Cluster of Angiostrongyliasis Cases Following Consumption of Raw Monitor Lizard in the Lao People's Democratic Republic and Review of the Literature

Angiostrongyliasis: A Changing Scenario?

Angiostrongyliasis is a parasitic disease caused by larvae of the genus Angiostrongylus, with Angiostrongylus cantonensis and Angiostrongylus costaricensis being the two main species causing diseases in humans [...].

Comparative biology of parasitic nematodes in the genus Angiostrongylus and related genera

The rise to prominence of some Angiostrongylus species through associated emerging disease in humans and dogs has stimulated calls for a renewed focus on the biology of this genus and three related genera. Although significant research efforts have been made in recent years these have tended to focus on individual species and specific aspects such as diagnosis and treatment of disease or new records of occurrence and hosts. This comprehensive review takes a comparative approach, seeking commonalities and differences among species and asking such questions as: Which species belong to this and to closely related genera and how are they related? Why do only some species appear to be spreading geographically and what factors might underlie range expansion? Which animal species are involved in the life cycles as definitive, intermediate, paratenic and accidental hosts? How do parasite larvae find, infect and develop within these hosts? What are the consequences of infection for host health? How will climate change affect future spread and global health? Appreciating how species resemble and differ from each other shines a spotlight on knowledge gaps and provides provisional guidance on key species characteristics warranting detailed study. Similarities exist among species, including the basic life cycle and transmission processes, but important details such as host range, climatic requirements, migration patterns within hosts and disease mechanisms differ, with much more information available for A. cantonensis and A. vasorum than for other species. Nonetheless, comparison across Angiostrongylus reveals some common patterns. Historically narrow definitive host ranges are expanding with new knowledge, combining with very broad ranges of intermediate gastropod hosts and vertebrate and invertebrate paratenic and accidental hosts to provide the backdrop to complex interactions among climate, ecology and transmission that remain only partly understood, even for the species of dominant concern. Key outstanding questions concern larval dynamics and the potential for transmission outside trophic relations, relations between infection and disease severity in different hosts, and how global change is altering transmission beyond immediate impacts on development rate in gastropods. The concept of encounter and compatibility filters could help to explain differences in the relative importance of different gastropod species as intermediate hosts and determine the importance of host community composition and related environmental factors to transmission and range. Across the group, it remains unclear what, physiologically, immunologically or taxonomically, delimits definitive, accidental and paratenic hosts. Impacts of infection on definitive host fitness and consequences for population dynamics and transmission remain mostly unexplored across the genus. Continual updating and cross-referencing across species of Angiostrongylus and related genera is important to synthesise rapid advances in understanding of key traits and behaviours, especially in important Angiostrongylus species that are emerging causative agents of disease in humans and other animals.

An Overview of Angiostrongylus cantonensis (Nematoda: Angiostrongylidae), an Emerging Cause of Human Angiostrongylosis on the Indian Subcontinent

Human angiostrongylosis is an emerging zoonosis caused by the larvae of three species of metastrongyloid nematodes of the genus Angiostrongylus, with Angiostrongylus cantonensis (Chen, 1935) being dominant across the world. Its obligatory heteroxenous life cycle includes rats as definitive hosts, mollusks as intermediate hosts, and amphibians and reptiles as paratenic hosts. In humans, the infection manifests as Angiostrongylus eosinophilic meningitis (AEM) or ocular form. Since there is no comprehensive study on the disease in the Indian subcontinent, our study aims at the growing incidence of angiostrongylosis in humans, alongside its clinical course and possible causes. A systematic literature search revealed 28 reports of 45 human cases from 1966 to 2022; eosinophilic meningitis accounted for 33 cases (75.5%), 12 cases were reported as ocular, 1 case was combined, and 1 case was unspecified. The presumed source of infection was reported in 5 cases only. Importantly, 22 AEM patients reported a history of eating raw monitor lizard (Varanus spp.) tissues in the past. As apex predators, monitor lizards accumulate high numbers of L3 responsible for acute illness in humans. For ocular cases, the source was not identified. Most cases were diagnosed based on nematode findings and clinical pathology (primarily eosinophilia in the cerebrospinal fluid). Only two cases were confirmed to be A. cantonensis, one by immunoblot and the other by q-PCR. Cases of angiostrongylosis have been reported in Delhi, Karnataka, Kerala, Maharashtra, Madhya Pradesh, Puducherry, Telangana, and West Bengal. With a population of more than 1.4 billion, India is one of the least studied areas for A. cantonensis. It is likely that many cases remain undetected/unreported. Since most cases have been reported from the state of Kerala, further research may focus on this region. Gastropods, amphibians, and reptiles are commonly consumed in India; however, typical preparation methods involve cooking, which kills the nematode larvae. In addition to studying rodent and mollusk hosts, monitor lizards can be used as effective sentinels. Sequence data are urgently needed to answer the question of the identity of Angiostrongylus-like metastrongylid nematodes isolated from all types of hosts. DNA-based diagnostic methods such as q-PCR and LAMP should be included in clinical diagnosis of suspected cases and in studies of genetic diversity and species identity of nematodes tentatively identified as A. cantonensis.

