A massive invasion of Parafasciolopsis fasciolaemorpha in elk (Alces alces) in Lublin Province, Poland

Liver fluke Parafasciolopsis fasciolaemorpha is a parasite typical of elk (Alces alces). The present study describes the identification of a massive invasion of the liver fluke P. fasciolaemorpha in an elk in the Sobibór Landscape Park, Eastern Poland. In February 2016, samples of liver and faeces were collected from the elk during postmorte examination. A section of liver tissue and three grams of faeces were examined for the presence of flukes or fluke eggs by decantation. In total, 11,150 juvenile and mature flukes of P. fasciolaemorpha were found in the examined liver. Multiple cavities with distinct walls, filled with dark liquid, trematodes, fluke eggs and cellular detritus were seen in the cross section of the parenchyma. Additionally, some of the bile ducts were plugged with calcerous deposits. The three grams of examined faeces were found to contain 322 grey and golden-coloured eggs of P. fasciolaemorpha. The presence of such a massive infection of P. fasciolaemorpha in the examined elk has a significant impact on the health of the individual. We can assume P. fasciolaemorpha has a significant influence on the health and abundance of the entire elk population in Poland.

KEY WORDS

Parafasciolopsis fasciolaemorpha, elk, Sobibór Landscape Park, Poland.

Disease surveillance of Atlantic herring: molecular characterization of hepatic coccidiosis and a morphological report of a novel intestinal coccidian

Surveillance for pathogens of Atlantic herring, including viral hemorrhagic septicemia virus (VHSV), Ichthyophonus hoferi, and hepatic and intestinal coccidians, was conducted from 2012 to 2016 in the NW Atlantic Ocean, New Jersey, USA. Neither VHSV nor I. hoferi was detected in any sample. Goussia clupearum was found in the livers of 40 to 78% of adult herring in varying parasite loads; however, associated pathological changes were negligible. Phylogenetic analysis based on small subunit 18S rRNA gene sequences placed G. clupearum most closely with other extraintestinal liver coccidia from the genus Calyptospora, though the G. clupearum isolates had a unique nucleotide insertion between 604 and 729 bp that did not occur in any other coccidian species. G. clupearum oocysts from Atlantic and Pacific herring were morphologically similar, though differences occurred in oocyst dimensions. Comparison of G. clupearum genetic sequences from Atlantic and Pacific herring revealed 4 nucleotide substitutions and 2 gaps in a 1749 bp region, indicating some divergence in the geographically separate populations. Pacific G. clupearum oocysts were not directly infective, suggesting that a heteroxenous life cycle is likely. Intestinal coccidiosis was described for the first time from juvenile and adult Atlantic herring. A novel intestinal coccidian species was detected based on morphological characteristics of exogenously sporulated oocysts. A unique feature in these oocysts was the presence of 3 long (15.1 ± 5.1 µm, mean ±SD) spiny projections on both ends of the oocyst. The novel morphology of this coccidian led us to tentatively name this parasite G. echinata n. sp.

High prevalence of the liver fluke Amphimerus sp. in domestic cats and dogs in an area for human amphimeriasis in Ecuador

Background

Amphimerus sp. is a liver fluke which recently has been shown to have a high prevalence of infection among an indigenous group, Chachi, who reside in a tropical rainforest in the northwestern region of Ecuador. Since it is unknown which animals can act as a reservoir and/or definitive hosts for Amphimerus sp. in this endemic area, a study was done to determine the prevalence of infection in domestic cats and dogs. This information is important to understand the epidemiology, life cycle and control of this parasite.

Methodology/Findings

In July 2012, three Chachi communities located on Rio Cayapas, province of Esmeraldas, were surveyed. A total of 89 of the 109 registered households participated in the study. Of the 27 cats and 43 dogs found residing in the communities, stool samples were collected from 14 cats and 31 dogs (total of 45 animals) and examined microscopically for the presence of Amphimerus eggs. The prevalence of infection was 71.4% in cats and 38.7% in dogs, with similar rates of infection in all three communities. Significantly more cats were infected than dogs (p = 0.042).

Conclusions/Significance

The data show a high rate of Amphimerus sp. infection in domestic cats and dogs residing in Chachi communities. It can be concluded that these animals act as definitive and reservoir hosts for this liver fluke and that amphimeriasis is a zoonotic disease. These findings provide important epidemiological data which will aid in the development and implementation of control strategies against the transmission of Amphimerus.

Amphimerus sp. is a fluke that infects the bile ducts of its definitive hosts. Recently, it has been shown that an indigenous Amerindian group, the Chachi, living in a rural and remote tropical area of Ecuador, are infected with this parasite. The epidemiology and life cycle of this parasite remains elusive, and research is needed to understand the mode of transmission and zoonotic potential of the parasite. It was hypothesized that the domestic animals of the Chachi households may act as definitive and reservoir hosts for Amphimerus infection. Hence, the presence and prevalence of infection in these animals residing in communities endemic for human amphimeriasis was investigated. Some 45 animal stool samples were examined microscopically for the presence of Amphimerus eggs. The results showed an infection rate of 71.4% in cats and 38.7% in dogs. The data provided evidence that these domestic animals act as both definitive and reservoir hosts for the parasite and that amphimeriasis is a zoonotic disease. The implementation of a mass treatment/control program must target both humans and animals in order to minimize the transmission of this liver fluke.

An overview of the host spectrum and distribution of Calodium hepaticum (syn. Capillaria hepatica): part 1-Muroidea

Calodium hepaticum (syn. Capillaria hepatica) is a worldwide-distributed species of zoonotic nematodes with a high affinity to the liver. Several rodent species of the superfamily Muroidea serve as main hosts for this pathogen. C. hepaticum has been found in Muroidean hosts in more than 60 countries in Europe; North, Central, and South America; Asia; Africa; and Oceania. C. hepaticum was documented in more than 90 Muroidean rodent species (Murinae, Deomyinae, Arvicolinae, Neotominae, Cricetinae, Sigmodontinae, Gerbillinae, and Cricetomyinae). Globally, the Norway rat (Rattus norvegicus) seems to be the main host species for this nematode. However, locally high prevalences (above 50 %) have also been observed in several other synanthropic (commensal and non-commensal) Muroidea species (e.g., Rattus tanezumi, Ondatra zibethicus, Apodemus sylvaticus). This review gives an overview of the distribution and host spectrum of C. hepaticum in Muroidea host species.

