Emerging human pulmonary dirofilariasis in Hungary: a single center experience

BACKGROUND

Human pulmonary dirofilariasis (HPD) is rare in Hungary, and it stems from Dirofilaria immitis, mainly transmitted through mosquito bites, with dogs as primary hosts. Despite its prevalence in veterinary settings, human cases are infrequent. Historically, Mediterranean countries report most HPD cases, but sporadic cases occur in temperate European regions. Radiologically, HPD often manifests in a non-specific manner, resembling pulmonary neoplasms, leading to unnecessary surgery and patient distress.

METHODS

This study presents a notable case series from Hungary, encompassing a 12-year period, documenting 5 instances of HPD with the aim to provide baseline estimate of occurrence for future comparison.

RESULTS

Among the patients studied, all were of middle age (median: 52 years, range: 37-69) and exhibited tumor-like lesions, primarily localized to the right lung, necessitating lobectomy or wedge resection. Histological examination consistently revealed a necrotizing granulomatous response characterized by remnants of helminths, without the presence of ovules. Furthermore, rigorous diagnostic procedures excluded other potential infectious agents through specialized staining techniques. Polymerase chain reaction analysis definitively confirmed the diagnosis of HPD in each case.

CONCLUSIONS

This case series highlights HPD as a seldom zoonosis, with a probable escalation in its occurrence within temperate regions. Therefore, clinicians should maintain a heightened awareness of HPD in the differential diagnosis of pulmonary coin lesions. Early recognition and diagnosis are paramount for appropriate management and prevention of potential complications associated with this increasingly recognized infectious entity.

Zoonotic dirofilariases: one, no one, or more than one parasite

Dirofilaria spp. are vector-borne filarial nematodes that affect a variety of animal species, including humans. Dirofilaria immitis and Dirofilaria repens are the two main zoonotic species, but also other wildlife-associated Dirofilaria species are occasionally reported as causative agents of human dirofilariasis, including Dirofilaria striata, Dirofilaria tenuis, Dirofilaria ursi, Dirofilaria spectans, and Dirofilaria magnilarvata. Since the etiological identity of most of the species mentioned here is arguable, we summarized and critically discussed data concerning infections in humans, focusing on the reliability of Dirofilaria species identification. We advocate the importance of combined morphological and genomic approaches to provide unequivocal evidence for their zoonotic potential and pathogenicity.

Parasitism of Dirofilaria incrassata Molin, 1858 in coatis (Nasua nasua)

Populations of the coati, Nasua nasua, like the populations of other wild animals, are regulated by several biotic or abiotic factors. For example, parasites act as a biotic factor affecting the dynamics and density of coati populations. The parasitic nematodes of coatis include Dirofilaria species, such as Dirofilaria immitis, Dirofilaria repens, and Dirofilaria incrassata. Considering that there are few records on parasitism by D. incrassata, including information on the life cycle or location in the host body, this study aimed to investigate the infection of N. nasua by D. incrassata in midwestern Brazil. Thus, two coatis (males and adults) from the Cerrado of Goiás, which died (cause unknown) at the Wild Animal Screening Center/IBAMA in the municipality of Goiânia, Goiás, Midwestern of Brazil, were dissected and all helminths found were collected, identified following specific keys and quantified. A total of 85 specimens of D. incrassata were collected, with a mean parasitic intensity of 42.5 and a parasitic amplitude ranging from 40 to 45, measuring 41-93 mm in length and 0.23-0.45 mm in width. All helminths were adults and were distributed in the superficial and deep fascia (at different levels) from the neck to the hind limb. Most helminths were tangled, with some encased in a connective tissue film. Most reported human heartworm cases refer to subcutaneous or ocular heartworm infection, mainly caused by D. repens, although other species of heartworm may be associated. D. incrassata was not reported as zoonotic agent, diferently of other Dirofilaria species associated with wild animals and with zoonotic potential in the Americas. This study reiterates N. nasua as the definitive host for D. incrassata and the subcutaneous tissue as the site of choice for this helminth in the adult form. In addition, it reports new body regions where the parasite occurs. This study is the first to document the occurrence of D. incrassata infestation in the State of Goiás, Brazil.

Testicular Dirofilariasis in an Italian 11-Year-old Child

Dirofilariasis is a rare infection caused by a vector-borne nematode that can be accidentally transmitted to humans. We report a case of a 11-year-old child with a painless scrotal cyst caused by Dirofilaria repens , initially suspected by ultrasound scan and then confirmed by histopathologic examination.

Human Pulmonary Dirofilariasis Due to Dirofilaria immitis: The First Italian Case Confirmed by Polymerase Chain Reaction Analysis, with a Systematic Literature Review

Dirofilariasis is a zoonosis caused by nematodes of the genus Dirofilaria.Dirofilaria immitis is cosmopolitan as regards its distribution in animals, being responsible for human pulmonary dirofilariasis in the New World. However, human infections by Dirofilaria immitis are exceptional in Europe, and the previously reported Italian cases of pulmonary dirofilariasis were due to Dirofilaria repens. We performed a systematic literature review of the Italian cases of human dirofilariasis due to Dirofilariaimmitis according to the PRISMA guidelines. We also report the first autochthonous case of human pulmonary dirofilariasis due to Dirofilariaimmitis, confirmed by polymerase chain reaction analysis. The patient was a 60-year-old man who lived in the Po river valley and had never traveled abroad; on histological examination, the 2-cm nodule found in his right upper lung was an infarct due to a parasitic thrombotic lesion. Only one other autochthonous (but conjunctival) case due to Dirofilariaimmitis (molecularly confirmed) was previously found in the same geographic area. Climatic changes, the increasing movements of animal reservoirs and vectors, and new competent carriers have expanded the geographic distribution of the Dirofilaria species, increasing the risk of human infections. Our report demonstrates that at least some pulmonary Italian cases of human dirofilariasis are due to Dirofilaria immitis, as in the New World.