Neuroangiostrongyliasis: Global Spread of an Emerging Tropical Disease

Neuroangiostrongyliasis (NAS) is an emerging parasitic disease caused by the neurotropic nematode Angiostrongylus cantonensis. Since it was first discovered, in rats in southern China in the 1930s, this tropical to subtropical parasite has spread to much of Southeast Asia, the Pacific Islands (including Hawaii), Australia, Japan, South America, the southeastern United States, the Caribbean, Africa, the Canary Islands, and the Balearic Islands. The parasite completes its natural life cycle in snails and slugs (intermediate hosts), and rats (definitive hosts). Humans become accidental hosts after ingesting infective third-stage larvae contained within uncooked or undercooked intermediate or paratenic hosts, an event that sometimes results in NAS, also known as rat lungworm disease. Although A. cantonensis larvae cannot complete their life cycle in humans, their migration into the brain and spinal cord combined with a powerful inflammatory reaction often leads to eosinophilic meningitis and can, in rare instances, lead to coma, paralysis, and death or, in other cases, chronic, disabling neurologic sequelae. Symptoms of NAS are diverse, which often makes it difficult to diagnose. Treatment may include administration of analgesics, corticosteroids, anthelminthics, and repeat lumbar punctures to reduce intracranial pressure. Unfortunately, few medical providers, even in endemic areas, are familiar with A. cantonensis or its epidemiology, diagnosis, and treatment. As the parasite continues to spread and NAS affects more people, medical practitioners, as well as the general public, must become more aware of this emerging zoonosis and the potentially devastating harm it can cause.

Epidemiological, clinical and laboratory aspects of Angiostrongylus cantonensis infection: an integrative review

This integrative literature review study analyzes the findings of the last 5 years of the parasite Angiostrongylus cantonensis. It is known that this nematode is found in the pulmonary arteries of rats, where it remains as a definitive host. From mice, the cycle spreads to animals, such as snails, which in contact with humans can trigger the disease. In humans, the parasite causes several neurological, abdominal manifestations and mainly meningitis. Based on the review of studies, its epidemiology shows worldwide distribution, although there are endemic cases for this parasite, such as asian countries. Laboratory findings generally showed altered CSF with turbidity, increased protein and eosinophilia, which generated meningeal signs in the patient, moreover MRI exams showed multiple alterations. Rare findings of the nematode in the eyeball, lung and signs of peritoneal inflammation were reported, which requires further studies to understand the whole pathophysiology. Finally, conservative treatment based on anthelmintics and anti-inflammatories brought good responses, although there are reports of deaths, which demonstrates the importance in the prevention and therapy of this disease.