An overview of the host spectrum and distribution of Calodium hepaticum (syn. Capillaria hepatica): part 2-Mammalia (excluding Muroidea)

Calodium hepaticum (syn. Capillaria hepatica) is a globally distributed zoonotic nematode with low host specificity and a high affinity to the liver. Although murid rodents are the main definite hosts, various other mammals can be affected with hepatic capillariasis: non-murid rodents, Insectivora, Chiroptera, Lagomorpha, Artiodactyla, Perissodactyla, Hyracoidea, Marsupialia, Carnivora, and Primates. Overall, more than 180 mammalian species (including humans) are known as suitable hosts of this pathogen. This review gives an overview of the distribution and host spectrum of C. hepaticum in non-Muroidean mammals in wildlife and zoos as well as in domesticated and laboratory animals. Furthermore, the role of spurious infections in animals and the dissemination of C. hepaticum by mammalian and non-mammalian animals are summarized.

[Capillaria hepatica infection in rodents from Anning Prefecture of Yunnan Province and experimental research on host animals]

OBJECTIVE

To investigate the prevalence of Capillaria hepatica in rodents from Anning Prefecture, Yunnan, and observe the susceptibility of C. hepatica to SD rats and KM mice.

METHODS

Rodents were trapped in a cultivated filed of Wenquan Town, Annning from March 2010 to March 2012. The species of rodents were identified. The liver was examined and a microscopic examination of tissue was performed by the tissue press technique for the presence of the typical bipolar eggs, adults or larval stages. The prevalence of C. hepatica in rodents was calculated. C. hepatica eggs were collected and cultured in vitro. Each SD rat or KM mouse was orally infected with approximately 1 000 C. hepatica eggs. The control groups with 4 SD rats or 4 KM mice received only normal saline. The experimental animals were euthanized at the 30th and 80th day post infection. Collected liver samples were processed for gross pathological and histological section examination.

RESULTS

A total of 115 rodents were captured and examined. C. hepatica eggs were found in 26 (22.6%) rodents. There was no significant difference in the prevalence between female (22.5%, 18/80) and males (22.9%, 26/115) (P > 0.05). The highest prevalence was found in Rattus norvegicus (10/11). Pathologi cal findings showed numerous white-yellow small nodules ranged from 0.1-0.2 cm in diameter. Under light microscope, C. hepatica eggs were ovoid [(50-65) microm x (25-30) microm]. At the 30th day post-infection, there were several adult worms and their eggs delimited by a fibrous capsule, and septal fibrosis formations occurred in the liver of SD rat. No worm or eggs were found in the mouse liver, but the liver presented inflammatory cell infiltration. At the 80th day post-infection, live worms disappeared from the focal lesions in the liver of SD rat, being replaced by partially calcified worm debris. Mature worms and eggs were seen in the KM mouse liver, however, septal fibrosis was absent.

CONCLUSION

This study has documented a high prevalence of C. hepaticum in R. norvegicus from Anning Prefecture. SD rat and KM mouse are the susceptible hosts of C. hepatica.

Parasitic liver disease in travelers

Liver disease is an important source of morbidity among ill returning travelers. Jaundice is one of the most common and obvious symptoms of liver disease, the differential diagnosis of which is extensive, especially in travelers. Jaundice in travelers can arise from both infectious and noninfectious causes. We herein summarize the most common parasitic etiologies that may lead to jaundice in the returned traveler, visitors of friends and relatives, or new immigrants, and describe the etiology, epidemiology, and pathogenesis of clinical features of each.

Preneoplastic conditions underlying bile duct cancer

BACKGROUND

Malignancies arising from the biliary tract can arise from the epithelial lining of the biliary tract and surrounding tissues. Conditions that predispose to malignancy as well as preneoplastic changes in biliary tract epithelia have been identified. In this overview, we discuss preneoplastic conditions of the biliary tract and emphasize their clinical relevance.

RESULTS

Chronic biliary tract inflammation predisposes to cancer in the biliary tract. Biliary tract carcinogenesis involves a multistep process as a consequence of chronic biliary epithelial injury or inflammation. Reminiscent of other gastrointestinal epithelial malignancies such as gastric, colon, and pancreatic cancer, biliary tract cancers may evolve via multistep progression from epithelial hyperplasia and dysplasia to malignant transformation. The potential role of initiating cells is also becoming recognized.

CONCLUSIONS

In spite of improved risk factor recognition, and advances in diagnostic tools, the early diagnosis of pre-malignant or malignant biliary tract conditions is extremely challenging, and there is a paucity of evidence on which to base their management. As a result, the role of pre-emptive surgery remains largely undefined.

High prevalence of liver and intestinal fluke infections among residents of Savannakhet Province in Laos

The prevalence of liver and intestinal fluke infections was surveyed on residents of Savannakhet Province, Laos. Fecal specimens were collected from a total of 981 residents in 4 Mekong riverside villages and examined by the Kato-Katz thick smear technique. The results revealed that the overall helminth egg positive rate was 84.2%, and the positive rate for small trematode eggs, including Opisthorchis viverrini, heterophyids, or lecithodendriids, was 67.1%. To obtain adult flukes, 38 small trematode egg positive cases were treated with a 20-30 mg/kg single dose of praziquantel and purged. Diarrheic stools were then collected from 29 people and searched for helminth parasites using stereomicroscopes. Mixed infections with O. viverrini and 6 kinds of intestinal flukes were found, namely, Haplorchis taichui, Haplorchis pumilio, Haplorchis yokogawai, Prosthodendrium molenkampi, Phaneropsolus bonnei, and echinostomes. The total number of flukes collected was 7,693 specimens (av. no. per treated person; 265.3). The most common species was O. viverrini, followed by H. taichui, P. molenkampi, echinostomes, H. pumilio, P. bonnei, and H. yokogawai. The results indicate that foodborne liver and intestinal fluke infections are prevalent among residents of Savannakhet Province, Laos.

Survey for zoonotic liver and intestinal trematode metacercariae in cultured and wild fish in An Giang Province, Vietnam

Although Vietnam has a high risk of fishborne zoonotic trematode (FZT) infections for humans, little information exists on the epidemiology of these infections in the country's fish. Because of the importance of cultured catfish and snakehead production in An Giang province, a major production area in the Mekong Delta of Vietnam, a survey for FZTs was carried out in randomly selected fish farms between June 2005 and March 2006. For comparison, wild fish from the same area were also surveyed. A total of 852 cultured fish from 4 districts were collected and examined by pepsin digestion to determine their FZT infection status. In Tra catfish, the prevalence of all types of metacercariae was 2.6%, of which the prevalence of Haplorchis pumilio was 0.7%. The overall prevalence of metacercariae in wild fish was 30.6%, of which 10.3% harbored zoonotic species: H. pumilio (2.8%) and Procerovum sp. (5.6%). The prevalence of Opisthorchis metacercariae, which were diagnosed as O. viverrini, was 1.9%. No metacercariae were found in cultured snakehead fish, although wild-caught snakehead fish had a FZT prevalence of 10.3%: 5.1% were O. viverrini 2.6% H. pumilio and 2.6% were Procerovum sp. These are the first reports of H. pumilio, Procerovum sp., and O. viverrini metacercariae in Vietnamese fish. These results indicate that consumption of improperly prepared fish represents a significant risk of acquiring FZTs in this south Vietnam region.

