Sarcocystis nesbitti causes acute, relapsing febrile myositis with a high attack rate: description of a large outbreak of muscular sarcocystosis in Pangkor Island, Malaysia, 2012

Sarcocystis sp. shed by the common boa snake (Boa constrictor) in Brazil

The genus Sarcocystis contains around 200 species and 25 of these infect snakes. Two Sarcocystis spp. shed by snakes have called special attention of the scientific community. S. nesbitti, which is shed by scrub pythons (Simalia amethistina), causes myopathy in humans that consume water or food contaminated with the parasite. Sporocysts of S. singaporensis, excreted by reticulated pythons (Malayopython reticulatus), is letal for rats and was successfully tested in the biological control of these rodents. A high biodiversity of snakes is found in Brazil, however, scarce information is available about Sarcocystis spp. in Brazilian snakes. Herein, we investigated Sarcocystis sp. in feces of the common boa (Boa constrictor) from Salvador, as it is widely distributed in Brazil and it is also bred in other countries. Feces of 65 boas were examined, and Sarcocystis sp. was found in 1/65 (1.53%) snakes. All snakes were alive, and for this reason, intestinal scrapping, which is the most sensitive method to detect the parasite, was not performed. Morphometric evaluation of sporocysts showed significant differences in their sizes. PCR and multilocus sequencing of four genetic markers (cox1, 18S, ITS1, and 28S) revealed that sporocysts corresponded to a new Sarcocystis species. Sequences of cox1 and 18S had identities of 100% and higher than 98%, respectively, with sequences obtained from the rodent Lagostomus maximus in Argentina. ITS1 and 28S sequences did not match with any known Sarcocystis sp. No ITS1 and 28S sequences were available for the Sarcocystis sp. found in the Argentinian L.maximus. Bioassay using the boa sporocysts was conducted in three mouse lineages and in Rattus norvegicus, but no parasitic stages were detected in these rodents. We concluded that the common boa is probably the definitive host of a new species of Sarcocystis sp. that has L. maximus or related rodents as intermediate hosts.

Zoonotic parasites associated with predation by dogs and cats

One of the most common behaviors of cats that have an indoor/outdoor lifestyle is to bring hunted "gifts" to their owners, represented by small mammals, reptiles and birds. Access to the outdoors by dogs and cats may represent a problematic issue, since they may be at risk of diseases, traffic accidents and ingestion of toxins. Yet, the impact of this population of roaming dogs and cats predating wildlife is another concerning issue that receives less attention. Despite these risks, most owners still prefer to give outdoor access to their pets to allow them to express their "natural instincts," such as hunting. Therefore, with a growing population of > 470 million dogs and 373 million cats worldwide, predation not only represents a threat to wildlife, but also a door of transmission for parasitic diseases, some of them of zoonotic concern. In this review, the role played by dogs, and especially cats, in the perpetuation of the biological life cycle of zoonotic parasites through the predation of rodents, reptiles and birds is discussed. Feral and domestics dogs and cats have contributed to the population collapse or extinction of > 63 species of reptiles, mammals and birds. Although the ecological impact of predation on wild populations is well documented, the zoonotic risk of transmission of parasitic diseases has not received significant attention. The parasitic diseases associated to predation vary from protozoan agents, such as toxoplasmosis, to cestodes like sparganosis and even nematodes such as toxocariasis. Raising awareness about predation as a risk of zoonotic parasitic infections in dogs and cats will aid to create responsible ownership and proper actions for controlling feral and free-roaming cat and dog populations worldwide.

M. Bulla-Castañeda DMBC, López Buitrago HA, Díaz Anaya AM, Madeira de Carvalho LM, Pulido-Medellín MO. Sarcocystis spp., a parasite with zoonotic potential

Sarcocystosis infection is caused by protozoan cysts of genus Sarcocystis spp. where S. hominis, S. heydorni (bovines) and S. suihominis (porcine) are the most relevant for humans because of their zoonotic potential. S. cruzi, S. suihominis and S. ovicanis represent the most pathogenic species for cattle, pigs and sheep respectively. This infection has a worldwide importance due to its high transmission; besides to represent a zoonosis, it generates great economics losses. The main diagnostic methods for this disease are artificial digestion, PCR, indirect ELISA, and compression analysis. It’s important to highlight few studies on Sarcocystis spp., especially the ones involving the pursuit of effective treatments to control the infection for both humans and animals, however, some studies have reported that treatments such as cotrimoxazole and albendazole with or without prednisone are effective in counteracting symptoms in humans, considering the lack of reports about Sarcocystis spp. prevalence in Colombia.

