High genetic diversity in the Dirofilaria repens species complex revealed by mitochondrial genomes of feline microfilaria samples from Narathiwat, Thailand

Genetic variability of Dirofilaria repens isolates from humans and dogs in Italy

Dirofilaria repens is a paradigmatic example of an emerging vector-borne pathogen (VBP) in both human and veterinary fields. The spatial expansion and the increasing zoonotic impact of this VBP can be related to several drivers including the genetic structure of parasite populations. Italy is one of the European countries traditionally endemic with the highest incidence of canine and human cases of subcutaneous dirofilariosis. The present study aimed to assess the genetic identity and variability of D. repens isolates of human and canine origin from areas of Central Italy, compared with those isolated from different areas of Europe by sequence analysis of mtDNA genes (i.e., 12 S rDNA and cox1). A total of twenty isolates of D. repens were obtained from biopsies of subcutaneous and ocular cases of dirofilariosis occurring in 10 dogs and 10 humans. The sequence analysis of 12 S rDNA showed that all the sequences obtained clustered as a monophyletic group with a strong nodal support, indicating that all sequence types represented D. repens. The cox1 and the 12 S sequence analysis did not show host-related polymorphisms between human and dog-derived specimens. The sequence analysis of cox1 was performed including 8 additional sequences previously obtained from human and canine isolates in the same areas. Out of the 28 sequences analyzed, 20 were grouped in a haplogroup comprising 15 haplotypes (i.e., DR1, DR2, DR4, DR5, DR7, DR8, DR10-DR18), 2 sequences matched to DR9, reported for the first time in Italy, and 6 showed peculiar polymorphisms that were not previously described. The results obtained have implications for a better understanding of the epidemiology and phylogeography of this emerging vector-borne zoonotic parasite.

Genetic diversity and characterization of Wolbachia endosymbiont in canine filariasis

Canine filariasis is caused by nematodes from the family Onchocercidae, which is transmitted by arthropod vectors. The disease is commonly found in Southeast Asia and exists worldwide. Some filarial nematodes are associated with intracellular bacteria of the genus Wolbachia, which plays an important role in embryogenesis, molting, and the long-term survival of adult worms. This study aims to characterize Wolbachia sp. and determine the association between Wolbachia and canine filarial nematode species in Thailand. A total of 46 dog blood samples that were naturally infected with filarial nematodes were obtained to identify filarial nematode species by Giemsa stained under a light microscope and confirmed using the molecular technique. In order to characterize Wolbachia sp., the nested PCR assay targeting the 16S rRNA gene showed that all samples of Dirofilaria immitis and fifteen samples of Candidatus Dirofilaria hongkongensis were grouped into Wolbachia supergroup C. In addition, all samples of Brugia spp. and five samples of Candidatus Dirofilaria hongkongensis were classified into Wolbachia supergroup D. The genetic diversity analysis conducted using the 16S rRNA gene revealed a similar result when analyzed through phylogenetic tree analysis. This is the first genetic diversity study of Wolbachia of Candidatus Dirofilaria hongkongensis in infected dogs in Thailand.

Advanced approaches for the diagnosis and chemoprevention of canine vector-borne pathogens and parasites-Implications for the Asia-Pacific region and beyond

Vector-borne pathogens (VBPs) of canines are a diverse range of infectious agents, including viruses, bacteria, protozoa and multicellular parasites, that are pernicious and potentially lethal to their hosts. Dogs across the globe are afflicted by canine VBPs, but the range of different ectoparasites and the VBPs that they transmit predominate in tropical regions. Countries within the Asia-Pacific have had limited prior research dedicated to exploring the epidemiology of canine VBPs, whilst the few studies that have been conducted show VBP prevalence to be high, with significant impacts on dog health. Moreover, such impacts are not restricted to dogs, as some canine VBPs are zoonotic. We reviewed the status of canine VBPs in the Asia-Pacific, with particular focus on nations in the tropics, whilst also investigating the history of VBP diagnosis and examining recent progress in the field, including advanced molecular methods, such as next-generation sequencing (NGS). These tools are rapidly changing the way parasites are detected and discovered, demonstrating a sensitivity equal to, or exceeding that of, conventional molecular diagnostics. We also provide a background to the armoury of chemopreventive products available for protecting dogs from VBP. Here, field-based research within high VBP pressure environments has underscored the importance of ectoparasiticide mode of action on their overall efficacy. The future of canine VBP diagnosis and prevention at a global level is also explored, highlighting how evolving portable sequencing technologies may permit diagnosis at point-of-care, whilst further research into chemopreventives will be essential if VBP transmission is to be effectively controlled.

