Human cystic echinococcosis: first molecular identification of Echinococcus canadensis G7 in Brazil.

Echinococcus granulosus sensu lato (s.l.) is a species complex with the potential to cause cystic echinococcosis (CE). Contact with the feces of domestic dogs (Canis familiaris) fed with raw viscera of intermediate livestock hosts is a risk factor for this infection in the southern region of Brazil. Although the region has been considered endemic to CE for many years, molecular data regarding the species of the complex causing CE in humans are scarce. This study aimed to perform a molecular analysis of the biological fluid from a human liver cyst to investigate the species responsible for CE. Genetic material obtained from the hydatid fluid of a hepatic cyst from a human with CE was subjected to PCR to amplify mitochondrial and nuclear DNA sequences. The phylogenetic analysis confirmed the human infection by Echinococcus canadensis G7 in the state of Paraná, Brazil. This is the first molecular record of E. canadensis G7 infecting a human in Brazil, and it is important to reiterate the risk of human CE caused by this species in South America, as reported by a previous study in Patagonia, Argentina. From the epidemiological point of view, this finding is of great relevance for the southern region of Brazil, since this parasite has previously only been detected in pigs in the state of Rio Grande do Sul, neighboring Paraná. The finding points to the importance of this identification in the molecular epidemiology of E. granulosus s.l., especially in South America.

Diversity of helminths with zoonotic potential and molecular characterization of Toxocara canis infecting domestic dogs from locations of Amazon and Atlantic Forest Brazilian biomes.

The coproparasitological examination of dogs (n=278) from two Brazilian biomes (Amazon [AZ] and Atlantic Forest [AF]) by centrifugal flotation demonstrated positivity values of 54.2% (AF) and 48.5% (AZ). The most prevalent parasites in AF were hookworms (81.0% - 47/58), Toxocara sp. (17.3% - 10/58) and Trichuris vulpis (12.1% - 7/58); while in AZ they were hookworms (86.7% - 72/83), Toxocara sp. (18.1% - 15/83), Dipylidium caninum (13.3% - 11/83) and T. vulpis (10.8% - 9/83). PCR was performed using the partial mitochondrial genes cytochrome c oxidase subunit 1 (pcox1) and NADH dehydrogenase 1 (pnad1) in 25 fecal samples positive for Toxocara sp. eggs and found one sample positive for pcox1 and six positives for pnad1. The sequencing of these samples was unsuccessful due to the difficulties inherent in copro-PCR+sequencing. The sequencing of 14 samples of T. canis adult helminths retrieved 11 sequences of 414 bp for pcox1 and nine sequences of 358 bp for pnad1. The phylogenetic trees of these sequences confirmed the species T. canis. Intraspecific genetic variation was only observed for pnad1. This is the second study involving molecular analysis of T. canis in dogs from Brazil and adds new information through the use of pnad1.

Genetic diversity of Echinococcus vogeli in the western Brazilian Amazon.

Human polycystic echinococcosis is a parasitic infection caused by the larval stage of Echinococcus vogeli, which occurs in rural areas of Central and South America. Until now, little information on the genetic variability of E. vogeli is available. Here, 32 samples from human-excised E. vogeli cysts had a 396-bp sequence of the mitochondrial cytochrome oxidase I (COI) gene sequenced and compared to another 17 COI sequences representing nine Echinococcus species. A Bayesian COI tree revealed that all E. vogeli sequences formed a monophyletic and well-supported clade with an E. vogeli reference sequence. The occurrence of geographically restricted E. vogeli COI haplotypes suggests retention of ancestral polymorphisms with little migration in Acre, Brazil.

Occurrence of Capillaria sp. in the liver of sheep (Ovis aries ) in a slaughterhouse in the state of Acre, Brazil.

