Differentiating Dracunculus medinensis from D. insignis, by the sequence analysis of the 18S rRNA gene

This study, undertaken as a component of the global Dracunculiasis Eradication Program (DEP), was designed to provide molecular tools to distinguish Dracunculus medinensis, the nematode causing human dracunculiasis, from other tissue-dwelling nematodes, including other Dracunculus species that infect humans and other animals. DNA was extracted from D. medinensis and from a closely related species that infects North American carnivores, D. insignis, so that the genes coding for the small-subunit ribosomal RNA (18S rRNA) of the parasites could be amplified, sequenced and compared. Sequences were obtained for 20 specimens of D. medinensis (from humans in Pakistan, Yemen and six African countries endemic for dracunculiasis) and three of D. insignis (from raccoons trapped in the state of Georgia in the southern U.S.A.). All of the D. medinensis 18S-rRNA sequences were found to be 1819 bases long and identical. The three D. insignis 18S-rRNA sequences were also found to be identical to each other but were 1821 bases long and differed from the D. medinensis 18S- rRNA sequence at eight positions (representing a difference of 0.44%). The 18S-rRNA coding region of a Guinea worm extracted from a dog in Ghana was indistinguishable from that of the D. medinensis isolates from human cases. These results provide the basis for the molecular differentiation of D. medinensis that will permit the DEP to determine, rapidly and accurately, whether a worm recovered from an area considered dracunculiasis-free is a specimen of D. medinensis or not.

Human external ophthalmomyiasis occurring in Barbados

Human infection with the sheep nasal botfly Oestrus ovis occurs sporadically. In most cases, there is a history of a strike in the eye by the adult fly. Human O. ovis has been reported rarely from the Americas. We report the first case of O. ovis infection in the Caribbean region, which occurred in an urban area of Barbados. The patient responded to removal of the larvae from the conjunctiva and symptomatic treatment.

Fatal autochthonous eosinophilic meningitis in a Jamaican child caused by Angiostrongylus cantonensis

A fatal case of infection with Angiostrongylus cantonensis is reported in a 14-month-old Jamaican boy. Although infection with Angiostrongylus was not considered initially, sections of multiple worms were observed in the brain and lungs at autopsy and confirmed the infection. This is the first reported fatality due to this infection in the Western Hemisphere, and follows shortly after an outbreak of eosinophilic meningitis among a group of travelers to Jamaica. The source of infection in this case could not be determined.

Canine onchocercosis in Greece: report of further 20 cases and molecular characterization of the parasite and its Wolbachia endosymbiont

Recently, sporadic cases of subconjunctival Onchocerca infection have been reported in dogs in Greece and Hungary. Herein we report further cases from Greece and the results of the molecular analysis of Onchocerca sp. removed from Greek dogs and its Wolbachia endosymbionts. Twenty dogs of various breeds, 1-11 years of age with subconjunctival onchocercosis (4 cases each in right or left eye, 12 cases in both eyes) were presented having similar manifestations. Periorbital swelling, exophthalmos, lacrimation, discharge, photophobia, conjunctival congestion, corneal edema, protrusion of the nictitating membrane, and subconjunctival granuloma or cyst formation were the most important clinical signs. After surgical excision of the periocular masses containing the worms, all animals recovered fully from onchocercosis. Based on the similarities of the clinical picture of the Greek and Hungarian cases, the similar morphology of the Greek and Hungarian isolates, and the identical sequences of the cytochrome oxidase gene of the filarial parasites and that of the 16S ribosomal RNA gene from their Wolbachia endosymbionts, the Onchocerca sp. isolated from dogs in Greece and Hungary appears to belong to the same species.

MOLECULAR AND BIOLOGIC CHARACTERISTICS OF TOXOPLASMA GONDII ISOLATES FROM WILDLIFE IN THE UNITED STATES

Toxoplasma gondii isolates can be grouped into 3 genetic lineages. Type I isolates are considered more virulent in outbred mice and have been isolated predominantly from clinical cases of human toxoplasmosis, whereas types II and III isolates are considered less virulent for mice and are found in humans and food animals. Little is known of genotypes of T. gondii isolates from wild animals. In the present report, genotypes of isolates of T. gondii from wildlife in the United States are described. Sera from wildlife were tested for antibodies to T. gondii with the modified agglutination test, and tissues from animals with titers of 1:25 (seropositive) were bioassayed in mice. Toxoplasma gondii was isolated from the hearts of 21 of 34 seropositive white-tailed deer (Odocoileus virginianus) from Mississippi and from 7 of 29 raccoons (Procyon lotor); 5 of 6 bobcats (Lynx rufus); and the gray fox (Urocyon cinereoargenteus), red fox (Vulpes vulpes), and coyote (Canis latrans) from Georgia. Toxoplasma gondii was also isolated from 7 of 10 seropositive black bears (Ursus americanus) from Pennsylvania by bioassay in cats. All 3 genotypes of T. gondii based on the SAG2 locus were circulating among wildlife.

Dracunculus medinensis and Schistosoma mansoni contain opiate alkaloids

The results of analysis, by high-performance liquid chromatography coupled with electrochemical detection and by nano-electrospray-ionization, double quadrupole/orthogonal-acceleration, time-of-flight mass spectrometry, indicate that adult Dracunculus medinensis and Schistosoma mansoni both contain the opiate alkaloid morphine and that D. medinesis also contains the active metabolite of morphine, morphine 6-glucuronide. From these and previous observations, it would appear that many helminths are probably using opiate alkaloids as potent immunosuppressive and antinociceptive signal molecules, to down-regulate immunosurveillance responsiveness and pain signalling in their hosts.

