A case report of serologically diagnosed pulmonary anisakiasis with pleural effusion and multiple lesions

Recombinase polymerase amplification combined with lateral flow dipstick assay for rapid visual detection of A.simplex (s. s.) and A.pegreffii in sea foods

Anisakiasis is a food-borne parasitic disease mainly caused by the third stage of Anisakis simplex (s. s.) and Anisakis pegreffii. Traditional methods for detecting of Anisakis involve morphology identification such as visual inspection, enzyme digestion, and molecular methods based on PCR, but they have certain limitations. In this study, the internal transcribed spacer 1 (ITS 1) regions of Anisakis were targeted to develop a visual screening method for detecting A. simplex (s. s.) and A. pegreffii in fish meat based on recombinase polymerase amplification (RPA) combined with lateral flow dipstick (LFD). Specific primers and probes were designed and optimized for temperature, reaction time, and detection threshold. LFD produced clear visual results that were easily identifiable after a consistent incubation of 10-20 min at 37 °C. The whole process of DNA amplification by RPA and readout by LFD did not exceed 30 min. In addition, the detection limit is up to 9.5 × 10-4 ng/μL, and the detection of the artificially contaminated samples showed that the developed assay can effectively and specifically detect A. simplex (s. s.) and A. pegreffii, which fully meet the market's requirements for fish food safety supervision.

Pericardial anisakiasis: unravelling diagnostic challenges in an unprecedented extra-abdominal manifestation: a case report

Background

Anisakis infects humans by consuming contaminated undercooked or raw fish, leading to gastric anisakiasis, gastro-allergic anisakiasis, or asymptomatic contamination. Although larvae usually die when penetrating the gastric tissue, cases of intra- and extra-abdominal spread were described. We report the first probable case of pericardial anisakiasis.

Case summary

A 26-year-old man presented to the emergency department because of progressive lower limb oedema and exertional dyspnoea. Two months prior, he had consumed raw fish without any gastrointestinal symptoms. The echocardiogram reported a circumferential pericardial effusion ('swinging heart') and mildly reduced left ventricular ejection fraction (LVEF). He was diagnosed with myopericarditis after a cardiac magnetic resonance. A fluorodeoxyglucose positron emission tomography scan revealed an intense pericardial metabolism. Blood tests exhibited persistent eosinophilia and mild elevation of Anisakis simplex IgE-as for past infestation. A pericardial drainage was performed, subsequently, serial echocardiograms revealed a spontaneous recovery of his LVEF. No autoimmune, allergic, or onco-haematologic diseases were identified. Based on a history of feeding with potentially contaminated raw fish and on long-lasting eosinophilia, we suspected a pericardial anisakiasis, despite a low but persistent titre of specific IgE. Albendazole was administered for 21 days, along with colchicine and ibuprofen for 2 months; pericardial effusion resolution and eosinophil normalization occurred two weeks after.

Discussion

We hypothesized that Anisakis larvae may have migrated outside the gastrointestinal tract, penetrating the diaphragm and settling in the pericardium, causing pericarditis and pericardial effusion. Clinicians should know that the pericardium may be another extra-abdominal localization of anisakiasis, beyond pleuro-pulmonary involvement.

Worm globalization

We report the first case of eosinophilic pleural effusion due to Anisakis spp. infection in a 39-years-old European subject hospitalized for worsening dyspnoea and abdominal and thoracic pain. Lung CT scan showed bilateral pleural effusion; thoracentesis revealed significant eosinophilia (45%), with normal eosinophils in the blood. Microbiological tests on pleural effusion were negative for bacteria, SARS-CoV-2, tuberculosis, fungi and parasites. The patient used to eat raw fish; Western blot was positive for Anisakis spp. in blood and pleural effusion. In the era of globalization, unusual parasitic infections should be considered also in nonendemic countries, especially in patients with unexplained eosinophilia.

Anisakiasis: Imaging findings

OBJECTIVE

To review the main findings for anisakiasis in the different imaging tests that can be used to diagnose it, based on studies done at our center.

CONCLUSION

The presence of Anisakis species in food consumed in Western countries is becoming more common. Patients with anisakiasis present with acute abdomen; there are no specific clinical signs or laboratory findings. Careful history taking is key to discovering exposure to Anisakis-contaminated food, but this task is hindered by unfamiliarity with the condition and lack of suspicion and is also confounded by the variable latency period after ingestion of Anisakis-contaminated food. Give the nonspecific presentation, patients with anisakiasis often undergo imaging tests to rule out other processes. Thus, radiologists need to be familiar with the spectrum of imaging findings that should lead to the inclusion of anisakiasis in the differential diagnosis, so they can guide clinicians toward directed history taking and specific tests.

