Outbreak of swimmer's itch in Central Italy: Description, causative agent and preventive measures

Molecular identification of Trichobilharzia species in recreational waters in North-Eastern Poland

Background

In Europe, avian schistosomes of the genus Trichobilharzia are the most common etiological agents involved in human cercarial dermatitis (swimmer's itch). Manifested by a skin rash, the condition is caused by an allergic reaction to cercariae of nonhuman schistosomes. Humans are an accidental host in this parasite's life cycle, while water snails are the intermediate, and waterfowl are the final hosts. The study aimed to conduct a molecular and phylogenetic analysis of Trichobilharzia species occurring in recreational waters in North-Eastern Poland.

Methodology

The study area covered three water bodies (Lake Skanda, Lake Ukiel, and Lake Tyrsko) over the summer of 2021. In total, 747 pulmonate freshwater snails (Radix spp., Lymnaea stagnalis) were collected. Each snail was subjected to 1-2 h of light stimulation to induce cercarial expulsion. The phylogenetic analyses of furcocercariae were based on the partial sequence of the ITS region (ITS1, 5.8S rDNA, ITS2 and 28SrDNA). For Radix spp. phylogenetic analyses were based on the ITS-2 region.

Results

The prevalence of the Trichobilharzia species infection in snails was 0.5%. Two out of 478 (0.4%) L. stagnaliswere found to be infected with Trichobilharzia szidati. Moreover, two out of 269 (0.7%) snails of the genus Radix were positive for schistosome cercariae. Both snails were identified as Radix auricularia. One of them was infected with Trichobilharzia franki and the other with Trichobilharzia sp.

Conclusions

Molecular identification of avian schistosome species, both at the intermediate and definitive hosts level, constitutes an important source of information on a potential threat and prognosis of local swimmer's itch occurrence, and helps to determine species diversity in a particular area.

Zoonotic Threats: The (Re)emergence of Cercarial Dermatitis, Its Dynamics, and Impact in Europe

Cercarial dermatitis (CD), or "Swimmer's itch" as it is also known, is a waterborne illness caused by a blood fluke from the family Schistosomatidae. It occurs when cercariae of trematode species that do not have humans as their definitive host accidentally penetrate human skin (in an aquatic environment) and trigger allergic symptoms at the site of contact. It is an emerging zoonosis that occurs through water and is often overlooked during differential diagnosis. Some of the factors contributing to the emergence of diseases like CD are related to global warming, which brings about climate change, water eutrophication, the colonization of ponds by snails susceptible to the parasite, and sunlight exposure in the summer, associated with migratory bird routes. Therefore, with the increase in tourism, especially at fluvial beaches, it is relevant to analyze the current epidemiological scenario of CD in European countries and the potential regions at risk.

Expanding the swimmer's itch pool of the Benelux: a first record of the neurotropic Trichobilharzia regenti and potential link to human infection

BACKGROUND

Swimmer's itch, an allergic contact dermatitis caused by avian and mammalian blood flukes, is a parasitic infection affecting people worldwide. In particular, avian blood flukes of the genus Trichobilharzia are infamous for their role in swimmer's itch cases. These parasites infect waterfowl as a final host, but incidental infections by cercariae in humans are frequently reported. Upon accidental infections of humans, parasite larvae will be recognized by the immune system and destroyed, leading to painful itchy skin lesions. However, one species, Trichobilharzia regenti, can escape this response in experimental animals and reach the spinal cord, causing neuroinflammation. In the last few decades, there has been an increase in case reports across Europe, making it an emerging zoonosis.

METHODS

Following a reported case of swimmer's itch in Kampenhout in 2022 (Belgium), the transmission site consisting of a private pond and an adjacent creek was investigated through a malacological and parasitological survey.

RESULTS

Six snail species were collected, including the widespread Ampullaceana balthica, a well-known intermediate host for Trichobilharzia parasites. Shedding experiments followed by DNA barcoding revealed a single snail specimen to be infected with T. regenti, a new species record for Belgium and by extension the Benelux. Moreover, it is the most compelling case to date of the link between this neurotropic parasite and cercarial dermatitis. Additionally, an Echinostomatidae sp. and Notocotylus sp. were isolated from two other specimens of A. balthica. However, the lack of reference DNA sequences for these groups in the online repositories prevented genus- and species-level identification, respectively.