A survey for Cyclospora spp. in Kenyan primates, with some notes on its biology

From March 1999 through August 2000, 511 stool samples collected from 11 different primate species in 10 geographically distinct locations in Kenya, East Africa, were screened for the presence of Cyclospora spp. oocysts. Positive samples (43/102, 42%) were identified in vervet monkeys (Cercopithecus aethiops) in 4 of 4 locations; 19/206 (9%) in yellow and olive baboons (Papio cynocephalus, P. anubis, respectively) in 5 of 5 locations; and 19/76 (25%) in black and white colobus monkeys (Colobus angolensis, C. guereza, respectively) from 2 of 3 locations. DNA sequences obtained from 18 S rRNA coding regions from respective subsets of these positive samples were typed as Cyclospora cercopitheci (samples from Cercopithecus aethiops). Cyclospora papionis (samples from Papio cynocephalus and P. anubis), and Cyclospora colobi (samples from Colobus angolensis and C. guereza). Cyclospora oocysts were not detected in samples collected from patas, highland sykes, lowland sykes, blue sykes, DeBrazza, or red-tailed monkeys. A coded map showing the geographic location of the collected samples is given. Stool samples from 1 troop of vervet monkeys were collected over a 12-mo period. Positive samples ranged between 21 and 63%. These results suggest that there is no strongly marked seasonality evident in Cyclospora infection in monkeys as has been noted in human infection. This is further confirmed by the recovery of positive samples collected from vervet monkeys, baboons, and colobus monkeys at all times of the year during this survey. This absence of seasonality in infection is especially notable because of the extreme weather patterns typical of Kenya, where marked rainy and dry seasons occur. A second noteworthy observation is that the striking host specificity of the Cyclospora species initially described was confirmed in this survey. Baboons were only infected with C. papionis, vervet monkeys with C. cercopitheci, and colobus monkeys with C. colobi, despite geographic overlaps of both the monkey and parasite species and wide geographic distribution of each parasite and monkey host.

Misidentification of Onchocerca volvulus as guinea worm

Over the past 10 years, the status of human infection with guinea worm (Dracunculus medinensis) in the Central African Republic (CAR) has been difficult to ascertain. It is unclear if indigenous cases are occurring and whether cases are migrating into the CAR from surrounding countries. A team of investigators visited the CAR in July-August 2000, to attempt to ascertain the presence of indigenous transmission. No cases of true guinea-worm infection (i.e. dracunculiasis) were detected, but three cases of human infection with Onchocerca volvulus, each of which had been misidentified as dracunculiasis, were detected. The unusual presentation of skin blisters and extraction of an intact female O. volvulus are described. As a result of this investigation, and the confusion of onchocerciasis being misidentified as dracunculiasis, the presence of endemic transmission of guinea worm in the CAR remains in question.

Gongylonema infection of the mouth in a resident of Cambridge, Massachusetts

We report a case of Gongylonema infection of the mouth, which caused a migrating, serpiginous tract in a resident of Massachusetts. This foodborne infection, which is acquired through accidental ingestion of an infected insect, such as a beetle or a roach, represents the 11th such case reported in the United States.

Outbreak of cyclosporiasis associated with basil in Missouri in 1999

During the summer of 1999, an outbreak of cyclosporiasis occurred among attendees of 2 events held on 24 July in different counties in Missouri. We conducted retrospective cohort studies of the 2 clusters of cases, which comprised 62 case patients. The chicken pasta salad served at one event (relative risk [RR], 4.25; 95% confidence interval [CI], 1.80-10.01) and the tomato basil salad served at the other event (RR, 2.95; 95% CI, 1.72-5.07) were most strongly associated with illness. The most likely vehicle of infection was fresh basil, which was included in both salads and could have been grown either in Mexico or the United States. Leftover chicken pasta salad was found to be positive for Cyclospora DNA by means of polymerase chain reaction analysis, and 1 sporulated Cyclospora oocyst was found by use of microscopy. This is the second documented outbreak of cyclosporiasis in the United States linked to fresh basil and the first US outbreak for which Cyclospora has been detected in an epidemiologically implicated food item.

Experimental Oesophagostomum bifurcum in monkeys

OESOPHAGOSTOMUM BIFURCUM: larvae, cultured from human stools collected in northern Ghana, were used to establish experimental infections in monkeys. A patent infection was established in a rhesus monkey (Macaca mulatta) and this infection was used to generate larvae to inoculate additional monkeys. In all, 17 animals were inoculated. Thirteen of 15 animals developed antibodies to the infection between 19 and 62 days post inoculation (PI); two animals had a positive response before inoculation. Four of ten animals developed patent infections between 88 and 134 days and passed eggs in the faeces. Egg shedding was consistent in only one animal, but at low levels of one or two eggs per 2 mg direct smear, and extended over a 400 day period. In the other three animals, egg shedding was sporadic and of only 2-4 weeks duration. In seven animals necropsied between 19 and 22 days PI, one to 17 early fourth-stage larvae were recovered from nodules in the bowel wall; in an eighth animal examined at 314 days, six immature adult worms (early fifth stage) were recovered from nodules in the bowel wall. The morphological features and growth of these recovered larvae are described. Three animals were inoculated with larvae that had been dried for one week at 28 degrees C; two animals began shedding eggs at 128 and 134 days PI, respectively. The present results suggest that the parasite obtained from humans is poorly adapted to lower primate hosts, and supports the concept that Oesophagostomum bifurcum found in humans and monkeys in the same geographical region of northern Ghana and Togo are distinct and that the infections in humans are not likely to represent zoonotic infections acquired from monkeys.

Ocular Onchocerca infections in two dogs in western United States

Two dogs, one from California and one from Arizona, were found to have aberrant infections caused by filarial nematodes of the genus Onchocerca. In both cases, the parasites are localized in or near the eye. In one case the worm was located in the cornea and was surgically removed. In the second case, a very marked granulomatous reaction was induced in the retrobulbar space, mimicking an abscess. This eye was enucleated. The worms in both instances were female, and were gravid, i.e. contained microfilariae in utero, indicating that a male worm(s) had been present and mating had occurred. The exact identity of the species of Onchocerca responsible cannot be determined, although the features observed are most like Onchocerca lienalis of cattle. These cases represent the fourth and fifth such cases reported from the US, and are especially interesting because of the unusual location of the worms, the small number of recognized cases, and the similarity to a recent zoonotic human infection.

