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Ratzlaff FR, Osmari V, da Silva D, de Paula Vasconcellos JS, Pötter L, Fernandes FD, de Mello Filho JA, de Avila Botton S, Vogel FSF, Sangioni LA. Identification of infection by Leishmania spp. in wild and domestic animals in Brazil: a systematic review with meta-analysis (2001-2021). Parasitol Res 2023; 122:1605-1619. [PMID: 37154922 DOI: 10.1007/s00436-023-07862-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 04/28/2023] [Indexed: 05/10/2023]
Abstract
Leishmaniasis is a zoonosis caused by protozoan species of the genus Leishmania. It generates different clinical manifestations in humans and animals, and it infects multiple hosts. Leishmania parasites are transmitted by sandfly vectors. The main objective of this systematic review was to identify the host, or reservoir animal species, of Leishmania spp., with the exception of domestic dogs, that were recorded in Brazil. This review included identification of diagnostic methods, and the species of protozoan circulating in the country. For this purpose, a literature search was conducted across index journals. This study covered the period from 2001 to 2021, and 124 studies were selected. Eleven orders possible hosts were identified, including 229 mammalian species. Perissodactyla had the highest number of infected individuals (30.69%, 925/3014), with the highest occurrence in horses. In Brazil, the most commonly infected species were found to be: horses, domestic cats, rodents, and marsupials. Bats, that were infected by one or more protozoan species, were identified as potential reservoirs of Leishmania spp. Molecular tests were the most commonly used diagnostic methods (94 studies). Many studies have detected Leishmania spp. (n = 1422): Leishmania (Leishmania) infantum (n = 705), Leishmania (Viannia) braziliensis (n = 319), and Leishmania (Leishmania) amazonensis (n = 141). Recognizing the species of animals involved in the epidemiology and biological cycle of the protozoan is important, as this allows for the identification of environmental biomarkers, knowledge of Leishmania species can improve the control zoonotic leishmaniasis.
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Affiliation(s)
- Fabiana Raquel Ratzlaff
- Laboratório de Doenças Parasitárias (LADOPAR), Departamento de Medicina Veterinária Preventiva, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, N°1000, Prédio 63D, Bairro Camobi, Santa Maria, RS, CEP 97105900, Brazil
| | - Vanessa Osmari
- Laboratório de Doenças Parasitárias (LADOPAR), Departamento de Medicina Veterinária Preventiva, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, N°1000, Prédio 63D, Bairro Camobi, Santa Maria, RS, CEP 97105900, Brazil
| | - Daniele da Silva
- Laboratório de Doenças Parasitárias (LADOPAR), Departamento de Medicina Veterinária Preventiva, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, N°1000, Prédio 63D, Bairro Camobi, Santa Maria, RS, CEP 97105900, Brazil
| | - Jaíne Soares de Paula Vasconcellos
- Laboratório de Doenças Parasitárias (LADOPAR), Departamento de Medicina Veterinária Preventiva, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, N°1000, Prédio 63D, Bairro Camobi, Santa Maria, RS, CEP 97105900, Brazil
| | - Luciana Pötter
- Laboratório de Pastos e Suplementos, Departamento de Zootecnia, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, N°1000, Bairro Camobi, Santa Maria, RS, CEP 97105900, Brazil
| | - Fagner D'ambroso Fernandes
- Laboratório de Doenças Parasitárias (LADOPAR), Departamento de Medicina Veterinária Preventiva, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, N°1000, Prédio 63D, Bairro Camobi, Santa Maria, RS, CEP 97105900, Brazil.
- Centro Universitário Ritter Dos Reis (UniRitter), Campus FAPA, Av. Manoel Elias, 2001 - Passo das Pedras, Porto Alegre, 91240-261, Brazil.
