative stresses associated with some systemic helminthic infections like trichinellosis are possible to precipitate neurodegenerative lesions and biomolecular changes in the brain , and manifest with IPD later in life.

Present status of trichinellosis - a neglected zoonosis in India

Trichinellosis is a meat-borne helminthic zoonosis, caused by different species of the genus Trichinella. The disease is cosmopolitan in distribution and affects around 10,000 people annually around the globe. Based on genetic, biochemical and biological variability, 9 valid species (T. britovi, T. murrelli, T. nativa, T. nelsoni, T. papuae, T. patagoniensis, T. pseudospiralis, T. spiralis and T. zimbabwensis) and 3 genotypes (Trichinella T6, T8 and T9) of the parasite have been recognized. These species infect around 100 mammalian species including domestic and wild pigs, horses, game animals and wild carnivores. The infection starts with consumption of raw or undercooked meat or meat products containing encysted muscle larvae of the parasite. Most of the infections or outbreaks have been associated with the consumption of meat or meat products of pigs, wild boars, horses, crocodiles, walruses and dogs. Trichinoscopy is used in the veterinary inspection of pork in slaughterhouses and meat-packing facilities in many countries. It is a rapid process, but low in sensitivity and fails to detect mild infection. The muscle digestion method using HCl-pepsin is more sensitive and thus preferred. Recent outbreak of trichinellosis in Uttarakhand state opened up issues related to rapid diagnosis and lack of consumer awareness regarding safe cooking habits of meat of pig origin. This status report is an attempt to compile the information on Trichinella spp. infection in animals and humans in India at one place to draw the attention of medical and veterinary personnels involved in disease investigation and active research on zoonotic diseases.

Outbreak of trichinellosis related to eating imported wild boar meat, Belgium, 2014

Trichinellosis is a rare parasitic zoonosis caused by Trichinella following ingestion of raw or undercooked meat containing Trichinella larvae. In the past five years, there has been a sharp decrease in human trichinellosis incidence rates in the European Union due to better practices in rearing domestic animals and control measures in slaughterhouses. In November 2014, a large outbreak of trichinellosis occurred in Belgium, related to the consumption of imported wild boar meat. After a swift local public health response, 16 cases were identified and diagnosed with trichinellosis. Of the 16 cases, six were female. The diagnosis was confirmed by serology or the presence of larvae in the patients' muscle biopsies by histology and/or PCR. The ensuing investigation traced the wild boar meat back to Spain. Several batches of imported wild boar meat were recalled but tested negative. The public health investigation allowed us to identify clustered undiagnosed cases. Early warning alerts and a coordinated response remain indispensable at a European level.

Areas of uncertainty in the management of human trichinellosis: a clinical perspective

There is disagreement between authorities on most facets of trichinellosis therapy. The most controversial issues are when to use corticosteroids and which antihelminthic drug should be administered, for how long and at what dose. These issues are particularly important in the treatment of severe, potentially fatal infections. A major reason for the lack of consensus regarding trichinellosis management is that there have been very few prospective, controlled clinical trials of this infection. After a brief review of pertinent epidemiological and clinical features of the disease, selected treatment concerns will be discussed and areas where more information is urgently required will be highlighted.

Characterisation of the Trichinella spiralis deubiquitinating enzyme, TsUCH37, an evolutionarily conserved proteasome interaction partner

Background

Trichinella spiralis is a zoonotic parasitic nematode that causes trichinellosis, a disease that has been identified on all continents except Antarctica. During chronic infection, T. spiralis larvae infect skeletal myofibres, severely disrupting their differentiation state.

Methodology and Results

An activity-based probe, HA-Ub-VME, was used to identify deubiquitinating enzyme (DUB) activity in lysate of T. spiralis L1 larvae. Results were analysed by immuno-blot and immuno-precipitation, identifying a number of potential DUBs. Immuno-precipitated proteins were subjected to LC/MS/MS, yielding peptides with sequence homology to 5 conserved human DUBs: UCH-L5, UCH-L3, HAUSP, OTU 6B and Ataxin-3. The predicted gene encoding the putative UCH-L5 homologue, TsUCH37, was cloned and recombinant protein was expressed and purified. The deubiquitinating activity of this enzyme was verified by Ub-AMC assay. Co-precipitation of recombinant TsUCH37 showed that the protein associates with putative T. spiralis proteasome components, including the yeast Rpn13 homologue ADRM1. In addition, the UCH inhibitor LDN-57444 exhibited specific inhibition of recombinant TsUCH37 and reduced the viability of cultured L1 larvae.

