Update on the diagnosis and treatment of food-borne trematode infections:

Diagnosis of Human Trematode Infections

Digenetic trematodes form a major group of human parasites, affecting a large number of humans, especially in endemic foci. Over 100 species have been reported infecting humans, including blood, lung, liver and intestinal parasites. Traditionally, trematode infections have been diagnosed by parasitological methods based on the detection and the identification of eggs in different clinical samples. However, this is complicated due to the morphological similarity between eggs of different trematode species and other factors such as lack of sensitivity or ectopic locations of the parasites. Moreover, the problem is currently aggravated by migratory flows, international travel, international trade of foods and changes in alimentary habits. Although efforts have been made for the development of immunological and molecular techniques, the detection of eggs through parasitological techniques remains as the gold standard for the diagnosis of trematodiases. In the present chapter, we review the current status of knowledge on diagnostic techniques used when examining feces, urine, and sputum and also analyze the most relevant characteristics used to identify eggs with a quick key for the identification of eggs.

Exudative pleural effusion caused by lung fluke infection: case report

The global incidence of lung fluke disease is low, and the infection is a rare cause of pleural effusion in adults. This article reports a case of exudative pleural effusion accompanied by eosinophilia in a 19-year-old male which was finally proven to be caused by lung fluke infection through antibody testing. This case highlights that lung fluke infection is an easily overlooked cause of pleural effusion. Eosinophilia is a potential marker of infection, and serological tests could further confirm the diagnosis.

Diagnosis and Risk Factors of Bovine and Human Fascioliasis in Cattle Farms from a Venezuelan Andean Rural Area

INTRODUCTION

Fascioliasis is caused in Venezuela by the trematode Fasciola hepatica, affecting herbivorous and human. The Venezuelan Andean region is endemic for bovine fascioliasis and its presence in humans is not known. The objective of this work was to detected positive cases of bovine and human fascioliasis by coprological and immunological techniques and determine the possible risk factors, in eight cattle farms of a Venezuelan Andean rural area.

METHODS

We studied 143 samples of feces and sera of bovines, and 34 samples of feces and sera of humans. Feces were examined by several coprologic techniques, while sera were evaluated by ELISA using two antigens: crude extract (CE) and surface proteins (SP) of F. hepatica, which were previously standardized and validated.

RESULTS

The frequency of fascioliasis in bovines was 21% by coprology, and 49.7% by SP-ELISA. The human detection was 0% by coprology, and 29.4% by SP-ELISA. There were statistical significative differences between cattle farms, regarding to the positive results by coprology and by SP-ELISA. About the possible risk factors, statistical association was found only with the presence of snails near or in the farms and consumption of non-channeled water (river, ditch or spring), both for cattle and for humans.

CONCLUSION

The results showed that the studied area is endemic for bovine fascioliasis, the human has been in contact with F. hepatica and there are risk factors for the transmission of the parasite in the studied farms.

Evaluation of possible prophylactic and therapeutic effect of mefloquine on experimental cryptosporidiosis in immunocompromised mice

Cryptosporidiosis is an imperative global health concern. Unfortunately, Nitazoxanide (NTZ) (the nowadays drug of choice) is not effective in treatment of immunocompromised patients. We aimed to assess the possible anti-cryptosporidial prophylactic and therapeutic effects of Mefloquine (MQ) on infected immunosuppressed murine models. Mice were divided into five groups; GI: received Mefloquine (400 mg/kg/day), GII: received NTZ (100 mg/kg/bid), GIII: received a combination, half dose regimen of both drugs, GIV: infected untreated and GV: non-infected untreated. Each treated group was divided into three subgroups; Ga prophylaxis (PX), thereafter infection, Gb first and Gc second treatment doses. Assessment was done by parasitological, histopathological and serological techniques. A significant oocyst clearance was detected in all prophylactically treated groups. GIa showed 77% reduction of the mean oocyst count in stool while GIb and GIIIc showed100% oocyst clearance. Histopathologically, the ileocecal sections from GIV showed loss of brush borders with marked villous atrophy. GIa induced a moderate improvement of those pathological changes. Moreover, the villi in GIb and GIIIc retained their normal appearance with minimal inflammatory cells. Serum interferon gamma levels showed highly significant increases in GI&GIII compared to GIV while a non-significant increase was observed in GIIa only. On the contrary, serum interleukin-17 levels showed a highly significant down-regulation in all treated groups in comparison to GIV. This study proved a marvelous effect of MQ-PX on cryptosporidiosis in immunosuppressed mice and thus it could be introduced as one of the most promising re-purposed prophylactic and therapeutic anti-cryptosporidial agents.