Dirofilaria repens predominates in shelter dogs from South Romania

Canine filarioids are zoonotic vector-borne parasitic nematodes distributed mostly in the tropics and subtropics. The aim of this study was to determine the prevalence, distribution, etiology and genetic variation of canine filarioid infections by three different PCR techniques in four Southern Romanian counties. Blood samples of 300 shelter dogs were screened for infections with canine filarioids by real-time PCR. To determine filarioid species and coinfections, samples positive in the initial screening were further tested by conventional PCR and sequenced. Results indicated that 17% of the tested dogs were positive for at least one filarioid species. The prevalence of D. repens infection was 11.7%, significantly higher than that of D. immitis (4.7%) and A. reconditum (1.3%) (p ≤ 0.003). The high prevalence of canine filarioid infections represents a challenge to animal and human health in the South of Romania, and they should be constantly monitored.

Prevalence of Dirofilaria repens in dogs living in deltaic coastal plain of the Volturno River (Italy): a geographical risk model of infection

The prevalence of vector-associated parasitic infections is high in central-southern Italy. The deltaic coastal plain of the Volturno River has been suspected, by veterinary practitioners, to have a high accidental incidence of Dirofilaria repens. Thus, the goal of this study was to evaluate the prevalence of dirofilariasis and other coinfections frequently described in dogs living in the Volturno area. Blood samples of 100 clinical asymptomatic dogs were examined using a Knott's technique and polymerase chain reaction in order to identify microfilariae. Other vector-borne coinfections were also investigated using ELISA kits. The results were analysed using statistical and Geographic Information System (GIS) software. Microfilariae of D. repens were detected in 10% of the dogs surveyed, with a presence of antibodies against Ehrlichia canis (4/10) and Dirofilaria immitis (1/10). Such high incidence should be considered in light of the zoonotic potential for D. repens and the support for more regular use of repellents to prevent the spread of this disease. The GIS analyses indicated that the study area provides suitable conditions to sustain populations of mosquito vectors and D. repens parasites throughout much of the year.

Dirofilaria immitis Pulmonary Dirofilariasis, Slovakia

Dirofilaria immitis is a parasite related to pulmonary dirofilariasis in humans, its accidental hosts. We detected an autochthonous case of D. immitis infection in a woman from Slovakia. The emergence and spread of this parasite in Europe indicates a critical need for proper diagnosis of infection.

Molecular characterization of canine filarioids in a previously non-endemic area of Rio de Janeiro State, Brazil

Dirofilaria immitis is the causative agent of canine heartworm disease, a severe health problem in dogs, especially in coastal areas of tropical and subtropical regions of the world. We employed molecular methods to investigate the occurrence of canine infection by filarioids in five municipalities of Baixada Fluminense (Magé, Duque de Caxias, Guapimirim, Nova Iguaçu, and São João de Meriti), a non-endemic area of Rio de Janeiro State, Southeast Brazil. A total of 110 canine blood samples collected from 2017 to 2018 and positive for microfilariae at the modified Knott's test were screened by cPCR targeting DNA fragments of the 12S rDNA gene for filarial nematodes. Seventy-seven samples (70%) tested positive at the molecular analysis. Of these, 72 were identified as D. immitis and 5 (4.5%) as Acanthocheilonema reconditum. Dirofilaria repens was not detected in the studied municipalities of Baixada Fluminense. This is the first record of D. immitis and A. reconditum in the Baixada Fluminense region, Rio de Janeiro State, Brazil. The prevalence of D. immitis cases in the five municipalities suggests the establishment and maintenance of its enzootic cycle in the studied region, which indicate vulnerability to the occurrence of epidemic cycles and, possibly, human cases.

Human dirofilariosis in Austria: the past, the present, the future

Background

Dirofilariosis is a vector-borne parasitosis caused by filarial nematodes of the genus Dirofilaria. In humans, who represent accidental hosts, dirofilariosis is mostly caused by Dirofilaria repens and Dirofilaria immitis. In Austria, the first reported case occurred in 1978. Since then, several (case) reports have been published.

Methods

A systematic and retrospective review of collected published cases and new, unpublished confirmed cases of human dirofilariosis occurring in Austria was performed. A nematode was extracted from the eyelid of a previously unreported case and subsequently characterized histologically and using molecular biology techniques.

Results

Data on a total of 39 cases of human dirofilariosis in Austria occurring between 1978 and 2020 are summarized. Over the past four decades the incidence has markedly increased, in particular after 1998. Of the 39 patients, men and women were equally affected, and the mean age was 47.1 years. The area most frequently affected was the head (38.5% of cases). Confined ocular involvement was observed in 23.1% of cases, and nematodes were isolated from the neck/trunk, extremities and the genito-inguinal area in 25.6, 15.4 and 15.4% of patients, respectively. Microfilariae were detected in two cases. Of the 39 patients, only 73.9% tested positive for anti-filarial antibodies and 56.3% for eosinophilia, despite successful isolation of a nematode; consequently, these measures did not represent reliable markers for dirofilariosis. Most patients had a travel history to countries endemic for Dirofilaria species. One patient who had not traveled abroad represented the only autochthonous case recorded to date. Dirofilaria repens was the predominant species, identified in 89.7% of cases. In the newly reported case of subcutaneous dirofilariosis, a live non-gravid Dirofilaria repens adult female of 12 cm length was isolated from the eyelid of the patient, and a video of the extraction is provided.

Conclusions

The incidence of human dirofilariosis cases has increased strikingly over the last four decades in Austria. More cases can be expected in the foreseeable future due to changes in human behavior and (travel) activities as well as climate changes and the associated alterations in the availability of the natural reservoir, the vectors and the intrinsic characteristics of the parasite.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04696-4.

Seasonal distribution and environmental parameters associated with Brugia pahangi and Dirofilaria immitis in naturally infected dogs in Bangkok and vicinity, Thailand

Dirofilaria immitis and Brugia pahangi are vector-borne parasites found in dogs and cats, including Thailand. In order to evaluate the effects of season and environmental parameters on the prevalence of these parasites, this retrospective study was conducted in 2019. A total of 79,506 canine blood samples were examined. B. pahangi was found in 0.55% of samples (438/79,506; 95% CI 0.50–0.61) while D. immitis was detected in 0.43% (345/79,506; 95% CI 0.39–0.48). One-way ANOVA found no effect of seasonal conditions on prevalence. For B. pahangi, the parameters rainfall, relative humidity and sunshine hours showed associations with p ≤ 0.20 and were included in multiple logistic regressions resulting in adjusted odds ratios of 0.53, 1.31 and 0.55, respectively. For D. immitis, only average temperature showed p ≤ 0.20, resulting in an odds ratio of 0.42. In conclusion, Thailand has environmental parameters that do not change very much during the year, so they might not affect the prevalence of two filarial nematodes. However, the threat of B. pahangi and D. immitis should not be ignored, especially in subtropical regions where their vectors are abundant. Both owners and veterinarians should be concerned about filarial prevention and control of D. immitis and B. pahangi.