Attempts to establish experimental Cyclospora cayetanensis infection in laboratory animals

Attempts were made to develop an animal model for Cyclospora cayetanensis to identify a practical laboratory host for studying human cyclosporiasis. Oocysts collected from stool of infected humans in the United States, Haiti, Guatemala, Peru, and Nepal were held in potassium dichromate solution to allow development of sporozoites. The following animal types were inoculated: 9 strains of mice, including adult and neonatal immunocompetent and immune-deficient inbred and outbred strains, rats, sandrats, chickens, ducks, rabbits, jirds, hamsters, ferrets, pigs, dogs, owl monkeys, rhesus monkeys, and cynomolgus monkeys. Most animals were inoculated by gavage, although some of the primates were fed oocysts on food items. The animals were examined for signs of infection, particularly diarrhea, and stool samples were examined for 4-6 wk after inoculation. None of the animals developed patent infections or signs of infection. We conclude that none of the animals tested is susceptible to infection with C. cayetanensis.

Evaluation of the whole blood filariasis ICT test for short-term monitoring after antifilarial treatment

The immunochromatographic (ICT) filariasis test is a rapid screening tool that will be useful for defining the prevalence and distribution of Wuchereria bancrofti as part of the global program to eliminate lymphatic filariasis. To address questions about its usefulness for monitoring control programs, we used the ICT filariasis test to assess residual antigen levels following antifilarial treatment. Our results demonstrate that antigen levels persist in microfilaria-negative persons for up to three years after treatment. Different strategies for monitoring control programs may have to be considered.

The capacity of the third-stage larvae of Oesophagostomum bifurcum to survive adverse conditions

Human infections with the intestinal nematode Oesophagostomum bifurcum are commonly found in the Sudan savannah of northern Togo and Ghana. Apparently, the long and hot dry season in this region does not prevent transmission, which is believed to take place through ingestion of the infective, third-stage larvae (L3). Oesophagostomum L3 cultured from human stools, unlike the larvae of Necator americanus, were shown to survive desiccation. In addition, 93% of the O. bifurcum L3 frozen for 24 h at -15 degrees C regained motility when brought back into ambient temperatures. The L3 also survived the acidity of an artificial mixture made to resemble the gastric juices of humans. Desiccated larvae could even be rehydrated in this mixture, indicating the possibility of dust-borne infections. The sturdiness of the L3 is likely to contribute to the high transmission intensity in northern Togo and Ghana.

Use of polymerase chain reaction to diagnose the fifth reported US case of autochthonous transmission of Trypanosoma cruzi, in Tennessee, 1998

In July 1998, the mother of an 18-month-old boy in rural Tennessee found a triatomine bug in his crib, which she saved because it resembled a bug shown on a television program about insects that prey on mammals. The gut contents of the Triatoma sanguisuga were found, by light microscopy and polymerase chain reaction (PCR), to be infected with Trypanosoma cruzi; PCR products hybridized with T. cruzi-specific oligonucleotide probes. Whole-blood specimens obtained from the child in July and August were negative by buffy-coat examination and hemoculture but positive by PCR and DNA hybridization, suggesting that he had low-level parasitemia. Specimens obtained after treatment with benznidazole were negative. He did not develop anti-T. cruzi antibody; 19 relatives and neighbors also were seronegative. Two of 3 raccoons trapped in the vicinity had positive hemocultures for T. cruzi. The child's case of T. cruzi infection-the fifth reported US autochthonous case-would have been missed without his mother's attentiveness and the availability of sensitive molecular techniques.

Evaluation of Streck Tissue Fixative, a Nonformalin Fixative for Preservation of Stool Samples and Subsequent Parasitologic Examination

We undertook a study to evaluate Streck tissue fixative (STF) as a substitute for formalin and polyvinyl alcohol (PVA) in fecal preservation. A comparison of formalin, PVA, (mercuric chloride based), and STF was done by aliquoting fecal samples into each fixative. Stool specimens were collected in Haiti, and parasites included Cyclospora cayetanensis , Giardia intestinalis , Entamoeba coli , Iodamoeba butschlii , Endolimax nana , Ascaris lumbricoides , Trichuris trichiura , Strongyloides stercoralis , and Necator americanus . Preserved stools were examined at various predetermined times (1 week, 1 month, and 3 months) to establish the quality of the initial preservation as well as the suitability of the fixative for long-term storage. At each time point, stool samples in fixatives were examined microscopically as follows: (i) in wet mounts (with bright-field and epifluorescence microscopy), (ii) in modified acid-fast-, trichrome-, and safranin-stained smears, and (iii) with two commercial test kits. At the time points examined, morphologic features remained comparable for samples fixed with 10% formalin and STF. For comparisons of STF- and 10% formalin-fixed samples, specific findings showed that Cyclospora oocysts retained full fluorescence, modified acid-fast- and safranin-stained smears of Cryptosporidium and Cyclospora oocysts were equal in staining quality, and results were comparable in the immunofluorescence assay and enzyme immunoassay commercial kits. Stool fixed in STF and stained with trichrome showed less-than-acceptable staining quality compared with stool fixed in PVA. STF provides an excellent substitute for formalin as a fixative in routine examination of stool samples for parasites. However, modifications to the trichrome staining procedures will be necessary to improve the staining quality for protozoal cysts fixed in STF to a level comparable to that with PVA.

Survey for Cyclospora cayetanensis in domestic animals in an endemic area in Haiti

From January 1997 through July 1998, we examined stool samples from 327 domestic animals, including pigs, cattle, horses, goats, dogs, cats, guinea pigs, chicken, ducks, turkeys, and pigeons in Leogane, Haiti, for the presence of Cyclospora cayetanensis infection. No coccidian oocysts morphologically compatible with C. cayetanensis were detected in any of the animal samples, despite their living in, or near, households with infected individuals. These results suggest that domestic animals are not reservoir hosts for C. cayetanensis and that in this endemic area, humans are the only natural host for this parasite.

Human Gongylonema infection in a resident of New York City

A case of infection with Gongylonema is described in a 41-year-old woman living in New York City. The patient sought medical attention with the complaint of a sensation of 1-year duration of something moving in her mouth. On two occasions she removed worms from her mouth, once from her lip, once from the gum. One of the specimens submitted for examination was an adult female Gongylonema. It is not possible to say whether the infection was acquired in New York City, or elsewhere, since the patient traveled frequently to Mississippi to visit relatives. As cases of delusional parasitosis continue to increase, clinicians and laboratorians alike need to be alert to the possibility that foreign objects removed from the mouth, or elsewhere, may indeed represent unusual parasitic infections, and that these objects should be examined before being discarded.