| | - José Américo de Mello Filho
- Laboratório de Análises Ambientais por Geoprocessamento (LAGEO), Departamento de Engenharia Rural, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, N°1000, Prédio 44 J, Bairro Camobi, Santa Maria, RS, CEP 97105-900, Brazil
| | - Sônia de Avila Botton
- Laboratório de Saúde Única (LASUS), Departamento de Medicina Veterinária Preventiva, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, nº 1000, Prédio 44, Bairro Camobi, Santa Maria, Rio Grande do Sul, CEP 97105-900, Brazil
| | - Fernanda Silveira Flores Vogel
- Laboratório de Doenças Parasitárias (LADOPAR), Departamento de Medicina Veterinária Preventiva, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, N°1000, Prédio 63D, Bairro Camobi, Santa Maria, RS, CEP 97105900, Brazil
| | - Luís Antônio Sangioni
- Laboratório de Doenças Parasitárias (LADOPAR), Departamento de Medicina Veterinária Preventiva, Centro de Ciências Rurais (CCR), Universidade Federal de Santa Maria (UFSM), Av. Roraima, N°1000, Prédio 63D, Bairro Camobi, Santa Maria, RS, CEP 97105900, Brazil
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Silva SS, Macedo LOD, Oliveira JCPD, Alves LC, Carvalho GAD, Ramos RAN. Canine visceral leishmaniasis: risk factors and spatial analysis in an endemic area of Northeastern Brazil. REVISTA BRASILEIRA DE PARASITOLOGIA VETERINARIA = BRAZILIAN JOURNAL OF VETERINARY PARASITOLOGY : ORGAO OFICIAL DO COLEGIO BRASILEIRO DE PARASITOLOGIA VETERINARIA 2023; 32:e003223. [PMID: 37222306 DOI: 10.1590/s1984-29612023029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/24/2023] [Indexed: 05/25/2023]
Abstract
Canine visceral leishmaniasis is a disease caused by the protozoon Leishmania infantum, an important agent of zoonotic concern. In this study we determined the seroprevalence, risk factors and spatial distribution of infection by L. infantum among dogs in the Pajeú microregion of the Sertão region of Pernambuco, Brazil. Canine serum samples (n = 247) were tested using the Dual Path Platform (DPP®) rapid screening test and ELISA/S7® confirmatory test; and risk factors were assessed through univariate analysis and logistical regression. The spatial distribution of reactive dogs was analyzed by drawing a map using QGIS. Seroprevalence of 13.7% (34/247) was detected, with cases predominating in the municipality of Tabira (26.4%; 9/34). Age above 10 years was considered to be a risk factor associated with the presence of anti-L. infantum antibodies. The high overall prevalence and spatial distribution of positive cases showed wide dispersion of reagents dogs in the study area. Therefore, preventive measures are needed in order to reduce the risk of infection for animals and humans.
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Affiliation(s)
- Samuel Souza Silva
- Laboratório de Parasitologia, Universidade Federal do Agreste de Pernambuco - UFAPE, Garanhuns, PE, Brasil
| | - Lucia Oliveira de Macedo
- Laboratório de Parasitologia, Universidade Federal do Agreste de Pernambuco - UFAPE, Garanhuns, PE, Brasil
| | | | - Leucio Câmara Alves
- Departamento de Medicina Veterinária, Universidade Federal Rural de Pernambuco - UFRPE, Recife, PE, Brasil
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Melo TBD, Silva TRM, Almeida TLACD, Tutija JF, Silva AOD, Lira MDS, Amorim D, Giannelli A, Ramos CADN, Alves LC, Carvalho GAD, Ramos RAN. Molecular detection of vector-borne pathogens in cats tested for FIV and FeLV. VETERINARY PARASITOLOGY: REGIONAL STUDIES AND REPORTS 2023; 40:100857. [PMID: 37068860 DOI: 10.1016/j.vprsr.2023.100857] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/08/2022] [Accepted: 03/09/2023] [Indexed: 03/18/2023]
Abstract
The aim of this study was to detect molecularly vector borne pathogens (VBPs) in domiciled cats tested for Feline immunodeficiency virus (FIV) and Feline leukemia virus (FeLV). Blood samples (n = 119) were analyzed microscopically and molecularly through PCR and sequenced for the detection of the following pathogens: piroplasmids., Bartonella henselae, Cytauxzoon felis, Ehrlichia canis, Leishmania spp., hemotropic Mycoplasma spp., Trypanosoma spp., and Ricketssia spp. Animals were also serological assessed for detection of antibodies against FIV and FeLV. Out of all animals, 20.16% (24/119) tested positive for at least one VBPs at molecular examination. Conversely, no animal resulted positive at microscopic analysis. The most prevalent pathogen was hemotropic Mycoplasma haemofelis (8.40%; 10/119), followed by Candidatus Mycoplasma haemominutum (5.88%; 7/119), E. canis (5.04%; 6/119), C. felis (0.84%; 1/119) and B. henselae (0.84%; 1/119). One animal (0.84%; 1/119) was co-infected with. E. canis and B. henselae. A total of 5.88% (7/119) and 1.68% (2/119) tested positive for FIV and FeLV, respectively. Data of this study demonstrate that owned cats can be at risk of hemotropic Mycoplasma spp., E. canis, C. felis and B. henselae. Therefore, preventive measures against vectors of these pathogens should be implemented in order to reduce the risk of exposition and consequently infection. Additionally, aggressive behaviors among cats should be avoided, especially because hemotropic Mycoplasma spp. may be transmitted through the bite of animals.