Paratenic hosts of Angiostrongylus cantonensis and their relation to human neuroangiostrongyliasis globally

The nematode parasite Angiostrongylus cantonensis (rat lungworm) has a complex life cycle involving rats (definitive hosts) and gastropods (intermediate hosts), as well as various paratenic hosts. Humans become infected and develop rat lungworm disease (neuroangiostrongyliasis) when they consume intermediate or paratenic hosts containing the infective parasite larvae. This study synthesizes knowledge of paratenic hosts of A. cantonensis and investigates their role in causing human neuroangiostrongyliasis worldwide. A literature review was conducted by searching PubMed, JSTOR and Scopus, pooling additional information from sources accumulated over many years by RHC, and snowball searching. The review identified 138 relevant articles published between 1962 and 2022. Freshwater prawns/shrimp, crayfish, crabs, flatworms, fish, sea snakes, frogs, toads, newts, lizards, centipedes, cattle, pigs and snails were reported to act as paratenic hosts in various regions including South and Southeast Asia, Pacific islands, the USA and the Caribbean, as well as experimentally. Human cases of neuroangiostrongyliasis have been reported from the 1960s onwards, linked, sometimes speculatively, to consumption of freshwater prawns/shrimp, crabs, flatworms, fish, frogs, toads, lizards and centipedes. The potential of paratenic hosts to cause neuroangiostrongyliasis depends on whether they are eaten, how frequently they are consumed, the preparation method, including whether eaten raw or undercooked, and whether they are consumed intentionally or accidentally. It also depends on infection prevalence in the host populations and probably on how high the parasite load is in the consumed hosts. To prevent human infections, it is crucial to interrupt the transmission of rat lungworm to humans, from both intermediate hosts and frequently consumed paratenic hosts, by adhering to safe food preparation protocols. Educating the general public and the medical community about this largely neglected tropical/subtropical disease is key.

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Neuroangiostrongyliasis, an emerging parasitic disease of humans and wildlife.

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Caused by the nematode Angiostrongylus cantonensis (rat lungworm).

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Infection primarily via ingestion of stage 3 larvae of the parasite.

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People eat raw intermediate or paratenic hosts infected with stage 3 larvae.

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Comprehensive review of paratenic hosts’ role in neuroangiostrongyliasis globally.

Sociocultural Factors Influencing Human Streptococcus suis Disease in Southeast Asia

The public health systems of Southeast Asian countries are financially challenged by a comparatively higher incidence of human S. suis infections than other geographical areas. Efforts to improve practices in production settings, including improved meat inspection regulations, prevention of the slaughtering of non-healthy pigs, and enhanced hygiene practices at processing facilities, along with improvements in the pork supply chain, all appear promising for reducing food cross-contamination with S. suis. However, opportunities for intervention at the societal level are also needed to effect changes, as population behaviors such as the consumption of raw pork, blood, and offal products are important contributors to the increased incidence of human S. suis disease in Southeast Asia. A plethora of factors are associated with the consumption of these high-risk dishes, including traditional culture and knowledge, shared beliefs, socio-economic level, and personal attitudes associated with gender and/or marital status. Education and intervention in behavioral attitudes that are sensible to cultural practices and traditions may provide additional means to reduce the burden of S. suis human disease in Southeast Asia.

Angiostrongylosis in Animals and Humans in Europe

Lungworms in the genus Angiostrongylus cause disease in animals and humans. The spread of Angiostrongylus vasorum within Europe and the recent establishment of Angiostrongylus cantonensis increase the relevance of these species to veterinary and medical practitioners, and to researchers in parasitology, epidemiology, veterinary science and ecology. This review introduces the key members of the genus present in Europe and their impacts on health, and updates the current epidemiological situation. Expansion of A. vasorum from localized pockets to wide distribution across the continent has been confirmed by a rising prevalence in foxes and increasing reports of infection and disease in dogs, while the list of carnivore and mustelid definitive hosts continues to grow. The tropically distributed rat lungworm A. cantonensis, meanwhile, has been recorded on islands south of Europe, previously the Canary Islands, and now also the Balearic Islands, although so far with limited evidence of zoonotic disease. Other members of the genus, namely, A. chabaudi, A. daskalovi and A. dujardini, are native to Europe and mainly infect wildlife, with unknown consequences for populations, although spill-over can occur into domestic animals and those in zoological collections. The epidemiology of angiostrongylosis is complex, and further research is needed on parasite maintenance in sylvatic hosts, and on the roles of ecology, behaviour and genetics in disease emergence. Improved surveillance in animals and humans is also required to support risk assessments and management.