EPIDEMIOLOGICAL CHARACTERISTICS OF AN INVADING PARASITE: DICROCOELIUM DENDRITICUM IN SYMPATRIC WAPITI AND BEEF CATTLE IN SOUTHERN ALBERTA, CANADA

Previous surveys of wild ungulates indicate that the liver fluke, Dicrocoelium dendriticum, was rare in the Cypress Hills area of southeastern Alberta. However, 41 of 59 wapiti (Cervus elaphus) sampled during the 2003 and 2004 hunting seasons from this region were infected, with 7 hosts containing >1,000 worms. Prevalence and mean intensity were similarly high in sympatric beef cattle and mule deer. Worm abundance in wapiti was age related, with calves containing significantly higher numbers of worms (mean +/- SD abundance = 825 +/- 1098) than adults (107 +/- 259). This pattern with host age was not evident in beef cattle, although the smaller sample sizes may be a contributing factor. These results indicate that D. dendriticum is now well established in Cypress Hills Park, circulating between at least 3 species of sympatric ungulates, including beef cattle.

Latent Schistosomiasis in Portuguese Soldiers

Schistosomiasis was diagnosed in two Portuguese soldiers who had been deployed to Portuguese colonies in Africa. The first veteran was diagnosed as having schistosomiasis 34 years after returning from Angola, and the second veteran was found with Schistosoma haematobium infection 40 years after returning from Mozambique. The patient with Schistosoma mansoni had an active infection, because eggs were recovered with living miracidia. The second patient had developed urothelial cancer, but eggs recovered were calcified.

The Schistosoma mansoni hepatic egg granuloma provides a favorable microenvironment for sustained growth of Leishmania donovani

Parasitic co-infections are prevalent in many parts of the world. However, relatively little is known about how an underlying infection may impact on the host's ability to control a newly acquired parasite, especially if both infect the same organ. We have studied this using an experimental co-infection model in C57BL/6 mice involving Schistosoma mansoni and Leishmania donovani, two important human pathogens affecting the liver. We show that mice with established S. mansoni infections fail to control L. donovani growth in the liver and spleen. The failure occurs despite the development of a functional anti-L. donovani Th1 response that can mediate granuloma formation and effective clearance of amastigotes from foci of infection in the hepatic parenchyma. Instead, anti-leishmanial immunity fails within the S. mansoni egg granuloma, consistent with a lack of L. donovani granuloma assembly in this tissue microenvironment and consequent lack of NO production. Persisting amastigote replication in the S. mansoni egg granulomas may thus explain the increased L. donovani burden in the liver and spleen. These results may have implications for human S. mansoni and L. donovani co-infections and also demonstrate that granulomatous tissue responses to helminth organisms can form a discrete niche facilitating survival of intracellular pathogens.

Clinical versus ultrasound examination in the evaluation of hepatosplenic schistosomiasis mansoni in endemic areas

The best way to appraise the size of abdominal organs remains undefined. Herein we compare the size of liver and spleen in hepatosplenic schistosomiasis using clinical and ultrasound (US) examination, and the size of the organs measured by US with their visualization below the costal margin ("palpable by US"). For this study, 411 individuals from an endemic area for schistosomiasis mansoni in Brazil have been selected. We found that palpable spleens and left liver lobes are larger than non palpable ones. Also, 23% of normal spleens measured by US were palpable on clinical examination, and 22% of spleens increased in size on US were non palpable. A total of 21% of normal spleens were "palpable by US". We also found 54% of normal sized right liver lobes palpable on clinical examination, whilst 54% of the increased livers, measured by US, were non palpable. About 76% of normal right liver lobes were "palpable by US". We conclude that the association of clinical, ultrasound and magnetic resonance imaging (MRI) examinations, in the near future, should give the investigators the necessary tools to perform a more accurate clinical diagnosis of hepatosplenic schistosomiasis mansoni.

Morbidity of schistosomiasis mansoni in the state of Minas Gerais, Brazil

From 2002 to 2005, a program of active search for patients with hepatosplenic schistosomiasis and schistosomal myeloradiculopathy has been implemented in the state of Minas Gerais by the local Health Department. The state was divided in 28 regional health centers and the local representatives have been trained to identify and direct patients with hepatosplenic schistosomiasis and neuroschistosomiasis to a reference center in Belo Horizonte, the capital of the state of Minas Gerais. Seventy five patients with hepatosplenic schistosomiasis and 54 with schistosomal myeloradiculopathy have been referred and examined in the reference center in a period of time of 3 years. Schistosomal myeloradiculopathy should be emphasized because the number of cases reported is increasing rapidly and when timely diagnosed and treated, they respond promptly to treatment. Left untreated, they die or become invalid for life. In our view, the time has come for more active investigation of the different aspects of morbidity caused by schistosomiasis mansoni in Brazil.

[Press debates, scandals, and implementation of a prevention policy: on hepatitis C in Egypt]

The scandal of hepatitis C infection in Egypt is not related to any social movement. The scandal was revealed by the press and handled by politicians but with strictly no involvement of infected persons. Unlike the AIDS epidemic, no social movement developed. This difference can probably be explained by the deficiency of the health care system resulting from the low-level resources available in Egypt.

Liver disease in Egypt: hepatitis C superseded schistosomiasis as a result of iatrogenic and biological factors

In Egypt, schistosomiasis was traditionally the most important public health problem and infection with Schistosoma mansoni the major cause of liver disease. From the 1950s until the 1980s, the Egyptian Ministry of Health (MOH) undertook large control campaigns using intravenous tartar emetic, the standard treatment for schistosomiasis, as community-wide therapy. This commendable effort to control a major health problem unfortunately established a very large reservoir of hepatitis C virus (HCV) in the country. By the mid-1980s, the effective oral drug, praziquantel, replaced tartar emetic a s treatment f o r schistosomiasis in the entire country. This both reduced schistosomal transmission and disease and interrupted the "occult" HCV epidemic. It was evident when diagnostic serology became available in the 1990s that HCV had replaced schistosomiasis as the predominant cause of chronic liver disease. Epidemiological studies reported a high prevalence and incidence of HCV, particutarly within families in rural areas endemic for schistosomiasis. Clinical studies showed 70% to 90% of patients with chronic hepatitis, cirrhosis, or hepatocellular carcinoma had HCV infections. Co-infections with schistosomiasis caused more severe liver disease than infection with HCV alone. Schistosomiasis was reported to cause an imbalance in HCV-specific T-cell responses leading to increased viral load, a higher probability of HCV chronicity, and more rapid progression of complications in co-infected persons. As complications of HCV usually occur after 20 years of infection, the peak impact of the Egyptian outbreak has not yet occurred. Efforts have been initiated by the Egyptian MOH to prevent new infections and complications of HCV in the estimated 6 million infected persons.