Conclusions

This study reports the identification of the first T. spiralis DUB, a cysteine protease that is putatively orthologous to the human protein, hUCH-L5. Results suggest that the interaction of this protein with the proteasome has been conserved throughout evolution. We show potential for the use of inhibitor compounds to elucidate the role of UCH enzymes in T. spiralis infection and their investigation as therapeutic targets for trichinellosis.

Trichinella spiralis is a parasitic nematode that infects mammals indiscriminately. Although the biggest impact of trichinellosis is observed in developing countries, the parasite is found on all continents except Antarctica. In humans, Trichinella infection contributes globally to helminth related morbidity and disability adjusted life years. In animals, infection is implicated as a serious agricultural problem and drug treatment is largely ineffective. During chronic infection, larvae invade skeletal muscle cells, forming a nurse cell complex in which they become encysted. The nurse cell is a product of the severe disruption of the host cell homeostasis. Proteins of the Ub/proteasome pathway are highly conserved throughout evolution, and considering their importance in the regulation of cell homeostasis, provide interesting and novel therapeutic targets for various diseases. In order to target this system in parasites, pathogen proteins that play a role in this pathway must be identified. We report the identification of the first T. spiralis deubiquitinating enzyme, and show evidence that the function of this protein as a proteasome interaction partner has been evolutionarily conserved. We show that members of this enzyme family are important for T. spiralis survival and that the use of inhibitor compounds may help elucidate their role in infection.

Cardiac involvement with parasitic infections

Parasitic infections previously seen only in developing tropical settings can be currently diagnosed worldwide due to travel and population migration. Some parasites may directly or indirectly affect various anatomical structures of the heart, with infections manifested as myocarditis, pericarditis, pancarditis, or pulmonary hypertension. Thus, it has become quite relevant for clinicians in developed settings to consider parasitic infections in the differential diagnosis of myocardial and pericardial disease anywhere around the globe. Chagas' disease is by far the most important parasitic infection of the heart and one that it is currently considered a global parasitic infection due to the growing migration of populations from areas where these infections are highly endemic to settings where they are not endemic. Current advances in the treatment of African trypanosomiasis offer hope to prevent not only the neurological complications but also the frequently identified cardiac manifestations of this life-threatening parasitic infection. The lack of effective vaccines, optimal chemoprophylaxis, or evidence-based pharmacological therapies to control many of the parasitic diseases of the heart, in particular Chagas' disease, makes this disease one of the most important public health challenges of our time.

Trichinellosis, a threatening and re-emerging disease in a Romanian western county

INTRODUCTION

Trichinellosis is frequently reported in east European countries like Romania, where the yearly incidence during 1990-1999 was 5.5 cases/100,000 inhabitants. Arad, a western Romanian county, is known as one of the most endemic regions of trichinellosis. A major and unforgettable epidemic of trichinellosis has developed at the beginning of 1973 in this county. The present study focuses on human trichinellosis patients from Arad County, emphasizing on epidemiological, clinical, laboratory, and therapeutic aspects.

PATIENTS AND METHODS

Retrospective analysis of the medical records of 335 patients found to have trichinellosis during 1996-2006 and hospitalized in Arad County. The mean age of the trichinellosis patients was 33.6 years, and majority (64.8%) were inhabitants of the rural areas.

RESULTS

Winter was the season with the highest number of cases (71.6%). Fever was the most frequent manifestation of the disease (85.4%), followed by myalgia (83%). Eosinophilia ranged predominantly between 20% and 20.99% (19.4%). Albendazole was the specific drug administered in 49.4% of the patients.

CONCLUSIONS

Trichinellosis still remains a concern and a major issue of public health in Arad County. Implementation of strict hygienic measures, especially in the rural areas, must be a priority.

Myocarditis

Viruses are the most common cause of myocarditis in economically advanced countries.

Enteroviruses and adenoviruses are the most common etiologic agents.

Viral myocarditis is a triphasic process. Phase 1 is the period of active viral replication in the myocardium during which the symptoms of myocardial damage range from none to cardiogenic shock. If the disease process continues, it enters phase 2, which is characterized by autoimmunity triggered by viral and myocardial proteins. Heart failure often appears for the first time in phase 2. Phase 3, dilated cardiomyopathy, is the end result in some patients. Diagnostic procedures and treatment should be tailored to the phase of disease.

Viral myocarditis is a significant cause of dilated cardiomyopathy, as proved by the frequent presence of viral genomic material in the myocardium, and by improvement in ventricular function by immunomodulatory therapy.