[Features of granulomatous inflammation in helminthiasis, mycoses and human protozoal diseases in forensic medical practice]

THE AIM OF THE STUDY

Is to draw the attention of forensic experts and histologists to the problem of infectious diseases occurring with the formation of granulomas. Was reviewed the general patterns of granulomatous diseases, as well as the peculiarities of pathomorphosis in helminthiasis (schistosomiasis, paragonimiasis, onchocerciasis, dirofilariasis, ascariasis, cysticercosis), mycoses (cryptococcosis, chromomycosis, coccidioidosis) and protozoal diseases, toxosomes. The article includes photomicrographs from the authors' personal archive, including those collected during their work in African countries Text is based on scientific data from articles, monographs, educational literature, personal experience and cases of forensic medical practice.

Pseudo-Tumor of the Epididymis, a Rare Clinical Presentation of Human Dirofilaria repens Infection: a Report of Autochthonous Case of Dirofilariasis in Southwestern Slovakia

PURPOSE

Dirofilariasis caused by the filarial nematode Dirofilaria repens is mainly a disease of dogs and other carnivores. Also, humans can be accidentally infected with this parasite. The infective third-stage filariform larvae are transmitted by various species of mosquitoes. Until this day, a total of 17 human cases caused by D. repens have been diagnosed in Slovakia, 11 subcutaneous, 4 ocular, 1 pulmonary and 1 in the epididymis. The aim of this report was to describe an unusual clinical case of dirofilariasis of the scrotum.

METHODS

Extirpated worm was subjected to the molecular and histological identification. PCR for the amplification of cytochrome oxidase subunit 1 (CO1) was performed using specific D. repens primer pair.

RESULTS

Here we document the 13th case of human dirofilariasis in a 46-year-old man from southwestern Slovakia. Very rare in humans, genital involvement manifests itself as pseudotumor nodule affecting the epididymis. The patient consulted a general practitioner due to a palpable subcutaneous lump in the scrotum. Routine laboratory analysis revealed blood eosinophilia (16.6%). The ultrasound examination was indicated, and subsequently, surgical excision of the right epididymal nodule was performed. On the basis of histological microscopic examination and PCR-based detection, the helminth was identified as Dirofilaria repens. This represents the ninth case of autochthonous dirofilariasis in Slovakia.

CONCLUSIONS

The majority of D. repens infections were recorded in southwestern regions of Slovak Republic, which are considered to be endemic areas for canine dirofilariasis. Our described patient also comes from southwestern part of Slovakia (Topoľníky, Dunajská Streda region).

Assessing the potential cross-reactivity using a commercial heartworm ELISA kits of serum from dogs naturally infected with Onchocerca lupi

Onchocerca lupi is an emerging zoonotic parasite of dogs, endemic to the southwestern USA and areas of the Old World. Currently, there are no specific serological diagnostic tests able to detect O. lupi infection. Recent literature has demonstrated that commercially available heartworm antigen tests, despite being highly sensitive, may cross-react with infections by other filarid nematodes. There is no information on potential cross-reactivity of such tests in serum of dogs infected with O. lupi. Our objective was to assess serum samples of dogs naturally-infected with O. lupi for potential cross-reactivity before and after heat-treatment using a commercial heartworm ELISA kit. We obtained serum from 23 dogs naturally-infected with O. lupi. These dogs presented with ocular disease, and were consulted to schedule either surgical removal of ocular nodules due to infection or enucleation. Samples were tested in triplicate using the DiroCHEK® Heartworm Antigen Test kit (Synbiotics Corporation, Zoetis, Kalamazoo, MI, USA) following the manufacturers' protocol pre- and post-heat-treatment. Samples were heat-treated using a dry heat block at 103 °C for 10 min and then centrifuged at 1818×g for 20 min. Out of a total of 23 dogs, 19 (82.6 %) had no antigen detected regardless of heat-treatment, three dogs tested positive before and after heat-treatment, and a single dog turned positive after heat-treatment. These three dogs that were positive before and after heat-treatment were confirmedly co-infected with Dirofilaria immitis by the veterinarians responsible for these cases, and we were unable to get the history or follow up with the dog that turned positive post-heat-treatment only. Our data suggest that O. lupi infections should not result in false-positives when using the DiroCHEK® in dog serum, before or after heat-treatment. Dogs with clinical ocular onchocercosis that test antigen-positive in DiroCHEK® are likely co-infected with D. immitis, and should be further tested, including evaluation of microfilariae in blood and diagnostic imaging. If heartworm infection is confirmed, the animals should be enrolled in the recommended treatment protocol in accordance to the guidelines of the American Heartworm Society or other local organizations.

Human case of subcutaneous nodule because of a novel genetic variation of Dirofilaria sp

A 75-year-old man presented with a 1-cm large elastic soft subcutaneous nodule on the left side of the umbilicus, which when excised showed presence of a helminthic form within the granulomatous lesions. Morphologically, the helminth was considered to be of the genus Dirofilaria, and the patient showed increased serum antibody titer against canine filaria. The partial DNA sequence of the mitochondrial 12S rRNA gene locus of this clinical isolate showed the highest nucleotide identity (89.6%) with Dirofilaria repens; however, the phylogenetic analysis addressed the haplotype and Dirofilaria ursi as outgroups of the clusters of D. repens and Dirofilaria immitis, which are the causal agents of most human dirofilariasis. As like bear filaria D. ursi, a wide variety of other carnivore-parasitizing filaria species have rarely been reported in humans. The newly detected genetic haplotype in this case may correspond to one of these species of Dirofilaria, though the genetic references are not available thus far.