Library-assisted nonlinear blind separation and annotation of pure components from a single 1H nuclear magnetic resonance mixture spectra

Due to its capability for high-throughput screening ¹H nuclear magnetic resonance (NMR) spectroscopy is commonly used for metabolite research. The key problem in ¹H NMR spectroscopy of multicomponent mixtures is overlapping of component signals and that is increasing with the number of components, their complexity and structural similarity. It makes metabolic profiling, that is carried out through matching acquired spectra with metabolites from the library, a hard problem. Here, we propose a method for nonlinear blind separation of highly correlated components spectra from a single ¹H NMR mixture spectra. The method transforms a single nonlinear mixture into multiple high-dimensional reproducible kernel Hilbert Spaces (mRKHSs). Therein, highly correlated components are separated by sparseness constrained nonnegative matrix factorization in each induced RKHS. Afterwards, metabolites are identified through comparison of separated components with the library comprised of 160 pure components. Thereby, a significant number of them are expected to be related with diabetes type 2. Conceptually similar methodology for nonlinear blind separation of correlated components from two or more mixtures is presented in the Supplementary material. Single-mixture blind source separation is exemplified on: (i) annotation of five components spectra separated from one ¹H NMR model mixture spectra; (ii) annotation of fifty five metabolites separated from one ¹H NMR mixture spectra of urine of subjects with and without diabetes type 2. Arguably, it is for the first time a method for blind separation of a large number of components from a single nonlinear mixture has been proposed. Moreover, the proposed method pinpoints urinary creatine, glutamic acid and 5-hydroxyindoleacetic acid as the most prominent metabolites in samples from subjects with diabetes type 2, when compared to healthy controls.

Mini-FLOTAC as an alternative, non-invasive diagnostic tool for Schistosoma mansoni and other trematode infections in wildlife reservoirs

BACKGROUND

Schistosomiasis and food-borne trematodiases are not only of major public health concern, but can also have profound implications for livestock production and wildlife conservation. The zoonotic, multi-host nature of many digenean trematodes is a significant challenge for disease control programmes in endemic areas. However, our understanding of the epidemiological role that animal reservoirs, particularly wild hosts, may play in the transmission of zoonotic trematodiases suffers a dearth of information, with few, if any, standardised, reliable diagnostic tests available. We combined qualitative and quantitative data derived from post-mortem examinations, coprological analyses using the Mini-FLOTAC technique, and molecular tools to assess parasite community composition and the validity of non-invasive methods to detect trematode infections in 89 wild Hubert's multimammate mice (Mastomys huberti) from northern Senegal.

RESULTS

Parasites isolated at post-mortem examination were identified as Plagiorchis sp., Anchitrema sp., Echinostoma caproni, Schistosoma mansoni, and a hybrid between Schistosoma haematobium and Schistosoma bovis. The reports of E. caproni and Anchitrema sp. represent the first molecularly confirmed identifications for these trematodes in definitive hosts of sub-Saharan Africa. Comparison of prevalence estimates derived from parasitological analysis at post-mortem examination and Mini-FLOTAC analysis showed non-significant differences indicating comparable results between the two techniques (P = 1.00 for S. mansoni; P = 0.85 for E. caproni; P = 0.83 for Plagiorchis sp.). A Bayesian model, applied to estimate the sensitivities of the two tests for the diagnosis of Schistosoma infections, indicated similar median posterior probabilities of 83.1% for Mini-FLOTAC technique and 82.9% for post-mortem examination (95% Bayesian credible intervals of 64.0-94.6% and 63.7-94.7%, respectively).

CONCLUSIONS

Our results showed that the Mini-FLOTAC could be applied as an alternative diagnostic technique for the detection of the zoonotic S. mansoni and other trematodes in rodent reservoirs. The implementation of non-invasive diagnostics in wildlife would offer numerous advantages over lethal sampling methodologies, with potential impact on control strategies of zoonotic helminthiases in endemic areas of sub-Saharan Africa and on fostering a framework of animal use reduction in scientific practice.

Diagnosis of Human Trematode Infections

Digenetic trematodes form a major group of human parasites, affecting a large number of humans, especially in endemic foci. Over 100 species have been reported infecting humans, including blood, lung, liver, and intestinal parasites. Traditionally, trematode infections have been diagnosed by parasitological methods based on the detection and the identification of eggs in different clinical samples. However, this is complicated due to the morphological similarity between eggs of different trematode species and other factors such as lack of sensitivity or ectopic locations of the parasites. Moreover, the problem is currently aggravated by migratory flows, international travel, international trade of foods, and changes in alimentary habits. Although efforts have been made for the development of immunological and molecular techniques, the detection of eggs through parasitological techniques remains as the gold standard for the diagnosis of trematodiases. In this chapter, we review the current status of knowledge on diagnostic techniques used when examining feces, urine, and sputum and also analyze the most relevant characteristics used to identify eggs with a quick key for the identification of eggs.

Establishing an international laboratory network for neglected tropical diseases: Understanding existing capacity in five WHO regions

Background. Limited laboratory capacity is a significant bottleneck in meeting global targets for the control and elimination of neglected tropical diseases (NTD). Laboratories are essential for providing clinical data and monitoring data about the status and changes in NTD prevalence, and for detecting early drug resistance. Currently NTD laboratory networks are informal and specialist laboratory expertise is not well publicised, making it difficult to share global expertise and provide training, supervision, and quality assurance for NTD diagnosis and research. This study aimed to identify laboratories within five World Health Organisation regions (South-East Asia, Eastern Mediterranean, Americas, Western Pacific and Europe) that provide NTD services and could be regarded as national or regional reference laboratories, and to conduct a survey to document their networks and capacity to support NTD programmes.

Methods. Potential NTD reference laboratories were identified through systematic searches, snowball sampling and key informants.