Der Wurm in der Leber

Patienten mit parasitär bedingten Leberleiden stellen in den meisten europäischen Ländern ein sehr kleines Kollektiv dar. Sie werden in der Differentialdiagnose von hepatischen Raumforderungen, Leberparenchymveränderungen, Schmerzen im rechten Oberbauch, Cholestase oder Transaminasenerhöhung, wenn überhaupt, meist zuletzt in Betracht gezogen. Den meisten Gesundheitseinrichtungen mangelt es an diagnostischer und therapeutischer Erfahrung. Diese Erkrankungen sind in spezialisierten Zentren (dies sind traditionsgemäß meist tropenmedizinische Einrichtungen) am besten aufgehoben. Wichtige Komponenten bei der Abklärung sind: Risikoanamnese (Herkunft, Reisen, Exposition), die geographische Verbreitung der Parasitosen, Inkubations- und Präpatenzzeit, Labor (Eosinophilie, IgE-Erhöhung, direkter Parasitennachweis, Serologie), sowie bildgebende Verfahren. Es werden die wichtigsten Parasitosen der Leber dargestellt: Schistosomiasis, Echinokokkose, Faszioliasis, Toxocariasis.

Current status of sensitivity to praziquantel in a focus of potential drug resistance in Egypt

A decade ago, a study revealed that praziquantel (PZQ) failed to cure 1.6% of those with intestinal schistomiasis in five villages of the Nile delta region. The recommended dosage of PZQ is a single 40 mg/kg oral dose, and each of these patients continued to pass viable Schistosoma mansoni eggs despite three successive doses at or above this level. The eggs passed by these uncured villagers produced adult worms that were, in most cases, significantly less responsive to PZQ in vitro. This report investigates the current sensitivity of S. mansoni infections to PZQ after 10 years of therapeutic pressure in the same villages, testing the hypothesis that the number of drug failures would have increased as continued drug pressure selected for worms with diminished sensitivity to PZQ. The data show that these villages have experienced a significant decrease in the prevalence and intensity of S. mansoni infections, with present infection rate of 10.9%, compared with 25.1% in 1994. The first treatment resulted in normal range of cure rates, between 73.8 and 92.3% in each of the five villages in the study. After three successive doses (40, 40, and 60 mg/kg, the same treatment protocol applied a decade ago) there were no uncured patients remaining in the study. This shows that there has not been an increase of drug failure, despite 10 years of therapeutic pressure in these villages where there had been resistant infections and worms with decreased response to PZQ.

Hepatopathy in complicated falciparum malaria: report from eastern India

A prospective study done in 216 children with complicated falciparum malaria showed hepatopathy in 33.3% of cases with a higher incidence in children aged above five years. Bilirubin and alanine aminotransferase were moderately raised in most cases. No significant association with other common complications and no higher risk of mortality was observed.

[Sonographic evaluation of periportal fibrosis in children living in a Schistosoma mansoni endemic region]

PURPOSE

To assess with ultrasound periportal fibrosis due to chronic Schistosoma mansoni infection in children living in an endemic region. Materials and methods. A total of 441 children underwent two stool examinations and abdominal sonography. Liver echotexture was assessed by two observers and compared to pre-defined image patterns and a fibrosis score was assigned ranging from 0 to 8. Ultrasound features were correlated to age, sex, and parasitologic findings.

RESULTS

Prevalence of Schistosoma mansoni infestation was 63%. Two cases of advanced fibrosis (E pattern or fibrosis score of 6) were observed. Fibrosis correlated with age. No correlation existed between fibrosis and intensity of egg-output. A correlation between the two examinors was noted in 84% of examinations with a kappa coefficient of 0.7.

CONCLUSION

Although severe periportal fibrosis is a rare finding in this endemic region, follow-up sonography must be performed because it is the only non invasive and reliable tool for detection of periportal fibrosis.

Periportal fibrosis in human Schistosoma mansoni infection is associated with low IL-10, low IFN-gamma, high TNF-alpha, or low RANTES, depending on age and gender

Schistosoma mansoni infection is highly endemic in parts of Uganda, and periportal fibrosis is common in communities along the shore of Lake Albert. In this study, we have identified cellular immune responses associated with fibrosis. A cohort of 199 individuals aged 6-50, resident in the village for at least 10 years or since birth, were examined for evidence of periportal fibrosis by ultrasound using the Niamey protocol. Whole-blood samples were assayed for levels of nine cellular immune molecules (IL-3, IL-4, IL-5, IL-10, IL-13, TNF-alpha, IFN-gamma, IL-1beta, and RANTES) in the absence of in vitro Ag stimulation, and after stimulation with egg and worm Ags. A lack of Ag specificity allowed the number of variables in the analysis to be reduced by factor analysis. The resulting factor scores were then entered into a risk analysis using a classification tree algorithm. Children, adult males, and adult females had different factors associated with fibrosis. Most cases of fibrosis in children (eight of nine) were associated with low (<47th percentile) IL-10 factor scores. Adult females at lowest risk had relatively high IFN-gamma factor scores (>83rd percentile), whereas those at highest risk had a combination of intermediate (32nd to 83rd percentile) IFN-gamma and relatively high (>60th percentile) TNF-alpha factor scores. Adult males at lowest risk of fibrosis had moderate TNF-alpha factor scores (55th to 82nd percentile), and a high risk was associated with either high TNF-alpha factor scores (>82nd percentile), or intermediate TNF-alpha combined with low RANTES factor scores (<58th percentile). These results demonstrate that periportal fibrosis is associated with cytokine production profiles that vary with both age and gender.