Seroepidemiological survey of human exposure to Dirofilaria spp. in Romania and Moldova

The present study aimed to evaluate the extent of Dirofilaria immitis and D. repens exposure in humans from eastern and southern areas of Romania and central Moldova by serological methods. The serological screening was performed on a total of 450 serum samples (187 from Romania and 263 from Moldova). The sera were collected using a convenience sampling with the help of physicians from the hospitals of the study areas. All samples were analysed by a non-commercial ELISA test for the detection of IgG antibodies against adult somatic antigens of D. immitis and D. repens. The results showed a total of 49 (10.9%; 95% CI = 8.3-14.1%) individuals from Romania and Moldova with a positive response to IgG antibodies against both adult somatic antigens of D. immitis and D. repens. Specifically, 48 (10.7%; 95% CI = 8.0-14.0%) patients were positive for IgG-antibodies against adult somatic antigens of D. immitis, one (0.2%; 95% CI = 0.4-1.2%) against D. repens antigens, and four (0.9%; 95% CI = 0.4-3.3%). were positive for antigens of both parasites. At country level, out of 187 samples from Romania, 13 (6.9%; 95% CI = 4.1-11.5%) were positive for anti-D. immitis IgG with high exposure in the southern part of the country (Bucharest). Of the 263 people from Moldova, 36 (13.7%; 95% CI = 10.0-18.4%) were positive for D. immitis antigens from which three (1.1%, 95% CI = 0.4-3.3%) were positive for the antibodies against antigens of both parasites. Only one sample was found positive for anti-D. repens IgG. Positive IgG-ELISA results were confirmed by Western blot analysis. In addition, for further confirmation, a complementary ELISA was performed for anti-WSP IgG antibodies against Wolbachia endosymbionts. Our findings showed a noticeable exposure of humans from Romania and Moldova to Dirofilaria parasites. Serology can be useful for indicating exposure to Dirofilaria spp. in a healthy population in order to obtain useful data on the epidemiological scenario of human dirofilariosis in Eastern Europe.

[Update on cutaneous dirofilariasis]

Dirofilariasis is a worldwide zoonotic infection that rarely affects humans and is caused by filarial nematodes of the genus Diroflaria transmitted by mosquitoes. Cutaneous dirofilariasis, due to D. repens, presents as inflammatory lesions that develop into subcutaneous nodules. These clinical symptoms may be consistent with Wells' cellulitis. Diagnosis of dirofilariasis involves demonstration of the presence of the nematode during skin biopsy and identification of the worm through macroscopic, histological and PCR analysis. Surgical resection of the nodule remains the gold standard treatment. The number of cases of human cutaneous dirofilariasis has increased in the recent years and the disease must not be misdiagnosed.

Molecular characterization of Dirofilaria spp. circulating in Portugal

Background

Dirofilariosis is a potentially zoonotic parasitic disease, mainly transmitted by mosquito vectors in many parts of the world. Data concerning the canine Dirofilaria species currently circulating in Portugal is scarce. Thereby, a large-scale study was conducted to determine the Dirofilaria spp. present in Portugal, based on a molecular approach, and also to optimize a reliable and highly sensitive species-specific polymerase chain reaction (PCR) assay that could be used for the simultaneous detection and differentiation of Dirofilaria immitis, Dirofilaria repens, and other concurrent filarial species in animal reservoirs.

Methods

Blood samples were collected from three districts of Portugal (Coimbra, Santarém and Setúbal) between 2011 and 2013. Samples were tested using rapid immunomigration tests (Witness® Dirofilaria), modified Knott’s technique and acid phosphatase histochemical staining. In addition, molecular analysis was performed by amplification of the internal transcribed spacer (ITS) region using two different PCR protocols, specific for molecular screening of canine filarial species.

Results

Of the 878 dogs sampled, 8.8% (n = 77) were positive for D. immitis circulating antigen and 13.1% (n = 115) positive for microfilariae by the modified Knott’s technique. Of the 134 samples tested by acid phosphatase histochemical staining, 100 (74.6%) were positive for D. immitis. Overall, 13.7% (n = 120) were positive by PCR for D. immitis by ITS2, of which 9.3% (67/720) were also positive by ITS1. ITS2 PCR was the most sensitive and specific method, capable of detecting mixed D. immitis and A. reconditum infections. Heterozygosity, in the form of double peaks, was detected by sequencing of both ITS regions. No D. repens was detected by any of the diagnostic methods.

Conclusions

The present study confirmed D. immitis as the dominant species of the genus Dirofilaria infecting Portuguese dogs, based on sequencing of ITS1 and ITS2 PCR fragments. Additionally, ITS2 PCR was the most adequate method for diagnosis and prevalence estimation.

The Mitochondrial Genomes of the Zoonotic Canine Filarial Parasites Dirofilaria (Nochtiella) repens and Candidatus Dirofilaria (Nochtiella) hongkongensis Provide Evidence for Presence of Cryptic Species

Background

Cutaneous dirofilariosis is a canine mosquito-borne zoonosis that can cause larva migrans disease in humans. Dirofilaria repens is considered an emerging pathogen occurring with high prevalence in Mediterranean areas and many parts of tropical Asia. In Hong Kong, a second species, Candidatus Dirofilaria hongkongensis, has been reported. The present study aimed to compare mitochondrial genomes from these parasites and to obtain population genetic information.

Methods and Findings

Complete mitochondrial genomes were obtained by PCR and Sanger sequencing or ILLUMINA sequencing for four worms. Cytochrome oxidase subunit 1 sequences identified three as D. repens (all from Europe) and one as C. D. hongkongensis (from India). Mitochondrial genomes have the same organization as in other spirurid nematodes but a higher preference for thymine in the coding strand. Phylogenetic analysis was in contradiction to current taxonomy of the Onchocercidae but in agreement with a recent multi-locus phylogenetic analysis using both mitochondrial and nuclear markers. D. repens and C. D. hongkongensis sequences clustered together and were the common sister group to Dirofilaria immitis. Analysis of a 2.5 kb mitochondrial genome fragment from macrofilaria or canine blood samples from Europe (42), Thailand (2), India (1) and Vietnam (1) revealed only small genetic differences in the D. repens samples including all European and the Vietnam sample. The Indian C. D. hongkongensis and the two Thai samples formed separate clusters and differences were comparatively large.