Cyclospora cayetanensis infections in Haiti: a common occurrence in the absence of watery diarrhea

Stool samples from a population-based cohort of mothers and children living in Leogane, Haiti were tested for Cyclospora cayetanensis from January 1997 through January 1998. Data on gastrointestinal symptoms were also collected. During the winter months of January to March, the infection was detected in 15-20% of the persons sampled. Most infections did not appear to be causing diarrhea and most infected persons had few oocysts detectable in concentrates of stool. The infection appears to have marked seasonality, with highest rates during the driest and coolest time of the year. It may be that in this tropical setting, high summer temperature is the critical environmental factor that influences the seasonality of infection. This study demonstrates that Cyclospora infections in Haiti are common in the general population.

A cluster of transfusion-associated babesiosis cases traced to a single asymptomatic donor

CONTEXT

The risk of acquiring babesiosis by blood transfusion is largely unknown since in areas where it is endemic it is often an asymptomatic infection.

OBJECTIVE

To investigate and treat a cluster of blood transfusion-associated babesiosis cases.

DESIGN

Case series and epidemiologic investigation.

SETTING

Urban inner-city hospital.

PATIENTS

Six persons who received Babesia microti-infected blood components from a donor.

MAIN OUTCOME MEASURE

Diagnosis and successful therapy of babesiosis following transfusion.

RESULTS

Six individuals (1 adult, 1 child, and 4 neonates) were exposed to products from a single blood donation by an asymptomatic Babesia-infected donor. Three of the 6 exposed patients became parasitemic. Polymerase chain reaction testing, animal inoculation studies, and indirect immunofluorescent antibody testing were used to confirm the presence of Babesia microti in the donor's blood and to establish the presence of infection in 3 of the 6 recipients. The 3 infected recipients and 1 additional recipient were treated without incident.

CONCLUSION

Physicians should consider babesiosis in the differential diagnosis of a febrile hemolytic disorder after blood transfusion. Prompt diagnosis is important since babesiosis is responsive to antibiotic therapy and, untreated, can be a fatal disease in certain risk groups.

Morphologic and molecular characterization of new Cyclospora species from Ethiopian monkeys: C. cercopitheci sp.n., C. colobi sp.n., and C. papionis sp.n

In recent years, human cyclosporiasis has emerged as an important infection, with large outbreaks in the United States and Canada. Understanding the biology and epidemiology of Cyclospora has been difficult and slow and has been complicated by not knowing the pathogen s origins, animal reservoirs (if any), and relationship to other coccidian parasites. This report provides morphologic and molecular characterization of three parasites isolated from primates and names each isolate: Cyclospora cercopitheci sp.n. for a species recovered from green monkeys, C. colobi sp.n. for a parasite from colobus monkeys, and C. papionis sp.n. for a species infecting baboons. These species, plus C. cayetanensis, which infects humans, increase to four the recognized species of Cyclospora infecting primates. These four species group homogeneously as a single branch intermediate between avian and mammalian Eimeria. Results of our analysis contribute toward clarification of the taxonomic position of Cyclospora and its relationship to other coccidian parasites.

Adult Dirofilaria repens in a subcutaneous granuloma on the chest of a dog

A 10-year-old, 9 kg, intact male crossbred dog was treated for nasal mites with milbemycin oxime using a dose of 1 mg/kg bodyweight orally, three times at 10-day intervals. One month after the initiation of this treatment a subcutaneous nodule developed on the sternum of the dog. The nodule was removed and found to contain a single, 82 mm long, thread-like nematode. Several exotic parasites were suspected as possibilities because the dog had been imported to Norway from South Africa. Microfilariae were not detected in the blood and heartworm antigen tests were negative. The worm was identified morphologically as an adult, female Dirofilaria repens. This is the first report of D repens from Norway. The case is of interest because of the differential diagnostic problem it posed and because infestation was recognised following treatment of another parasitic condition with a broad-spectrum, antiparasitic drug. In addition, the case provides a reminder of the necessity to be aware of geographical differences in disease occurrence which can produce unexpected disease in non-endemic areas as a consequence of increased international travel with pets.

Subconjunctival infection with Dirofilaria repens: serological confirmation of cure following surgery

Cases of zoonotic dirofilariasis infection, caused by Dirofilaria repens, occur widely throughout European, African, Middle Eastern, and Asian countries. The reports of this infection in humans in Spain are limited, and we herein report the case of a 43-year-old man from Elche (Alicante), Spain, who was seen with acute hyperemic reactivity of the temporal limbus of the right eye. A large nematode was visualized on examination and the intact worm was surgically removed. The parasite was identified as a mature but infertile female D repens. The level of serum antibodies against D repens was monitored for 6 months after surgery using immunoenzymatic assays. Serological results confirmed, as expected, the presence of a single worm and the parasitological cure after the surgical removal of the parasite. To our knowledge, this is the fourth autochthonous case of D repens infecting humans in Spain and also the first autochthonous case of subconjunctival localization.

Adult Toxocara cati infections in U.S. children: report of four cases

We report four cases of passage of subadult or adult Toxocara cati worms by young children ages 20 months to seven years. Worms were expelled rectally in two cases and in two cases they were vomited. A single worm was passed in two cases, three worms in one case, and 15 worms in the fourth case. All worms that were available for study were identified as T. cati by morphologic criteria, including the arrow-shaped cervical alae and the digitiform shape of the male tail. None of the four children exhibited clinical signs of ocular or visceral larva migrans, and in two cases where serum samples were available, neither child had a titer to Toxocara. These results further the argument that these children acquired the worms through the ingestion of immature worms passed by infected cats, not through the ingestion of infective eggs. Although the children were generally not ill as a result of these unusual infections, it does serve to reinforce the public health issue that potential serious consequences can occur where children have exposure to an environment that has been contaminated with cat feces, or, more specifically, infective eggs, and could become infected with larval forms of Toxocara.