Eosinophilic Enteritis Due to Anisakis: A Call for Pathologists' Attention

Anisakis simplex, a common parasite of the fish we eat, can cause eosinophilic enteriis by direct parasitization. The authors describe six cases of intestinal anisakiasis dignosed by morphologic and immunologic studies in vivo and in vitro, five being retospective cases of unclassified eosinophilic enteritis. All patients presented with symptoms of acute abdomen requiring urgent surgery. They all had segmental lesions in the jejunum and/or ileum. Histologically the authors observed eosinophilic miroabscesses; in two cases Anisakis larvae were found. None of the patients declared having eaten raw fish. The surgical pathologist plays a basic role in detecting this disase, although additional serologic investigation of anti-Anisakis IgE and a skin test should be done whenever possible.

Molecular epidemiology and risk factors for Anisakis simplex s.l. infection in blue whiting (Micromesistius poutassou) in a confluence zone of the Atlantic and Mediterranean: Differences between A. simplex s.s. and A. pegreffii

Our study determined parameters of parasitization of Anisakis simplex s.l. in Micromesistius poutassou in a confluence zone of the Atlantic and Mediterranean, with a total prevalence of 82%. Also, in the three seasons analyzed, high prevalence's values were found, reaching 100% in spring; however mean intensity and abundance values were higher in winter. The use of molecular techniques to differentiate between Anisakis genotypes of the larvae characterized allowed obtaining values of 99.7% Anisakis simplex s.l. (50.1% A. simplex s.s., 42.9% A. pegreffii, 7.0% A. simplex s.s. - A. pegreffii hybrids) and 0.3% A. typica. The infections found in the fish were of both single and mixed species, in all the different possible combinations. The presence of A. simplex s.l. in the viscera varied according to genotype and season. Likewise, factors associated with the presence of the parasite in the ventral or dorsal musculature were different, where A. simplex s.s. proportion was double than that of A. pegreffii. The ecology of the two sibling species with regard to their location in fish and the influence of the season were different.

Parametrial anisakidosis

Anisakidosis is a parasitic infection caused by anisakid nematodes in the genera Anisakis and Pseudoterranova. Infection is not uncommon in the United States due to increased raw seafood consumption. We report the first known case of parametrial anisakidosis in a 42-year-old woman and review existing literature.

Scanning electron microscopy of Anisakis larvae following different treatments

Ingestion of fish parasitized with Anisakis larvae can produce infestation and/or allergy in consumers. Technological and food processing treatments have been applied to parasitized fish in order to kill the larvae and avoid the infestation; however, their influence on allergenicity has not been studied. Four lots of hake (Merluccius merluccius) steaks artificially parasitized with Anisakis larvae were subjected to two storage chilling (5 degrees C +/- 1 degrees C) and freezing (-20 degrees C +/- 1 degrees C) treatments and two food processing treatments of heat (final temperature 86.3 degrees C) and microwave (final temperature 66.9 degrees C) and studied by scanning electron microscopy, environmental scanning electron microscopy (ESEM) (acid [pH = 2] and water preparations), and emission of fluorescence. Anisakis larvae were resistant to acid conditions, remaining alive after treatment. Larvae in the heat- and microwave-treated lots presented coagulated and disrupted zones in the cuticle with release of fluids. The cylindrical shape changed to a dehydrated appearance mainly observed by ESEM. Fluorescence was only noticeable in the frozen larvae. Larvae without apparent changes, together with dehydrated ones, were observed by ESEM in the frozen lot; nevertheless, no disruptions in the cuticle were perceptible. Further studies are needed in order to elucidate if the changes observed in the cuticle reduce the resistance of the parasites to the action of gastric enzymes in the gastrointestinal tract and to determine the release of allergens to the flesh by the live larvae during chilled storage of the fish.

Sushi delights and parasites: the risk of fishborne and foodborne parasitic zoonoses in Asia

Because of the worldwide popularization of Japanese cuisine, the traditional Japanese fish dishes sushi and sashimi that are served in Japanese restaurants and sushi bars have been suspected of causing fishborne parasitic zoonoses, especially anisakiasis. In addition, an array of freshwater and brackish-water fish and wild animal meats, which are important sources of infection with zoonotic parasites, are served as sushi and sashimi in rural areas of Japan. Such fishborne and foodborne parasitic zoonoses are also endemic in many Asian countries that have related traditional cooking styles. Despite the recent increase in the number of travelers to areas where these zoonoses are endemic, travelers and even infectious disease specialists are unaware of the risk of infection associated with eating exotic ethnic dishes. The aim of this review is to provide practical background information regarding representative fishborne and foodborne parasitic zoonoses endemic in Asian countries.

[Anisakiasis: an infestation to be known by surgeons]

BACKGROUND

Anisakis infestation is related to the consumption of raw or undercooked fish. It can cause allergic reactions, or abdominal pain when the gastrointestinal tube is involved. Its incidence is rising in Europe.