Conclusion

Genetic differences between Dirofilaria spp. causing cutaneous disease can be considerable whereas D. repens itself was genetically quite homogenous. C. D. hongkongensis was identified for the first time from the Indian subcontinent. The full mitochondrial genome sequence strengthens the hypothesis that it represents an independent species and the Thai samples might represent another cryptic species, Candidatus Dirofilaria sp. ‘Thailand II’, or a quite divergent population of C. D. hongkongensis.

The mitochondrial genomes of the zoonotic parasite species Dirofilaria repens and Candidatus Dirofilaria hongkongensis were characterized and compared to the genomes of other filariae. The resulting phylogeny is largely in agreement with recent molecular data. C. D. hongkongensis was placed as a sister group to D. repens and both as a common sister to D. immitis. The large genetic difference between D. repens and C. D. hongkongensis further supports the hypothesis that both are distinct valid species. Two canine samples from Thailand that were diagnosed as D. repens are either from a C. D. hongkongensis population that is quite divergent from the Indian population or might represent another currently unrecognized species in the genus.

Major Parasitic Zoonoses Associated with Dogs and Cats in Europe

Some of the most important zoonotic infectious diseases are associated with parasites transmitted from companion animals to man. This review describes the main parasitic zoonoses in Europe related to dogs and cats, with particular emphasis on their current epidemiology. Toxoplasmosis, leishmaniosis, giardiosis, echinococcosis, dirofilariosis and toxocariosis are described from the animal, as well as from the human host perspectives, with an emphasis on parasite life cycle, transmission, pathogenicity, prevention and identification of knowledge gaps. In addition, priorities for research and intervention in order to decrease the risks and burden of these diseases are presented. Preventing zoonotic parasitic infections requires an integrated multidisciplinary 'One Health' approach involving collaboration between veterinary and medical scientists, policy makers and public health officials.

Dirofilariasis Mimicking an Acute Scrotum

Human infections caused by Dirofilaria repens have been reported in many areas of the world. We describe a case of a 3-year-old child with an intrascrotal mass caused by D repens mimicking an acute scrotum. This represents the first case of scrotal dirofilariasis described in pediatric age with such an unusual presentation.

Canine filarial infections in Liguria, north-west Italy

This paper reports the findings of a study on the presence of various species of filarial nematodes in dogs in Liguria, north-west Italy, a region traditionally considered free from the disease. Between 2009 and 2012 blood samples were taken from 365 dogs in rural areas in Liguria. The blood samples were then submitted to Knott's test, histochemical staining, polymerase chain reaction (PCR) and the enzyme-linked immunosorbent assay (ELISA) for Dirofilaria immitis antigens. Overall, 35 of the 365 dogs were positive using Knott's test for microfilariae (prevalence 9.6%; 95% confidence interval (CI): 6.6-12.6%). Acanthocheilonema reconditum was the most prevalent species (8.0%), while Dirofilaria repens (1.4%) and Dirofilaria immitis (0.6%) were less common. One co-infection by D. repens and A. reconditum was observed. All morphological identifications were confirmed by histochemical staining and PCR. In addition, a retrospective analysis of data on D. immitis antigens in 11,363 samples of canine sera was carried out. Sera were collected and analysed for D. immitis antigens by the Istituto Zooprofilattico Sperimentale (IZS) of Piedmont, Liguria and Aosta Valley (Imperia section) between 2004 and 2013 during annual tests for leishmaniasis on autochthonous dogs throughout Liguria. Serological data from IZS showed an overall seroprevalence of 0.65% (95% CI: 0.50-0.80%) for D. immitis throughout the region. The present study updates the epidemiological map of canine filarial infections in Italy and suggests the need for surveillance and prophylaxis in Liguria.

Clinical case presentation and a review of the literature of canine onchocercosis by Onchocerca lupi in the United States

Background

Onchocerca lupi, a filarioid of zoonotic concern, infects dogs and cats causing ocular lesions of different degrees, from minor to severe. However, infected animals do not always display overt clinical signs, rendering the diagnosis of the infection obscure to the majority of veterinarians. Canine onchocercosis has been reported in the Old World and the information on its occurrence in the United States, as well as its pathogenesis and clinical management is still meagre. This study reports on the largest case series of O. lupi infection from the United States and reviews previous cases of canine onchocercosis in this country.

Methods

Information on the clinical history of a series of eight cases of O. lupi infection in dogs diagnosed in Minnesota, New Mexico, Colorado and Florida, from 2011 to 2014, was obtained from clinical records provided the veterinary practitioners. Nematodes were morphologically identified at species level and genetically analyzed.

Results

All dogs displayed a similar clinical presentation, including subconjunctival and episcleral nodules, which were surgically removed. Each dog was subjected to post-operative therapy. Whitish filaria-like parasites were morphologically and molecularly identified as O. lupi.

Conclusions

This study confirms that O. lupi is endemic in the United States, indicating that the distribution of the infection is probably wider than previously thought. With effect, further studies are urgently needed in order to improve the diagnosis and to assess the efficacy of therapeutic protocols, targeting the parasite itself and/or its endosymbionts.

Molecular analysis of Dirofilaria repens removed from a subcutaneous nodule in a Japanese woman after a tour to Europe

A premature female Dirofilaria species, subsequently identified as Dirofilaria repens by its morphological features and mitochondrial 12S ribosomal RNA (12S rRNA) gene sequence, was removed from a subcutaneous nodule of the right temporal region of the head in a Japanese woman 2 years after she noticed swelling of her left calf following an insect sting during a tour to Europe; headache symptoms were noticed a few months later. The sequences of the mitochondrial 12S rRNA and cytochrome c oxidase subunit I genes from the organism were almost identical to those of sequences AM779772 (100% homology, 337/337) and AM749233 (99.8% homology, 536/537) of D. repens isolated from humans in Italy. However, the phylogenetic position of the 18S rRNA-internal transcribed spacer 1-5.8S rRNA region was in the same cluster as that of sequence JX290195 of Dirofilaria sp. “hongkongensis” (96.7% homology, 348/360), which was recently reported from Hong Kong as a novel Dirofilaria species. Information on regional genetic variation in D. repens isolated from animals and humans remains scarce. We report the detailed genetic features of this filaria as a reference isolate from a specific endemic area, to enrich the genetic database of D. repens.

