An Unusual Case of Gastric Gnathostomiasis Caused by Gnathostoma spinigerum Confirmed by Video Gastroscopy and Morphological and Molecular Identification.

Human gnathostomiasis is a harmful foodborne parasitic infection caused by nematodes of the genus Gnathostoma. Here, we report an unusual case of gastric gnathostomiasis seen in a hospital in Thailand along with the clinical characteristics, treatment, and outcome. A 39-year-old man presented with complaints of epigastric pain, dizziness, and history of passing dark, tarry stools for 2 days. The patient had a history of consuming raw freshwater fish. Supplementary differential diagnosis was performed via rapid serological testing, and presence of the causative agent was confirmed based on video gastroscopy, morphology of the removed parasite, and molecular identification. After its surgical removal from the stomach, the parasite was morphologically identified as Gnathostoma species. Molecular identification was performed via DNA extraction from the recovered worm, and amplification and sequencing of the second internal transcribed spacer (ITS2) region and partial cytochrome c oxidase subunit I (cox1) gene. The ITS2 and cox1 sequences were consistent with those of Gnathostoma spinigerum. Clinicians in endemic areas should therefore be aware of the rare clinical manifestations and use of supplementary serological tests to facilitate early diagnosis and treatment of gastric gnathostomiasis.

Larval Gnathostomes and Spargana in Chinese Edible Frogs, Hoplobatrachus rugulosus, from Myanmar: Potential Risk of Human Infection.

Chinese edible frogs, Hoplobatrachus rugulosus, were examined to estimate the potential risks of human gnathostomiasis and sparganosis in Myanmar. A total of 20 frogs were purchased in a local market of Yangon and examined with naked eyes and the artificial digestion method after skin peeling in June 2018 and June 2019. Larvae of gnathostomes and Spirometra (=spargana) were detected in 15 (75.0%) and 15 (75.0%) frogs with average intensities of 10.5 and 6.3 larvae per infected frog, respectively. Gnathostome larvae were 2.75-3.80 (av. 3.30) mm long and 0.29-0.36 (0.33) mm wide. They had a characteristic head bulb with 4 rows of hooklets, a muscular long esophagus, and 2 pairs of cervical sac. The mean number of hooklets were 41, 44, 47, and 50 on the 1st, 2nd, 3rd, and 4th row, respectively. Collected spargana were actively moving, particularly with the scolex part, and have ivory-white color and variable in size. Conclusively, it has been first confirmed that Chinese edible frogs, H. rugulosus, are highly infected with larval gnathostomes and spargana in this study. Consuming these frogs is considered a potential risk of human gnathostomiasis and sparganosis in Myanmar.

Infection Status of Gnathostoma spinigerum Larvae in Asian Swamp Eels, Monopterus albus, Purchased from Local Markets in Cambodia.

Present study was performed to know the infection status of Gnathostoma sp. larvae in swamp eels from Cambodia. We purchased total 30 Asian swamp eels, Monopterus albus, from local markets in Pursat and Takeo Provinces and Phnom Penh on May and November 2017 and May 2018. All collected eels were transferred to our laboratory with ice and each of them was examined by artificial digestion method. A total of 15 larval gnathostomes (1-5 larvae) were detected from 55.6% (5/9) swamp eels in Pursat Province. No larval gnathostomes were found in 21 swamp eels in Takeo Province and Phnom Penh. The advanced third-stage larvae (AdL3) detected were 2.575-3.825 (3.250) mm in length and 0.375-0.425 (0.386) mm in width. They had the characteristic head bulb (av. 0.104×0.218 mm) with 4 rows of hooklets, long muscular esophagus (1.048 mm), and 2 pairs of cervical sacs (0.615 mm). The number of hooklets in 4 rows on the head bulb was 41, 44, 47, and 50. In scanning electron microscopy, characteristic features were 4 rows of hooklets on the head bulb, cervical papillae, tegumental spines regularly arranged in transverse striations, and anus. The larval gnathostomes were identified as AdL3 of Gnathostoma spinigerum based on the morphological characters. By the present study, it has been confirmed that G. spinigerum larvae are infected in Asian swamp eels, M. albus, in Pursat Province, Cambodia.