Results. Thirty-two laboratories responded to the survey. The laboratories covered 17 different NTDs and their main regional and national roles were to provide technical support and training, research, test validation and standard setting. Two thirds of the laboratories were based in academic institutions and almost half had less than 11 staff. Although greater than 90 per cent of the laboratories had adequate technical skills to function as an NTD reference laboratory, almost all laboratories lacked systems for external verification that their results met international standards.

Conclusions. This study highlights that although  many laboratories believed they could act as a reference laboratory, only a few had all the characteristics required to fulfil this role as they fell short in the standard and quality assurance of laboratory processes. Networks of high quality laboratories are essential for the control and elimination of disease and this study presents a critical first step in the development of such networks for NTDs.

Surveillance and diagnosis of zoonotic foodborne parasites

Foodborne parasites are a source of human parasitic infection. Zoonotic infections of humans arise from a variety of domestic and wild animals, including sheep, goats, cattle, camels, horses, pigs, boars, bears, felines, canids, amphibians, reptiles, poultry, and aquatic animals such as fishes and shrimp. Therefore, the implementation of efficient, accessible, and controllable inspection policies for livestock, fisheries, slaughterhouses, and meat processing and packaging companies is highly recommended. In addition, more attention should be paid to the education of auditors from the quality control (QC) and assurance sectors, livestock breeders, the fishery sector, and meat inspection veterinarians in developing countries with high incidence of zoonotic parasitic infections. Furthermore, both the diagnosis of zoonotic parasitic infections by inexpensive, accessible, and reliable identification methods and the organization of effective control systems with sufficient supervision of product quality are other areas to which more attention should be paid. In this review, we present some examples of successful inspection policies and recent updates on present conventional, serologic, and molecular diagnostic methods for zoonotic foodborne parasites from both human infection and animal‐derived foods.

On the presence and immunoregulatory functions of extracellular microRNAs in the trematode Fasciola hepatica

Liver flukes represent a paraphyletic group of endoparasitic flatworms that significantly affect man either indirectly due to economic damage on livestock or directly as pathogens. A range of studies have focussed on how these macroscopic organisms can evade the immune system and live inside a hostile environment such as the mammalian liver and bile ducts. Recently, microRNAs, a class of short noncoding gene regulators, have been proposed as likely candidates to play roles in this scenario. MicroRNAs (miRNAs) are key players in development and pathogenicity and are highly conserved between metazoans: identical miRNAs can be found in flatworms and mammalians. Interestingly, miRNAs are enriched in extracellular vesicles (EVs) which are secreted by most cells. EVs constitute an important mode of parasite/host interaction, and recent data illustrate that miRNAs play a vital part. We have demonstrated the presence of miRNAs in the EVs of the trematode species Dicrocoelium dendriticum and Fasciola hepatica (Fhe) and identified potential immune-regulatory miRNAs with targets in the host. After our initial identification of miRNAs expressed by F. hepatica, an assembled genome and additional miRNA data became available. This has enabled us to update the known complement of miRNAs in EVs and speculate on potential immune-regulatory functions that we review here.

Immune response of rats vaccinated orally with various plant-expressed recombinant cysteine proteinase constructs when challenged with Fasciola hepatica metacercariae

Background

Cysteine proteinases of Fasciola hepatica are important candidates for vaccine antigens because of their role in fluke biology and host-parasite relationships. In our previous experiments, we found that a recombinant cysteine proteinase cloned from adult F. hepatica (CPFhW) can protect rats against liver fluke infections when it is administered intramuscularly or intranasally in the form of cDNA. We also observed considerable protection upon challenge following mucosal vaccination with inclusion bodies containing recombinant CPFhW produced in Escherichia coli.

In this study, we explore oral vaccination, which may be the desired method of delivery and is potentially capable of preventing infections at the site of helminth entry. To provide antigen encapsulation and to protect the vaccine antigen from degradation in the intestinal tract, transgenic plant-based systems are used.

Methodology

In the present study, we aimed to evaluate the protective ability of mucosal vaccinations of 12-week-old rats with CPFhW produced in a transgenic-plant-based system. To avoid inducing tolerance and to maximise the immune response induced by oral immunisation, we used the hepatitis B virus (HBV) core protein (HBcAg) as a carrier. Animals were immunised with two doses of the antigen and challenged with 25 or 30 metacercariae of F. hepatica.

Conclusions

We obtained substantial protection after oral administration of the plant-produced hybrids of CPFhW and HBcAg. The highest level of protection (65.4%) was observed in animals immunised with transgenic plants expressing the mature CPFhW enzyme flanked by Gly-rich linkers and inserted into c/e1 epitope of truncated HBcAg. The immunised rats showed clear IgG1 and IgM responses to CPFhW for 4 consecutive weeks after the challenge.

Infection with Fasciola hepatica, a liver fluke, is one of the most significant veterinary problems due to the worldwide distribution of this parasite, a wide spectrum of host organisms and the resulting economic loss. Human fasciolosis caused by F. hepatica is recognised by the World Health Organization as an important emerging but neglected tropical disease. Development of an effective vaccine against this disease is becoming a priority, especially as the appearance of drug-resistant strains undermine the currently employed drug-based treatments. The two primary issues when developing a vaccine are the selection of an appropriate vaccine antigen and the route of antigen administration. In our studies, we use one of the F. hepatica cysteine proteinases, which are promising antigens for vaccine construction. We evaluate the immunogenicity and protective ability of various modifications of this cysteine proteinase produced in plants. We show that substantial protection can be obtained when plant-expressed hybrid proteins are administered orally.