Zoonotic Onchocerca (Nematoda:Filarioidea) in the cornea of a Colorado resident

OBJECTIVE

A female patient, resident in the state of Colorado, presented with iritis of the right eye. Slit-lamp examination showed the presence of a thin, threadlike worm entwined in the cornea. The patient was taken to surgery for removal of the parasite.

DESIGN

A case report.

INTERVENTION

A 3-mm-long supertemporal incision was made in the cornea and further dissected until the worm could be grasped and removed by gentle traction.

RESULTS

The worm, a filarial nematode, was identified as a member of the genus Onchocerca, most likely Onchocerca cervicalis, a natural parasite of horses. The patient had an uneventful recovery, and 1 week after surgery, her visual acuity, intraocular pressure, and corneal edema were all resolving.

CONCLUSION

In the United States and elsewhere, most cases of zoonotic filarial infection involving the eye are caused by Dirofilaria or Dipetalonema-like worms. However, the current case was caused by a species of Onchocerca. This is the first case of zoonotic Onchocerca from the eye to be reported, only the second case of zoonotic Onchocerca in the United States, and the seventh case worldwide. The worm was removed surgically, and the patient had an uneventful recovery.

Longitudinal analysis of the development of filarial infection and antifilarial immunity in a cohort of Haitian children

Longitudinal studies are being conducted in Leogane, Haiti to investigate the relationship between acquisition of filarial infection and development of antifilarial immunity as well as the impact of maternal infection on this relationship. Children (0-24 months of age) residing in Leogane were enrolled and were examined periodically to monitor parasitologic status and to collect serum for antigen and antifilarial antibody determinations. To examine the development of filarial antigenemia and antifilarial antibody responses in this cohort, serum samples were selected from a cross section of the population at two (n = 82) and four years of age (n = 76). Antigen prevalence increased from 6% among two-year-olds to more than 30% among four-year-olds, but in only one four-year-old child were microfilaria detected in a 20-microl smear. The proportion of antigen-positive children born to antigen-positive mothers was higher than the proportion of antigen-positive children born to antigen-negative mothers (9.8% versus 0% for two-year-olds; P = 0.15; and 39.6% versus 22.7% for four-year-olds; P = 0.18). Antifilarial IgG4 levels were significantly higher among antigen-positive children at both two and four years of age (P < 0.001). In analyses of paired samples, antifilarial IgG4 responses increased significantly more among children who acquired infection by four years of age than among children who remained antigen negative, whereas antifilarial IgG1 and IgG2 responses changed equally for antigen-positive and -negative children. Antifilarial antibody levels were not influenced by maternal infection status, but were significantly influenced by age, antigen status, and the neighborhood within the community. These results provide evidence that children acquire infection early in life and suggest that antifilarial antibody responses may peak in early childhood.

Zoonotic filariasis

Filariae of animals, especially those of mammals, often infect humans and typically produce cryptic infections. These "zoonotic" infections have been reported from virtually all parts of the world including temperate zones. Infections may be symptomatic or not, and the parasites are found in surgical tissue biopsy specimens or, more rarely, are removed intact from superficial sites such as the orbit or conjuctivae. Typically, these worms tend to occupy tissue sites similar to those occupied in the natural animal host, with the exception of the eyes. Many kinds of filariae have been isolated from humans, including species of Dirofilaria, Brugia, Onchocerca, Dipetalonema, Loaina and Meningonema. Worms have been found in subcutaneous tissues, the heart and lungs, lymphatics, the eye, and the central nervous system. Specific identification of these filariae is based on their morphological features in histologic sections. Unfortunately, some of these worms cannot be identified even at the generic level. There are other species of filariae, presumed to be zoonotic, which produce patent infections in humans but are poorly and incompletely known. These include Microfilaria semiclarum and Microfilaria bolivarensis. It is probable that almost any filaria parasitizing animals can, under proper circumstances, infect humans and undergo some degree of development. Undoubtedly, additional species of filariae will continue to be isolated from humans in the future.

First reported outbreak of abdominal angiostrongyliasis

Human abdominal angiostrongyliasis is a potentially fatal disease caused by Angiostrongylus costaricensis, a nematode found in the Americas. During the period of December 1994 through August 1995, an outbreak of this disease occurred in Guatemala. We identified 22 cases of abdominal angiostrongyliasis and conducted a matched case-control study to identify risk factors for illness. The median age of the 18 cases enrolled in the study was 37 years (range, 9-68 years), and 11 (61.1%) were male. Consumption of the following six raw food items was associated with angiostrongyliasis: mint (odds ratio [OR], 6.9; 95% confidence interval [CI], 1.5-66.0), shrimp (OR, infinite; 95% CI, 1.4 to infinite), and four kinds of ceviche that reportedly contained raw mint (OR for consumption of mint or ceviche that contained mint, 7.0; 95% CI, 1.0-315). We conclude that raw mint was the likely vehicle of infection for this outbreak. To our knowledge, this is the first reported outbreak of abdominal angiostrongyliasis and the first time that a specific food item has been epidemiologically linked to the disease.

Clearance of Wuchereria bancrofti antigen after treatment with diethylcarbamazine or ivermectin

The present study was undertaken to assess the relationship between microfilarial clearance and clearance of circulating filarial antigen from the blood of Wuchereria bancrofti-infected persons following chemotherapy with either diethylcarbamazine or ivermectin. Patients received either 12 weekly doses of 6 mg/kg of diethylcarbamazine (DEC), a single dose of 6 mg/kg of DEC, a single dose of 420 microg/kg of ivermectin, or 20 microg/kg of ivermectin, followed by 6 mg/kg of DEC five days later. Microfilarial clearance was marked in all groups, but was significantly less in the single-dose DEC. In contrast, as monitored by the Og4C3 monoclonal anitbody assay, clearance of circulating filarial antigen was highly variable, not only between groups but within each group. As a result, there were few statistically significant differences in antigen clearance between groups. In no instance did the antigen level fall to zero, even in individuals that remained microfilaria negative during two or three years of follow-up. These results suggest that living adult worms persist in almost all persons treated with DEC and/or ivermectin.