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Affiliation(s)
- Thyara Bezerra de Melo
- Graduate Program of Animal Bioscience, Federal Rural University of Pernambuco, Recife, Brazil
| | - Tatiene Rossana Mota Silva
- Graduate Program of Animal Bioscience, Federal Rural University of Pernambuco, Recife, Brazil; Laboratory of Parasitology, Federal University of the Agreste of Pernambuco, Garanhuns, Brazil
| | | | - Juliane Franciele Tutija
- Faculty of Veterinary and Animal Sciences, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | - Angélica Oliveira da Silva
- Faculty of Veterinary and Animal Sciences, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | | | | | | | | | - Leucio Câmara Alves
- Department of Veterinary Medicine, Federal Rural University of Pernambuco, Recife, Brazil
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Silva ARD, Andrade GB, Carvalho JKMR, Barreto WTG, Santos FM, Sousa KCMD, André MR, Ferreira LC, Menezes RC, Herrera HM. The outcomes of polyparasitism in stray cats from Brazilian Midwest assessed by epidemiological, hematological and pathological data. REVISTA BRASILEIRA DE PARASITOLOGIA VETERINARIA = BRAZILIAN JOURNAL OF VETERINARY PARASITOLOGY : ORGAO OFICIAL DO COLEGIO BRASILEIRO DE PARASITOLOGIA VETERINARIA 2022; 31:e004222. [PMID: 35792756 DOI: 10.1590/s1984-29612022033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/30/2022] [Indexed: 06/15/2023]
Abstract
We evaluated the epidemiological, hematological, and pathological data of Leishmania spp., Toxoplasma gondii, Platynosomum illiciens, feline immunodeficiency virus (FIV), and feline leukemia virus (FeLV) infections and the coinfections in stray cats of an endemic area for leishmaniasis. The diagnosis was performed by serological tests and necropsy. We described gross lesions and histopathological findings. We used immunohistochemistry and chromogenic in situ hybridization for L. infantum detection. We found infection in 27 out of 50 sampled cats, among them, 14 presented coinfections. A strong correlation between splenomegaly and lymphadenomegaly with FeLV, and an association between hepatic lesions and cachexia with parasitism due to P. illiciens were observed. Moreover, we found a significant increase in the monocyte count in the FeLV-infected and a decrease in the red blood cell count in the FIV-infected animals. Amastigote forms of Leishmania spp. and tissue changes were detected in lymphoid organs of an animal coinfected with P. illiciens, T. gondii, and FIV. Polyparasitism recorded in stray cats of the Brazilian Midwest should be considered in effective control strategies for public health diseases. Moreover, stray cats of Campo Grande may be a source of infection of FIV, FeLV and P. illiciens for populations of domiciled cats.