Seasonal and Spatial Environmental Influence on Opisthorchis viverrini Intermediate Hosts, Abundance, and Distribution: Insights on Transmission Dynamics and Sustainable Control

BACKGROUND

Opisthorchis viverrini (Ov) is a complex-life-cycle trematode affecting 10 million people in SEA (Southeast Asia). Human infection occurs when infected cyprinid fish are consumed raw or undercooked. Ov requires three hosts and presents two free-living parasitic stages. As a consequence Ov transmission and infection in intermediate and human hosts are strongly mediated by environmental factors and understanding how environmental variability influences intermediate host abundance is critical. The objectives of this study were 1) to document water parameters, intermediate hosts abundance and infection spatio-temporal variation, 2) to assess their causal relationships and identify windows of transmission risk.

METHODOLOGY/PRINCIPAL FINDINGS

Fish and snails were collected monthly for one year at 12 sites in Lawa Lake, an Ov-endemic region of Khon Kaen Province in Northeast Thailand. Physicochemical water parameters [pH, temperature (Tp), dissolved oxygen (DO), Salinity, electrical conductivity (EC), total dissolved solid (TDS), nitrite nitrogen (NO2-N), lead (Pb), total coliform bacteria (TCB) and fecal coliform bacteria (FCB)] were measured. Multivariate analyses, linear models and kriging were used to characterize water parameter variation and its influence on host abundance and infection prevalence. We found that sampling sites could be grouped in three clusters and discriminated along a nitrogen-salinity gradient where higher levels in the lake's southern region predicted higher Bithynia relative abundance (P<0.05) and lower snail and fish species diversity (P<0.05). Highest Bithynia abundance occurred during rainy season (P<0.001), independently of site influence. Cyprinids were the most abundant fish family and higher cyprinid relative abundance was found in areas with higher Bithynia relative abundance (P<0.05). Ov infection in snails was anecdotal while Ov infection in fish was higher in the southern region (P<0.001) at sites showing high FCB.

CONCLUSIONS/SIGNIFICANCE

Our results indicate that water contamination and waterways configuration can influence freshwater communities' assemblages possibly creating ideal conditions for sustained transmission. Sustainable control may require a better appreciation of the system's ecology with wise governance and development planning particularly in the current context of SEA agricultural intensification and landscape modification.

Single-Ascending-Dose Pharmacokinetic Study of Tribendimidine in Opisthorchis viverrini-Infected Patients

Praziquantel is the only drug available for the treatment of Opisthorchis viverrini infections. Tribendimidine has emerged as a potential treatment alternative; however, its pharmacokinetic (PK) properties have not been sufficiently studied to date. Via two phase IIa dose-finding studies, 68 O. viverrini patients were treated with 25- to 600-mg doses of tribendimidine using 50- and 200-mg tablet formulations. Plasma, blood, and dried blood spots (DBS) were sampled at selected time points. The two main metabolites of tribendimidine, active deacetylated amidantel (dADT) and acetylated dADT (adADT), were analyzed in plasma, blood, and DBS. PK parameters were estimated by noncompartmental analysis. An acceptable agreement among plasma and DBS concentrations was observed, with a mean bias of ≤10%, and 60% dADT and 74% adADT concentrations being within ±20% margins. We found that 200-mg tribendimidine tablets possess immediate floating characteristics, which led to variable time to maximal concentration of drug (Tmax) values (2 to 24 h) between individuals. Dose proportionality was observed for dADT from 25 to 200 mg using 50-mg tablets, but at higher dosages (200 to 600 mg), saturation occurred. The median ratio of the area under the plasma concentration-time curve from 0 to 24 h (AUC0-24) of dADT to the AUC0- 24 of adADT ranged from 0.8 to 26.4, suggesting substantial differences in acetylation rates. Cure rates ranged from 11% (25-mg dose) to 100% (400-mg dose). Cured patients showed significantly higher dADT maximal serum concentrations (Cmax) and AUC0-24 values than uncured patients. Tribendimidine is a promising drug for the treatment of opisthorchiasis. However, the tablet formulation should be optimized to achieve consistent absorption among patients. Further studies are warranted to assess the large differences between individuals in the rate of metabolic turnover of dADT to adADT. (This study has been registered with the ISRCTN Registry under no. ISRCTN96948551.).

Early developmental stages of Ascaris lumbricoides featured by high-resolution mass spectrometry

Ascaris lumbricoides is responsible for a highly disseminated helminth parasitic disease, ascariosis, a relevant parasitosis that responds for great financial burden on the public health system of developing countries. In this work, metabolic fingerprinting using high-resolution mass spectrometry (HRMS) was employed to identify marker molecules from A. lumbricoides in different development stages. We have identified nine biomarkers, such as pheromones and steroidal prohormones in early stages, among other molecules in late development stages, making up four molecules for fertilized eggs, four marker molecules for first larvae (L1) and one marker molecule for third larvae (L3). Therefore, our findings indicate that this approach is suitable for biochemical characterization of A. lumbricoides development stages. Moreover, the straightforward analytical method employed, with almost no sample preparation from a complex matrix (feces) using high-resolution mass spectrometry, suggests that it is possible to seek for an easier and faster way to study animal molding processes.