Laboratory diagnosis of Cyclospora infections

The laboratory diagnosis of newly recognized infectious agents, such as Cyclospora cayetanensis, is frequently problematic because appropriate diagnostic techniques and algorithms are not available. The methods currently available for diagnosis of Cyclospora are described and compared, including concentration procedures, examination of wet preparations, various staining techniques, and the use of molecular-based assays. Because of the autofluorescent properties of the oocysts, particular attention is drawn to the role of fluorescent microscopy in providing a rapid, inexpensive, and sensitive technique for diagnosis of Cyclospora infections in stool samples. In addition to text descriptions, photomicrographs are provided to illustrate Cyclospora oocysts in wet and stained preparations and compare them with Cryptosporidium and Isospora oocysts, the other two most common coccidian infections in man.

Investigation of the influence of maternal infection with Wuchereria bancrofti on the humoral and cellular responses of neonates to filarial antigens

Epidemiological data indicate that maternal filarial infection might be associated with increased susceptibility to filarial infection in offspring. To examine the influence of maternal infection on development of antifilarial immunity in neonates, paired cord and maternal sera and mononuclear cells were collected in an area where Wuchereria bancrofti infection is endemic. Anti-filarial humoral responses (IgG, IgM and IgE) non-parasite-specific humoral responses (total IgE), proliferation induced by filarial antigen and production of cytokines (interleukin-2, interleukin-4 and interferon-gamma) were all monitored. Few cord serum samples had detectable antifilarial IgM of IgE and neither these responses nor total IgE levels differed as a function of maternal infection status. Of cord-blood mononuclear cells assayed, a relatively small proportion exhibited reactivity to filarial antigens. Based on these limited responses to filarial antigens, few neonates display evidence of in-utero sensitization to filarial antigens.

Transfusion-transmitted babesiosis in Washington State: first reported case caused by a WA1-type parasite

Most cases of babesiosis reported in the United States have been tickborne and caused by Babesia microti, the etiologic agent of all previously described transfusion-transmitted cases. A 76-year-old man with the first recognized case of transfusion-transmitted infection with the recently identified WA1-type Babesia parasite is described. The subject received multiple blood transfusions in 1994. Indirect immunofluorescent antibody testing of serum from 57 blood donors implicated a 34-year-old man (WA1 titer, 1:65,536) whose donation had been used for packed red cells. Isolates of the organisms that infected the recipient and the donor, both of whom were spleen-intact residents of Washington State, were obtained by hamster inoculation. The DNA sequence of a 536-bp region of the nuclear small subunit-rRNA gene of both isolates was identical to that of WA1 (isolated in 1991 from the index WA1 case-patient). Effective measures for preventing transmission of babesiosis by blood transfusion are needed.

Uniform staining of Cyclospora oocysts in fecal smears by a modified safranin technique with microwave heating

Cyclospora, a coccidian protist, is increasingly being identified as an important, newly emerging parasite that causes diarrhea, flatulence, fatigue, and abdominal pain leading to weight loss in immunocompetent persons with or without a recent travel history as well as in patients with AIDS. Modified Kinyoun's acid-fast stain is the most commonly used stain to identify the oocyst of this parasite in fecal smears. Oocysts of Cyclospora stain variably by the modified acid-fast procedure, resulting in the possible misidentification of this parasite. We examined fecal smears stained by six different procedures that included Giemsa, trichrome, chromotrope, Gram-chromotrope, acid-fast, and safranin stains. We report on safranin-based stain that uniformly stains oocysts of Cyclospora a brilliant reddish orange, provided that the fecal smears are heated in a microwave oven prior to staining. This staining procedure, besides being superior to acid-fast staining, is fast, reliable, and easy to perform in most clinical laboratories.

Evaluation of selected antiprotozoal drugs in the Babesia microti-hamster model

The presently used therapy for Babesia microti infections, a combination of quinine and clindamycin, does not always result in parasitologic cures. To identify possible alternative chemotherapeutic agents for such infections, we screened, in the hamster-B. microti system, 12 antiprotozoal drugs that have either recently been released for human use or were in experimental stages of development at the Walter Reed Army Institute of Research for the treatment of malaria and leishmaniasis. Several well-recognized antimalarial drugs, such as mefloquine, halofantrine, artesunate, and artelenic acid, exhibited little or no effect on parasitemia. Two 8-aminoquinolines, WR006026 [8-(6-diethylaminohexylamino)-6-methoxy-4-methylquinoline dihydrochloride] and WR238605 [8-[(4-amino-1-methylbutyl)amino]-2,6-dimethoxy-4-methyl-5 -(3-trifluoromethylphenoxy-7) quinoline succinate], produced clearance of patent parasitemia. Furthermore, blood from infected hamsters treated with WR238605 via an intramuscular injection failed to infect naive hamsters on subpassage, thus producing a parasitologic cure. These two compounds merit further screening in other systems and may prove useful in treating human babesiosis.

Respiratory symptoms and subcutaneous granuloma caused by mesocercariae: a case report

A 38-year-old man with no history of pulmonary disease developed intermittent hives and bronchospasms shortly after returning from a hunting trip. Approximately one year later, examination of an excised subcutaneous nodule demonstrated infection with a mesocercaria (larval trematode). The morphology of the parasite was consistent with infection with a parasite of the Alaria spp. or Strigea spp. Eating undercooked wild goose meat during the hunting trip was the most likely source of infection. This appears to be the first report of human infection with mesocercariae acquired through the ingestion of wild goose meat.

