Gnathostomiasis
Gnathostomiasis is a kind of
parasitic diseases caused by Gnathostoma spp. The diseases is a zoonotic food
borne diseases which is normally caused by the consumption of fresh fishes
containing advance third stage larva of Gnathostoma spp. water copepod or
cyclops. The disease is mainly characterizing by the migratory pain and skin
piercing pain.
There are many different species
of Gnathostoma spp however only five species have been reported as the
medically important one cause infections to human beings. These are
G. binucleatum, G. doloresi,
G. hispidum, G. nipponicum and G. spinigerum. G. malaysiae ia a potential
pathogen which has not been reported in Thailand.
The disease is highly prevalent
in South east Asia including Thailand, China, Japan and also been reported from
India. The diseases is also been reported from Latin America and many parts of
Mexico.
Life cycle:
Gnathostoma spp has two
intermediate hosts to complete their life cycle. Human is only accidental hosts
in which they can’t complete their sexual life cycles. The definitive hosts for
the parasite are the fresh water fish eating animals such as dogs, cats,
leopards and etc. The advance stage larva they harvest from the fish can be
developed into an adult worm in their intestine. They lay the eggs and pass
through the feces. The Unembryonated eggs are changed into embryonated eggs and
are hatched to release first stage larva in the fresh water. These larvae are
nutrient for many cyclopes including copepods. Once they are eaten by copepods
of the fresh water, the first stage of larva (L1) is changed in to the second
stage (L2) of larva in their intestine. The cyclops are then consumed by the
fresh water fishes, where the larva developed into the advance third stage
larva (L3), an infective form of Gnathostoma spp. Some animals eat those fresh
water fishes and where the parasite complete their life cycles. Initially the
parasite move through the skin to tissue and then to liver and abdominal
cavity. They remained 4 weeks there and returned back to stomach where the
parasite changed into adult worms. These adults worm then lay eggs and complete
their life cycles within the 6 months. However, when human consume undercooked
or raw fresh water foods, they acquire the infective form of larva. These
larvae move to intestine and from where they migrate to skin via the tissue.
They start migrating aimlessly in different parts if body such as lungs, eye,
GI tract, genitourinary tract and cause migratory swellings. Rarely but very
fatal, they can also migrate to central nervous system and spinal cord to cause
CNS Gnathostomiasis.
Figure 1: Life cycle of
Gnathostoma spinigerum. (Adapted from an
image from the CDC-DPDx [www.dpd.cdc.gov/dpdx/HTML/gnathostomiasis.htm].)
Pathogenesis:
The mechanism of pathogenesis of
Gnathostomiasis are due to combined action of mechanical trauma, ES products of
parasites and host inflammatory response. The mechanical trauma is caused due
to aimless migration of larva through the skin and many other body parts. This
causes migratory swellings and moving piercing pain. During the migration of
larva, due to spines throughout their body, there is itchy, irritation and
urticaria in the body. Another important factor in pathogenesis of
Gnathostomiasis is by the ES biproducts from the adult worms. The ES biproduct
contain the proteases, toxic substances, anti-inflammatory molecules and
anticoagulants. The biproducts initially degrade the tissues and deteriorate
the protein of the hosts for their nutrients. They also act as anticoagulant
and inhibit the activation of platelets. Most importantly these products also
disturb the immune response of host. The host inflammatory response specially
in parasitic infections may have role in cytotoxicity of its own cells. During
the infection, they inhibit the cytotoxic effects of NK cell by decreasing
NKG2D expression. They also interfere with functions of monocytes or
macrophages related to phagocytosis by reducing the FCrR-1 (CD64) expression
and finally damage the immune cells by apoptosis.
Clinical manifestations:
General clinical signs and
symptoms
Fever, malaise, nausea, anorexia,
vomiting, urticaria, epigastric pain or upper right quadrant pain and diarrhea.
Normally the incubation period is
24 to 48 hrs.
Once they start to migrate in the
skin (cutaneous infections), one may feel the migratory swellings, moving
piercing pain, eosinophilia,
Further the larva can spread to
many other organs randomly causing visceral infections to lungs, GI tract,
Genitourinary tract, eyes and rarely to CNS causing
Increased pressure on
intracranial
Fever, neck stiffness
photophobia, migratory neurological findings, paralysis, cranial nerve
involvement and urinary retention,
Finally, death
Cutaneous
Gnathostomiasis
Cutaneous
gnathostomiasis is the most common manifestation of infection and is known by
several local names, e.g., Yangtze River’s edema and Shanghai’s rheumatism in
China, tuao chid in Japan, and paniculitis nodular migratoria eosinofilica in
Latin America. It typically presents with intermittent migratory swellings,
(nodular migratory panniculitis), usually affecting the trunk or upper limbs.