Detection of Clonorchis sinensis circulating antigen in sera from Chinese patients by immunomagnetic bead ELISA based on IgY

BACKGROUND

Clonorchiasis, caused by Clonorchis sinensis, is widely distributed in Southeast Asia including China. Clonorchiasis is included in control programs of neglected tropical diseases by World Health Organization (WHO) because it is one of the major health problems in most endemic areas. Diagnosis of clonorchiasis plays a key role in the control programs. However, so far, there is no satisfactory method for clonorchiasis because of low sensitivity, poor practicality and high false positivity of available diagnostic tools.

METHODOLOGY/PRINCIPAL FINDINGS

We developed an immunomagnetic bead enzyme-linked immunosorbent assay (ELISA) based on IgY (egg yolk immunoglobulin) against cysteine proteinase of C. sinensis for detection of circulating antigen in serum samples of patients infected with C. sinensis. The polyclonal IgY, coated with magnetic beads, was used as a capture antibody and a monoclonal IgG labeled with horseradish peroxidase as a detection antibody in the IgY-based immunomagnetic bead ELISA system (IgY-IMB-ELISA). The results showed that the sensitivity of IgY-IMB-ELISA was 93.3% (14 of 15) in cases of heavy infection (5000 to 9999 eggs per gram feces, i.e, EPG 5000-9999), 86.7% (13 of 15) in cases of moderate infection (EPG 1000-4999) and 75.0% (9 of 12) in cases of light infection (EPG <1000) of clonorchiasis. Together 36 of total 42 (85.7%) serum samples of human clonorchiasis gave a positive reaction. There was a significant correlation between ELISA optical density and egg counts (EPG) with a correlation coefficient of 0.83 in total 42 patients. There were no positive results in patients with trichinosis (n = 10) or cysticercosis (n = 10). Cross-reactivity was 6.7% (2 of 30) with schistosomiasis japonica and 10.0% (3 of 30) with paragonimiasis, respectively. No positive reaction was found in 20 healthy persons.

CONCLUSIONS

Our findings suggest that IgY-IMB-ELISA appears to be a sensitive and specific assay for detection of circulating antigen in human clonorchiasis.

Distinct miRNA signatures associate with subtypes of cholangiocarcinoma from infection with the tumourigenic liver fluke Opisthorchis viverrini

BACKGROUND & AIMS

Intrahepatic cholangiocarcinoma (ICC) is a significant public health problem in East Asia, where it is strongly associated with chronic infection by the food-borne parasite Opisthorchis viverrini (OV). We report the first comprehensive miRNA expression profiling by microarray of the most common histologic grades and subtypes of ICC: well differentiated, moderately differentiated, and papillary ICC.

METHODS

MicroRNA expression profiles from FFPE were compared among the following: ICC tumour tissue (n = 16), non-tumour tissue distally macrodissected from the same ICC tumour block (n = 15), and normal tissue (n = 13) from individuals undergoing gastric bypass surgery. A panel of deregulated miRNAs was validated by qPCR.

RESULTS

Each histologic grade and subtype of ICC displayed a distinct miRNA profile, with no cohort of miRNAs emerging as commonly deregulated. Moderately differentiated ICC showed the greatest miRNA deregulation in quantity and magnitude, followed by the papillary subtype, and then well differentiated ICC. Moreover, when ICC tumour tissues were compared to adjacent non-tumour tissue, similar miRNA dysregulation profiles were observed.

CONCLUSIONS

We show that common histologic grades and subtypes of ICC have distinct miRNA profiles. As histological grade and subtypes are associated with ICC aggressiveness, these profiles could be used to enhance the early detection and improve the personalised treatment for ICC. These findings also suggest the involvement of specific miRNAs during ICC tumour progression and differentiation. We plan to use these insights to (a) detect these profiles in circulation and (b) conduct functional analyses to decipher the roles of miRNAs in ICC tumour differentiation.

Treatment Options and Considerations for Intestinal Helminthic Infections

Objective: To review the literature regarding the epidemiology and treatment of intestinal helminthic infections. Data Sources: A literature search of MEDLINE (1946-January 2014), EMBASE (1980-January 2014), International Pharmaceutical Abstracts (1970-January 2014), and the Cochrane Library (1996-January 2014) was performed using the following terms: intestinal, helminthic, humans, United States, and individual drug names (albendazole, ivermectin, mebendazole, nitazoxanide, praziquantel, pyrantel pamoate). Secondary and tertiary references were obtained by reviewing related articles. Study Selection and Data Extraction: All English-language articles identified from the data sources and clinical studies using anthelmintic agents were included. Data Synthesis: The 2011 removal and continued absence of mebendazole from the market has left limited options for helminth infections. For hookworm, albendazole has a 72% cure rate compared to 32% for pyrantel pamoate. Albendazole, ivermectin, and nitazoxanide appear to be effective for Ascaris with cure rates of 88%, 100%, and 91%, respectively. Both albendazole and pyrantel pamoate have been evaluated for pinworm with cure rates of 94.1% and 96.3%, respectively. Combination therapy with ivermectin and albendazole produces cure rates of 38% to 80% for whipworm. For Strongyloides stercoralis, ivermectin cure rates are 93.1% to 96.8% compared with 63.3% for albendazole. Praziquantel is effective for intestinal trematode infections with cure rates of 97% to 100% while its efficacy against tapeworm ranges from 75% to 85%. Conclusions: Albendazole is the drug of choice for hookworm, Ascaris lumbricoides, and pinworm. In combination with ivermectin, it is the first-line agent for whipworm. Ivermectin is preferred for Strongyloides stercoralis, and praziquantel is effective against most nematodes and trematodes.