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Affiliation(s)
| | - Gisele Braziliano Andrade
- Programa de Pós-graduação em Ciências Ambientais e Sustentabilidade Agropecuária, Universidade Católica Dom Bosco, Campo Grande, MS, Brasil
| | | | - Wanessa Teixeira Gomes Barreto
- Programa de Pós-graduação em Ecologia e Conservação, Universidade Federal de Mato Grosso do Sul - UFMS, Campo Grande, MS, Brasil
| | - Filipe Martins Santos
- Programa de Pós-graduação em Ciências Ambientais e Sustentabilidade Agropecuária, Universidade Católica Dom Bosco, Campo Grande, MS, Brasil
| | | | - Marcos Rogério André
- Departamento de Patologia Veterinária, Universidade Estadual Paulista - UNESP, Jaboticabal, SP, Brasil
| | - Luiz Claudio Ferreira
- Laboratório de Pesquisa Clínica em Dermatozoonoses em Animais Domésticos, Instituto Nacional de Infectologia Evandro Chagas - INI, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Caldas Menezes
- Laboratório de Pesquisa Clínica em Dermatozoonoses em Animais Domésticos, Instituto Nacional de Infectologia Evandro Chagas - INI, Rio de Janeiro, RJ, Brasil
| | - Heitor Miraglia Herrera
- Programa de Pós-graduação em Biotecnologia, Universidade Católica Dom Bosco, Campo Grande, MS, Brasil
- Programa de Pós-graduação em Ciências Ambientais e Sustentabilidade Agropecuária, Universidade Católica Dom Bosco, Campo Grande, MS, Brasil
- Departamento de Medicina Veterinária, Universidade Católica Dom Bosco, Campo Grande, MS, Brasil
- Programa de Pós-graduação em Ecologia e Conservação, Universidade Federal de Mato Grosso do Sul - UFMS, Campo Grande, MS, Brasil
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Nascimento LFJ, Cirilo TM, Gomes DS, Gomes ACA, Lima VFS, Scher R, Jain S, Fujiwara RT, Dolabella SS. Epidemiological and diagnostic aspects of feline leishmaniasis with emphasis on Brazil: a narrative review. Parasitol Res 2021; 121:21-34. [PMID: 34761278 PMCID: PMC8580739 DOI: 10.1007/s00436-021-07372-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022]
Abstract
The leishmaniases are a group of diseases caused by the protozoan parasite belonging to the genus Leishmania. In the New World, although dogs are considered the main parasite reservoir, in the last two decades, several studies have confirmed the role of cats (Felis catus) in the epidemiology of the disease and feline leishmaniasis (FeL) is now considered to be an emerging disease. The present review summarizes the current knowledge about FeL, focusing on important immunopathological aspects, epidemiology, and diagnostic methods applied for felines in Brazil. Cats are infected with the same species of Leishmania found in dogs (i.e., Leishmania infantum). Like dogs, skin lesions are the most common in cats with clinical FeL, mainly affecting the cephalic region and less frequently the legs which may be accompanied by generalized signs or visceral involvement. Information on the immune response of cats to Leishmania infection is scarce; however, efficient infection control is seen in most cases. For diagnosis, generally, the same methods as those in dogs are used, mainly serological tools. But there is a lack of studies focusing the performance of these methods for diagnosing FeL. The estimated overall prevalence of FeL in Brazil is 8%, with L. infantum being the most prevalent species. However, infections with Leishmania braziliensis and Leishmania amazonensis have also been reported. In conclusion, although there has been an increase in the publication related to FeL in Brazil in recent years, there is a lack of research relating immune response and diagnosis of these animals. Cats have been shown to be competent hosts for Leishmania parasites, and their role in the epidemiology of the disease cannot be underestimated, especially in areas of Brazil where the disease is historically endemic.
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Affiliation(s)
- Luiz F J Nascimento
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, SE, 49100-000, Brazil
| | - Tatyane M Cirilo
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, SE, 49100-000, Brazil
| | - Dharliton S Gomes
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, SE, 49100-000, Brazil
| | - Ana Carolina A Gomes
- Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, 31270-901, Brazil
| | - Victor F S Lima
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, SE, 49100-000, Brazil
| | - R Scher
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, SE, 49100-000, Brazil
- Departamento de Morfologia, Instituto de Ciências Biológicas e da Saúde, Universidade Federal de Sergipe, São Cristóvão, SE, 49100-000, Brazil
| | - S Jain
- Programa de Pós-Graduação em Biotecnologia Industrial, Universidade Tiradentes, Aracaju, SE, 49032-490, Brazil
| | - Ricardo T Fujiwara
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, SE, 49100-000, Brazil.
- Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, 31270-901, Brazil.
| | - Silvio S Dolabella
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, SE, 49100-000, Brazil.
- Departamento de Morfologia, Instituto de Ciências Biológicas e da Saúde, Universidade Federal de Sergipe, São Cristóvão, SE, 49100-000, Brazil.