Larval Gnathostomes and Zoonotic Trematode Metacercariae in Fish from a Local Market in Yangon City, Myanmar.

A survey was performed to investigate the infection status of zoonotic helminth larvae in fish from a local market of North Dagon District in Yangon City, Myanmar. A total of 486 fish in 13 species were collected 8 times from December 2015 to December 2019. All fish were transported under ice to a laboratory in Korea and examined for helminth larvae using artificial digestion method. Larval gnathostomes and metacercariae of more than 8 zoonotic trematode species, i.e., Opisthorchis viverrini, Haplorchis taichui, H. pumilio, H. yokogawai, Centrocestus spp., Stellantchasmus falcatus, Pygidiopsis cambodiensis, and Procerovum sp., were detected. Larval gnathostomes were found in 58 (16.0%) out of 362 fish of 6 species, with mean intensity of 2.8 per fish infected. Metacercariae of O. viverrini were detected in 10 (2.9%) out of 349 fish of 5 species, with mean intensity of 16.9 per fish infected. Metacercarial prevalences of 4 intestinal flukes, H. taichui, H. pumilio, H. yokogawai, and Centrocestus spp., were 16.8%, 26.0%, 12.5%, and 15.0% in the positive fish species, respectively, and mean metacercarial intensity was 63.3, 26.8, 86.2, and 8.7 per fish infected. Metacercariae of S. falcatus and P. cambodiensis were detected only from the mullet, Chelon macrolepis. Metacercariae of Procerovum sp. were found in Channa striata and Anabas testudineus. Collectively, it was confirmed that the fish were infected with gnathostome larvae and metacercariae of O. viverrini and intestinal flukes in Yangon City, Myanmar.

Two cases of cutaneous gnathostomiasis after eating raw Salangichthys microdon (icefish, shirauo).

Cutaneous gnathostomiasis (CG) is a disease caused by ingestion of third-stage Gnathostoma larva in raw snakes, freshwater fish or frogs. The common causative organisms of CG in Japan include G. nipponicum, G. spinigerum, G. doloresi, G. binucleatum and G. hispidum. We report two cases of CG after eating many raw Japanese icefishes (Salangichthys microdon). In both cases, linear itchy eruptions on the trunk developed after eating many S. microdon. We performed genetic analysis in the first case, which revealed G. nipponicum. Of note, this is the first case of CG diagnosed based on genetic analysis in Japan. In Japan, eating whole small raw freshwater fish is common. The most popular types of raw small freshwater fish consumed in Japan are S. microdon (shirauo in Japanese) and Leucopsarion petersii (shirouo in Japanese). Usually, S. microdon are born in rivers, but live in both the sea and rivers. They feed on small fish and freshwater water fleas and spawn in rivers in the spring. On the other hand, L. petersii are born in rivers, but move to the sea soon after hatching. They feed on plankton such as copepod in the sea. They do not feed on anything when they return to rivers to spawn in the spring. Therefore, we hypothesize that S. microdon are more easily parasitized by G. nipponicum.

Molecular identification and genetic diversity of Gnathostoma spinigerum larvae in freshwater fishes in southern Lao PDR, Cambodia, and Myanmar.

Gnathostomiasis, an emerging food-borne parasitic zoonosis in Asia, is mainly caused by Gnathostoma spinigerum (Nematoda: Gnathostomatidae). Consumption of raw meat or freshwater fishes in endemic areas is the major risk factor. Throughout Southeast Asia, including Thailand, Lao PDR, Cambodia, and Myanmar, freshwater fish are often consumed raw or undercooked. The risk of this practice for gnathostomiasis infection in Lao PDR, Cambodia, and Myanmar has never been evaluated. Here, we identified larvae of Gnathostoma species contaminating freshwater fishes sold at local markets in these three countries. Public health authorities should advise people living in, or travelling to, these areas to avoid eating raw or undercooked freshwater fishes. Identification of larvae was done using molecular methods: DNA was sequenced from Gnathostoma advanced third-stage larvae recovered from snakehead fishes (Channa striata) and freshwater swamp eels (Monopterus albus). Phylogenetic analysis of a portion of the mitochondrial cytochrome c oxidase subunit I gene showed that the G. spinigerum sequences recovered from southern Lao PDR, Cambodia, and Myanmar samples had high similarity to those of G. spinigerum from China. Sequences of the nuclear ribosomal DNA internal transcribed spacer 2 region closely resembled sequences of G. spinigerum from Thailand, Indonesia, the USA, and central Lao PDR. This is the first molecular evidence of G. spinigerum from freshwater fishes in southern Lao PDR, Cambodia, and Myanmar.