Genetic and geographical delineation of zoonotic vector-borne helminths of canids

Several zoonotic vector-borne helminths (VBHs) infesting canids cause serious veterinary and medical diseases worldwide. Increasing the knowledge about their genetic structures is pivotal to identify them and therefore to settle effective surveillance and control measures. To overcome the limitation due to the heterogeneity of large DNA sequence-datasets used for their genetic characterization, available cytochrome c oxidase subunit 1 (cox1) (n = 546) and the 12S rRNA (n = 280) sequences were examined using combined bioinformatic approach (i.e., distance-clustering, maximum likelihood phylogeny and phylogenetic evolutionary placement). Out of the 826 DNA available sequences from GenBank, 94.7% were characterized at the haplotype level regardless sequence size, completeness and/or their position. A total of 89 different haplotypes were delineated either by cox1 (n = 35), 12S rRNA (n = 21) or by both genes (n = 33), for 14 VBHs (e.g., Acanthocheilonema reconditum, Brugia spp., Dirofilaria immitis, Dirofilaria repens, Onchocerca lupi and Thelazia spp.). Overall, the present approach could be useful for studying global genetic diversity and phylogeography of VBHs. However, as barcoding sequences were restricted to two mitochondrial loci (cox1 and 12S rRNA), the haplotype delineation proposed herein should be confirmed by the characterization of other nuclear loci also to overcome potential limitations caused by the heteroplasmy phenomenon within the mitogenome of VBHs.

Case Report: An Eyelid Nodule Caused by Candidatus Dirofilaria hongkongensis Diagnosed by Mitochondrial 12S rRNA Sequence

A 59-year-old female living in Rayong Province, eastern Thailand, presented with painless, right upper eyelid nodule for 3 months. Upon removal of the eyelid mass, a well-circumscribed, firm globular mass with diameter about 1 cm was found. Histopathological examination revealed an immature female dirofilarial worm reminiscent of Dirofilaria repens, characterized by prominent sharp longitudinal ridges at external surface of the cuticle. Analysis of the mitochondrial 12S rRNA sequence showed that the worm belongs to Candidatus Dirofilaria hongkongensis. It is likely that some infections previously reported as D. repens based on histological examination may have actually been due to Candidatus D. hongkongensis.

Human subcutaneous dirofilariasis: the 'migrating' skin tumor

A 46-year-old woman presented with facial pain and discomfort. Diagnosis of subcutaneous dirofilariasis was reached after several months from symptom onset. Dirofilariasis should be suspected, also in non-endemic areas, in patients with a migrating subcutaneous nodule. Plastic surgery is preferred, as the face is often involved.

Emergence of Dirofilaria repens (Spirurida: Onchocercidae) in dogs in Eastern Thailand

Background and Aim:

Dirofilaria repens is a zoonotic vector-borne parasite of dogs and cats. It is not commonly found in every part of Thailand, except the southern part. This study was conducted to investigate the prevalence of this parasite in Eastern Thailand in 2019.

Materials and Methods:

A total of 8003 blood samples were collected from private veterinary clinics and animal hospitals in Eastern Thailand. Blood parasites were examined using buffy coat thin blood smears with Wright-Giemsa staining. D. repens was morphologically identified and confirmed using the acid phosphatase activity technique.

Results:

The first case of D. repens was found in March 2019. The prevalence of D. repens from January to December 2019 was 0.44% (35/8003) (95% confidence interval 0.30-0.61).

Conclusion:

The prevalence data of D. repens in Eastern Thailand indicate that this parasitic infection should be considered as a zoonotic vector-borne disease. A strategic plan to control zoonotic transmission alongside a preventive program should be emphasized and encouraged among pet owners and veterinarians.