Dirofilaria repens in the Russian Federation: current epidemiology, diagnosis, and treatment from a federal reference center perspective

BACKGROUND

Dirofilariasis is an emerging zoonotic infection in which the human serves as an accidental host. Russia has been one of the most important endemic regions worldwide for Dirofilaria repens, the most prevalent Dirofilaria species in Europe.

METHODS

Based on a cohort of patients at the Rostov Medical University, we provide an epidemiological description of 236 human cases, reporting common clinical symptoms and treatment options for D. repens infections in humans. The performance of a non-commercial immunoassay was validated in a diagnostic sub-study (diagnostic accuracy 83%). Data from mosquito surveys and cross-sectional surveys of dogs, the main reservoir of D. repens, are also presented.

RESULTS

Results showed important variations in prevalence depending on sex, geographic location, and the use of dogs (professional service dogs or pets).

CONCLUSIONS

The particularly high prevalence of Dirofilaria infection in professional dogs used in the police force and armed forces poses a particular problem, since these dogs may serve as epidemiologically important amplifiers within the region of the former Soviet Union.

Seroreactivity to Dirofilaria antigens in people from different areas of Serbia

BACKGROUND

The Northern part of Serbia is hyperendemic-endemic for canine dirofilarioses. Considering this fact, many human dirofilarial infections could be expected, however only about 30 cases in Serbia have been described until today. Aims of this survey were to assess the people reactivity to the antigens of D. repens and D. immitis and to identify risk factors for the contact exposure.

METHODS

Investigation included sera taken from 297 people (179 women and 118 men) living in different areas of Serbia (Pančevo, Novi Sad, Zaječar, Leskovac, Vranje, Niš, Pirot). Sera were analysed by means of two indirect enzyme-linked immunosorbent (ELISA) home-designed that use as antigens adult somatic/metabolic polyproteins of D. repens (DR) and D. immitis (DI), respectively. The results were elaborated using the statistical method of descriptive and quantitative analysis.

RESULTS

Significant differences by area in the reactivity of human sera to dirofilarial antigens were not observed (p = 0.056). A high seroreactivity was demonstrated in people from the towns of northern Serbia (Pančevo = 27,1%; Novi Sad = 16,3%), as well as in people from Zaječar (eastern Serbia = 15,8%) and Vranje (southern Serbia = 15,1%). No differences were evidenced between people reactivity to polyproteins of the two dirofilarial species, nor differences related to the gender of examinees. Factor risks evidenced were: i) place of residence; ii) spending work time outdoors during the mosquito season; iii) spending time outdoors and nearby rivers, lakes, swamps or canals; unespectedly, iv) cat owning.

CONCLUSION

The findings emerging from this investigation indicate that clinicians and public health authorities should pay greater attention to this zoonosis. Continuing education and training of physicians will greatly contribute to the knowledge of the actual impact of filarial worms on animal and public health, and allow for the planning of suitable measures to prevent the infections.

Molecular detection of Dirofilaria immitis, Dirofilaria repens and Setaria tundra in mosquitoes from Germany

Background

As a result of globalization and climate change, Dirofilaria immitis and Dirofilaria repens, the causative agents of dirofilariosis in Europe, continue to spread from endemic areas in the Mediterranean to northern and northeastern regions of Europe where autochthonous cases of dirofilarial infections have increasingly been observed in dogs and humans. Whilst D. repens was recently reported from mosquitoes in putatively non-endemic areas, D. immitis has never been demonstrated in mosquitoes from Europe outside the Mediterranean.

Methods

From 2011 to 2013, mosquitoes collected within the framework of a German national mosquito monitoring programme were screened for filarial nematodes using a newly designed filarioid-specific real-time PCR assay. Positive samples were further processed by conventional PCR amplification of the cytochrome c oxidase subunit I (COI) gene, amplicons were sequenced and sequences blasted against GenBank.

Results

Approximately 17,000 female mosquitoes were subjected to filarial screening. Out of 955 pools examined, nine tested positive for filariae. Two of the COI sequences indicated D. immitis, one D. repens and four Setaria tundra. Two sequences could not be assigned to a known species due to a lack of similar GenBank entries. Whilst D. immitis and the unknown parasites were detected in Culex pipiens/torrentium, D. repens was found in a single Anopheles daciae and all S. tundra were demonstrated in Aedes vexans. All positive mosquitoes were collected between mid-June and early September.

Conclusion

The finding of dirofilariae in German mosquitoes implies the possibility of a local natural transmission cycle. While the routes of introduction to Germany and the origin of the filariae cannot be determined retrospectively, potential culicid vectors and reservoir hosts must prospectively be identified and awareness among physicians, veterinarians and public health personnel be created. The health impact of S. tundra on the indigenous cervid fauna needs further investigation.

Dirofilariosis in the Americas: a more virulent Dirofilaria immitis?

Dirofilarioses are widespread diseases caused by filarioid nematodes (superfamily Filarioidea) of the genus Dirofilaria, which are transmitted by a plethora of mosquito species. The principal agent of canine dirofilariosis in the Americas is Dirofilaria immitis, which may also occasionally infest humans, resulting in pulmonary nodules that may be confounded with malignant lung tumours. Because human cases of dirofilariosis by D. immitis are relatively frequent in the Americas and rare in Europe and other eastern countries, where Dirofilaria repens is the main causative agent, the existence of a more virulent strain of D. immitis in the Americas has been speculated. Recently, a case of human ocular infestation by Dirofilaria sp. was diagnosed in Pará State, northern Brazil, where canine heartworm dirofilariosis is endemic. The nematode was shown to be morphologically and phylogenetically related to D. immitis but it was genetically distinct from reference sequences, including those of D. immitis infesting dogs in the same geographical area. This finding raised questions regarding the aetiology of human dirofilariosis in the Americas, since information on the genetic makeup of filarioids infesting dogs and humans is meagre. Further studies would be needed to better characterize filarioids infesting dogs, wild animals, and humans in the Americas and to assess the existence of a more virulent D. immitis strain in this continent. Finally, the competence of different culicid species/strains from Europe and the Americas as vectors of Dirofilaria species should be investigated. Such studies would help us to understand possible variations in transmission patterns and even to predict possible scenarios that may emerge in the future, with the introduction of non-endemic Dirofilaria species/strains in free areas through importation of infested animals, vectors, or both.