Repurposing drugs for the treatment and control of helminth infections

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Drug repurposing continues to be the central drug discovery strategy for helminths.

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Most repurposed drugs come from veterinary medicine and known drug classes.

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Only a handful of drugs have advanced clinically.

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More collaborations and funding are needed to advance discoveries to the market.

Helminth infections are responsible for a considerable public health burden, yet the current drug armamentarium is small. Given the high cost of drug discovery and development, the high failure rates and the long duration to develop novel treatments, drug repurposing circumvents these obstacles by finding new uses for compounds other than those they were initially intended to treat. In the present review, we summarize in vivo and clinical trial findings testing clinical candidates and marketed drugs against schistosomes, food-borne trematodes, soil-transmitted helminths, Strongyloides stercoralis, the major human filariases lymphatic filariasis and onchocerciasis, taeniasis, neurocysticercosis and echinococcosis. While expanding the applications of broad-spectrum or veterinary anthelmintics continues to fuel alternative treatment options, antimalarials, antibiotics, antiprotozoals and anticancer agents appear to be producing fruitful results as well. The trematodes and nematodes continue to be most investigated, while cestodal drug discovery will need to be accelerated. The most clinically advanced drug candidates include the artemisinins and mefloquine against schistosomiasis, tribendimidine against liver flukes, oxantel pamoate against trichuriasis, and doxycycline against filariasis. Preclinical studies indicate a handful of promising future candidates, and are beginning to elucidate the broad-spectrum activity of some currently used anthelmintics. Challenges and opportunities are further discussed.

Persistent digestive disorders in the tropics: causative infectious pathogens and reference diagnostic tests

BACKGROUND

Persistent digestive disorders account for considerable disease burden in the tropics. Despite advances in understanding acute gastrointestinal infections, important issues concerning epidemiology, diagnosis, treatment and control of most persistent digestive symptomatologies remain to be elucidated. Helminths and intestinal protozoa are considered to play major roles, but the full extent of the aetiologic spectrum is still unclear. We provide an overview of pathogens causing digestive disorders in the tropics and evaluate available reference tests.

METHODS

We searched the literature to identify pathogens that might give rise to persistent diarrhoea, chronic abdominal pain and/or blood in the stool. We reviewed existing laboratory diagnostic methods for each pathogen and stratified them by (i) microscopy; (ii) culture techniques; (iii) immunological tests; and (iv) molecular methods. Pathogen-specific reference tests providing highest diagnostic accuracy are described in greater detail.

RESULTS

Over 30 pathogens may cause persistent digestive disorders. Bacteria, viruses and parasites are important aetiologic agents of acute and long-lasting symptomatologies. An integrated approach, consisting of stool culture, microscopy and/or specific immunological techniques for toxin, antigen and antibody detection, is required for accurate diagnosis of bacteria and parasites. Molecular techniques are essential for sensitive diagnosis of many viruses, bacteria and intestinal protozoa, and are increasingly utilised as adjuncts for helminth identification.

CONCLUSIONS

Diagnosis of the broad spectrum of intestinal pathogens is often cumbersome. There is a need for rapid diagnostic tests that are simple and affordable for resource-constrained settings, so that the management of patients suffering from persistent digestive disorders can be improved.

New developments in epidemiology, diagnosis, and treatment of fascioliasis

PURPOSE OF REVIEW

This review focuses on the recent developments in the epidemiology, burden of disease, diagnostic tests, and treatment of fascioliasis.

RECENT FINDINGS

Recent epidemiologic data suggest that either the endemic areas are expanding or disease is being recognized in areas where it was not previously observed. In addition, recent data highlight the effects of fascioliasis on childhood anemia and nutrition. Diagnosis remains problematic, but newer diagnostic tests including antibody, antigen, and DNA detection tests may facilitate earlier diagnosis. Recent studies suggest that point-of-care testing may soon be possible. Treatment with triclabendazole is effective, but resistance is emerging in livestock and may pose a threat for patients.

SUMMARY

Fascioliasis continues to emerge as an important neglected disease, with new studies highlighting the under-recognized burden of disease. Further studies are needed on burden of disease, improved diagnosis, and alternative to triclabendazole treatment.

Parasite neuropeptide biology: Seeding rational drug target selection?