Heartworm disease - Overview, intervention, and industry perspective

Dirofilaria immitis, also known as heartworm, is a major parasitic threat for dogs and cats around the world. Because of its impact on the health and welfare of companion animals, heartworm disease is of huge veterinary and economic importance especially in North America, Europe, Asia and Australia. Within the animal health market many different heartworm preventive products are available, all of which contain active components of the same drug class, the macrocyclic lactones. In addition to compliance issues, such as under-dosing or irregular treatment intervals, the occurrence of drug-resistant heartworms within the populations in the Mississippi River areas adds to the failure of preventive treatments. The objective of this review is to provide an overview of the disease, summarize the current disease control measures and highlight potential new avenues and best practices for treatment and prevention.

Human and Animal Dirofilariasis in Southeast of France

Dirofilariasis is one of the oldest known zoonotic infections of humans mainly caused by the filarial parasites of the species Dirofilaria immitis and Dirofilaria repens, which primarily infect dogs. A five-year survey (2017 to 2021) was conducted among the dog population to assess the molecular prevalence of Dirofilaria spp. in southeast France. Morphological and genetic analysis were performed on filaroids from dogs and one infected woman from the studied area. A total of 12 (13%) dogs scored molecularly positive for Dirofilaria spp. of which nine carried blood microfilariae. Ocular dirofilariasis was detected in a 79-year-old woman with no travel history. Both electron microscopy and molecular sequencing identified the worm in the human case as D. repens. Molecularly, D. repens isolates were identical in the human and dog cases, representing the only genotype reported so far in France. Despite the distribution of this genotype through all Europe, it was grouped separately with the other two European genotypes and with Asian ones. As in almost all previous human cases in France, D. repens parasites were mainly recovered from the ocular region of patients and were geographically concentrated in the southeastern regions. Data demonstrate the sympatric occurrence of D. immitis and D. repens with high risk of infection to human and dog populations in these investigated geographical areas, thereby underlining the urgent need to implement preventive chemoprophylactic strategies and vector control to reduce the risk of these filaroids in dog and human populations.

Genetic diversity of vector-borne pathogens in spotted and brown hyenas from Namibia and Tanzania relates to ecological conditions rather than host taxonomy

Background

Improved knowledge on vector-borne pathogens in wildlife will help determine their effect on host species at the population and individual level and whether these are affected by anthropogenic factors such as global climate change and landscape changes. Here, samples from brown hyenas (Parahyaena brunnea) from Namibia (BHNA) and spotted hyenas (Crocuta crocuta) from Namibia (SHNA) and Tanzania (SHTZ) were screened for vector-borne pathogens to assess the frequency and genetic diversity of pathogens and the effect of ecological conditions and host taxonomy on this diversity.

Methods

Tissue samples from BHNA (n = 17), SHNA (n = 19) and SHTZ (n = 25) were analysed by PCRs targeting Anaplasmataceae, Rickettsia spp., piroplasms, specifically Babesia lengau-like piroplasms, Hepatozoidae and filarioids. After sequencing, maximum-likelihood phylogenetic analyses were conducted.

Results

The relative frequency of Anaplasmataceae was significantly higher in BHNA (82.4%) and SHNA (100.0%) than in SHTZ (32.0%). Only Anaplasma phagocytophilum/platys-like and Anaplasma bovis-like sequences were detected. Rickettsia raoultii was found in one BHNA and three SHTZ. This is the first report of R. raoultii from sub-Saharan Africa. Babesia lengau-like piroplasms were found in 70.6% of BHNA, 88.9% of SHNA and 32.0% of SHTZ, showing higher sequence diversity than B. lengau from South African cheetahs (Acinonyx jubatus). In one SHTZ, a Babesia vogeli-like sequence was identified. Hepatozoon felis-like parasites were identified in 64.7% of BHNA, 36.8% of SHNA and 44.0% of SHTZ. Phylogenetic analysis placed the sequences outside the major H. felis cluster originating from wild and domestic felids. Filarioids were detected in 47.1% of BHNA, 47.4% of SHNA and 36.0% of SHTZ. Phylogenetic analysis revealed high genetic diversity and suggested the presence of several undescribed species. Co-infections were frequently detected in SHNA and BHNA (BHNA median 3 pathogens, range 1–4; SHNA median 3 pathogens, range 2–4) and significantly rarer in SHTZ (median 1, range 0–4, 9 individuals uninfected).

Conclusions

The frequencies of all pathogens groups were high, and except for Rickettsia, multiple species and genotypes were identified for each pathogen group. Ecological conditions explained pathogen identity and diversity better than host taxonomy.