Clinical signs, treatment, and outcome for California sea lions (Zalophus californianus) with Sarcocystis-associated polyphasic rhabdomyositis

OBJECTIVE

To describe clinical signs, treatment, and outcome for California sea lions (Zalophus californianus) with Sarcocystis-associated polyphasic rhabdomyositis.

ANIMALS

38 free-ranging juvenile to adult California sea lions examined at a rehabilitation center in California between September 2015 and December 2017.

PROCEDURES

Medical records at The Marine Mammal Center were reviewed to identify sea lions in which sarcocystosis had been diagnosed.

RESULTS

Clinical signs were highly variable and associated with polyphasic rhabdomyositis attributed to Sarcocystis neurona infection. Generalized severe muscle wasting, respiratory compromise, and regurgitation secondary to megaesophagus were the most profound clinical findings. Respiratory compromise and megaesophagus were associated with a poor prognosis. Eight of the 38 sea lions were treated and released to the wild, and 2 subsequently restranded and were euthanized. Two additional animals received no targeted treatment and were released. The remaining 28 animals were either euthanized or died during treatment.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that unlike other marine mammals, which typically develop encephalitis, California sea lions with sarcocystosis often have polyphasic rhabdomyositis with highly variable clinical signs and that extensive diagnostic testing may be required to confirm the diagnosis. Treatment with an antiprotozoal drug in combination with corticosteroids may resolve clinical disease, but the prognosis is guarded.

SARCOCYSTOSIS IN A CAPTIVE FLOCK OF THICK-BILLED PARROTS (RHYNCHOPSITTA PACHYRHYNCHA) FROM 2005 TO 2016: MORBIDITY, MORTALITY, DIAGNOSTICS, AND MANAGEMENT STRATEGIES

Sarcocystosis was diagnosed in a captive flock of thick-billed parrots (Rhynchopsitta pachyrhyncha) at the Wildlife Conservation Society's Queens Zoo. Since the index case in 2005, 45% of mortalities in birds over 30 days of age were due to sarcocystosis. Sarcocystis falcatula was repeatedly identified as the causative agent. The disease predominantly affected younger adult parrots. Administration of antiparasitic medications prior to development of respiratory signs prolonged life in infected birds, but disease was fatal until utilization of a three-drug combination (pyrimethamine, trimethoprim-sulfamethoxazole, and ponazuril). This protocol may require in excess of 6 mo of therapy to achieve clinical resolution of active disease. Plasma creatine kinase activity was found to be the most useful test in diagnosing infection and monitoring response to therapy. Polymerase chain reaction (PCR) for apicomplexan organisms on antemortem whole blood, blood smears, or dried blood spots helped confirm suspected cases, but due to the poor sensitivity was sometimes misleading when assessing response to therapy or resolution of clinical disease. Preventive measures, focusing on exclusion and removal of Virginia opossums (Didelphis virginiana) from zoo grounds failed to curtail the occurrence of sarcocystosis in the flock. Other preventative steps, such as modification of feeding stations to exclude potential arthropod paratenic hosts and prophylaxis trials with diclazuril, appeared to successfully mitigate new infections. Given the diagnostic and therapeutic challenges, prevention of exposure to S. falcatula is essential to ex-situ conservation efforts for thick-billed parrots.

Epidemiological and Histopathological Investigation of Sarcocystis spp. in Slaughtered Dromedary Camels (Camelus dromedarius) in Egypt