CONCLUSIONS

The presence of T. regenti in Belgium might have severe clinical implications and its finding highlights the need for increased vigilance and diagnostic awareness among medical professionals. The lack of species-level identification of the other two parasite species showcases the barcoding void for trematodes. Overall, these findings demonstrate the need for a Belgian framework to rapidly detect and monitor zoonotic outbreaks of trematode parasites within the One Health context.

A putative new genus of avian schistosome transmitted by Biomphalaria straminea (Gastropoda: Planorbidae) in Brazil, with a discussion on the potential involvement in human cercarial dermatitis

Human cercarial dermatitis (HCD) caused by avian schistosomes is an emerging health issue in different parts of the world. Nevertheless, parasite diversity, life cycle, and involvement in HCD remain poorly known or neglected in South America. Herein, we reported data obtained during a long-term malacological survey carried out in Pampulha Reservoir, an urban eutrophic waterbody from Brazil between 2009 and 2012. An ocellate brevifurcate cercaria emerged from 55 of 16,235 (0.34%) specimens of Biomphalaria straminea. Samples of the cercariae were subjected to morphological, experimental, and molecular study (analysis of partial sequences of nuclear 28S and mitochondrial cox1 genes). The molecular analysis revealed that the larva corresponds to an avian schistosome; however, it does not correspond to any named genus. A close related isolate was previously reported in Biomphalaria sudanica from Kenya (molecular divergences of 0.54% and 9.62% for 28S and cox1, respectively). The morphology of this cercaria was compared with other avian schistosome larvae from Biomphalaria spp. Attempts to infect experimentally ducks (Cairina moschata) and mice revealed cutaneous manifestations after exposure to cercariae, but adult parasites were not obtained in these hosts. Phylogenetic analysis suggests this parasite is a putative new genus and species of avian schistosome. The potential involvement of the larvae herein described in cases of HCD in Brazil cannot be ruled out. Surprisingly, HCD was not reported in the country so far, which can be related to difficulties in its diagnosis in areas of overlap with human schistosomes.

Invaders as Diluents of the Cercarial Dermatitis Etiological Agent

Research on alien and invasive species focuses on the direct effects of invasion on native ecosystems, and the possible positive effects of their presence are most often overlooked. Our aim was to check the suitability of selected alien species (the snail Physa acuta, the bivalve Dreissena polymorpha, and the gammarid Dikerogammarus villosus) as diluents for infectious bird schistosome cercariae—the etiological factor of swimmer’s itch. It has been hypothesized that alien species with different feeding habits (scrapers, filterers and predators) that cohabit the aquatic environment with intermediate hosts of the schistosomatid trematodes are capable of feeding on their free-swimming stages—cercariae. In the laboratory conditions used, all experimental animals diluted the cercariae of bird schistosome. The most effective diluents were P. acuta and D. villosus. However, a wide discrepancy in the dilution of the cercariae between replicates was found for gammarids. The obtained results confirm the hypothesis that increased biodiversity, even when alien species are involved, creates the dilution effect of the free-living stages of parasites. Determining the best diluent for bird schistosome cercariae could greatly assist in the development of current bathing areas protection measures against swimmer’s itch.

Avian schistosome species in Danish freshwater lakes: relation to biotic and abiotic factors

Due to the increased prevalence of human infections with bird schistosome larvae (cercarial dermatitis) associated with bathing in Danish lakes, a nationwide survey of infected intermediate host snails was conducted in 2018-2020. Pulmonate snails (10,225 specimens) were collected from 39 freshwater lakes (in the four major geographic regions in Denmark) and subjected to shedding. Released schistosome cercariae were isolated and identified by polymerase chain reaction and sequencing whereby Trichobilharzia regenti, Trichobilharzia franki, Trichobilharzia szidati and Trichobilharzia anseri were recorded. Infections were primarily determined by biotic factors such as the presence of final host birds and intermediate host snails and water temperature was noted as an important abiotic parameter associated with the infection. No clear connection with other abiotic factors (conductivity, alkalinity, pH, nitrogen, phosphorous) was seen. The widespread occurrence of infected snails, when compared to previous investigations, suggests that climate changes at northern latitudes could be responsible for the increased risk of contracting cercarial dermatitis.