Graphic Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04835-x.

Seasonal distribution and environmental parameters associated with Brugia pahangi and Dirofilaria immitis in naturally infected dogs in Bangkok and vicinity, Thailand

Dirofilaria immitis and Brugia pahangi are vector-borne parasites found in dogs and cats, including Thailand. In order to evaluate the effects of season and environmental parameters on the prevalence of these parasites, this retrospective study was conducted in 2019. A total of 79,506 canine blood samples were examined. B. pahangi was found in 0.55% of samples (438/79,506; 95% CI 0.50–0.61) while D. immitis was detected in 0.43% (345/79,506; 95% CI 0.39–0.48). One-way ANOVA found no effect of seasonal conditions on prevalence. For B. pahangi, the parameters rainfall, relative humidity and sunshine hours showed associations with p ≤ 0.20 and were included in multiple logistic regressions resulting in adjusted odds ratios of 0.53, 1.31 and 0.55, respectively. For D. immitis, only average temperature showed p ≤ 0.20, resulting in an odds ratio of 0.42. In conclusion, Thailand has environmental parameters that do not change very much during the year, so they might not affect the prevalence of two filarial nematodes. However, the threat of B. pahangi and D. immitis should not be ignored, especially in subtropical regions where their vectors are abundant. Both owners and veterinarians should be concerned about filarial prevention and control of D. immitis and B. pahangi.

Molecular Identification of New Cases of Human Dirofilariosis (Dirofilaria repens) in Italy

(1) Dirofilariosis is a vector-borne parasitic disease mainly in domestic and wild carnivores caused by Dirofilaria (Noctiella) repens, which is endemic in many countries of the Old World, and D. immitis, which has a worldwide distribution. In recent years, an increase in the number of human cases has been reported, suggesting that dirofilariosis is an emergent zoonosis. Here, we describe further cases (N = 8), observed in Central Italy during the years 2018-2019. (2) Molecular diagnosis was performed on: (i) live worms extracted from ocular conjunctiva, cheek, and calf muscle; (ii) histological sections of surgically removed nodules from parenchymal lung, coccyx, and breast. (3) Sequence analysis (650-bp) of the mitochondrial cytochrome oxidase subunit I gene (mtDNA cox1) showed a match of 100% with the sequences of D. repens previously deposited in GenBank. ELISA test to detect IgG against filarial antigens was performed on four patients' sera and resulted positive in two patients who showed ocular and subcutaneous dirofilariosis, respectively. Microfilariae have been never detected in the peripheral blood of the patients. (4) The occurrence of N = 8 new cases of human D. repens-infections observed in a two-year period suggests an increased circulation of the parasite in Italy. Therefore, dirofilariosis should be included in differential diagnosis in patients presenting subcutaneous and/or pulmonary nodules. Molecular diagnosis of the etiological agents is fundamental. Specific serological diagnosis needs to be improved in future research work.

Mitochondrial Genome of Brugia malayi Microfilariae Isolated From a Clinical Sample

Lymphatic filariasis is a neglected parasitic disease that is a leading cause of long-term disability. Information obtained from genome sequencing of filarial worm can help us identify systems in the worm that are likely to be useful for novel drug design. Brugia (B.) malayi is still the only lymphatic-dwelling filarial parasite with a nearly complete, fully annotated, and published genome. However, most previous studies were based on the FR3 strain of B. malayi, which originally was isolated from a human patient, and was adapted to the rodent model, then maintained in laboratories for more than 60 years. It is uncertain whether genetic variation exists, thus, sequencing of clinical isolates of lymphatic dwelling filarial parasites is a high priority. Here, we report for the first time the complete mitochondrial genome of B. malayi microfilariae from clinical isolate. Complete mitochondrial (mt) genome of the microfilariae isolated from a blood sample taken from a Thai subject living in Narathiwat Province, which is an endemic area of brugian filariasis, was assembled with sequencing reads obtained by Illumina sequencing. Gene annotation, phylogenetic analysis and single nucleotide polymorphism (SNP) were deployed. A complete 13,658-bp mt genome of B. malayi microfilaria was obtained, and it shows 68x coverage. Based on gene annotation, the mt genome consists of 12 protein-coding, two rRNA, and 23 tRNA genes. Phylogenetic analysis using all protein sequences of DNA sequences of mt genome or cytochrome c oxidase subunit I (COX1) revealed a close relationship among three lymphatic filariae (i.e., B. timori, zoonotic B. pahangi, and Wuchereria spp.). The SNPs in the COX1 gene can differentiate microfilariae of B. malayi in human from those found in canine. Furthermore, the number, order and transcription, and direction of B. malayi microfilariae mitochondrial genes were the same as those found in the FR3 strain of B. malayi. The comparison on mitochondrial genome of B. malayi could have important implications on the development of a new intervention or vaccine to treat or prevent this disease in endemic areas/regions around the world.