Sarcocystosis is considered one of the major parasitic diseases with a worldwide distribution. It is caused by the obligatory intracellular protozoan parasites of the genus Sarcocystis. Besides its public health issues, sarcocystosis results in significant economic losses due to its impact on productivity and milk yield. A wide range of final and intermediate hosts have been identified, including mammals, birds, and reptiles; however, few studies have investigated the contribution of camels to maintaining the epidemiological foci of the disease in countries such as Egypt. The present study was conducted to grossly and histopathologically identify the prevalence rate of Sarcocystis spp. in camels (N = 100) from the Aswan Governorate, Egypt. Furthermore, the major risk factors related to the development of sarcocystosis in camels were investigated. Samples from the diaphragm, cardiac muscle, esophagus, and testes of the slaughtered camels were collected. Interestingly, Sarcocystis was detected in 75% of the examined camels. Following the studied variable factors, camels aged 5 years or more were found to be at higher risk, with an infection rate of 87.7% (57 of 65) than those younger than 5 years. The infection rate was 81.4% (57 of 70) in males and 60% (18 of 30) in females. The esophagus was the most affected organ (49%), followed by the diaphragm (26%) and cardiac muscle (17%), whereas none of the testes samples were affected. Taken together, the present study demonstrates the high prevalence of Sarcocystis in the examined camels and suggests the importance of these animals in preserving the epidemiological foci of sarcocystosis in Egypt. Future research should map the circulating strains in Egypt and aim to raise public health awareness about the importance of sarcocystosis and other related zoonotic diseases.

Zoonotic Parasites of Reptiles: A Crawling Threat

Reptiles are reservoirs of a wide range of pathogens, including many protozoa, helminths, pentastomids, and arthropod parasitic species, some of which may be of public health concern. In this review we discuss the zoonotic risks associated with human–reptile interactions. Increased urbanization and introduction of exotic species of reptile may act as drivers for the transmission of zoonotic parasites through the environment. In addition, being a part of human diet, reptiles can be a source of life-threatening parasitoses, such as pentastomiasis or sparganosis. Finally, reptiles kept as pets may represent a risk to owners given the possibility of parasites transmitted by direct contact or fecal contamination. Awareness of reptile-borne zoonotic parasitoses is important to advocate control, prevention, and surveillance of these neglected diseases.

Species of protozoa, helminths, pentastomids, and arthropod vectors exploit reptiles as definitive or paratenic hosts, which may represent a public health concern.

The zoonotic risk is associated with human–reptile interactions and includes environmental contamination, reptile consumption, or keeping reptiles as pets.

Exotic reptile species may introduce new zoonotic parasites in a previously nonendemic region.

Pentastomiasis and sparganosis are life-threatening food-borne parasitoses.

In our households, if precautions are not taken, reptiles may transmit zoonotic parasites by direct contact or fecal contamination.

Trained veterinarians, physicians, and public health officials are important to advocate for proper diagnostics, parasite identification and treatment, as well as for surveillance strategies and food inspection in areas where reptiles are consumed.

Seroprevalence of Sarcocystis falcatula in Two Islands of Malaysia using Recombinant Surface Antigen 4

Sarcocystosis was diagnosed worldwide by serodiagnostic tests utilising the whole parasite, for which the protozoa were maintained in vitro are more costly. In this study, antigenicity of Sarcocystis falcatula recombinant protein (rSfSAG4) was investigated towards the local communities of Pangkor and Tioman Islands and its seroprevalence was surveyed in these islands. A total of 348 human sera were tested using rSfSAG4 by Western blot and ELISA. High prevalence of sarcocystosis was observed in Tioman Island (80.6%) than in Pangkor Island (50.0%) by Western blot. In ELISA, the seroprevalence observed in Tioman Island was 45.9%, whereas in Pangkor Island 63.0%. In other parasitic infections, the prevalence was 34.0% by Western blot and 46.0% by ELISA. In healthy control group, 7% by Western blot and 8% by ELISA showed positivity to rSfSAG4. It is suggested SfSAG4 is a candidate antigen to measure seroprevalence of sarcocystosis.

Are molecular tools clarifying or confusing our understanding of the public health threat from zoonotic enteric protozoa in wildlife?