Although sheep farming has grown in the state of Acre over the past four decades, little is known about occurrences of helminthiases in the herds of this region. The objective of the study was to assess the occurrences of non-intestinal helminthiasis among sheep slaughtered in Rio Branco. A total of 110 sheep livers were inspected from two slaughter batches (july 2014 and march 2015) in a slaughterhouse in Rio Branco. Livers with macroscopic lesions were photographed and were then subjected to histopathological analysis under an optical microscope. The macroscopic lesions showed small nodes with inflammatory characteristics and areas of fibrosis, which appeared to be calcified, thus suggesting a granulomatous reaction. Of the 110 evaluated livers, we noticed 110 nodules in total; these nodules have an average size of 0.5 cm. The histopathological analysis showed alterations to the architecture of the hepatic lobe, with multiple foci of necrosis and polymorphonuclear cells. Two samples revealed the presence of helminths from Nematode class and Capillaria sp. eggs identified by the typical morphology and morphometry. This seems to be the first report of Capillaria sp. in sheep livers in Brazil, and it serves as an important alert regarding animal health surveillance and control and regarding the Capillaria sp. zoonotic role in humans.

Occurrence of Capillaria sp. in the liver of sheep (Ovis aries ) in a slaughterhouse in the state of Acre, Brazil / Ocorrência de Capillaria sp. em fígado de ovino ( Ovis aries) em um abatedouro no estado do Acre, Brasil

Abstract Although sheep farming has grown in the state of Acre over the past four decades, little is known about occurrences of helminthiases in the herds of this region. The objective of the study was to assess the occurrences of non-intestinal helminthiasis among sheep slaughtered in Rio Branco. A total of 110 sheep livers were inspected from two slaughter batches (july 2014 and march 2015) in a slaughterhouse in Rio Branco. Livers with macroscopic lesions were photographed and were then subjected to histopathological analysis under an optical microscope. The macroscopic lesions showed small nodes with inflammatory characteristics and areas of fibrosis, which appeared to be calcified, thus suggesting a granulomatous reaction. Of the 110 evaluated livers, we noticed 110 nodules in total; these nodules have an average size of 0.5 cm. The histopathological analysis showed alterations to the architecture of the hepatic lobe, with multiple foci of necrosis and polymorphonuclear cells. Two samples revealed the presence of helminths from Nematode class and Capillaria sp. eggs identified by the typical morphology and morphometry. This seems to be the first report of Capillaria sp. in sheep livers in Brazil, and it serves as an important alert regarding animal health surveillance and control and regarding the Capillaria sp. zoonotic role in humans.

Resumo Embora a ovinocultura tenha despertado o interesse de criadouros no estado do Acre nas últimas quatro décadas, pouco se conhece sobre a ocorrência de helmintoses no plantel de ovinos dessa região. O objetivo do presente estudo foi avaliar a possibilidade de ocorrência de helmintíases não intestinais entre ovinos abatidos no município de Rio Branco. Foram inspecionados 110 fígados de ovinos em dois abates (julho de 2014 e março de 2015) em um abatedouro no município de Rio Branco. Fígados com lesões macroscópicas foram fotografados com posterior análise histopatológica por microscopia de luz. Nas lesões macroscópicas foram encontrados pequenos nódulos apresentando características inflamatórias com áreas de fibrose, aparentemente calcificadas, sugerindo uma reação granulomatosa. Dos 110 fígados avaliados, observou-se 110 nódulos no total; estes nódulos têm um tamanho médio de 0,5 cm. A análise histopatológica mostrou alterações na arquitetura do lóbulo hepático, com múltiplos focos de necrose, além da formação de abscessos hepáticos constituídos por polimorfonucleares. Duas amostras revelaram a presença de helmintos da Classe Nematoda e ovos de Capillaria sp. identificados pela morfologia típica e morfometria. Esse resultado parece ser o primeiro registro de Capillaria sp. em fígado de ovino no Brasil, o que é um importante alerta para a vigilância no controle sanitário animal e o seu papel zoonótico para humanos.

First parasitological, histopathological and molecular characterization of Echinococcus vogeli Rausch and Bernstein, 1972 from Cuniculus paca Linnaeus, 1766 in the Cerrado biome (Mato Grosso do Sul, Brazil).