Canine and feline vector-borne diseases of zoonotic concern in Southeast Asia

Dogs and cats are important hosts and reservoirs of many viral, bacterial, protozoal, and helminthic pathogens transmitted by arthropods, including some of zoonotic concern. By sharing the same environment, these companion animals play an important role in the transmission of zoonotic pathogens to humans in various regions and socioeconomic contexts. While canine and feline vector-borne diseases (VBD) are of major concern in wealthy regions (e.g. Europe and North America), less attention has been received in developing countries such as those in Southeast Asia (SEA). This review provides summarized and updated information on canine and feline VBD with emphasis on those of zoonotic concern in SEA. Of these, zoonotic bacteria (i.e. Bartonella henselae, Bartonella clarridgeiae, and Rickettsia felis) and filarial nematodes (i.e. Brugia malayi, Dirofilaria repens, and Dirofilaria immitis) stand out as the most important in veterinary and human medicine. Additionally, the recent finding of Leishmania infantum in dogs in SEA raised more concerns about the spreading of this zoonotic agent in this region. Further epidemiological surveys, especially in countries with extremely scant information such as Cambodia, Laos, Myanmar, and Timor-Leste are advocated. Additionally, effective control measures of canine and feline VBD as well as their arthropod vectors should be simultaneously performed for the management of zoonotic infections.

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Many canine and feline vector-borne infections affect animals and humans in Southeast Asia.

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Ticks, fleas and mosquitoes are the most common vectors transmitting pathogens to dogs, cats and humans in Southeast Asia.

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Bartonella henselae, Rickettsia felis and Dirofilaria repens are of concern to human health in this region.

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Collaboration between governments and researchers is encouraged for a better management of vector-borne diseases.

TroCCAP recommendations for the diagnosis, prevention and treatment of parasitic infections in dogs and cats in the tropics

The Tropical Council for Companion Animal Parasites Ltd. (TroCCAP) is a not-for-profit organisation whose mission is to independently inform, guide and make best-practice recommendations for the diagnosis, treatment and control of companion animal parasites in the tropics and sub-tropics, with the aim of protecting animal and human health. In line with this primary mission, TroCCAP recently developed guidelines for the diagnosis, treatment and control of feline and canine parasites in the tropics. The development of these guidelines required unique and complex considerations to be addressed, often inapplicable to developed nations. Much of the tropics encompass middle-to-low income countries in which poor standards of environmental hygiene and large populations of stray dogs and cats coexist. In these regions, a range of parasites pose a high risk to companion animals, which ultimately may place their owners at risk of acquiring parasitic zoonoses. These considerations led to the development of unique recommendations with regard, for example, to deworming and endoparasite testing intervals for the control of both global and 'region-specific' parasites in the tropics. Moreover, the 'off-' or 'extra'-label use of drugs for the treatment and control of parasitic infections is common practice in many tropical countries and many generic products lack manufacturers' information on efficacy, safety, and quality control. Recommendations and advice concerning the use of such drugs and protocols are also addressed in these guidelines. The formation of these guidelines is an important first step towards improving the education of veterinarians specifically regarding best-practice for the diagnosis, treatment and control of canine and feline parasites in the tropics.

On the validity of "Candidatus Dirofilaria hongkongensis" and on the use of the provisional status Candidatus in zoological nomenclature

The fast development of molecular taxonomy is impacting our knowledge of the world parasite diversity at an unprecedented level. A number of operational taxonomic units have been uncovered and new species described. However, it is not always that new parasite species are being described in compliance with the International Code of Zoological Nomenclature. This is the case of “Candidatus Dirofilaria hongkongensis”, a nematode found in dogs, jackals and humans in Hong Kong and parts of India. This name has been proposed without a formal description and without the designation of a holotype, and therefore is an unavailable name. Finally, we argue that using the provisional status Candidatus in zoological nomenclature is inappropriate, considering this term is not considered in the International Code of Zoological Nomenclature.