Emerging infectious diseases are frequently zoonotic, often originating in wildlife, but enteric protozoa are considered relatively minor contributors. Opinions regarding whether pathogenic enteric protozoa may be transmitted between wildlife and humans have been shaped by our investigation tools, and have led to oscillations regarding whether particular species are zoonotic or have host-adapted life cycles. When the only approach for identifying enteric protozoa was morphology, it was assumed that many enteric protozoa colonized multiple hosts and were probably zoonotic. When molecular tools revealed genetic differences in morphologically identical species colonizing humans and other animals, host specificity seemed more likely. Parasites from animals found to be genetically identical - at the few genes investigated - to morphologically indistinguishable parasites from human hosts, were described as having zoonotic potential. More discriminatory molecular tools have now sub-divided some protozoa again. Meanwhile, some infection events indicate that, circumstances permitting, some "host-specific" protozoa, can actually infect various hosts. These repeated changes in our understanding are linked intrinsically to the investigative tools available. Here we review how molecular tools have assisted, or sometimes confused, our understanding of the public health threat from nine enteric protozoa and example wildlife hosts (Balantoides coli - wild boar; Blastocystis sp. - wild rodents; Cryptosporidium spp. - wild fish; Encephalitozoon spp. - wild birds; Entamoeba spp. - non-human primates; Enterocytozoon bieneusi - wild cervids; Giardia duodenalis - red foxes; Sarcocystis nesbitti - snakes; Toxoplasma gondii - bobcats). Molecular tools have provided evidence that some enteric protozoa in wildlife may infect humans, but due to limited discriminatory power, often only the zoonotic potential of the parasite is indicated. Molecular analyses, which should be as discriminatory as possible, are one, but not the only, component of the toolbox for investigating potential public health impacts from pathogenic enteric protozoa in wildlife.

Biocontrol of rats in an urban environment in Southeast Asia using Sarcocystis singaporensis

BACKGROUND

Upon request of the local administration a control campaign targeting commensal rats (Rattus rattus, R. exulans) was conducted in 30 sub-districts (villages) of the World Heritage town Luang Prabang, Northern Laos, using rat bait containing lethal quantities of the parasitic protist Sarcocystis singaporensis. The associated investigations assessed the short-term control efficacy, willingness of residents to co-operate (community approach), and temporal and spatial changes of the urban rat population in response to treatment.

RESULTS

Biological rodent control significantly reduced rodent activity (percentage of positive tracking patches) in the town, from a mean of 25.3% (±12.8% SD) before (January-February) down to 8.0% (±4.4%) after (June) treatment. Reduction of rodent activity relative to three untreated villages was 83%. Similarly, residents observed significantly fewer rats on their properties after the campaign (mean percentage of households (HHs) per village with sightings), whereby reduction of sightings amounted to 57%. There was significant correlation between residents' observation rates and rodent activity. Among 94 rats trapped before and after treatment each, proportions of adult R. exulans and juvenile R. rattus were higher after rodent control, suggesting that a considerable part of the adult house rat population had been removed. Furthermore, a 5% post-campaign incidence of infection suggested that few rats had survived bait uptake.

CONCLUSION

S. singaporensis may be used successfully as tactical biocontrol agent for culling of rats in urban environments. We propose additional components of a long-term rodent management strategy for the town, without which the impact of culling campaigns would be limited. © 2019 Society of Chemical Industry.

Finding Sarcocystis spp. on the Tioman Island: 28S rRNA gene next-generation sequencing reveals nine new Sarcocystis species

The Tioman Island of Malaysia experienced acute muscular sarcocystosis outbreaks from 2011 to 2014. So far, a previous study based on the 18S rRNA gene sequencing has reported S. singaporensis, S. nesbitti and Sarcocystis sp. YLL-2013 in water samples acquired from the island, thus confirming the waterborne nature of this emerging parasitic disease. This study aimed to improve the detection methods for Sarcocystis, in order to have a clearer picture of the true diversity of Sarcocystis species in Tioman. A new primer set (28S R7F-28S R8 Deg R) was designed to amplify the 28S rRNA gene of Sarcocystis. Subsequently, Sarcocystidae was detected in 65.6% (21/32) of water samples and 28% (7/25) of soil samples acquired between 2014 and 2015 from Tioman. Next-generation sequencing (NGS) on 18 of the positive samples was then performed using amplicons generated from the same primer set. This yielded 53 potentially unique Sarcocystidae sequences (290 bp), of which nine of the most abundant, prevalent and unique sequences were named herein. In contrast, NGS of the 18S rRNA gene V9 hypervariable region of 10 selected samples detected only two Sarcocystis species (160 bp). S. mantioni was the most ubiquitous sequence found in this study.