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Feline Leishmaniosis: An Emerging Public Health Problem. Vet Sci 2021; 8:vetsci8090173. [PMID: 34564567 PMCID: PMC8473070 DOI: 10.3390/vetsci8090173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/17/2022] Open
Abstract
Leishmaniosis is the third most important vector-borne disease in humans, preceded by malaria and lymphatic filariasis, and it is considered endemic in tropical and subtropical areas, where higher temperatures favor development of its vector, sandflies. This zoonotic disease is caused by infection of protozoa Leishmania spp. and the most serious mucocutaneous and visceral form is produced by Leishmania infantum, which predominates in the Mediterranean region. The usual hosts for this parasite are dogs and humans, but an increment in cases of L. infantum infection has been observed in cats in the last years. This increase could be due to the use of sandflies repellents in dogs, obligating the parasite to looking for other hosts. The role of cats in the epidemiology of this disease is unknown, although increase of prevalence of feline leishmaniosis has been observed in endemic areas in the last years. Diagnostic techniques and treatments in cats are not standardized, which makes it difficult to establish prevalence and epidemiology of feline leishmaniosis. Furthermore, the clinical signs and immune response against Leishmania in cats are different to those in dogs, with an observed increment of drug resistance. It is necessary to increase our knowledge about L. infantum infection in cats, including clinical signs, transmission, treatments, and the role of cats in the increasing of zoonoses. Finally, new alternative treatments are required for controlling the spread of this disease in all species of mammals.
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Skin Lesions in Feline Leishmaniosis: A Systematic Review. Pathogens 2021; 10:pathogens10040472. [PMID: 33924616 PMCID: PMC8070508 DOI: 10.3390/pathogens10040472] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 11/17/2022] Open
Abstract
Feline leishmaniosis (FeL) is increasingly reported throughout the world and skin lesions predominate in the clinical picture. There are, however, few evidence-based data on cutaneous feline leishmaniosis and directions are strongly needed for a better management of the disease. In this study, we systematically reviewed what is currently known about the clinical dermatological presentation of FeL through analysis of the literature and, further, by adding unpublished cases managed by Italian veterinary dermatologists. Sixty-six feline cases of cutaneous leishmaniosis published in 33 articles between 1990 and 2020 met the inclusion criteria and were analyzed. Six unpublished cases of cutaneous FeL managed by Italian dermatologists were also reviewed. The majority of cases were reported from South America, followed by Europe and North America. Nodules were the most frequently reported clinical signs and the presence of Leishmania in lesioned skin was assessed mainly by cytology. A total of six Leishmania species have been identified as being responsible for skin lesions. Coinfections by FIV or FeLV were reported in 12.1% and 9.1% of the cases, respectively. Clinical data including treatment have been analyzed and discussed to provide directives for proper management of the disease for which cats may also serve as domestic reservoirs for human infections.
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Pereira A, Maia C. Leishmania infection in cats and feline leishmaniosis: An updated review with a proposal of a diagnosis algorithm and prevention guidelines. CURRENT RESEARCH IN PARASITOLOGY & VECTOR-BORNE DISEASES 2021; 1:100035. [PMID: 35284863 PMCID: PMC8906079 DOI: 10.1016/j.crpvbd.2021.100035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/27/2021] [Indexed: 04/15/2023]
Abstract
Leishmaniosis is a vector-borne disease caused by protozoans of the genus Leishmania, which are transmitted to vertebrates, including cats, through the bites of female phlebotomine sand flies. An increasing number of epidemiological and experimental studies concerning Leishmania infection in cats, as well as case reports of clinical leishmaniosis in these felids, have been published in recent years. In the present study, a comprehensive review was made by sourcing the National Library of Medicine resources to provide updated data on epidemiology, immunopathogenesis, diagnosis, treatment, and prevention of feline leishmaniosis. Cats were found infected with Leishmania parasites worldwide, and feline leishmaniosis appears as an emergent disease mostly reported in countries surrounding the Mediterranean Sea and in Brazil. Cats with impaired immunocompetence seem to have a higher risk to develop clinical disease. The main clinical and clinicopathological findings are dermatological lesions and hypergammaglobulinemia, respectively. Diagnosis of feline leishmaniosis remains a challenge for veterinarians, in part due to the lack of diagnosis support systems. For this reason, a diagnostic algorithm for clinical decision support is herein proposed. No evidence-based treatment protocols are currently available, and these remain empirically based. Control measures are limited and scarce. Thus, a set of prevention guidelines are herein suggested.
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