A filtration-based rapid test using a partially purified third-stage larval antigen to detect specific antibodies for the diagnosis of gnathostomiasis.

Human gnathostomiasis is an emerging food-borne parasitic disease caused by nematodes of the genus Gnathostoma. Currently, serological tests are commonly applied to support clinical diagnosis. In the present study, a simple and rapid filtration-based test, dot immune-gold filtration assay (DIGFA) was developed using a partially purified antigen of Gnathostoma third-stage larvae (L3). A total of 180 serum samples were tested to evaluate the diagnostic potential of DIGFA for gnathostomiasis. The diagnostic sensitivity and specificity were 96.7% (29/30) and 100% (25/25), respectively. The cross-reactivity with sera from other helminthiasis patients ranged from 0 to 4%, with an average of 1.6% (2/125). DIGFA using a partially purified L3 antigen was not only simple and rapid, but also more accurate than standard assays for the diagnosis of human gnathostomiasis. DIGFA may represent a promising tool for application in laboratories or in the field, without requiring any instrumentation.

VISCERAL GNATHOSTOMIASIS WITH SIMULTANEOUS DAMAGE TO THE UPPER AND LOWER PARTS OF THE GASTROINTESTINAL TRACT.

In this article, we described a rare atypical clinical case of tropical helminthiasis - a visceral gnathostomiasis with simultaneous damage of the upper and lower parts of the gastrointestinal tract. The visceral form is the rarest variant and among the literary data, only single cases of this form are described in the world. Therefore the management of such patients requires an individual and balanced approach since it is almost impossible to predict the consequences of any medical interventions. This determines the clinical uniqueness of this case and requires further research of clinical guidelines for the management of such injuries.

Case Report: Ocular Gnathostomiasis in Venezuela Most Likely Acquired in Texas.

A 69-year-old male dentist in Caracas, Venezuela, was referred to our Cornea Clinic with a history of pain, photophobia, and blurred vision on his left eye. Routine biomicroscopic examination with a slit lamp showed a worm in the corneal stroma of his left eye. The worm was surgically removed and was identified morphologically as Gnathostoma binucleatum.

Imported gnathostomiasis manifesting as cutaneous larva migrans and Löffler's syndrome.

Here, we report an unusual case of invasive gnathostomiasis in a returning traveller, with a shifting pattern of relapsing cutaneous disease. The previously fit and well 32-year-old man first presented with serpiginous, pruriginous erythematous tracks characteristic of cutaneous larva migrans shortly after returning from South-East Asia. He was systemically well with no other symptoms. After ivermectin therapy, he re-presented with respiratory symptoms, peripheral eosinophilia and transient pulmonary infiltrates; the classic triad of Löffler's syndrome associated with invasive helminth infection. Gnathostoma spinigerum immunoblot was positive. After a second round of ivermectin therapy his respiratory symptoms resolved, but the patient's cutaneous disease relapsed repeatedly over months, with migratory erythematous swellings appearing and settling after a few days. He was treated with a 21-day course of albendazole and is lesion free at 40 weeks post initial presentation.

Histopathological changes in the liver and stomach of Didelphis virginiana (Didelphimorphia: Didelphidae) during natural infection with Gnathostoma turgidum (Nematoda: Gnathostomidae).