Morbidity of schistosomiasis mansoni in rural Alexandria, Egypt

A parasitological survey of stool and urine of 2577 from 3281 individuals living in Abis villages, Alexandria was undertaken in 1998 in order to investigate the prevalence of schistosomiasis in this area and risk factors for hepatic morbidity. A random sample of 1082 individuals was interviewed using a questionnaire regarding risk factors for liver morbidity. All interviewed adults (total: 728) were clinically examined for evidence of organomegally (hepatomegally and/or splenomegally). Individuals with clinically detected organomegally were referred for detailed investigations (total: 65). The criteria for severe hepatic morbidity were AST/ALT ratio higher than 1, prothrombin activity < 70%, and evidence of portal hypertension. The results revealed that prevalence of S. mansoni accounted for 20.5%, with low intensity of infection and increased with age to reach a maximum of 40-46.3% at 15-30 years of age. Intensity of infection followed the same pattern. All tested urine samples were negative for S. haemato-bium. The prevalence of clinically detected organomegally was 10.3% among adults (75/728). Significant risk factors for developing organomegally were age > or = 35 years (2.2 folds), farming occupation (1.7 fold), history of parenteral anti-schisto-somal treatment (PAT) with or without tablets (2.03 folds), and heavy water canal exposure (2.85 folds). Detailed morbidity study on 65 individuals with clinically detected organomegally showed that 52.3% reported heavy score for water canal exposure, 33.8% were positive for HCV antibodies, and 7.7% for HBV antibodies. Procollagen level was higher than 5.5 microg/l in 26.2% of this group. The results of Doppler ultrasonography showed that 33.3% recorded a portal vein diameter > or = 13 mm, 26.2% periportal fibrosis more than grade 2 (> 5 mm), 19% hepatofugal direction of portal blood flow, 30.2% collaterals, 28.6% splenomegaly, and 17.5% hepatofugal direction of splenic blood flow. The burden of severe hepatic morbidity was alarming among this group: 33.8% with portal hypertension, 24.6% with prothrombin activity < 70, and 13.8% with AST/ALT ratio > 1. There was a 4.44 and 3.7 fold increased risk for portal hypertension with elevated levels of PIIIP and positive serologic tests for HCV and/or HBV infections, respectively. Similarly, a 4.58 and 18.35 fold increased risk for AST/ALT more than one was attributed to these two factors, respectively. Elevated procollagen level was significantly associated with viral infection (HCV and/or HbsAG). Seropositivity for HCV antibodies was found strikingly high in adults above 35 years (positive HCV antibodies in 45.9% of individuals). This indicates a high level of endemicity in the study area which is also endemic for S. mansoni. So, a heavy burden of severe liver disease exist in rural Alexandria is attributed to combined infection of S. mansoni and hepatitis viruses. This emphasizes the need for intervenetion strategies targeting these two main liver offenders.

Prevalence of pulmonary hypertension in patients with hepatosplenic Mansonic schistosomiasis--prospective study

BACKGROUND/AIMS

Thirty-four patients with portal hypertension and previous history of esophageal varices hemorrhage due to hepatosplenic Mansonic schistosomiasis were prospectively studied.

METHODOLOGY

All patients underwent invasive hemodynamic monitoring with introduction of a pulmonary artery catheter. Hemodynamic evaluation was characterized by an increased cardiac index (4.90 +/- 1.27 L/min/m2) associated to a decrease in systemic vascular resistance index (1461 +/- 443.04 dynes.sec/cm5.m2).

RESULTS

Mean pulmonary artery pressure (17.97 +/- 6.97 mmHg) and right atrial pressure (7.65 +/- 3.67 mmHg) were increased while pulmonary vascular resistance index was decreased (147.95 +/- 126.21 dynes.sec/cm5.m2). Twenty-four patients (70.5%) presented pulmonary hypertension (mean pulmonary artery pressure > 15 mmHg); in fifteen (44.1%) pulmonary pressure was between 15 and 20 mmHg, in three between 20 and 25 mmHg and, in four patients, pulmonary pressure was higher than 25 mmHg.

CONCLUSIONS

In conclusion, pulmonary hypertension is a frequent complication in patients with portal hypertension due to hepatosplenic Mansonic schistosomiasis and, in 20.6% of the cases, it can be considered as moderate or severe. Our results suggest that shunt surgeries, which can aggravate pulmonary hypertension, should be employed very cautiously in the treatment of schistosomal portal hypertension.

[Schistosomiasis in hyperendemic area of Taquarendi: I- Schistosoma mansoni infection and severe clinical forms]

The study was carried out in Taquarendi (Bahia), a caatinga zone with a small irrigated strip of land, where Biomphalaria glabrata snails are found. From the 1,532 inhabitants, 1,105 (72.1%) were submitted to clinical examination and 1058 out of them (95.7%) made stool examinations. Prevalence of schistosomiasis was 73.1% and 16.2% of these patients eliminated more than 1,000 eggs per gram of stool. By clinical examination, the size and the consistency of the left liver lobe were increased in 54% of the individuals and the spleen was palpable in 21.8%. The diagnosis of hepatosplenomegaly and of the advanced hepatointestinal clinical form was made, respectively, in 9.8% and 3.7%. A direct relationship between such clinical forms of the disease and the worm load over 1.000 S. mansoni eggs/g of fezes was found.

Schistosomiasis mansoni in low transmission areas: abdominal ultrasound

In endemic areas with low prevalence and low intensity of infection, the diagnosis of hepatic pathology due to the Schistosoma mansoni infection is very difficult. In order to establish the hepatic morbidity, a double-blind study was achieved in Venezuelan endemic areas, with one group of patients with schistosomiasis and the other one of non-infected people, that were evaluated clinically and by abdominal ultrasound using the Cairo classification. Schistosomiasis diagnosis was established based on parasitologic and serological tests. The increase of the hepatic size at midclavicular and midsternal lines (in hepatometry) and the hard liver consistency were the clinical parameters able to differentiate infected persons from non infected ones, as well as the presence of left lobe hepatomegaly detected by abdominal ultrasound. The periportal thickening, especially the mild form, was frequent in all age groups in both infected and uninfected patients. There was not correlation between the intensity of infection and ultrasound under the current circumstances. Our data suggest that in Venezuela, a low endemic area of transmission of schistosomiasis, the hepatic morbidity is mild and uncommon. The Cairo classification seems to overestimate the prevalence of periportal pathology. The specificity of the method must be improved, especially for the recognition of precocious pathology. Other causes of hepatopathies must be investigated.

Hepatozoon kisrae n. sp. infecting the lizard Agama stellio is transmitted by the tick Hyalomma cf. aegyptium

Hepatozoon kisrae n. sp. was found infecting a starred lizard at a site in southeastern Samaria, Palestine. These lizards were also hosts to the ixodid tick Hyalomma cf. aegyptium, which was demonstrated to be the vector of this hemogregarine. Hepatozoon and tick infections occurred in lizards within a very restricted locality; at a second site, nearby, ticks occurred without Hepatozoon infection. Micro- and macromeronts occurred mainly in the lungs, while cyst-like merogonic stages, mainly dizoic, occurred in the liver. Mature intraerythrocytic gametocytes were stout and encapsulated. Development from oocysts to sporocysts took place in the tick hemocoel, and was examined by transmission electron microscopy. Lizards were successfully infected when fed on sporocyst-infected ticks or viscera of infected lizards. Ticks become infected when fed on infected lizards; sporogony was complete when the ticks reached adult stage, over 40 days after initial attachment.