Polycystic echinococcosis (PE) is caused by Echinococcus vogeli metacestodes (larval stage) in Neotropical countries. E. vogeli is trophically-transmitted between predators bush dogs (Speothos venaticus) and prey pacas (Cuniculus paca). In Brazil, reported PE cases are restricted to the Amazon biome. In this study, metacestodes from a paca hunted in Mato Grosso do Sul state (Cerrado biome) were identified morphological and histopathological techniques and further confirmed by molecular testing (sequencing of cytochrome C oxidase subunit I (cox1) gene) for the first time. Images of the whole liver showed superficial bubble-like hepatic masses. The parasitological analysis revealed large hooks (41.3 ±â€¯1.2 µm length/12.8 ±â€¯0.8 µm width) and small hooks (33.0 ±â€¯1.5 µm length/11.1 ±â€¯1.2 µm width), consistent with E. vogeli. Microscopically, the liver showed protoscoleces, a thick laminated layer, fibrosis, and inflammatory infiltrate in the adventitial layer. The DNA sequencing confirmed E. vogeli with 99% homology with sequences deposited in the GenBank. In addition, this finding greatly extends the geographic range of animal polycystic echinococcosis into the Cerrado. It is likely to occur in new biomes, where bush dogs and pacas share a given area in a trophic relationship.

First genetic characterization of Fasciola hepatica in Argentina by nuclear and mitochondrial gene markers.

Fasciola hepatica is a trematode showing genetic variation among isolates from different regions of the world. The objective of this work was to characterize for the first time F. hepatica isolates circulating in different regions of Argentina. Twenty-two adult flukes were collected from naturally infected bovine livers in different areas from Argentina and used for DNA extraction. We carried out PCR amplification and sequence analysis of the ribosomal internal transcribed spacer 1 (ITS1), mitochondrial nicotinamide adenine dinucleotide dehydrogenase subunits 4 and 5 (nad4 and nad5) and mitochondrial cytochrome c oxidase subunit I (cox1) genes as genetic markers. Phylogenies were reconstructed using maximum parsimony algorithm. A total of 6 haplotypes were found for cox1, 4 haplotypes for nad4 and 3 haplotypes for nad5. The sequenced ITS1 fragment was identical in all samples. The analyzed cox1 gene fragment is the most variable marker and is recommended for future analyses. No geographic association was found in the Argentinean samples.

Light and scanning electron microscopy study of in vitro effects of artesunate in newly excysted metacercariae of Echinostoma paraensei (Trematoda: Digenea).

Chemotherapy of food-borne trematodes relies on two drugs, praziquantel and tricabendazole, and there is growing interest in finding alternative therapies. Plant oil extracts have long been used in traditional Chinese medicine as sources of bioactive compounds with antiparasitic activity. Species of the genus Echinostoma are used as good models to test effective compounds against food-borne trematodes. This study evaluated the anthelmintic activity of crude artesunate extracts in vitro on newly excysted metacercariae of Echinostoma paraensei by light and scanning electron microscopy (SEM). The flukes were incubated with 1 µg/mL, 10 µg/mL, 25 µg/mL, 50 µg/mL and 100 µg/mL of artesunate for 4, 12, 24, 48 and 72 h. When the exposure time and concentration of artesunate increased, there were changes in motor activity, tegument damage and death. Blebs and swelling were the most common damages quantified on the tegument. The in vitro study reproduced results described for other immature flukes incubated with artemisinin derivatives. Excysted metacercariae of E. paraensei constitute a good model to study in vitro drug effects.

First molecular identification of Echinococcus vogeli and Echinococcus granulosus (sensu stricto) G1 revealed in feces of domestic dogs (Canis familiaris) from Acre, Brazil.

BACKGROUND: Echinococcus granulosus (sensu lato) (s.l.) and Echinococcus vogeli are causative agents of chronic zoonotic diseases such as cystic and polycystic echinococcosis, respectively. In Brazil, polycystic echinococcosis has a restricted geographical distribution in the North Region, while cystic echinococcosis is observed in the South Region. Domestic dogs (Canis familiaris) fed with raw viscera represent a risk factor for E. granulosus (s.l.) infection in the South Region. Although this practice is frequent, it remains unclear whether domestic dogs are infected with E. vogeli in the state of Acre, located in the Amazon basin in the North Region of Brazil. The aim of this study was to investigate this gap in the polycystic echinococcosis epidemiology. METHODS: Sixty-five fecal samples were collected from the ground in five municipalities (Sena Madureira, n = 14; Rio Branco, n = 06; Bujari, n = 06; Xapuri, n = 30; and Epitaciolândia, n = 09) located in the state of Acre, northern Brazil. The samples were screened for parasites by copro-PCR using the cox1 gene associated with automated sequencing. RESULTS: Echinococcus vogeli was molecularly confirmed in a sample from Sena Madureira and E. granulosus (sensu stricto) (s.s.) (G1) in a sample from Rio Branco. CONCLUSIONS: These findings indicate that molecular assays are useful in typing Echinococcus taxa from fecal samples of dogs in northern Brazil. The present study is the first molecular record of E. vogeli in domestic dogs found in the state of Acre, reinforcing their role as a source of infection for humans. Because E. granulosus (s.s.) (G1) was detected for the first time in the North Region, from the epidemiological standpoint this finding is highly relevant, because it expands the known geographical distribution, which was previously restricted to the South Region of Brazil.