Microfilarial periodicity of Dirofilaria repens in naturally infested dogs

In the past years, canine and human cases of infestation by Dirofilaria repens (Spirurida, Onchocercidae) have been increasingly reported in several European countries. Subcutaneous dirofilariosis by D. repens may either be asymptomatic in dogs or may be characterized by subcutaneous nodules and other symptoms. Information on the periodicity of D. repens microfilariae in naturally infested animals is scant, and this might impair the accurate diagnosis of subcutaneous dirofilariosis and appropriate control plans. In the present study, eight dogs infested with D. repens were sampled twice daily at 12-h intervals for ten consecutive days, and the dog with the highest mean value of microfilariaemia was further sampled every 4 h for four consecutive days. The blood was microscopically and molecularly examined for microfilariae, and, additionally, negative samples were also subjected to a real-time PCR to evaluate the level of circulating DNA. The results demonstrated significant variations in circadian rhythms of D. repens larvae, with higher values of microfilariae per milliliter in the evening samples. A significant variation was also found at the individual level for the dogs with the highest values of microfilariaemia. All samples which were negative at the light microscopy and positive at the real-time PCR displayed levels of circulating parasite DNA <1 microfilaria per milliliter. Biological and clinical implications have been here discussed.

Is Dirofilaria repens endemic in the Havelland district in Brandenburg, Germany?

In Brandenburg, northeastern Germany, an outbreak of zoonotic Dirofilaria repens in a sledge dog kennel was detected in January, 2012. Using the modified Knott test, 8 out of 28 adult dogs were microfilaria positive. A D. repens-specific PCR based on the internal transcribed spacer 2 region detected filarial DNA in 11 of these dogs. Northeastern Germany is currently considered to be free of Dirofilaria. The 39% prevalence within the kennel and the fact that the dogs transiently stayed in endemic areas only during the winter suggest that autochthonous infections occurred. Analysis of weather data shows that extrinsic development of Dirofilaria was continuously possible in the summers of 1994-2012, thus allowing active transmission within the area.

Treatment of Dirofilaria repens microfilariaemia with a combination of doxycycline hyclate and ivermectin

Dirofilaria repens is one of the most widespread mosquito-borne filarioid responsible for infestations in dogs, usually characterized by nodules and other skin lesions. Additionally, the zoonotic potential of this nematode is of public health concern, given that D. repens has been often associated to human dirofilariosis in the Old World. In the present study, the therapeutic efficacy against D. repens microfilariae of a protocol based on doxycycline hyclate (Ronaxan(®), Merial), 10mg/kg every day for 30 days, and ivermectin (Cardotek 30(®), Merial), 6 μg/kg every 15 days for 6 months, was preliminarily investigated in two naturally infested dogs. Blood samples were collected every 30 days during 6 months of treatment and examined by a Knott's modified test and a duplex real-time PCR. The results here presented indicate that this therapeutic protocol, applied monthly, could be effective for treating microfilariaemia in dogs affected by subcutaneous dirofilariosis.

Qualitative risk assessment for the endemisation of Dirofilaria repens in the state of Brandenburg (Germany) based on temperature-dependent vector competence

Climate change with an increase in average temperature may be responsible for propagation of temperature-dependent vectors and/or vector-associated pathogens in regions that were previously not endemic. The analysis of climate data of Brandenburg state (Germany) had showed that the extrinsic development of Dirofilaria repens, the causative agent of canine subcutaneous dirofilariosis, was possible from the years 2001 to 2012. This finding, associated to the movement of infected dogs and their relocation from endemic European areas to Germany makes possible a rapid endemization of the infection and highlight the risk for human health, being D. repens a frequent cause of zoonotic infections.

Nodular lesions due to infestation by Dirofilaria repens in dogs from Italy

BACKGROUND

Canine subcutaneous dirofilariosis caused by Dirofilaria repens is an important cause of human dirofilariosis in the Old World.

OBJECTIVES

To describe the clinical and pathological features of infestation by D. repens in dogs with cutaneous nodules and to discuss key diagnostic procedures.

ANIMALS

Sixteen privately owned dogs of different breeds, ages and genders with subcutaneous nodules were positive for D. repens on at least one diagnostic test.

METHODS

Diagnostic tests included cytological examination of fine-needle aspiration biopsies, detection of circulating larvae by Knott's test, morphological and molecular identification of adult parasites and microfilariae, and histopathological examination of excised nodules.

RESULTS

Twelve animals were positive for D. repens microfilariae, using cytology and at least one other diagnostic test. Four of twelve dogs screened by Knott's test had circulating D. repens microfilariae, and three of them were co-infected with Dirofilaria immitis. In eight dogs, adult nematodes were morphologically identified as D. repens. Nodular panniculitis was observed in all cases, with nodules containing either one or several cross-sections of nematodes and microfilariae. The nematodes extracted were identified as D. repens by an RT-PCR on the second internal transcribed spacer (ITS-2).

CONCLUSIONS AND CLINICAL IMPORTANCE

Adults and larvae of D. repens can induce skin nodules in dogs, and these lesions should be carefully evaluated in endemic areas. Clinicians should be aware that correct tissue sampling (including the storage of part of a sample in ethanol instead of formalin) is pivotal to achievement of a specific diagnosis. Cytology of fine-needle tissue aspirates was shown to be useful.