Dirofilarioses in cats: European guidelines from the ABCD on prevention and management

OVERVIEW

Dirofilaria immitis and Dirofilaria repens are the most important filarial worms, causing heartworm disease and subcutaneous dirofilariosis, respectively. D repens is currently considered an emerging zoonotic agent in Europe.

LIFE CYCLE AND INFECTION

Filarial worms infect mainly dogs, but also cats, ferrets, wild carnivores and humans. The life cycle involves an intermediate mosquito host. Compared with dogs, cats are imperfect hosts for dirofilarial worms. After inoculation, only a low number of L3 larvae develop to the adult stage in a small percentage of cats. Heartworm disease in cats may be associated with severe pulmonary thromboembolism and an eosinophilic inflammatory response in the lungs, potentially leading to sudden death. Otherwise self-cure occurs in most cases after 18-48 months. Subcutaneous dirofilariosis may present as subcutaneous nodules or dermatitis.

DIAGNOSIS AND TREATMENT

Diagnosis in cats is more difficult compared with dogs and needs a multistep approach (antigen and antibody tests, as well as diagnostic imaging). Cats with acute heartworm disease require stabilisation within an intensive care unit. Cats with respiratory signs or suggestive radiographic changes should receive prednisolone and follow-up with a similar multistep approach. Adulticidal therapy is not safe in cats.

PREVENTION

In endemic areas cats should receive year-round chemoprophylaxis from 2 months of age.

Dirofilaria hongkongensis infection presenting as recurrent shoulder mass

In 2012, a novel canine Dirofilaria species, D. hongkongensis was identified in Hong Kong that caused human diseases and subsequently reported in an Austrian traveller returning from the Indian subcontinent. Here we present a case of human infection by D. hongkongensis manifested as recurrent shoulder mass. Diagnosis was achieved by cox1 gene sequencing of the excised specimen. The case illustrated that parasitic infection represents an important differential diagnosis for musculoskeletal lesions.

The prevalence of Dirofilaria immitis and D. repens in the Old World

Dirofilaria immitis and D. repens are endemic throughout Europe and southern eastern regions of Asia and reported with increasing frequency in Africa. Nevertheless, the increased awareness of veterinary practitioners, even in countries where the prevalence is low, has led to a decrease D. immitis prevalence in dogs, especially in previously endemic/hyper-endemic areas. Prevalence has significantly increased, however, in areas where heartworm has apparently spread more recently, such as Central and North Eastern Europe. Furthermore, autochthonous cases have been observed in Siberia. Low seroprevalence has been reported in Croatia, while in Romania it has reached 14%. In Greece, the prevalence ranges between 0.7% and 25% whilst in Turkey is 0-18%. Data for canine dirofilariosis in Africa is scarce, and most are case reports. Overall, the dominant species is Achanthocheilonema dracunculoides, although both D. immitis and D. repens have been reported from some countries. In the Far East, the prevalence ranges from 2% to 15% in northeastern of China. In Hong Kong a novel species has been found in dogs and humans (Candidatus Dirofilaria hongkongensis). In India, the prevalence ranges from 4.7%-29.5% in Northeastern states. The main factors that have influenced the spreading of Dirofilaria infections are the climate changes and the introduction of new, invasive, competent mosquito species such as Aedes albopictus and Ae. koreicus. Other factors include relocation and insufficient prevention in dogs, manly in the new areas of colonization. Feline heartworm infection has been diagnosed in every European country when diagnosed either by the Knott test or by serology for circulating antibodies and antigens of the parasite. However, prevalence is much lower than in dogs. In spite of the continuing spreading of heartworm infection, D. repens is the main concern in Europe, mostly for physicians, while the infection is nearly always asymptomatic in dogs. The infection is spreading from Portugal to the Southeastern regions of Finland and Siberia, and in some areas its prevalence overlaps that of D. immitis. Many reasons make more difficult the control of D. repens than D. immitis: the frequent lack of clinical symptoms of suspicion, the specific diagnosis being possible only by blood examination and the inefficacy of some macrocyclic lactones.