Polycystic echinococcosis in the state of Acre, Brazil: contribution to patient diagnosis, treatment and prognosis.

The lack of knowledge regarding polycystic hydatid disease results in delayed or even incorrect diagnosis. The lack of systematic information regarding treatment also makes it difficult to assess the results and prognosis in patients with peritoneal and hepatic lesions caused by Echinococcus vogeli. Here we describe the clinical features of patients, propose a radiological classification protocol and describe a therapeutic option for the treatment of hydatid disease that previously had only been used for cases of cystic echinococcosis (Echinococcus granulosus). A prospective cohort study was initiated in 1999 and by 2009 the study included 60 patients. These patients were classified according to the PNM classification (parasite lesion, neighbouring organ invasion and metastases) and placed in one of three therapeutic modalities: (i) chemotherapy with albendazole at a dose of 10 mg/kg/day, (ii) surgical removal of cysts or (iii) percutaneous puncture of the cysts via puncture, aspiration, injection and re-aspiration (PAIR). The results were stratified according to therapeutic outcome: "cure", "clinical improvement", "no improvement", "death" or "no information". The PNM classification was useful in indicating the appropriate therapy in cases of polycystic hydatid disease. In conclusion, surgical therapy produced the best clinical results of all the therapies studied based on "cure" and "clinical improvement" outcomes. The use of PAIR for treatment requires additional study.

Polycystic echinococcosis in the state of Acre, Brazil: contribution to patient diagnosis, treatment and prognosis

The lack of knowledge regarding polycystic hydatid disease results in delayed or even incorrect diagnosis. The lack of systematic information regarding treatment also makes it difficult to assess the results and prognosis in patients with peritoneal and hepatic lesions caused by Echinococcus vogeli. Here we describe the clinical features of patients, propose a radiological classification protocol and describe a therapeutic option for the treatment of hydatid disease that previously had only been used for cases of cystic echinococcosis (Echinococcus granulosus). A prospective cohort study was initiated in 1999 and by 2009 the study included 60 patients. These patients were classified according to the PNM classification (parasite lesion, neighbouring organ invasion and metastases) and placed in one of three therapeutic modalities: (i) chemotherapy with albendazole at a dose of 10 mg/kg/day, (ii) surgical removal of cysts or (iii) percutaneous puncture of the cysts via puncture, aspiration, injection and re-aspiration (PAIR). The results were stratified according to therapeutic outcome: "cure", "clinical improvement", "no improvement", "death" or "no information". The PNM classification was useful in indicating the appropriate therapy in cases of polycystic hydatid disease. In conclusion, surgical therapy produced the best clinical results of all the therapies studied based on "cure" and "clinical improvement" outcomes. The use of PAIR for treatment requires additional study.

Histopathological findings of an uncommon co-infection: Echinococcus vogeli, HIV, hepatitis C virus, and hepatitis B virus.

Our work represents the first case report of polycystic echinococcosis co-infection with HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV). Structural liver alterations were found to be related to parasitic structures and necroinflammatory foci (karyopyknosis, karyorrhexis, and karyolysis), consistent with Echinococcus vogeli. Visceral adipose tissue and intrahepatic triglyceride droplets (macrovesicular and microvesicular steatosis) indicated abnormal fat anabolism, which probably resulted from both viral-induced hepatopathy and drug-related toxicity. In summary, our results suggest that the observed liver abnormalities reflected the coincident exposure to hepatotropic viruses and parasites causing polycystic echinococcosis and were not indicative of opportunistic relationships among these pathogens.

Susceptibility of a Brazilian wild rodent isolate of Schistosoma mansoni to praziquantel in mice.