Atypical Presentation of Human Acute Muscular Sarcocystosis: Sarcocystis Nesbitti Confirmed on Molecular Testing

Patient: Male, 51

Final Diagnosis: Acute muscular sarcocystosis

Symptoms: Fever • myalgia

Medication: —

Clinical Procedure: —

Specialty: Infcetious Diseases

Molecular Evidence of Sarcocystis Species Infecting Reptiles in Peninsular Malaysia

BACKGROUND

The genus Sarcocystis consists of intracellular coccidian protozoan parasites with the ability to invade muscle tissue and mature into sarcocysts, causing the zoonotic disease sarcocystosis. These parasites have an obligatory two-host life cycle, which correlates with prey-predator relationship. The distribution and prevalence of Sarcocystis in reptiles remains unclear, despite several previous reports. The aim of this study was to identify the genetic assemblage of the species of Sarcocystis infecting Malaysian snakes and lizards by screening stool samples.

METHODS

Overall, 54 fecal samples of various snake species and four fecal samples of several lizard species in Malaysia were taken within the course of August 2015 to January 2016 from Seremban, Melaka, Tioman Island, Pahang, Klang and Langkawi Wildlife Park located in Malaysia. The samples were examined for Sarcocystis through PCR amplification of the 18S rDNA sequence at the Department of Parasitology, University of Malaya.

RESULTS

Fourteen snake fecal samples were positive via PCR; however, only eight samples (14%) were found positive for Sarcocystis species, whereas four were positive for other genera and the identity of another three samples was unable to be determined. Further phylogenetic analysis of the 18S rDNA sequences revealed that the snakes were infected with either S. singaporensis, S. lacertae, or undefined Sarcocystis species closely related to either S. singaporensis or S. zuoi. Sarcocystis nesbitti infection was not identified in any of the infected snakes.

CONCLUSION

This is the first report of identification of S. lacertae in the black-headed cat snake.

Seroprevalence of sarcocystosis in the local communities of Pangkor and Tioman Islands using recombinant surface antigens 3 (rSAG3) of Sarcocystis falcatula

OBJECTIVE

To investigate the seroprevalence of Sarcocystosis in the local communities of Pangkor and Tioman islands, Malaysia, by using antigenic recombinant surface antigens 2 and 3 from Sarcocystis falcatula (rSfSAG2 and rSfSAG3) as the target proteins via Western blot and ELISA assays.

METHODS

SfSAG2 and SfSAG3 genes were isolated from S. falcatula and expressed in Escherichia coli expression system. A total of 348 serum samples [volunteers from both islands (n = 100), non-Sarcocystis parasitic infections patients (n = 50) and healthy donors (n = 100)] were collected and tested with purified SfSAGs in Western blot and ELISA assays to measure the seroprevalence of human sarcocystosis.

RESULTS

None of the sera in this study reacted with rSfSAG2 by Western blot and ELISA. For rSfSAG3, relatively high prevalence of sarcocystosis was observed in Tioman Island (75.5%) than in Pangkor Island (34%) by Western blot. In ELISA, the different prevalence rate was observed between Tioman Island (43.8%) and Pangkor Island (37%). The prevalence rate in other parasitic infections (amoebiasis, cysticercosis, filariasis, malaria, toxocariasis and toxoplasmosis) was 30% by Western blot and 26% by ELISA. Only 8% (by Western blot) and 10% (by ELISA) of healthy donors showed reactivity towards rSfSAG3.

CONCLUSION

This is the first study reporting a seroprevalence of sarcocystosis in Pangkor and Tioman Islands, Malaysia. The combination of Western blot and ELISA is suitable to be used for serodiagnosis of sarcocystosis. With further evaluations, SfSAG3 can potentially be used to confirm infection, asymptomatic screening, surveillance and epidemiological studies.

Sarcocystis myopathy in a patient with HIV-AIDS

Sarcocystosis is a zoonotic infection that causes intestinal and muscular illnesses in humans. Sarcocystosis was until recently considered rare in humans. To complete their life cycle, Sarcocystis species require both a definitive and an intermediate host. Humans are the definitive host when infected by one of two species: Sarcocystis hominis (from eating undercooked beef) or Sarcocystis suihominis (from eating uncooked pork). Infection with either of these species results in intestinal sarcocystosis, causing a self-limited disease characterized by nausea, abdominal pain, and diarrhea. Humans act as the intermediate host when infected by Sarcocystis nesbitti, resulting in the markedly different clinical picture of muscular sarcocystosis. Most documented cases of muscular sarcocystosis were assumed to be acquired in Malaysia, in addition to other regions of Southeast Asia and India. Published cases of muscular sarcocystosis from the Middle East, Central and South America, and Africa are all rare. Although the clinical presentation of muscular sarcocystosis remains to be fully characterized, fever, myalgia, and headache are among the most common symptoms. Here, we report a patient from sub-Saharan Africa with chronic Sarcocystis myopathy and well-controlled HIV-AIDS.