The rationale for identifying drug targets within helminth neuromuscular signalling systems is based on the premise that adequate nerve and muscle function is essential for many of the key behavioural determinants of helminth parasitism, including sensory perception/host location, invasion, locomotion/orientation, attachment, feeding and reproduction. This premise is validated by the tendency of current anthelmintics to act on classical neurotransmitter-gated ion channels present on helminth nerve and/or muscle, yielding therapeutic endpoints associated with paralysis and/or death. Supplementary to classical neurotransmitters, helminth nervous systems are peptide-rich and encompass associated biosynthetic and signal transduction components - putative drug targets that remain to be exploited by anthelmintic chemotherapy. At this time, no neuropeptide system-targeting lead compounds have been reported, and given that our basic knowledge of neuropeptide biology in parasitic helminths remains inadequate, the short-term prospects for such drugs remain poor. Here, we review current knowledge of neuropeptide signalling in Nematoda and Platyhelminthes, and highlight a suite of 19 protein families that yield deleterious phenotypes in helminth reverse genetics screens. We suggest that orthologues of some of these peptidergic signalling components represent appealing therapeutic targets in parasitic helminths.

Preventive chemotherapy and the fight against neglected tropical diseases

Preventive chemotherapy is the public health strategy recommended by the WHO against a set of neglected tropical diseases that includes four groups of helminth infections (lymphatic filariasis, onchocerciasis, schistosomiasis and soil-transmitted helminthiasis) and one chlamydial (trachoma) infection. This article presents the characteristics of preventive chemotherapy interventions directed against each disease targeted by this strategy and provides an update on the status of their implementation worldwide.

Efficacy of a single oral dose of oxfendazole against Fasciola hepatica in naturally infected sheep

The efficacy of a single oral dose of 30 mg/kg of oxfendazole against Fasciola hepatica was evaluated in a controlled study in naturally infected sheep. Sheep were diagnosed by stool microscopy after sedimentation, and positive animals were randomized to oxfendazole (N = 20) or no treatment (N = 20). A new stool exam was performed 10 days after treatment. All stool microscopies were performed masked to the treatment group. No side effects were noticed. All sheep in the control group remained infected with similar counts of eggs per gram of stools. None of the animals in the treatment group showed Fasciola eggs in stools after 10 days of treatment. A single dose of oxfendazole is highly effective against F. hepatica, providing a new drug alternative for the control of fascioliasis or integrated zoonosis control.

Anthelmintic activity of medicinal plants used in Côte d'Ivoire for treating parasitic diseases

Natural products play an important role in the discovery and development of new pharmaceuticals. In the present study, we assessed the anthelmintic properties of medicinal plants used in Cote d'Ivoire. Ethanolic extracts from 50 medicinal plants were tested in vitro against trematodes (Echinostoma caproni, Schistosoma mansoni) and nematodes (Ancylostoma ceylanicum, Heligmosomoides bakeri, Trichuris muris). Active extracts were evaluated for their cytotoxicity and followed up in vivo in mice harbouring adult S. mansoni, E. caproni and T. muris at single oral doses of 400 or 800 mg/kg. All extracts tested were active against at least one helminths species. Ten of the 65 extracts tested (15.4%) in vitro revealed activity against all helminths tested. Of 65 extracts tested in vitro at a concentration of 2 mg/ml, all caused death of schistosomula and 34.4% and 39.1% were lethal against adult S. mansoni and E. caproni 72 h post-incubation, respectively. The highest activity against A. ceylanicum in vitro was observed with Sclerocarya birrea at 2 mg/ml, which resulted in death of adult worms and inhibition of activity of third-stage larvae (L3). Of the extracts, 41.5% completely inhibited movement of H. bakeri L3 at minimal lethal concentration (MLC) values of 20-200 μg/ml 48 h post-incubation, and 15.4% paralysed adult H. bakeri at 200 μg/ml 72 h after incubation. Of the extracts, 19% resulted in death of adult T. muris at MLC values of 10-100 μg/ml. In vivo, none of the extracts tested revealed activity against E. caproni. Olax subscorpioidea achieved total and female worm burden reductions of 60% and 84%, respectively in S. mansoni-infected mice. Combretum mucronatum was the most active extracts in vivo against T. muris with a worm burden reduction of 85.3%. In conclusion, several of the medicinal plants used in Côte d'Ivoire are active against different helminths, hence might play a role in the treatment of helminthiases. Further studies are necessary to isolate the active components from these extracts.

Correlation between discharged worms and fecal egg counts in human clonorchiasis

BACKGROUND

Stool examination by counting eggs per gram of feces (EPGs) is the best method to estimate worm burden of Clonorchis sinensis in infected humans. The present study investigated a correlation between EPGs and worm burden in human clonorchiasis.

METHODS AND FINDINGS

A total of 60 residents, 50 egg-positive and 10 egg-negative, in Sancheong-gun, Korea, participated in this worm collection trial in 2006-2009. They were diagnosed by egg positivity in feces using the Kato-Katz method. After administration of praziquantel, they were purged with cathartics on the next day, and then discharged adult worms were collected from their feces. Their EPGs ranged from 0 to 65,544. Adult worms of C. sinensis were collected from 17 egg-positive cases, and the number of worms ranged from 1 to 114 in each individual. A positive correlation between EPGs and numbers of worms was demonstrated (r = 0.681, P<0.001). Worm recovery rates were 9.7% in cases of EPGs 1-1,000 and 73.7% in those of EPGs over 1,000. No worms were detected from egg-negative subjects. Maximum egg count per worm per day was roughly estimated 3,770 in a subject with EPGs 2,664 and 106 collected worms.