Hepatosplenic schistosomiasis in field-based studies: a combined clinical and sonographic definition

A combined clinical and sonographic classification of hepatosplenic schistosomiasis mansoni to be used in field-based studies is proposed herein. Seven hundred forty one individuals out of 892 (83%), living in an area endemic for schistosomiasis in Brazil, have been submitted to clinical and ultrasound examinations. Based on two stool examinations the overall prevalence for schistosomiasis in this area was 73%. Abdominal palpation was performed with patients in dorsal decubit, during deep breath, by two experienced physicians and a portable ultrasound was used for the evaluation of liver fibrosis, portal collaterals and spleen size. Four groups of individuals were identified using data obtained by abdominal palpation and ultrasound examination: (1) palpable spleen and intense periportal thickening in 9 individuals (1.2%); (2) spleen not palpable and intense periportal thickening in 15 (2%); (3) palpable spleen with light to moderate periportal thickening in 32 (4.3%), and (4) palpable spleen with a normal liver on ultrasound in 30 (4%). The definition of hepatosplenic schistosomiasis in field-based studies as the finding of Schistosoma mansoni eggs in the stools in an individual with splenomegaly is not acceptable anymore. Abdominal ultrasound should be combined with clinical examination to accurately identify hepatosplenics in endemic areas for schistosomiasis.

Morbidity of schistosomiasis mansoni in the highlands of Madagascar and comparison of current sonographical classification systems

To study the morbidity of schistosomiasis mansoni in the highlands of Madagascar, a cross-sectional study examined the extent to which liver fibrosis occurred in a rural community. The Managil and the Cairo classification systems were used. A second purpose was to investigate the effect of the measurements of 2 different branches of the portal vein (either segmental or sub-segmental branches) on the resulting staging of morbidity using the Cairo classification system. In a rice farmer village, 656 inhabitants (95% of the total population) were parasitologically examined; 561 patients underwent sonographic work-up based on the Managil scoring system, and in 307 randomized patients the outer to outer diameters of both the segmental and the sub-segmental branches of the portal vein were measured and scored by the Cairo classification system. Overall prevalence of schistosomiasis mansoni in the study area in 1994 was 68.3%. Upon sonographic examination and scoring by the Managil system 23.4% of the population showed liver changes (Managil degree I/II/III, 20%/2.5%/0.9%). Measuring the sub-segmental branches only and scoring by the Cairo classification, 19% of the study population were found to have liver changes, none with severe fibrosis. By contrast, 82% were found to have liver changes (Cairo degree 1/2/3, 70%/11%/2%) when the segmental branches were measured. The diameters of the sub-segmental branches were about two-thirds of those of the segmental branches. Both the Cairo- and the Managil-examination protocols have pitfalls. Using the Cairo classification, a considerable systematic error in classifying morbidity is created by measuring different branches of the portal vein.

[Relationship between the prevalence of hepatic milk spots in pig and the egg density of Ascaris suum in Kitakyushu Municipal Meat Inspection and Control Center]

The hepatic milk spots of pigs are chronic interstitial hepatitis, and are caused by the migration of pig ascarid worm, Ascaris suum, into the liver. A large number of livers are condemned in meat inspection centers as defective food once they are found to have developed milk spots, and thus the economic loss is great. Eggs of Ascaris suum from 120 caecum feces of slaughtered pigs were detected by the nylon mesh filtration (Makiya) technique and they were related to the condemnation data of the milk spot livers in Kitakyushu Municipal Meat Inspection and Control Center from April 2000 to February 2001. The condemnation rate was continuously more than 50% at some particular pig farms, the average rate being as high as 73% during this period. Liver milk spots and Ascarid infection from some 200 mg of caecum feces sampled with the template of the filtration technique were compared. As a result, a close agreement was observed between the two kinds of positive data, and a significant correlation was expected between the average egg density (EPG) of sampled pigs and the prevalence rate of milk spots of the same groups. These results proved that this filtration technique can be used as an effective inspection method for detecting milk spot liver.

Geographic differences in hepatosplenic complications of schistosomiasis mansoni and explanatory factors of morbidity

In a study in three neighbouring villages of southern Madagascar, where Schistosoma mansoni is hyperendemic, ultrasound examination using the Niamey protocol showed marked differences in the burden of disease from one village to another. Hepatosplenic schistosomiasis was more frequent in the village with the highest geometric mean egg counts and the earliest onset of infections, demonstrating that the morbidity induced by S. mansoni may vary greatly within a given area. True representativeness of study populations, a keystone of epidemiological studies, is mandatory to obtain a clear picture of a wide area. Ultrasound examinations in a small number of villages, or even a single one, may be a questionable approach. Using logistic regression analysis, the explanatory variables found to be significantly associated with a risk of severe hepatosplenic disease in our study were sex, age, village of residence and S. mansoni egg counts. On the other hand, a concurrent infection with an intestinal helminth seems to reduce the risk of severe hepatosplenic disease. Further studies should assess the role and possible impact of intestinal helminths on S. mansoni associated-morbidity.

Morbidity associated with Schistosoma mansoni infection determined by ultrasound in an endemic area of Brazil, Caatinga do Moura

Morbidity in schistosomiasis is caused by a granulomatous response to Schistosoma mansoni eggs deposited in peripheral portal veins. Ultrasonography has been useful to assess the impact of control programs on the prevalence of hepatic fibrosis. In the present study, ultrasonographic criteria proposed by the World Health Organization were used to classify the degree of hepatic fibrosis in 164 schistosomiasis patients from an endemic area of Brazil. The majority of subjects (89%) had degree I or II hepatic fibrosis. Periportal tract thickness, portal vein diameter, splenic vein diameter, and spleen size were positively correlated (P < 0.01). Ultrasonography was repeated on 21 patients one year later and hepatic fibrosis had progressed in 17. Ultrasonography was performed after treatment on 39 subjects and periportal fibrosis had regressed in 27.

Hepatobiliary and pancreatic ascariasis

Ascariasis is a helminthic infection of global distribution with more than 1.4 billion persons infected throughout the world. The majority of infections occur in the developing countries of Asia and Latin America. Of 4 million people infected in the United States, a large percentage are immigrants from developing countries. Ascaris-related clinical disease is restricted to subjects with heavy worm load, and an estimated 1.2 to 2 million such cases, with 20,000 deaths, occur in endemic areas per year. More often, recurring moderate infections cause stunting of linear growth, cause reduced cognitive function, and contribute to existing malnutrition in children in endemic areas. HPA is a frequent cause of biliary and pancreatic disease in endemic areas. It occurs in adult women and can cause biliary colic, acute cholecystitis, acute cholangitis, acute pancreatitis, and hepatic abscess. RPC causing hepatic duct calculi is possibly an aftermath of recurrent biliary invasion in such areas. Ultrasonography can detect worms in the biliary tract and pancreas and is a useful noninvasive technique for diagnosis and follow-up of such patients. ERCP can help diagnose biliary and pancreatic ascariasis, including ascaris in the duodenum. Also, ERCP can be used to extract worms from the biliary and pancreatic ducts when indicated. Pyrantel pamoate, mebendazole, albendazole and levamisole are effective drugs and can be used for mass therapy to control ascariasis in endemic areas.