OBJECTIVE

To analyze a group of patients complaining of right iliac fossa pain with ileitis or colitis and establish its relationship with Anisakis spp. infection.

PATIENTS AND METHODS

During a 3-months period, 28 patients with abdominal pain were referred to the hospital with a diagnosis of ileitis or colitis by imaging, endoscopy or surgery. Specific serology for Anisakis was performed in all of them.

RESULTS

At imaging study, 14 patients had ileitis or colitis, three intestinal obstruction and one acute appendicitis. Fourteen patients were operated on and 7 of them underwent resection; histopathologic diagnosis were eosinophilic ileitis (2 cases) or colitis (3 cases), non specific ileitis (1 case) and Crohn's disease (1 case). Another patient had an endoscopic biopsy that concluded eosinophilic colitis. Anisakis serology was positive in 25 (89%), negative in two and unknown in one. All patients were discharged uneventfully.

CONCLUSIONS

Digestive anisakiasis may present as acute abdomen. Surgeons should know and consider this diagnosis in patients with ileitis or colitis, moreover if an antecedent of raw or undercooked fish ingestion is present. A conservative approach is best performed but the clinical picture can require an emergent laparotomy.

Pulmonary anisakiasis presenting as eosinophilic pleural effusion

A 63-year-old man developed a pleural effusion with marked eosinophilia, which was more prominent in the pleural fluid than in the peripheral blood. The pleural effusion spontaneously disappeared 7 days after admission. A multiple dot enzyme-linked immunosorbent assay for anisakiasis was strongly positive for both the serum and pleural fluid. The serum IgG titre for Anisakis simplex gradually decreased over 7 months. It is suspected that Anisakis larvae can penetrate the alimentary canal, and then migrate into the pleural cavity through the diaphragm. Screening with a serological test is useful in the diagnosis of this condition; human pulmonary anisakiasis.

Anisakis y anisakiosis

The nematode Anisakis simplex (AS) is a world wide distributed parasite that infects consumers of raw or undercoocked parasitized fish. The clinical manifestation of Anisakiosis depend on the site in the digestive tract in which larva lodges. The symptoms develops as a result of the inflammation when the larvae penetrates the gastric mucous. Most of asymptomatic subjects show high levels of specific IgE to AS. Diagnosis of AS allergy is not simple, due to cross-reactivity with other allergens. In childhood is more difficult to make a right diagnosis than in adult population. Most of positive prick test to AS correspond to children with positive prick tests to other allergens. Cross-reactivity between this parasite and other parasites with a higher prevalence in childhood, is the cause of a false diagnosis. The secretor-excretory antigen shows a better specificity, recognizing the true parasitized patients. This antigen could be used as indicator of parasitization. To follow prevention rules AS, avoid consumption of raw fish unless frozen for 48 hours or ingestion of fresh fish always cooked for more than 20 minutes at least at 60 C.

Effects of ivermectin and albendazole against Anisakis simplex in vitro and in guinea pigs

The activity of ivermectin and albendazole against larval Anisakis simplex was tested in vitro and in experimentally infected guinea pigs. Before drug exposure the medium for half of the larvae was adjusted to pH 2.0 with 1 N HCl, whereas the other half was held at pH 7.0. To these solutions, ivermectin was added to full concentrations of 1, 2, 5, 10, 50, 100, or 200 microg/ml, and for albendazole, 300, 400, and 500 microg/ml. Animals from group I were given 0.1 ml of 1% (3.3 mg/kg) ivermectin, whereas guinea pigs from group II were each given 5-7 mg (16.6-23.3 mg/kg) of albendazole orally. The efficacy of both drugs against L, A. simplex was high in vitro and in vivo against the larvae in different organs of guinea pigs.

Anisakis simplex-sensitized patients: should fish be excluded from their diet?

BACKGROUND

Anisakis simplex (A.s.) allergy is an emerging disease. The third-stage larvae of this nematode are a source of hidden allergens in fish. There are no clear guidelines concerning dietary restrictions for patients with serum-specific IgE to this parasite.

OBJECTIVE

To follow up the clinical data and immunological parameters of patients sensitized to A.s. during 6 to 23 months.

METHODS

The clinical symptoms and serologic status of 17 patients with specific IgE and positive skin prick test results to A.s. were studied prospectively. Six of these had anaphylaxis (ANA) attributed to A.s. and 11 patients experienced concomitant chronic urticaria (CU). All patients were advised not to eat fish for 6 months.