Myocarditis of any etiology usually presents with heart failure, but the second most common presentation is ventricular arrhythmia. As a result, myocarditis is one of the most common causes of sudden death in young people and others without preexisting structural heart disease.

Myocarditis can be definitively diagnosed by endomyocardial biopsy. However, it is clear that existing criteria for the histologic diagnosis need to be refined, and that a variety of molecular markers in the myocardium and the circulation can be used to establish the diagnosis.

Treatment of myocarditis has been generally disappointing. Accurate staging of the disease will undoubtedly improve treatment in the future. It is clear that immunosuppression and immunomodulation are effective in some patients, especially during phase 2, but may not be as useful in phases 1 and 3. Since myocarditis is often selflimited, bridging and recovery therapy with circulatory assistance may be effective. Prevention by immunization or receptor blocking strategies is under development.

Giant cell myocarditis is an unusually fulminant form of the disease that progresses rapidly to heart failure or sudden death. Rapid onset of disease in young people, especially those with other autoimmune manifestations, accompanied by heart failure or ventricular arrhythmias, suggests giant cell myocarditis.

Peripartum cardiomyopathy in economically developed countries is usually the result of myocarditis.

Clinical aspects, diagnosis and treatment of trichinellosis

Trichinellosis, the human disease induced by worms of the genus Trichinella, is caused by the consumption of raw or undercooked meat of various types of animals and has a worldwide prevalence of approximately eleven million. Since there are no pathognomonic signs or symptoms, clinical diagnosis is difficult and the only reliable diagnostic methods are serodiagnosis and muscle biopsy. Treatment consists of benzimidazoles and glucocorticosteroids, yet in order for these drugs to be effective, they must be administered before the end of the acute stage; thus early diagnosis is fundamental. To aid in the recognition and treatment of trichinellosis, an overall description of its clinical aspects, diagnosis and treatment has been prepared.

Opinion on the diagnosis and treatment of human trichinellosis

The clinical diagnosis of trichinellosis is difficult because there are no pathogenic signs or symptoms and in diagnosing the infection epidemiological data are of great importance. Trichinellosis usually begins with a sensation of general discomfort and headache, increasing fever, chills and sometimes diarrhoea and/or abdominal pain. Pyrexia, eyelid or facial oedema and myalgia represent the principal syndrome of the acute stage, which can be complicated by myocarditis, thromboembolic disease and encephalitis. High eosinophilia and increased creatine phosphokinase activity are the most frequently observed laboratory features and the parasitological examination of a muscle biopsy and the detection of specific circulating antibodies will confirm the diagnosis. The medical treatment includes anthelmintics (mebendazole or albendazole) and glucocorticosteroids. Mebendazole is usually administered at a daily dose of 5 mg/kg but higher doses (up to 20 - 25 mg/kg/day) are recommended in some countries. Albendazole is used at 800 mg/day (15 mg/kg/day) administered in two doses. These drugs should be taken for 10 - 15 days. The use of mebendazole or albendazole is contraindicated during pregnancy and not recommended in children aged < 2 years. The most commonly used steroid is prednisolone, which may alleviate the general symptoms of the disease. It is administered at a dose of 30 - 60 mg/day for 10 - 15 days.

Searching for antibodies against Trichinella spiralis in the sera of patients with fever of unknown cause

Human cases of trichinellosis are often difficult to identify because the signs and symptoms of the disease, if the infection produces any at all, are non-specific, being similar to those observed in several other infectious diseases. In an investigation of Mexican patients with fever of unknown aetiology, attempts were made to develop a serodiagnostic test for the detection of antibodies specific for Trichinella spiralis. The excretory and secretory products of T. spiralis larvae (from the muscle tissue of experimentally infected rats) were used as the antigens in an enzyme-linked immuno-electrotransfer blot assay. The sera tested came from patients with fever of unknown cause (N=250), patients confirmed to have infectious or parasitic diseases other than trichinellosis (N=134) and 168 apparently healthy subjects. Overall, 4% of the samples from the febrile group, 1.8% of those from the healthy subjects but none of the sera from those with 'other diseases' reacted with the antigens of interest (of 45, 49 and 55 kDa). The results not only confirm that human infection with T. spiralis may be asymptomatic but also indicate that such infection may be mis-diagnosed.

New aspects of human trichinellosis: the impact of new Trichinella species

Trichinellosis is a re-emerging zoonosis and more clinical awareness is needed. In particular, the description of new Trichinella species such as T. papuae and T. murrelli and the occurrence of human cases caused by T pseudospiralis, until very recently thought to occur only in animals, requires changes in our handling of clinical trichinellosis, because existing knowledge is based mostly on cases due to classical T spiralis infection. The aim of the present review is to integrate the experiences derived from different outbreaks around the world, caused by different Trichinella species, in order to provide a more comprehensive approach to diagnosis and treatment.