[Role of gastropods in epidemiology of human parasitic diseases]

Pulmonate and prosobranch snails, being necessary hosts for parthenogenetic generations of digenetic trematodes, participate in transmission of all trematodoses important from medical point of view. Role of particular gastropods in epidemiology of these diseases is discussed in details. Invasion of land snails and slugs is mainly passive by eggs containing developed miracidia, while enter of these larvae into snails inhabiting fresh-water environments is usually active. Generations in the snail host between miracidia and cercariae vary considerable, depending upon the fluke species. Generally, the cercaria is produced by the sporocyst or the redia. Cercariae usually actively penetrate out of the infected snail and enter water. Leaving out of account cases of encystation of cercariae in external environment (liver flukes of the family Fasciolidae) and active penetration into the final host (blood flukes of the family Schistosomatidae), encystation of these larvae takes place in the second intermediate host. Cercariae of medically important flukes may develop into metacercariae in tissues of fish (liver flukes - Opisthorchis felineus, Clonorchis sinensis, intestinal flukes--Heterophyes heterophyes, Metagonimus yokogawai, Troglotrema salmincola), as well as in crustaceans (pulmonary flukes of the genus Paragonimus), insects (the bipathogenic liver fluke Dicrocoelium dendriticum and other species of the family Plagiorchiidae incidentally found in man), and gastropods (flukes of the family Echinostomatidae, among them perhaps the best known is the Oriental species--Echinostoma ilocanum). In prevention and control of human trematodoses, especially in endemic foci, elimination of snail hosts is a great importance. Using molluscides may be objectionable from the stadpoint of environmental modification through their toxicity to other organisms. Biological control of snail hosts is more attractive. It includes introduction and management of predators, parasites, or pathogens, and intramolluscan competition. Moreover, certain slugs and terrestrial snails participate in transmission of nematode larval stages, including species known as pathogenic for man - the strongylid nematodes of the genus Angiostrongylus). Such infections may be prevented by abstanding from eating raw or inadequately cooked molluscs in endemic areas.

Hepatic schistosomiasis

Schistosomiasis is a major, worldwide cause of morbidity and mortality. Disease from the organism Schistosoma mansoni results from egg deposition in the liver, intestines, and other organs and is associated with an intense, granulomatous response from the human host. Clinical manifestations range from mild to severe intestinal forms, and hepatosplenic schistosomiasis, which is associated with hepatic fibrosis, portal hypertension, esophageal varices, and splenomegaly. This article presents information about the epidemiology, immunopathogenesis and clinical aspects of the disease, the relationship between hepatic schistosomiasis and viral infections, diagnosis, therapy, and control strategies for schistosomiasis.

[Strongyloidosis. Part VII. Epidemiology and prevention (1)]

The source of invasion of Strongyloides stercoralis and the routes of transmission strongyloidosis were presented. The survival, development and behavior forms parasitic and free-living generation of S. stercoralis in soil and host was also described.

Susceptibility to periportal (Symmers) fibrosis in human schistosoma mansoni infections: evidence that intensity and duration of infection, gender, and inherited factors are critical in disease progression

Lethal disease in Schistosoma mansoni infections is mostly due to portal hypertension caused by hepatic periportal fibrosis. To evaluate the factors that may determine severe disease, livers and spleens were examined by ultrasound in a Sudanese population living in a village where S. mansoni is endemic. Early (FI), moderate (FII), or advanced (FIII) fibrosis was observed in 58%, 9%, and 3% of the population, respectively. Although FI affected 50%-70% of the children and adolescents, FII prevalence was low in subjects </=20 years old but increased sharply (45%-58%) in men 21-30 years old and was associated with the highest infections. Portal and splenic vein diameters were increased in one-third of persons with FII and in almost all with FIII disease. Severe disease, FII or FIII with portal hypertension, affected 6% of the population, was associated with splenomegaly, occurred mostly in adult men, and was clustered in a few pedigrees. These observations suggest that infection intensity and duration, gender-related factors, and inherited factors are important in fibrosis development.

Diagnostic value of connective tissue metabolites in Schistosoma mansoni related liver disease

Reliable non-invasive markers of hepatosplenic involvement in schistosomiasis are needed for determination of morbidity levels in endemic populations and for diagnosis and follow-up of affected individuals. Serum levels of connective tissue metabolites have been investigated as fibrosis markers in various hepatic disorders, but their accuracy in the detection of hepatosplenic schistosomiasis under endemic conditions has not been fully elucidated. 206 adult inhabitants of a Tanzanian village highly endemic for schistosomiasis mansoni (prevalence 88%) underwent clinical, parasitological and sonographic work-up; sera were tested for aminoterminal procollagen III-peptide (PIIIP), carboxyterminal procollagen IV peptide (NC1) and laminin. Connective tissue marker levels did not correlate with the presence or intensity of infection. NC1 levels were significantly correlated with periportal liver fibrosis (P < 0.001), splenomegaly (P < 0.002), portal vein dilatation (P < 0.004) and the presence of portosystemic collaterals (P < 0.001); for PIIIP and laminin, none of the respective relationships was significant. Due to wide overlap of NC1 levels between individuals with normal sonography findings and those with advanced periportal fibrosis and portal hypertension, the sensitivity and positive predictive value of this markers to detect these individuals were low (< 40%), although specificity and overall accuracy in the given setting were good (80-90%). It is concluded that PIIIP and laminin are not useful as diagnostic serum markers of hepatosplenic schistosomiasis at the community level; NC1 was significantly related to various indices of hepatosplenic involvement, but its low sensitivity precludes its use as a screening tool under endemic conditions.

The situation of hepatosplenic schistosomiasis in Brazil today

Specific chemotherapy against schistosomiasis together with environmental changes occurring in endemic areas of Brazil are causing a revolution in the clinico-pathological presentation of the disease when comparing to date from 10 to 15 years ago. To update the subject, an inquiry was made among the most experienced Brazilian investigators in this field. They agree that a decrease of about 50 to 70% in prevalence, and an even higher decrease in incidence are taking place in Brazil today. The prevalence of schistosome-infection has decreased in some areas and increased in other, with spreading sometimes occurring to peri-urban regions, indicating that schistosomiasis control depends on the application of multiple measures. General clinical and pathological manifestations related to hepatosplenic disease, such as ascites, gastric hemorrhages, big-spleen syndrome, cor pulmonale, glomerulopathy, etc. are also less severe nowadays than they used to be in the past.