Gnathostoma turgidum is a nematode parasite that exploits the stomach of Virginian opossums, Didelphis virginiana, in Latin America. The opossum is the definitive host of G. turgidum in the wild. Intrahepatic growth and maturation of the parasite, subsequent migration to the stomach and spontaneous expulsion are common. However, the histopathological lesions caused by G. turgidum are poorly described. A better understanding of the life cycle of this parasite and the pathological changes in natural host-parasite interactions could help to clarify the progression of human infections caused by Gnathostoma binucleatum. The aim of this work was to study morphological changes in the liver and stomach of D. virginiana during natural infection and adult worm expulsion. Three opossums naturally infected with G. turgidum were captured from an endemic area of gnathostomosis. Three uninfected opossums captured from a non-endemic area were used as controls. The opossums were sacrificed at different stages of infection (March, May and December), and a histopathological study of their livers and stomachs was conducted. Injuries in livers were observed by histopathology - areas of necrosis and collagen septa were identified. Parasites caused nodules with necrosis on the periphery of lesions, and collagen fibres were also observed in stomachs. Collagen septa may be caused by antigenic remains of the parasite. Further immunological studies are necessary to verify that stimulation is caused by these factors.

Case Report: Clinical Features of Intermittent Migratory Swelling Caused by Gnathostomiasis with Complete Follow-up.

A 15-year-old Thai girl was referred to the Hospital for Tropical Diseases of Mahidol University with a 3-week history of an intermittent migratory mass on the forehead. She was diagnosed with cutaneous gnathostomiasis. The patient was treated with albendazoleat 400 mg orally twice a day for 3 weeks, with good compliance. She revisited the hospital after 3 months and was seen to have been unresponsive to the initial treatment. There was intermittent swelling in her right upper eyelid along with mild redness around her right upper and lower eyelids. Another attempt of treatment was made with ivermectin 0.2 mg/kg/day for two consecutive days. This is a case of gnathostomiasis in full sequence, with complete follow-up. The case report starts from the beginning of the symptoms until the antibodies against Gnathostoma spinigerum decline to negative, confirmed by the western blot test. It took around 18 months to see the western blot test change to a negative result. The resolved clinical symptoms were possibly due to the responsiveness of the patient to ivermectin or the albendazole and ivermectin combination or even the coadministration of antibiotics afterward.

Genetic diversity of infective larvae of Gnathostoma spinigerum (Nematoda: Gnathostomatidae) in freshwater swamp eels from Thailand.

Human gnathostomiasis is a food-borne zoonosis caused by a tissue nematode of the genus Gnathostoma. The disease is highly endemic in Asia, including Thailand. The freshwater swamp eel (Monopterus albus), the second intermediate host of the gnathostome nematode, has an important role in transmitting the infection in Thailand. Surveys on the infective larvae of Gnathostoma spinigerum based on morphological features in freshwater swamp eels have been performed continuously and reported in Thailand. However, there is still limited molecular data on intra-species variations of the parasite. In this study, a total of 19 third-stage larvae of morphologically identified G. spinigerum were collected from 437 liver samples of freshwater swamp eels purchased from a large wholesale market in Bangkok, Thailand. Molecular characterization based on mitochondrial cytochrome c oxidase subunit I (COI) sequences was performed to elucidate their genetic variations and phylogenetic relationship. Among the 19 infective larvae recovered from these eels, 16 were sequenced successfully. Phylogenetic analyses inferred from the partial COI gene showed the presence of three distinct COI haplotypes. Our findings confirm the presence of G. spinigerum as the main species in Thailand.

Gnathostomiasis in Brazil: an emerging disease with a challenging diagnosis.

This case report describes the second reported case of gnathostomiasis acquired in Brazil. The French traveller returned from a sport fishing trip from Tocantins where he was repeatedly consuming raw freshwater fish marinated with lemon juice. Gnathostoma infection was diagnosed based on clinical symptoms, dietary record and by detection of specific antibodies in the blood.

Cloning and expression of a 16-kDa recombinant protein from Angiostrongylus cantonensis for use in immunoblot diagnosis of human angiostrongyliasis.