Serological evaluation of thin-layer immunoassay-enzyme-linked immunosorbent assay for antibody detection in human trichinellosis

A new immunoenzymatic test, named the thin-layer immunoassay-enzyme-linked immunosorbent assay (TIA-ELISA), was evaluated for antibody detection in human trichinellosis using excretion and secretion products prepared from Trichinella spiralis muscle larvae. Serum samples from people with positive muscle biopsies or symptoms compatible with the disease (n = 8 or 26, respectively), all reactive in enzyme-linked immunoelectrotransfer blot assay (EITB), as well as 67 serum samples from healthy, EITB-negative people, were tested in an ELISA and TIA-ELISA. TIA-ELISA was performed in polystyrene plastic petri dishes by adding dots of 10 microl each of antigen (7 microg/ml) followed by adding diluted serum and the conjugate. Finally, the substrate mixed with agar was added to develop the reaction. Enzymatic by-products were easily detected by the naked eye as defined dots. Sensitivity and specificity were 76 and 94% for ELISA, and both parameters were 91% for TIA-ELISA. The kappa correlation indices for both tests in relation to EITB were 0.73 and 0.80, respectively. The TIA-ELISA can be carried out with common laboratory equipment in 3 h and uses lower quantities of antigen than EITB and ELISA. Since TIA-ELISA is easy to perform, cheap, sensitive, and specific, the test could be an acceptable alternative to use in clinical laboratories lacking specialized equipment needed for ELISA and EITB and in field studies for antibody detection in human trichinellosis.

Low incidence of cardiac abnormalities in treated trichinosis: a prospective study of 62 patients from a single-source outbreak

PURPOSE

The reported incidence of cardiac involvement in trichinosis is highly variable, ranging from 21% to 75%. This study sought to determine the incidence and type of cardiac lesions in trichinosis using serial echocardiographic examinations.

SUBJECTS AND METHODS

Sixty-two consecutive patients admitted to the Banja Luka Medical Center during an outbreak of trichinosis (November to December 1996) were included in the study. Diagnosis was made by typical clinical presentation, positive epidemiologic history, serologic testing, and the detection of Trichinella larvae in contaminated meat. All patients underwent serial electrocardiograms and two-dimensional and Doppler echocardiographic examinations within 20 days after the onset of symptoms. Repeated echocardiographic examinations were performed weekly during the hospital stay in all patients with electrocardiographic abnormalities or an abnormal initial echocardiogram.

RESULTS

Cardiac involvement (electrocardiographic and/or echocardiographic changes) was detected in 8 (13%) of the 62 patients. Nonspecific transient electrocardiographic ST-T changes were found in 6 patients (10%); 1 patient had frequent premature ventricular complexes. Echocardiographic examinations revealed pericardial effusions in 6 patients (10%), 5 of whom had minimal effusions without impairment of global and regional left ventricular systolic function. One patient had hypokinesis of the interventricular septum with a small pericardial effusion, both of which resolved within 2 weeks. Only 2 of the patients with electrocardiographic abnormalities lacked echocardiographic evidence of cardiac involvement. At 6-month follow-up, none of the patients had electrocardiographic or echocardiographic abnormalities.

CONCLUSIONS

The incidence of cardiac involvement in trichinosis appears to be lower than previously reported. Pericardial effusion is the most common manifestation of cardiac involvement, and nonspecific transient electrocardiographic changes, traditionally ascribed to myocarditis, more frequently reflect pericarditis.

Clinical aspects of infection with Trichinella spp

Isolated cases and outbreaks of infection with Trichinella spp. occur frequently throughout the world, sometimes resulting in fatalities. The clinical presentations of signs and symptoms are remarkably constant for most of the species of Trichinella, but in infections with Trichinella nativa and Trichinella britovi, classical symptoms of trichinellosis may be absent. It is important to be able to correlate the clinical presentation of trichinellosis with the life cycle of these helminths in order to make an accurate diagnosis. Knowledge of the epidemiology of the disease enables the physician to identify other potential cases, since most epidemics can be traced back to a common source of raw or undercooked meat. A comprehensive summary relating the most important clinical variables is presented graphically for easy reference to the text. Symptoms and signs are considered in relation to severity of infection. Laboratory findings and diagnostic techniques, including new modalities (e.g., DNA and antigen detection), are discussed. A discussion of treatment and preventive measures concludes our review.