CONCLUSIONS

The numbers of the worms are significantly correlated with the egg counts in human clonorchiasis. It is estimated that at least 110 worms are infected in a human body with EPGs around 3,000, and egg productivity of a worm per day is around 4,000.

Efficacy and safety of artemether in the treatment of chronic fascioliasis in Egypt: exploratory phase-2 trials

Background

Fascioliasis is an emerging zoonotic disease of considerable veterinary and public health importance. Triclabendazole is the only available drug for treatment. Laboratory studies have documented promising fasciocidal properties of the artemisinins (e.g., artemether).

Methodology

We carried out two exploratory phase-2 trials to assess the efficacy and safety of oral artemether administered at (i) 6×80 mg over 3 consecutive days, and (ii) 3×200 mg within 24 h in 36 Fasciola-infected individuals in Egypt. Efficacy was determined by cure rate (CR) and egg reduction rate (ERR) based on multiple Kato-Katz thick smears before and after drug administration. Patients who remained Fasciola-positive following artemether dosing were treated with single 10 mg/kg oral triclabendazole. In case of treatment failure, triclabendazole was re-administered at 20 mg/kg in two divided doses.

Principal Findings

CRs achieved with 6×80 mg and 3×200 mg artemether were 35% and 6%, respectively. The corresponding ERRs were 63% and nil, respectively. Artemether was well tolerated. A high efficacy was observed with triclabendazole administered at 10 mg/kg (16 patients; CR: 67%, ERR: 94%) and 20 mg/kg (4 patients; CR: 75%, ERR: 96%).

Conclusions/Significance

Artemether, administered at malaria treatment regimens, shows no or only little effect against fascioliasis, and hence does not represent an alternative to triclabendazole. The role of artemether and other artemisinin derivatives as partner drug in combination chemotherapy remains to be elucidated.

Fasciola hepatica and F. gigantica are two liver flukes that parasitize herbivorous large size mammals (e.g., sheep and cattle), as well as humans. A single drug is available to treat infections with Fasciola flukes, namely, triclabendazole. Recently, laboratory studies and clinical trials in sheep and humans suffering from acute fascioliasis have shown that artesunate and artemether (drugs that are widely used against malaria) also show activity against fascioliasis. Hence, we were motivated to assess the efficacy and safety of oral artemether in patients with chronic Fasciola infections. The study was carried out in Egypt and artemether administered according to two different malaria treatment regimens. Cure rates observed with 6×80 mg and 3×200 mg artemether were 35% and 6%, respectively. In addition, high efficacy was observed when triclabendazole, the current drug of choice against human fascioliasis, was administered to patients remaining Fasciola positive following artemether treatment. Concluding, monotherapy with artemether does not represent an alternative to triclabendazole against fascioliasis, but its role in combination chemotherapy regimen remains to be investigated.

Human infections with Dicrocoelium dendriticum in Kyrgyzstan: the tip of the iceberg?

Dicrocoelium dendriticum is the causative agent of a rare food-borne zoonosis of the human biliary tract, dicrocoeliasis, for which few human prevalence data are available. Infection occurs through the ingestion of ants containing metacercariae, whereas pseudo-infections (presence of D. dendriticum eggs in stool in the absence of adult worms) are due to the consumption of infected animal liver. Here, results from a cross-sectional survey carried out among 138 children aged 2-15 yr in a peri-urban area of Kyrgyzstan are reported. Each child provided 1 stool sample that was subjected to the FLOTAC technique. Eggs of D. dendriticum were diagnosed in 11 children (prevalence 8.0%; 95% confidence interval 4.5-13.7%). Although no distinction could be made between true and pseudo-infections, the prevailing animal husbandry system and the diet and hygienic conditions of the study area suggest that the social-ecological system in Kyrgyzstan is conducive for human transmission of D. dendriticum. There is a need to investigate the epidemiology of dicrocoeliasis in Kyrgyzstan, placing emphasis on the distinction between true and pseudo-infections.

In vitro trematocidal effects of crude alcoholic extracts of Artemisia annua, A. absinthium, Asimina triloba, and Fumaria officinalis: trematocidal plant alcoholic extracts

Trematode infections negatively affect human and livestock health, and threaten global food safety. The only approved human anthelmintics for trematodiasis are triclabendazole and praziquantel with no alternative drugs in sight. We tested six crude plant extracts against adult Schistosoma mansoni, Fasciola hepatica, and Echinostoma caproni in vitro. Mortality was best achieved by ethanolic extracts of Artemisia annua (sweet Annie), Asimina triloba (paw-paw), and Artemisia absinthium (wormwood) which, at 2 mg/mL, killed S. mansoni and E. caproni in 20 h or less (except for wormwood), F. hepatica between 16 and 23 h (sweet Annie), or 40 h (paw-paw). Some extracts were active at 0.2 mg/mL and 20 μg/mL, although more time was required to kill trematodes. However, aqueous A. annua and methanol extracts of Fumaria officinalis had no activity. Chromatographic analysis of the three best extracts established that A. annua and A. triloba extracts contained bioactive artemisinin and acetogenins (asimicin and bullatacin), respectively. The anthelmintic activity of our extracts at such low doses indicates that their anthelmintic activity deserves further testing as natural alternative controls for parasites of both animals and humans. Our results also support recent evidence that synergistic effects of multiple bioactive compounds present in crude plant extracts is worth exploring.