Migratory routes, domesticated birds and cercarial dermatitis: the distribution of Trichobilharzia franki in Northern Iran

Background: One of the major migration routes for birds going between Europe and Asia is the Black Sea-Mediterranean route that converges on the Volga Delta, continuing into the area of the Caspian Sea. Cercarial dermatitis is a disorder in humans caused by schistosome trematodes that use aquatic birds and snails as hosts and is prevalent in areas of aquaculture in Northern Iran. Before the disorder can be addressed, it is necessary to determine the etiological agents and their host species. This study aimed to document whether domestic mallards are reservoir hosts and if so, to characterize the species of schistosomes. Previous work has shown that domestic mallards are reservoir hosts for a nasal schistosome. Results: In 32 of 45 domestic mallards (Anas platyrhynchos domesticus) (71.1%), the schistosome Trichobilharzia franki, previously reported only from Europe, was found in visceral veins. Morphological and molecular phylogenetic analysis confirmed the species designation. These findings extend the range of T. franki from Europe to Eurasia. Conclusion: The occurrence of cercarial dermatitis in Iran is high in areas of aquaculture. Previous studies in the area have shown that domestic mallards are reservoir hosts of T. regenti, a nasal schistosome and T. franki, as shown in this study. The genetic results support the conclusion that populations of T. franki from Iran are not differentiated from populations in Europe. Therefore, the schistosomes are distributed with their migratory duck hosts, maintaining the gene flow across populations with compatible snail hosts in Iran.

Nitric oxide debilitates the neuropathogenic schistosome Trichobilharzia regenti in mice, partly by inhibiting its vital peptidases

Background

Avian schistosomes, the causative agents of human cercarial dermatitis (or swimmer’s itch), die in mammals but the mechanisms responsible for parasite elimination are unknown. Here we examined the role of reactive nitrogen species, nitric oxide (NO) and peroxynitrite, in the immune response of mice experimentally infected with Trichobilharzia regenti, a model species of avian schistosomes remarkable for its neuropathogenicity.

Methods

Inducible NO synthase (iNOS) was localized by immunohistochemistry in the skin and the spinal cord of mice infected by T. regenti. The impact of iNOS inhibition by aminoguanidine on parasite burden and growth was then evaluated in vivo. The vulnerability of T. regenti schistosomula to NO and peroxynitrite was assessed in vitro by viability assays and electron microscopy. Additionally, the effect of NO on the activity of T. regenti peptidases was tested using a fluorogenic substrate.

Results

iNOS was detected around the parasites in the epidermis 8 h post-infection and also in the spinal cord 3 days post-infection (dpi). Inhibition of iNOS resulted in slower parasite growth 3 dpi, but the opposite effect was observed 7 dpi. At the latter time point, moderately increased parasite burden was also noticed in the spinal cord. In vitro, NO did not impair the parasites, but inhibited the activity of T. regenti cathepsins B1.1 and B2, the peptidases essential for parasite migration and digestion. Peroxynitrite severely damaged the surface tegument of the parasites and decreased their viability in vitro, but rather did not participate in parasite clearance in vivo.

Conclusions

Reactive nitrogen species, specifically NO, do not directly kill T. regenti in mice. NO promotes the parasite growth soon after penetration (3 dpi), but prevents it later (7 dpi) when also suspends the parasite migration in the CNS. NO-related disruption of the parasite proteolytic machinery is partly responsible for this effect.

Confirmation of the presence of zoonotic Trichobilharzia franki following a human cercarial dermatitis outbreak in recreational water in Slovakia

Human cercarial dermatitis is a parasitic disease that causes an allergic reaction in the skin (swimmer's itch) as a consequence of contact with cercariae of bird schistosomes present in water, mainly of the genus Trichobilharzia Skrjabin et Zakarow, 1920. The main objective of the study was to confirm the presence of the zoonotic disease agent following reports of human infections in recreational water in Slovakia. We identified two species of freshwater snails at Košice Lake, Radix auricularia (Linnaeus, 1758) and Physa acuta (Draparnaud, 1805). Trematode infections were observed only in R. auricularia. Of the 62 snails collected, 11 (17.7%) were infected with 5 different species of larval stages of trematodes. The blood fluke Trichobilharzia franki was found in 2 (3.2%) of the examined snails. The present record provides the first evidence that T. franki from the pulmonate snail R. auricularia represents a source of human cercarial dermatitis in recreational water in Slovakia. Our finding complements the easternmost records of both swimmer's itch and the confirmed occurrence of a bird schistosome in a waterbody in Europe. The present work suggests that the health risks associated with trichobilharziasis need to be further studied by detailed monitoring of the occurrence of the major causative agent of human cercarial dermatitis, T. franki.