The therapeutic effects of praziquantel (PZQ) against a Schistosoma mansoni isolate derived from Nectomys squamipes (isolate R) and a susceptible isolate (BH) were analyzed in Swiss mice by fecal egg counting, adult worm reduction and oogram pattern. Infected mice were orally administrated with 62.5mg/kg (group 1), 125mg/kg (group 2), 250mg/kg (group 3) and 500mg/kg (group 4), each dose divided over 3 days (49, 50 and 51 days after infection). The data were analyzed using one-way analysis of variance (ANOVA). In regard to isolate R, no fecal eggs were observed with 250 mg/Kg and 500 mg/kg (p<0.05), whereas BH excretion reached zero with all doses. Mean worm burden reduction was significantly (p<0.05) higher at the two highest concentrations, regardless of isolate. At 62.5mg/kg, the percentage of immature eggs varied from 17% (isolate R) to 38% (isolate BH). At 125 mg/kg, the percentage of immature eggs varied from 20% (isolate R) to 16% (isolate BH). At 250 mg/kg, immature eggs dropped significantly to 1% (isolate R) and 4% (isolate BH). At 500 mg/kg, no immature eggs were found in isolate R, whereas in BH was 8%. No dosage significantly (p>0.05) affected the percentage of mature eggs, regardless of isolate. There was a large increase (p<0.001) in the percentages of dead eggs in all treated groups of 62% and 64% in groups 3 and 4, respectively (isolate R). The percentage of dead eggs rose from 34% (group 1) to 58% (group 3) in isolate BH. Although group 4 showed lowest increase in the percentage of dead eggs (46%), it was higher (p<0.001) compared to the 8% in the control. Our findings indicate that the wild isolate from N. squamipes is susceptible to PZQ.

Atypical polycystic echinococcosis without liver involvement in Brazilian patients.

Echinococcus vogeli is known to occur in the neotropics, causing polycystic echinococcosis (PE) in humans. The liver and lungs are the most commonly affected organs. In this paper, we report six cases of human PE in the mesenteries without primary liver involvement. All patients, four males and two females (median age 34 years; range 20-48 years), lived in a forested area (Acre, Brazil). Physical examination revealed abdominal masses. The patients were evaluated by abdominal CT scan, exploratory laparotomy and serology by immunoblot assay. CT scans revealed multiple and cystic lesions with calcified edges in the mesenteric segments. During exploratory laparotomy, polycystic lesions were excised from omentum, mesentery, pancreas and inferior vena cava. Positive serology identified 21 and 31 kDa subunits. We recommend that PE should be investigated in patients from tropical forests in northern Brazil exhibiting abdominal masses with no clearly defined diagnosis.

A new heligmonellid species (Nematoda) from Oligoryzomys nigripes (Rodentia: Sigmodontinae) in the Atlantic Forest, Brazil.

Stilestrongylus lanfrediae n. sp. is described from the small intestine of Oligoryzomys nigripes (Cricetidae: Sigmodontinae) collected in the Atlantic Forest (Rio de Janeiro State, Teresópolis, Brazil). The new species shows some similarities to Stilestrongylus stilesi, Stilestrongylus freitasi, Stilestrongylus inexpectatus, Stilestrongylus moreli, and Stilestrongylus andalgala, but it can be distinguished from these species by the following combination of characters: 26 ridges in males and 25 in females at the mid-body, asymmetrical caudal bursa with a pattern of type 2-2-1, rays 6 markedly shorter than other lateral rays, rays 8 inserted asymmetrically on dorsal trunk and shorter than other species, and a proportion of spicule length in relation to body length (SpL/BL) of 25-29%. The new species is also distinguished from other species of Stilestrongylus by the asymmetry of the branches of the dorsal ray and by having the longest spicules.

A new metastrongilid species (Nematoda: Metastrongylidae): a lungworm from Akodon montensis (Rodentia: Sigmodontinae) in Brazil.

Angiostrongylus lenzii n. sp. (Nematoda: Metastrongyloidea) is described and illustrated from the pulmonary artery of the wild rodent Akodon montensis Thomas, 1913, collected in the municipality of Teresopólis, Rio de Janeiro State, Brazil. It represents the 17th species of the genus and the 2nd in South America as parasites in rodents. This new species is the most similar morphologically to Angiostrongylus vasorum, Angiostrongylus gubernaculatus, Angiostrongylus schmidti, and Angiostrongylus morerai. It can be distinguished from them by the morphology of the caudal bursa, ventral rays 2 and 3 with conspicuous knobs, differences in width and length of lateral and dorsal rays, presence of rays 8, and length of spicules.