Vector-borne helminths of dogs and humans in Europe

Presently, 45% of the total human population of Europe, as well as their domestic and companion animals, are exposed to the risk of vector-borne helminths (VBH) causing diseases. A plethora of intrinsic biological and extrinsic factors affect the relationship among helminths, vectors and animal hosts, in a constantly changing environment. Although canine dirofilarioses by Dirofilaria immitis and Dirofilaria repens are key examples of the success of VBH spreading into non-endemic areas, another example is represented by Thelazia callipaeda eyeworm, an emergent pathogen of dogs, cats and humans in several regions of Europe. The recent finding of Onchocerca lupi causing canine and human infestation in Europe and overseas renders the picture of VBH even more complicated. Similarly, tick-transmitted filarioids of the genus Cercopithifilaria infesting the skin of dogs were recently shown to be widespread in Europe. Although for most of the VBH above there is an increasing accumulation of research data on their distribution at national level, the overall impact of the diseases they cause in dogs and humans is not fully recognised in many aspects. This review investigates the reasons underlying the increasing trend in distribution of VBH in Europe and discusses the diagnostic and control strategies currently available. In addition, this article provides the authors' opinion on some topics related to VBH that would deserve further scientific investigation.

Pseudo-tumor of the scrotum, a rare clinical presentation of dirofilariasis: a report of two autochtonous cases due to Dirofilaria repens

In Europe, human dirofilariasis refers to a group of autochtonous parasitic infections caused by tissue nematodes of the genus Dirofilaria, responsible for two distinct clinical presentations: Dirofilaria immitis usually presenting as pulmonary lesions and Dirofilaria repens as subcutaneous nodules. Rare in humans, genital involvement manifests itself as pseudotumor nodules affecting the scrotum, epididymis, or spermatic cord. We report on two cases of Dirofilaria repens infections, involving the spermatic cord and epididymis.

Human and animal dirofilariasis: the emergence of a zoonotic mosaic

Dirofilariasis represents a zoonotic mosaic, which includes two main filarial species (Dirofilaria immitis and D. repens) that have adapted to canine, feline, and human hosts with distinct biological and clinical implications. At the same time, both D. immitis and D. repens are themselves hosts to symbiotic bacteria of the genus Wolbachia, the study of which has resulted in a profound shift in the understanding of filarial biology, the mechanisms of the pathologies that they produce in their hosts, and issues related to dirofilariasis treatment. Moreover, because dirofilariasis is a vector-borne transmitted disease, their distribution and infection rates have undergone significant modifications influenced by global climate change. Despite advances in our knowledge of D. immitis and D. repens and the pathologies that they inflict on different hosts, there are still many unknown aspects of dirofilariasis. This review is focused on human and animal dirofilariasis, including the basic morphology, biology, protein composition, and metabolism of Dirofilaria species; the climate and human behavioral factors that influence distribution dynamics; the disease pathology; the host-parasite relationship; the mechanisms involved in parasite survival; the immune response and pathogenesis; and the clinical management of human and animal infections.

Molecular xenomonitoring of Dirofilaria immitis and Dirofilaria repens in mosquitoes from north-eastern Italy by real-time PCR coupled with melting curve analysis

Background

Dirofilaria immitis and Dirofilaria repens are transmitted by bloodsucking culicid mosquitoes belonging to Culex, Aedes, Ochlerotatus, Anopheles and Mansonia genera.

The detection of filarioids in mosquitoes for assessing distribution of vectors and/or of pathogens in a given area (also known as “xenomonitoring”), when based on individual dissection of wild-caught female mosquitoes is time consuming and hardly applicable in large epidemiological surveys.

Our study aimed to evaluate the recently developed duplex real-time PCR for screening large number of culicids and to assess their positivity for D. immitis and D. repens in an area where both species are endemic.

Methods

A duplex real-time PCR was used to detect and differentiate D. immitis and D. repens in mosquitoes collected in six provinces of the Veneto region using 43 carbon dioxide-baited traps under the frame of an entomological surveillance program to monitor the vectors of West Nile disease. From early May till October 2010, unfed female mosquitoes (n = 40,892) were captured in 20 selected sites.

Results

Mosquitoes identified as Culex pipiens, Ochlerotatus caspius, Aedes vexans and Culex modestus were grouped into 995 pools according to species, day and site of collection (from minimum of 1 to maximum of 57). Out of 955 pools, 23 (2.41 %) scored positive for Dirofilaria spp. of which, 21 (2.2 %) for D. immitis and two (0.21 %) for D. repens. An overall Estimated Rate of Infection (ERI) of 0.06 % was recorded, being higher in Och. caspius and Ae. vexans (i.e., 0.18 % and 0.14 %, respectively). At least one mosquito pool was positive for Dirofilaria spp. in each province with the highest ERI recorded in Vicenza and Padova provinces (i.e., 0.42% and 0.16 %, respectively). Mosquitoes collected in all provinces were positive for D. immitis whereas, only two (i.e., Padova and Rovigo) provinces scored positive for D. repens. All mosquito species, except for Cx. modestus, were positive for D. immitis, whereas D. repens was only found in Cx. pipiens.

Conclusions

The results suggest that both Dirofilaria species are endemic and may occur in sympatry in the examined area. The molecular approach herein used represents a powerful tool for surveillance programs of D. immitis and D. repens in the culicid vectors towards a better understanding of the epidemiology of the infections they cause and their seasonal transmission patterns.

A multiplex PCR for the simultaneous detection of species of filarioids infesting dogs

The present study reports the applicability of a multiplex PCR for the simultaneous detection and differentiation of common filarioids infecting dogs, i.e., Dirofilaria immitis, Dirofilaria repens, Acanthocheilonema reconditum and Cercopithifilaria sp. Amplicons of different sizes (i.e., 170 bp, 480 bp, 590 bp and 300 bp, respectively) of regions within the mitochondrial cytochrome c oxidase subunit 1 (cox1) gene were amplified on a single-step multiplex PCR using a mix of species-specific forward primers coupled with a single reverse primer. Experiments were carried out by amplifying genomic DNA extracted from blood or skin samples test-positive for microfilariae (mff). The number of mff present in each blood sample was quantified (from 800 to 25,000 mff/ml for A. reconditum and D. repens, respectively) and mixed blood samples were tested for the simultaneous detection of DNA from these mff. Specific amplicons for blood-circulating mff of A. reconditum, D. immitis and D. repens and for those whose adults are localized in skin (i.e., A. reconditum and Cercopithifilaria sp.) were simultaneously detected on agarose gel up to a dilution of 250 mff/ml for D. repens. The specific identity of the amplicons was confirmed by sequencing. The multiplex PCR assay reported herein represents a new tool for the molecular detection and differentiation of canine filarioids in blood and skin samples.