RESULTS

Four patients from the ANA group excluded fish, and ANA did not recur. Two other patients with ANA refused to exclude fish; one remained free of symptoms and the other experienced several urticarial episodes. During this 6-month period total IgE levels decreased in all six ANA patients; specific IgE for A.s. decreased in four patients and increased in two. Two patients from the CU group did not exclude fish, and symptoms persisted in these two patients. Clinical improvement was observed in 78% of the patients with CU who excluded fish. Total and specific IgE levels decreased in all the patients with CU.

CONCLUSIONS

Because ANA symptoms are very severe, patients should always be advised to exclude fish until specific food allergens are identified. However, in patients with CU and specific IgE to A.s., only the clinical response to fish ingestion will determine the need for strict fish avoidance.

Eosinophilia and helminthic infections

Among microbial agents, helminths are the most common cause of eosinophilia. An approach to the evaluation of a patient with eosinophilia is outlined, with particular emphasis on clues in the history, examination and routine laboratory data that can help with the diagnosis. Multiple helminthic infections have been associated with eosinophilia, and the characteristic modes of spread, clinical manifestations, diagnostic tests and therapeutic considerations of these infections are discussed.

Gastroallergic anisakiasis: borderline between food allergy and parasitic disease-clinical and allergologic evaluation of 20 patients with confirmed acute parasitism by Anisakis simplex

BACKGROUND

Human subjects can be parasitized by Anisakis simplex by eating raw or undercooked fish. Gastric anisakiasis is probably the most frequent clinical entity presenting with severe epigastric pain, vomiting, and diarrhea. In gastroallergic anisakiasis hypersensitivity symptoms predominate.

OBJECTIVE

We sought to describe clinical features, laboratory data, and gastroscopic findings in gastroallergic anisakiasis.

METHODS

We selected 40 patients presenting to the emergency department with an acute allergic reaction, and if we suspected acute parasitism by A simplex, a fiberoptic gastroscopy was performed. In 20 patients we could detect one or more nematodes; these patients are referred to as group A. Those in whom no worm could be found are referred to as group B (n = 20). A detailed history, clinical features, gastroscopic findings, laboratory data, and skin prick test responses were compared.

RESULTS

Long-time intervals of up to 26 hours between fish intake and onset of hypersensitivity symptoms were found (group A, 5.4 +/- 6.3 hours; group B, 5.3 +/- 2.6 hours). Patients in groups A and B did not differ with respect to allergic symptoms (urticaria, angioedema, erythema, bronchospasm, and anaphylaxis) or the mainly light abdominal symptoms (upper abdominal pain, nausea, vomiting, and diarrhea). No significant differences were found with respect to age, time interval between fish intake and onset of symptoms, white cell and eosinophil counts, specific IgE levels against A simplex, or total IgE levels.

CONCLUSIONS

The peculiar sometimes long-time interval between fish intake and onset of allergic symptoms render the diagnosis difficult. An early gastroscopy can confirm the diagnosis and prevent complications. We suggest that gastroallergic anisakiasis be considered a distinct clinical entity in which the predominant symptoms are hypersensitivity symptoms and in which the correct diagnosis is not only important in the management of the acute reaction but also in the prevention of further allergic episodes.

Human immunoglobulin isotype profiles produced in response to antigens recognized by monoclonal antibodies specific to Anisakis simplex

BACKGROUND

Anisakis simplex is a medically important pathogen which not only causes anisakiasis but may provoke allergy reactions, ranging from mild urticaria to anaphylactic shock.

OBJECTIVE

To investigate anti-Anisakis isotype profiles in anisakiasis and Anisakis allergy patients.

METHODS

Capture ELISA techniques were used to investigate the isotype profiles of antibodies specific for two defined Anisakis simplex antigens, in serum from Japanese patients with confirmed anisakiasis and from Spanish patients with allergy to Anisakis. The antigens were 'UA2R antigens' (two proteins with MW of 48 and 67 kDa, recognized by our monoclonal antibody UA2) and 'UA3R antigens' (two proteins with MW of 139 and 154 kDa, recognized by our monoclonal antibody UA3).

RESULTS

Considering IgG, the two most frequent isotypes in the response to the UA2R antigens were IgG1 and IgG2, with IgG4 detected in only one case; in response to the UA3R antigens, by contrast, the two most frequent isotypes were IgG1 and IgG4 (though IgG2 remained reasonably frequent). As regards potential utility for serodiagnosis, 95% of the Japanese anisakiasis patients and 84% of the allergy patients showed detectable IgG1 antibodies to the UA3R antigens. Furthermore, all allergy patients showed IgE antibodies to these antigens.

CONCLUSION

Anisakis simplex contains antigens that induce responses which are differentially regulated. Because of their immunogenicity, immunodominance and allergenic nature, we consider that the 139/154-kDa antigens recognized by our MoAb UA3 are good candidates for use in tests for the diagnosis of anisakiasis and of the allergy caused by this parasite.