Th1-like antifilarial immune responses predominate in antigen-negative persons

To characterize immune responses associated with the putatively immune state in bancroftian filariasis (that is, both microfilaria and antigen free), humoral and cellular responses were compared among antigen- and microfilaria-negative, antigen-positive and microfilaria-negative, and microfilaria-positive individuals. Antifilarial isotype levels were measured by enzyme-linked immunosorbent assay. Peripheral blood mononuclear cell responses were measured by proliferation, by bioassay for interleukin-2 (IL-2) and IL-10, and by reverse transcription-PCR for IL-4, IL-5, and gamma interferon. The absence of circulating filarial antigen was associated with Th1-like responses, including significantly higher proliferative (P < 0.001) and IL-2 (P = 0.008) responses and a higher prevalence of gamma interferon (0.02 < P < 0.1) responses. Significantly elevated antifilarial immunoglobulin G4 (IgG4) levels (P = 0.0035) were associated with antigenemia, whereas microfilaremia was associated with significantly decreased antifilarial IgG2 levels (P = 0.0014). IL-4 mRNA levels were not significantly different among the three groups; however, there was a subpopulation of microfilaremic individuals who did not make detectable levels of IL-4 mRNA and who produced low antifilarial IgG4 levels compared with those of individuals who had detectable levels of IL-4 mRNA. IL-5 mRNA levels also were not significantly different among groups; however, more microfilaremic individuals produced IL-5 mRNA in response to adult filarial antigens, and total parasite-specific IL-4 and IL-5 mRNA levels were significantly correlated (P = 0.05). Although longitudinal data are not currently available, the elevated Th1-like responses in antigen- and microfilaria-negative individuals are consistent with the hypothesis that these responses contribute to protection in putatively immune individuals.

Pathology of acute fatal babesiosis in hamsters experimentally infected with the WA-1 strain of Babesia

A strain of Babesia (strain WA-1), recently isolated from a human in Washington State, was found to be unusually virulent for hamsters; it caused acute infection and death in a large proportion of animals 5 to 7 days after inoculation. To assess the basic pathologic lesions associated with this infection, 30 male Syrian hamsters (Mesocricetus auratus) were inoculated intraperitoneally with the WA-1 strain. Twelve animals (40%) died within 5 to 6 days. The other 18 animals, all infected and clinically ill, were killed on the sixth or seventh day for biochemical study. All 12 animals that died from the infection showed high parasitemia, heavy intravascular hemolysis, and pronounced vascular stasis with red-cell sequestration in the spleen, liver, lungs, kidneys, and brain. Serologic study revealed severe anemia (mean hematocrit, 29) with hemolyzed serum and marked elevation of the serum transaminases. The mechanism of death was thought to be diffuse anoxic tissue damage secondary to vascular stasis, which led to multiorgan failure.

Zoonotic Brugian lymphadenitis. An unusual case with florid monocytoid B-cell proliferation

Human infection with a zoonotic Brugia species in the United States is uncommon. Positive identification of the filarial nematode is required for histopathologic diagnosis. Many cases may go unrecognized because of the nonspecific clinical manifestations and the nondiagnostic histologic changes occurring in involved lymph nodes. A case of zoonotic Brugia lymphadenitis is described in a patient from Rhode Island, in which a small nongravid female worm was identified in a lymph node biopsy specimen. The lymph node also showed a spectrum of reaction changes including the presence of florid monocytoid B-cell proliferation, which has not been described in association with zoonotic Brugian filariasis.

A fatal case of babesiosis in Missouri: identification of another piroplasm that infects humans

OBJECTIVE

To characterize the etiologic agents (MO1) of the first reported case of babesiosis acquired in Missouri.

DESIGN

Case report, serologic testing, animal inoculations, and molecular studies.

SETTING

Southeastern Missouri.

PATIENT

A 73-year-old man who had had a splenectomy and had a fatal case of babesiosis.

MEASUREMENTS

Serum specimens from the patient were assayed by indirect immunofluorescent antibody testing and immunoprecipitation for reactivity with antigens from various Babesia species. Whole blood obtained from the patient before treatment was inoculated into hamsters and jirds and into calves and bighorn sheep that had had splenectomy and were immunosuppressed with dexamethasone. Piroplasm-specific nuclear small-subunit ribosomal DNA was recovered from the patient's blood by using broad-range amplification with the polymerase chain reaction; a 144 base-pair region of the amplification product was sequenced; and phylogenetic analysis was done to compare MO1 with various Babesia species.

RESULTS

Indirect immunofluorescent antibody testing showed that the patient's serum had strong reactivity with Babesia divergens, which causes babesiosis in cattle and humans in Europe, but that it had minimal reactivity with B. microti and WA1, which are the piroplasms previously known to cause zoonotic babesiosis in the United States. Immunoprecipitations showed that MO1 is more closely related to B. divergens than to B. canis (a canine parasite). None of the experimentally inoculated animals became demonstrably parasitemic. Phylogenetic analyses, after DNA sequencing, showed that MO1 is most closely related to B. divergens (100% similarity).

CONCLUSIONS

Although MO1 is probably distinct from B. divergens, the two share morphologic, antigenic, and genetic characteristics; MO1 probably represents a Babesia species not previously recognized to have infected humans. Medical personnel should be aware that patients in the United States can have life-threatening babesiosis even though they are seronegative to B. microti and WA1 antigen.

A survey of knowledge, attitudes, and perceptions (KAPs) of lymphatic filariasis, elephantiasis, and hydrocele among residents in an endemic area in Haiti

To assess knowledge, attitudes, and perceptions about bancroftian filariasis, 104 residents of an endemic area in Haiti were interviewed. Questions focused on 1) whether people understood the relationship between infection and disease, 2) recognition of the role that mosquitoes play in transmission, 3) perceived importance of hydrocele and elephantiasis in relation to other recognized diseases, and 4) the willingness of the community to participate in a control program. Fewer than 50% of residents had heard of filariasis and only 6% of those surveyed knew that it was transmitted by mosquitoes. In contrast, all persons knew of the clinical conditions of hydrocele and elephantiasis. Hydrocele was thought to be caused by trauma (60%) or trapped gas (30%); elephantiasis by walking bare foot on soil or water (37%) or by use of ceremonial powder that had been sprinkled on the ground (23%). Of 76 respondents, 53% and 38% thought that hydrocele could be treated through surgery or a drug, respectively, whereas 86 respondents, 85% and 15% believed that either surgery or a drug could be used to treat elephantiasis. In this context, persons were not referring to a specific drug; rather, they believed a drug existed (possibly in some other country) that could cure these conditions. Hydrocele and elephantiasis ranked second to acquired immunodeficiency syndrome as perceived health problems, most likely because residents believed treatment for conditions such as malaria, intestinal worms, anemia, and diarrhea was easily obtained. Responses were influenced by age, sex, and symptoms, but none of these effects were statistically significant except that persons with hydrocele or elephantiasis were more likely to have sought treatment than persons without these conditions (P = 0.0006). The survey results indicate that awareness of the causes of disease, the relationship between infection and disease, and goals of treatment must be heightened through community-based education campaigns to increase the possibility of acceptance and support of control programs.