Chronic Japanese schistosomiasis and hepatocellular carcinoma: ten years of follow-up in Yamanashi Prefecture, Japan

In a preliminary study carried out in the study area we found that 19.1% (173/907) of patients with chronic liver disease and 51% (35/68) of hepatocellular carcinoma cases were infected with Japanese schistosomiasis. Analysis of data from 571 autopsies revealed a similarly high incidence of schistosomiasis among cases of hepatoma and other liver diseases. A prospective case-control study conducted over 10 years showed that hepatoma developed in 5.4% (26/484) of chronic schistosomiasis cases and in 7.5% (23/307) of patients with chronic liver disease (hepatitis, cirrhosis, etc). The difference was not statistically significant (P = 0.228). A high incidence of hepatitis C virus (HCV) antibody (HCVAb) was found in the schistosomiasis group (36.5%; 95% CI = 44.9-28.1%) and in the chronic liver disease group (56.0%), 39% of whom had chronic hepatitis (P = 0.028). Various factors that might have contributed to the development of hepatoma and schistosomiasis were investigated, but no evidence of a significant correlation between schistosomiasis and hepatoma was found. The high incidence of HCVAb was considered to have been responsible for the development of hepatocellular carcinoma in chronic schistosomiasis patients. The role of HBV infection in the development of hepatoma in schistosomiasis patients was not confirmed after an assay for HCVAb was included in the study.

Platynosomum fastosum in ex-captive orangutans from Indonesia

The liver fluke Platynosomum fastosum was identified upon necropsy of three ex-captive orangutans (Pongo pygmaeus) which had been part of a rehabilitation program for reintroduction to the wild. This trematode has not been reported in orangutans previously and is commonly found in cats in Southeast Asia. Cross infection from cats via intermediate hosts, to orangutans kept in captivity as pets, could explain their presence in the latter. Although P. fastosum caused intrahepatic and bile duct damage, death of the hosts could not be attributed solely to the presence of the liver fluke infection.

Hepatolithiasis and biliary parasites

Hepatolithiasis, or the presence of intrahepatic stones, is prevalent in East Asia and is characterized by the finding of stones within the intrahepatic bile ducts proximal to the confluence of the right and left hepatic ducts. Bile stasis and bacterial infection have been incriminated as the major aetiopathogenic factors. Clinical features include recurrent pyogenic cholangitis, multiple liver abscesses, secondary biliary cirrhosis and cholangiocarcinoma. The goals of management include accurate localization of pathologies, control of biliary sepsis and the elimination of stones and stasis. Ultrasonography, computed tomography and direct cholangiography complement each other in defining the stones, strictures and degree of liver damage. Non-operative biliary decompression by endoscopy and interventional radiology is effective in controlling the infection, but surgery remains the mainstay for the treatment of stones and strictures. Intra-operative ultrasound and flexible choledochoscopy, combined with percutaneous transhepatic cholangioscopy and intraductal lithotripsy, facilitate stone removal. Balloon dilatation and biliary stenting serve to open the bile duct strictures. The creation of a hepaticocutaneous jejunostomy after conventional surgery allows atraumatic access to the biliary system for the removal of recurrent stones. The management of biliary parasites begins with conservative measures, including analgesics and anti-helminthic therapy. In refractory cases or patients with acute cholangitis, endoscopic biliary drainage and the extraction of worms may be necessary. Improvement in sanitation plays a crucial role in the epidemiological control of these biliary diseases.

Prevalence of hepatitis E virus IgG antibodies in patients from a referral unit of liver diseases in Salvador, Bahia, Brazil

Hepatitis E virus (HEV) is prevalent in Asia and Africa. Recently, it was also described in Mexico, but epidemiologic data from other Latin American countries are scarce. The seroprevalence of anti-HEV in a referral hepatology unit in northern Brazil was determined by testing for anti-HEV IgG in 701 serum samples from our serum bank. Specimens analyzed were from 200 blood donors, 79 patients with acute viral hepatitis (AVH), 392 hemodialyzed patients, and 30 carriers of schistosomiasis. Duplicate test results for anti-HEV were positive in four (2%) of 200 of the blood donors, three (10%) of the 30 carriers of schistosomiasis, and in none of the 392 hemodialyzed patients. Fourteen (17.7%) of the AVH patients were positive, as were six (25%) of 24 with hepatitis A virus, three (11%) of 26 with hepatitis B virus, 0 (0%) of 12 with hepatitis C virus, and five (29%) of 17 with non-A, non-B, non-C hepatitis viruses. Among AVH cases, those with hepatitis A virus had a higher frequency of anti-HEV positivity compared with all other hepatotropic viruses (P < 0.0003). We conclude that HEV is prevalent in northern Brazil. The higher prevalence in patients compared with blood donors could be explained by the lower social condition of patients who sought public health service in this area, in contrast with the heterogeneous socioeconomic distribution of blood donors. Patients with AVH due to hepatitis A had a greater frequency of anti-HEV, probably because of similar routes of transmission for both hepatitis A and E viruses. Finally, the absence of anti-HEV in the hemodialyzed group could be explained by a lower immunologic response found in patients with chronic renal failure.

Duodenal and hepatic toxoplasmosis in a patient with HIV infection: review of the literature

We report a case of watery diarrhea due to duodenal toxoplasmosis in a patient with the acquired immunodeficiency syndrome. Treatment with pyrimethamine, clindamycin, and folinic acid decreased the diarrhea as well as the duodenal toxoplasma cyst load. Hepatic toxoplasmosis was also present, associated with an elevated serum alkaline phosphatase activity and a minimally elevated lactate dehydrogenase level.

Severe and complicated falciparum malaria in Melanesian adults in Papua New Guinea

Severe falciparum malaria usually occurs in children, but also occurs in nonimmune migrants or partially immune adults in areas of unstable transmission. We have studied prospectively 70 adult patients with strictly defined severe malaria from the south coast of Papua New Guinea where malaria transmission is not intense. Only 19 (27.1%) were migrants from areas where malaria transmission does not occur; many other patients were periurban dwellers who had become infected after visits to their home villages. The most common clinical features were jaundice or hepatic dysfunction, impaired consciousness, renal failure, cerebral malaria, and anemia. Hypoglycemia was common following treatment with quinine. The overall case fatality rate was 18.6%; renal failure and cerebral malaria in particular were associated with a poor outcome. Reduction in mortality might be achieved by aggressive therapy of renal failure with earlier institution of dialysis; the use of preventive measures for immigrants or urban dwellers returning to high transmission areas might reduce the incidence of this dangerous disease.