These nonpitting edematous swellings vary in size and may be pruritic, painful,
or erythematous. They usually occur within 3 to 4 weeks of ingestion of the
larvae, typically last 1 to 2 weeks, and are commonly due to only one larva,
but on occasion infection with two or more has been found. The swellings are
due to both mechanical damage from the larva and the host’s
immunological
response to the parasite and its secretions. As the larva migrates,
subcutaneous hemorrhages may be seen along its tracks, which are pathognomonic
of gnathostomiasis and can help differentiate it from other causes of larva
migrans, e.g., sparganosis or strongyloidiasis. Episodes of swelling slowly
become less intense and shorter in duration, but in untreated patients’
symptoms may recur intermittently for up to 10 to 12 years.
Visceral Disease
The Gnathostoma larva is highly
invasive and motile and therefore can produce an extremely wide range of
symptoms affecting virtually any part of the body. In noncerebral disease the
larvae may continue to cause intermittent symptoms until they die after about
12 years, if left untreated.
Pulmonary
manifestations. Pulmonary symptoms that have been attributed to infection
with Gnathostoma
spp.
include cough, pleuritic chest pain, heamoptysis, lobar consolidation or collapse,
pleural effusions, and pneumo- or hydropneumothorax.
Gastrointestinal
manifestations. Gastrointestinal manifestations are less common in humans but
may present as sharp abdominal pains as the larva migrates through the liver
and spleen or as a chronic mass in the right lower quadrant. Less commonly,
there may be acute right iliac fossa pain with fever mimicking acute
appendicitis or intestinal obstruction. Infection has also been found as an
incidental (and asymptomatic) finding at surgery for a different problem.
Genitourinary
manifestations. Involvement of the genitourinary tract is uncommon, but
hematuria and the passage of the larva in the urine have been reported. Other
symptoms attributed to Gnathostoma spp. include profuse vaginal bleeding, cervicitis,
balanitis, an adnexal mass, and hematospermia.
Ocular. The eye is the
only organ in which the larva may be visualized, and therefore there are many
more literature reports of ocular involvement than of involvement of other
organs. Eye involvement has led to symptoms of uveitis (usually anterior),
iritis, intraocular hemorrhage, glaucoma, retinal scarring, and detachment.
Auricular manifestations.
Various
reports have described a wide variety of manifestations, which include
mastoiditis, sensorineural hearing loss, and extrusion of the larva from the external
auditory canal, the soft palate, the cheek, the tip of tongue, and the tympanic
membrane.
CNS
manifestations. In the subsequent year the parasite was found on the surface
of the cerebral
hemisphere and
attached to the choroid plexus of the lateral ventricle in two patients with
fatal meningoencephalitis. There have been several case series of CNS diseases,
which has increased understanding of the pathophysiology. Compared to other
forms of disease, the CNS form of the infection carries the highest mortality,
with reported rates of 8 to 25%, and 30% of survivors having long-term sequelae.
Treatments
Albendazole (200 mg)
400-800 mg/kg/day for 21 days
Ivermectin (6 mg)
200 microgram/KG/single dose for
14 days.
Diagnosis:
Diagnosis of Gnathostomiasis can
be done with Microscopy, Immunodiagnosis and by Molecular techniques
The larva is removed by surgery
and identified under the microscope by the numbers of hooks present, different
rows od hooks and also by spines arrangements. Very difficult to identify.
Immunodiagnosis:
Mainly ELISA and Immunoblot are
used.
Using CsAg, crude somatic antigen
IgG1 is analyzed with high sensitivity and specificity.
In immunoblot, same antigens is
used to detect IgG4 antibody.
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My husband was diagnosed of ALS (Amyotrophic Lateral Sclerosis) 2 years ago at Patton State Hospital California, the doctor told us there was no known cure for the disease, we were given medications to help the symptoms. After 1 year and 2 months, the symptoms has got worse and we had to look for an alternative treatment since the doctors were not helping. I read an article online last 2 month about Dr. Yare herbal healing home in Africa who prepare and sell herbal medicines to cure all kind of disease including ALS/MND, I contacted the herbal Doctor through his email and purchased the ALS herbal remedy, we received the herbal remedy within 3 days and my husband immediately commenced usage, He drank the ALS herbal Tonic Doc. Yare prepared for him. OMG!! after 1 week of usage some of the symptoms like clumsiness and his very slurred speech had stopped, he continue usage the 4th week he'd got a lot better that even the doctors could not believe it. It totally cured him and we have told so many people about it. Now my husband can work a distance without any assistant. With doc. Yare, you can get that incurable disease cured. its all thanks to God and also to you Doc. Yare, for your continued help, and wonderful knowledge of God's life-saving herbs.You are truly a Godsent!! If you have or know anyone still suffering from ALS/MND/MSA/FSHD/MS or any other disease, you can contact him on website : http://bit.ly/2dBFYeW dryareherbalcurehome@gmail.com Call or Whatsup: +2348164653711. Please share with family, friends and anyone you know suffering from any disease, together we fight to stay healthy.
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