Examination of Sarcocystis spp. of giant snakes from Australia and Southeast Asia confirms presence of a known pathogen - Sarcocystis nesbitti

We examined Sarcocystis spp. in giant snakes from the Indo-Australian Archipelago and Australia using a combination of morphological (size of sporocyst) and molecular analyses. We amplified by PCR nuclear 18S rDNA from single sporocysts in order to detect mixed infections and unequivocally assign the retrieved sequences to the corresponding parasite stage. Sarcocystis infection was generally high across the study area, with 78 (68%) of 115 examined pythons being infected by one or more Sarcocystis spp. Among 18 randomly chosen, sporocyst-positive samples (11 from Southeast Asia, 7 from Northern Australia) the only Sarcocystis species detected in Southeast Asian snakes was S. singaporensis (in reticulated pythons), which was absent from all Australian samples. We distinguished three different Sarcocystis spp. in the Australian sample set; two were excreted by scrub pythons and one by the spotted python. The sequence of the latter is an undescribed species phylogenetically related to S. lacertae. Of the two Sarcocystis species found in scrub pythons, one showed an 18S rRNA gene sequence similar to S. zamani, which is described from Australia for the first time. The second sequence was identical/similar to that of S. nesbitti, a known human pathogen that was held responsible for outbreaks of disease among tourists in Malaysia. The potential presence of S. nesbitti in Australia challenges the current hypothesis of a snake-primate life cycle, and would have implications for human health in the region. Further molecular and biological characterizations are required to confirm species identity and determine whether or not the Australian isolate has the same zoonotic potential as its Malaysian counterpart. Finally, the absence of S. nesbitti in samples from reticulated pythons (which were reported to be definitive hosts), coupled with our phylogenetic analyses, suggest that alternative snake hosts may be responsible for transmitting this parasite in Malaysia.

Muscular sarcocystosis: an index case in a native Malaysian

A previously healthy 20-year-old man presented with prolonged intermittent low grade fever and cough for 6months. He had bilateral calf pain and lower limb weakness 2days prior to admission. Physical examination revealed multiple enlarged lymph nodes with hepatomegaly. There was bilateral calf tenderness with evidence of proximal myopathy. Full blood picture showed lymphocytosis with reactive lymphocytes and eosinophilia. Creatine kinase and lactate dehydrogenase were markedly elevated. Over 2 weeks of admission, patient was treated symptomatically until the muscle biopsy of right calf revealed eosinophilic myositis with muscular sarcocystosis. He was treated with albendazole and high-dose corticosteroids. Symptoms subsided on reviewed at 2weeks and the dose of corticosteroid was tapered down slowly over a month. Due to poor compliance, he was readmitted 1month later because of relapsed. High-dose corticosteroid was restarted and duration for albendazole was prolonged for 1month. His symptom finally resolved over 2weeks.

Sarcocystis fayeri in skeletal muscle of horses with neuromuscular disease

Recent reports of Sarcocystis fayeri-induced toxicity in people consuming horse meat warrant investigation on the prevalence and molecular characterization of Sarcocystis spp. infection in horses. Sarcocysts in skeletal muscle of horses have been commonly regarded as an incidental finding. In this study, we investigated the prevalence of sarcocysts in skeletal muscle of horses with neuromuscular disease. Our findings indicated that S. fayeri infection was common in young mature horses with neuromuscular disease and could be associated with myopathic and neurogenic processes. The number of infected muscles and number of sarcocysts per muscle were significantly higher in diseased than in control horses. S. fayeri was predominantly found in low oxidative highly glycolytic myofibers. This pathogen had a high glycolytic metabolism. Common clinical signs of disease included muscle atrophy, weakness with or without apparent muscle pain, gait deficits, and dysphagia in horses with involvement of the tongue and esophagus. Horses with myositis were lethargic, apparently painful, stiff, and reluctant to move. Similar to humans, sarcocystosis and cardiomyopathy can occur in horses. This study did not establish causality but supported a possible association (8.9% of cases) with disease. The assumption of Sarcocysts spp. being an incidental finding in every case might be inaccurate.