Immunopurification and measurement of IgE in serum samples from bancroftian filariasis patients

Patent infection with Wuchereria bancrofti is associated with increased levels of filaria-specific IgG4 and IgE. In vitro quantification of filaria-specific IgE is hampered by its small proportion in serum relative to other isotypes and by potential competition with IgG4 for the same epitopes on parasite antigens. To determine if IgG4 or other isotypes inhibit the detection of parasite-specific IgE, total IgE was affinity purified prior to filaria-specific IgE enzyme-linked immunosorbent assay. Briefly, anti-human IgE mouse monoclonal antibody 6H10 was coupled to Affigel, and 50 microliters of patient serum was incubated on microcolumns for 16 hr. Total IgE was eluted with 25 mM triethylamine (pH 11.2) and levels of total and filaria-specific IgE and total IgG4 were assessed in the filtrates and eluates. Sera from 14 patients with W. bancrofti microfilaremia (Mf+) and 17 amicrofilaremic patients with chronic pathology (CP) were assayed. Filtrates and eluates were devoid of IgE and IgG4, respectively. The average yield of total IgE in the eluates was 70% (SEM = 6.5; range 21-100%) of that measured in the serum. Antifilarial IgE levels in column eluates were significantly higher in serum samples from CP patients than Mf+ patients. Antibody inhibition of IgE was assessed by comparing the levels of anti-filarial IgE detected in eluates and serum. Evidence for antibody-mediated inhibition of IgE detection was obtained with 2/2 samples from Indian tropical pulmonary eosinophilia patients, but only 2/14 and 4/17 Mf+ and CP patients, respectively.

Reduced antifilarial IgG4 responsiveness in a subpopulation of microfilaremic persons

Antifilarial IgG4 is a marker of active filarial infection; however, 10% of microfilaremic persons may have low levels of antifilarial IgG4. To gain insight into how persons with microfilaremia with low antifilarial IgG4 levels (< 10 micrograms/mL) differ from those with high levels (> 170 micrograms/mL), total IgG4 and IgE and filaria-specific IgE, IgG1, and IgG2 were measured by ELISA in serum samples collected from 85 microfilaremic Haitians. Persons with lower levels of antifilarial IgG4 had significantly lower total IgG4 and total IgE (P < .01), lower levels of antifilarial IgG1, IgG2, and IgE (P < .01, = .03, and < .01, respectively), and higher antigenemia and microfilaremia (P < .01) than did persons with higher levels of antifilarial IgG4. Increased antigen loads in microfilaremic persons may be associated with a down-regulation of antibody production, which extends to all isotypes.

Acquisition and expression of humoral reactivity to antigens of infective stages of filarial larvae

Measurement of anti-larval responses in filaria-exposed populations may shed light on the natural history of exposure to Wuchereria bancrofti. Using serum samples obtained by a cross-sectional survey of 172 individuals from two neighbourhoods in Leogane, Haiti, antibody responses directed against infective stage filarial larvae (L3) were assayed by enzyme-linked immunosorbent assay (ELISA), immunofluorescence (IFA), and immunoblot for the presence of anti-larval antibodies. ELISA results indicated that virtually all members of both neighbourhoods mounted an anti-larval antibody response within the first five years of life, suggesting that exposure to infection is universal. In a multiple linear regression analysis that modelled antibody levels as a function of age, gender, microfilaria status, and neighbourhood (as a proxy for transmission intensity), isotype-specific antibody levels were found to be significantly influenced by both age and neighbourhood. Antibodies directed against the surface of L3 also were age-dependent; the prevalence of IgG antibodies detected by IFA was significantly higher in children than in adults. The prevalence of antibody recognition of 16.7 and 72.3 kDa L3 antigens on immunoblots was significantly greater for serum samples from microfilaraemic than amicrofilaraemic persons. These results suggest that antibody responses to larval antigens are influenced to varying degrees by age, transmission intensity, and microfilaraemia status.

Survival and infectivity of Babesia in blood maintained at 25 C and 2-4 C

Babesia microti-infected blood was stored at room temperature (approximately 25 C) or refrigerated (4 C) for 30 days. To assess viability of the parasites after storage at these 2 temperatures, a 0.25-ml aliquot was inoculated into each of 2 hamsters in 2 separate experiments at days 3, 7, 10, 14, 17, 21, 25, and 30. Blood films were prepared and examined weekly for the presence of parasites from all hamsters. Of hamsters inoculated with blood held at room temperature, only those inoculated at day 3 became positive, whereas 4/4 hamsters inoculated with refrigerated blood on day 17 became parasitemic and 1/4 hamsters inoculated with blood held for 21 days became parasitemic. These results indicate that under blood banking conditions, this intracellular protozoan parasite can remain infective and transfusion-acquired infection with this parasite could occur throughout most of the time that blood is normally stored.

The role of tadpoles and frogs as paratenic hosts in the life cycle of Dracunculus insignis (Nematoda: Dracunculoidea)

The possibility exists that paratenic hosts play a role in the life cycle of various Dracunculus species. In the present study, we established that tadpoles of 2 genera of frogs (Xenopus and Rana) were capable of ingesting copepods infected with third-stage larvae (L3) of Dracunculus insignis. Once ingested, the L3s migrated from the gut to the somatic tissues of the tadpoles. In Xenopus, the dracunculid larvae persisted through the metamorphosis of the tadpoles into adult frogs. These observations confirm the concept that paratenic hosts, such as tadpoles or frogs, may be important means of transporting infective larvae of Dracunculus species up the food chain and facilitate transmission to the definitive hosts.