Angistrongylus cantonensis is a zoonotic nematode parasite and causative agent of human angiostrongyliasis, which clinically presents as eosinophilic meningitis or meningoencephalitis. Diagnosis of the disease is problematic since parasitologic findings are infrequent, and infection determinations must be based on the clinical symptoms and serological tests with limited specificities and sensitivities. The aim of the present study was to identify and generate a novel recombinant protein from A. cantonensis and evaluate its efficacy in the diagnosis of human angiostrongyliasis when incorporated into a Western blot serodiagnostic system. A cDNA protein expression library from adult A. cantonensis was constructed, followed by immunoscreening with serum from confirmed infected patients to identify and isolate immunoreactive clones. One clone, designated fAC40, possessed a partial sequence encoding a LisH protein domain with a predicted molecular weight of 16 kDa and containing four predicted antigenic peptides. By incorporating recombinant fAC40 in Western immunoblot tests using a serum panel consisting of confirmed and clinically diagnosed cases of human angiostrongyliasis and other helminthic infections, fAC40 exhibited a sensitivity and specificity of 91.8 and 100 %, respectively, and a positive and negative predictive value of 100 and 97.19 %, respectively, in the diagnosis of angiostrongyliasis. Importantly, it was not reactive with antibodies from serum of patients infected with Gnathostoma spinigerum and Cysticercus cellulosae, infections that clinically present neurological symptoms similar to angiostrongyliasis. These data demonstrate that the 16-kDa recombinant protein from A. cantonensis possesses high potential as a candidate antigen for a more sensitive and specific serodiagnosis of human angiostrongyliasis.

The complete mitochondrial genomes of Gnathostoma doloresi from China and Japan.

Gnathostoma doloresi is one of the neglected pathogens causing gnathostomiasis. Although this zoonotic parasite leads to significant socioeconomic concerns globally, little is known of its genetics and systematics. In the present study, we sequenced and characterized the complete mitochondrial (mt) genomes of G. doloresi isolates from China and Japan. The lengths of the mt genomes of the G. doloresi China and Japan isolates are 13,809 and 13,812 bp, respectively. Both mt genomes encode 36 genes, including 12 protein-coding genes (PCGs), 2 ribosomal RNA genes, and 22 transfer RNA genes. The gene order, transcription direction, and genome content are identical with its congener G. spinigerum. Phylogenetic analyses based on concatenated amino acid sequences of 12 PCGs by Bayesian inference (BI) indicated that G. doloresi are closely related to G. spinigerum. Our data provide an invaluable resource for studying the molecular epidemiology, phylogenetics, and population genetics of Gnathostoma spp. and should have implications for further studies of the diagnosis, prevention, and control of gnathostomiasis in humans and animals.

Cross-Reactivity Pattern of Asian and American Human Gnathostomiasis in Western Blot Assays Using Crude Antigens Prepared from Gnathostoma spinigerum and Gnathostoma binucleatum Third-Stage Larvae.

Gnathostomiasis is a zoonotic parasitosis endemic in many Asian and some Latin American countries. Most human infections are caused by Gnathostoma spinigerum in Asia and Gnathostoma binucleatum in the Americas, and recently, imported cases have been increasing among travelers returning from endemic regions. Confirmation of the clinical diagnosis relies largely on serologic tests, with a G. spinigerum-antigen-based immunoblot currently being the diagnostic method of choice. However, we repeatedly experienced that sera from patients with clinically suspected American gnathostomiasis gave negative results in this assay. Therefore, we used homologous methods to prepare G. spinigerum- and G. binucleatum-antigen-based immunoblot assays, and evaluated the cross-reactivity of the two assays. The results show incomplete cross-reactivity between the two assays: the G. spinigerum-antigen-based immunoblot apparently only detects Asian gnathostomiasis caused by G. spinigerum, whereas the G. binucleatum-antigen-based immunoblot is apparently capable of detecting American as well as Asian gnathostomiasis.

Intraocular gnathostomiasis: A rare case report from Central India.

We report the first case of intraocular gnathostomiasis from Central India. A 29-year-old male from Indore, Madhya Pradesh, presented with pain and redness of the right eye since 1 month. Slit lamp examination revealed anterior uveitis, multiple iris atrophic patches, and a live worm hooked on iris. The worm was removed through a small sclerocorneal tunnel. Microscopy confirmed Gnathostoma spinigerum. The patient was treated with oral albendazole and steroids. The case is reported because of its rarity.