Successful outcome of hepatic polycystic echinococcosis managed with surgery and chemotherapy.

Echinococcus vogeli has been reported to cause human polycystic echinococcosis. A 43-year-old Brazilian woman was admitted to hospital complaining of mild epigastric discomfort. Computed tomography (CT) revealed multiple cystic lesions with calcified edges in several hepatic segments. At exploratory laparotomy, polycystic lesions were excised from the liver, omentum and peritoneum. No remaining cysts were observed on a post-surgery CT scan. The patient was asymptomatic when discharged on Day 19 post-operatively. She was prescribed albendazole therapy for 6 months. Follow-up CT performed 11 months later revealed no evidence of recurrence. Surgery combined with chemotherapy may improve the quality of life of patients with polycystic echinococcosis.

Intraspecific variation of Echinococcus granulosus in livestock from Peru.

Echinococcus granulosus infection is a problem of public health in livestock-rearing regions of Latin America, like in Peru. This species is characterized by the morphometry of the large and small rostellar hooks in both metacestodes and adult worms. The aim of this work was to study biometrical characteristics of rostellar hooks in hydatid cysts (lung and liver) from some Peruvian provinces (Arequipa, Cuzco, Huancavelica, Junin and Puno). The biometrical analysis was obtained in a digital system for image analysis. The following parameters were studied: area, perimeter, length and width total of the handle, the blade and the distance between the blade and the guard of large and small hooks. For statistical analysis Student's t-test and Analysis of Variance (ANOVA) with Pos-test of Tukey were used, considering the values of p< or =0.05 as of statistic significance. All morphometric characters of large and small hooks were highly significant (p<0.000), when data were compared among the samples from the different provinces. Rostellar hooks in specimens from Huancavelica presented smallest measurements, whereas hooks in specimens from Junin were bigger in relation to the total and blade measurements. Generally, samples from Arequipa presented the biggest large hooks in relation to the handle parameters. The rostellar hooks of cattle and sheep hosts varied depending on the geographic localization, host and organ. Hooks recovered from the lungs were larger than those collected in the liver. It was concluded that morphometry using computer image analysis allows the characterization of E. granulosus. The rostellar hooks presented morphometric polymorphism.

Notes on human cases of cystic echinococcosis in Peru.

Cystic echinococcosis (CE) is a high prevalent zoonosis in the central and southern Peruvian Andes. Serum samples (n50)from patients presenting presumptive clinical and radiological diagnosis of CE (group 1), were tested for antibodies against Echinococcus granulosus metacestode using Arc-5 double diffusion assay (DD5), immunoelectrophoresis (IEF), and immunoelectrotransfer blot (EITB) techniques. Serum samples (n18) from patients presenting other parasite infections (paragonomiasis, cysticercosis, and fascioliasis) or healthy blood donors (n15), were designated as control groups. The overall sensitivity of the tests was of 94% (DD5 and IEF tests) or 96% (EITB test). Only patients from group 1 were seropositive for CE. Polypeptides of 21, 31, and 48 kDa were considered positive for CE. Based on these results, this study demonstrates that CE also occurs in other coastal departments (Piura, Ancash, Ica, Arequipa, and Tacna) besides Lima.

Notes on human cases of cystic echinococcosis in Peru

Cystic echinococcosis (CE) is a high prevalent zoonosis in the central and southern Peruvian Andes. Serum samples (n50)frompatients presenting presumptive clinical and radiological diagnosis of CE (group 1), were tested for antibodies against Echinococcus granulosus metacestode using Arc-5 double diffusion assay (DD5), immunoelectrophoresis (IEF), and immunoelectrotransfer blot (EITB) techniques. Serum samples (n18) from patients presenting other parasite infections (paragonomiasis, cysticercosis, and fascioliasis) or healthy blood donors (n15), were designated as control groups. The overall sensitivity of the tests was of 94 percent (DD5 and IEF tests) or 96 percent (EITB test). Only patients from group 1 were seropositive for CE. Polypeptides of 21, 31, and 48 kDa were considered positive for CE. Based on these results, this study demonstrates that CE also occurs in other coastal departments (Piura, Ancash, Ica, Arequipa, and Tacna) besides Lima.