Human Extraintestinal Sarcocystosis: What We Know, and What We don't Know

There are over 150 known Sarcocystis species, and at least one is capable of infecting and causing disease in man. Extraintestinal (muscular) sarcocystosis and intestinal sarcocystosis are the two known manifestations of disease in humans. In this series of six cases and review, we focus on the invasive extraintestinal (“muscular”) form of sarcocystosis in humans. This disease, which until recently was rarely described, has become relevant particularly as an imported condition in travelers due to a recent series of outbreaks reported from Malaysia. Human intestinal sarcocystosis is ubiquitous across the globe. However, absolute numbers of probable and particularly confirmed cases are few, with only several hundred described to date. Characteristically, patients exhibit signs and symptoms either 1–2 weeks after exposure, or after 4–8 weeks. Whether people remain asymptomatic or develop disease apparently depends on the infecting species, host factors, and the inoculum size. The definitive host(s) remain uncertain, and identification of the animal reservoir(s) requires further research. A better understanding of the epidemiology of the disease, as well as its immunological determinants, is hampered by the lack of reliable serological diagnostic methods. Additionally, DNA seems to be contained very effectively within the encysted parasite, thereby rendering PCR detection unreliable. Physicians should suspect the condition in patients with suggestive symptoms and a possible history of exposure. Surveillance networks for imported infectious diseases are formidable tools to help detect and localize outbreaks.

Eosinophilia in Rheumatologic/Vascular Disorders

Peripheral and tissue eosinophilia can be a prominent feature of several unique rheumatologic and vascular diseases. These diseases span a wide range of clinical features, histologic findings, therapeutic approaches, and outcomes. Despite the rare nature of these entities--which makes large-scale studies challenging--knowledge has continued to grow regarding their epidemiology, pathophysiology, and management. This review compares and contrasts 5 rheumatologic and vascular conditions in which eosinophilia can be seen: eosinophilic granulomatosis with polyangiitis (Churg-Strauss), immunoglobulin G4-related disease, diffuse fasciitis with eosinophilia, eosinophilia-myalgia syndrome, and eosinophilic myositis.

Human Invasive Muscular Sarcocystosis Induces Th2 Cytokine Polarization and Biphasic Cytokine Changes, Based on an Investigation among Travelers Returning from Tioman Island, Malaysia

Sarcocystis nesbitti is a parasite responsible for a biphasic eosinophilic febrile myositis syndrome in two recent outbreaks in Malaysia. We demonstrate Th2 cytokine polarization in infected travelers, an overall cytokine production decrease in the early phase of the disease suggestive of initial immunosuppression, and elevated levels of proinflammatory and chemotactic cytokines in the later myositic phase.

Human infections with Sarcocystis species

Recurrent outbreaks of muscular sarcocystosis among tourists visiting islands in Malaysia have focused international attention on sarcocystosis, a disease once considered rare in humans. Sarcocystis species require two hosts, definitive and intermediate, to complete their life cycle. Humans can serve as definitive hosts, with intestinal sarcocystosis for two species acquired from eating undercooked meat: Sarcocystis hominis, from beef, and Sarcocystis suihominis, from pork. Symptoms such as nausea, stomachache, and diarrhea vary widely depending on the number of cysts ingested but appear more severe with pork than with beef. Humans serve as intermediate hosts for Sarcocystis nesbitti, a species with a reptilian definitive host, and possibly other unidentified species, acquired by ingesting sporocysts from feces-contaminated food or water and the environment; infections have an early phase of development in vascular endothelium, with illness that is difficult to diagnose; clinical signs include fever, headache, and myalgia. Subsequent development of intramuscular cysts is characterized by myositis. Presumptive diagnosis based on travel history to tropical regions, elevated serum enzyme levels, and eosinophilia is confirmed by finding sarcocysts in muscle biopsy specimens. There is no vaccine or confirmed effective antiparasitic drug for muscular sarcocystosis, but anti-inflammatory drugs may reduce symptoms. Prevention strategies are also discussed.