A retrospective study of ehrlichiosis in 62 dogs from North Carolina and Virginia

Prevalence, genetic, and biochemical evaluation of immune response of police dogs infected with Babesia vogeli

Background and Aim:

Babesia species are tick-borne protozoan parasites of apicomplexan type which infect the erythrocytes of dogs it ranges from subclinical to severe cases, depending on different factors such as immune status, age, and presence of other co-infections with the Babesia species. Hence, this study aimed to identify the protozoan parasites infecting police dogs of different breeds, ages, and both sexes in Egypt. Concerning molecular detection of Babesia vogeli using conventional polymerase chain reaction sequencing and phylogenetic analysis, followed by the assessment of immunological and biochemical status of infected dogs.

Materials and Methods:

The blood of 242 police K9 dogs was collected. The age, breed, sex, and health status with clinical signs of dogs were recorded. Hematological, biochemical, and oxidative stress analyses of the blood were performed together with gene expression analysis using two genes (gamma interferon [IFN-γ] and tumor necrosis factor-alpha [TNF-α]). The identification of the causative agent was performed using molecular analysis of the 18S ribosomal RNA (rRNA). The 18S rRNA region of canine Babesia spp. was successfully amplified, and sequencing data were deposited in GenBank (accession number: MT565474.1), which resembled those of B. vogeli.

Results:

The results of blood samples screening revealed that of the 242 blood samples, 62 were positive for B. vogeli infection. The infection rate in male dogs was higher than that in female dogs. The police dogs were classified into the following three groups of dogs: (1^st group) healthy, (2^nd infected with B. vogeli, and mixed infection of B. vogeli and Ehrlichia canis). The oxidative stress biomarkers levels in B. vogeli infected dogs were greater than that of healthy dogs. Likewise, IFN-γ and TNF-α level in B. vogeli infected dogs were elevated in infected dogs.

Conclusion:

Our findings demonstrated that B. vogeli had completely adverse effects on the health condition of the police dogs that may lead to death in some dogs.

Demonstrating the presence of Ehrlichia canis DNA from different tissues of dogs with suspected subclinical ehrlichiosis

Background

Nowadays, Ehrlichia canis receives increasing attention because of its great morbidity and mortality in animals. Dogs in the subclinical and chronic phases can be asymptomatic, and serological tests show cross-reactivity and fail to differentiate between current and past infections. Moreover, there could be low parasitaemia, and E. canis might be found only in target organs, hence causing results to be negative by polymerase chain reaction (PCR) on blood samples.

Methods

We evaluated by PCR the prevalence of E. canis in blood, liver, spleen, lymph node and bone marrow samples of 59 recently euthanised dogs that had ticks but were clinically healthy.

Results

In total, 52.55% of the blood PCRs for E. canis were negative, yet 61.30% yielded positive results from tissue biopsies and were as follows: 63.15% from bone marrow; 52.63% from liver; 47.36% from spleen; and 15.78% from lymph node. In addition, 33% had infection in three tissues (spleen, liver and bone marrow).

Conclusions

Our results show the prevalence of E. canis from tissues of dogs that were negative by blood PCR. Ehrlichia canis DNA in tissue was 30% lower in dogs that tested negative in PCR of blood samples compared to those that were positive. However, it must be taken into account that some dogs with negative results were positive for E. canis in other tissues.

Evaluation of heart rate variability and behavior of electrocardiographic parameters in dogs affected by chronic Monocytic Ehrlichiosis

Canine Monocytic Ehrlichiosis (CME) is a systemic disease prevalent in the entire world caused by the obligate intracellular bacteria Ehrlichia canis. The occurrence of myocarditis with a high prevalence of arrhythmias in dogs affected by this disease in the cytopenic phase has already been proven. This study aims to evaluate the concentrations of CK MB, cTnI and NT-proBNP in dogs affected by Ehrlichia canis in the chronic phase since the intense stimulation of the immune system can lead to myocarditis; to evaluate if the condition can lead to arrhythmic events and, if so, define their frequency and classification through conventional and ambulatory electrocardiogram tests (Holter method) for a period of 24 hours; to analyze heart rate variability in the time domain and whether the condition can lead to autonomic imbalance; and to determine the survival rate of affected dogs, identifying possible risk factors for mortality at this stage of the disease. For this purposes, we evaluated clinical, hematological and biochemical data, as well as the concentrations of cardiac biomarkers Creatine Kinase-MB (CK MB), Cardiac Troponin I (cTnI) and N-terminal pro-peptide natriuretic type B (NT-proBNP). We also analyzed conventional and ambulatory electrocardiography (24-hour Holter) and heart rate variability (HRV) in 20 dogs afflicted by cytopenic CME in the chronic phase of the disease (G1) and compared the results with a control group comprised of ten healthy dogs (G2). G1 was monitored during the treatment for 28 days, during which eight (8) of the 20 infected dogs died (40%). Anorexia, vomiting, fatigue, hypoalbuminemia, heart murmurs and increased concentrations of alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were common clinical signs. The mean concentrations of cTnI and CKMB were significant (0.24 ng / mL ± 0.5, 229 ± 205 IU / mL) in comparison to the control group (0.042 ± 0.07 ng / mL, 126 ± 46.12 IU / mL). No significant differences were observed between NT-proBNP concentrations in G1 (135.46 ± 29.7) and G2 (138.28 ± 19.77). Nine of the twenty dogs (45%) presented a high frequency of arrhythmias during 24-hour recording, ranging from first and second-degree atrioventricular block, ventricular and supraventricular ectopic events and sinus tachycardia. No sinus pause was observed. One dog had 120 episodes of unsustained ventricular tachycardia and two episodes of sustained ventricular tachycardia. The short-term and long-term HRV data, represented by SDNN (ms), SDANN (ms) and pnn50 (%) were also significant lower (83 ± 65, 56.05 ± 37.3 and 14.56 ± 20, respectively) in comparison to the healthy animals (268 ± 74.6, 168.3 ± 39.14 and 55.87 ± 12.8, respectively). These results suggest that cytopenic CME is characterized by an arrhythmogenic component and intense stimulation of the sympathetic autonomic nervous system in the heart, reflecting an imbalance in the activity of the ANS.

ACVIM consensus statement on the diagnosis and treatment of chronic hepatitis in dogs

This consensus statement on chronic hepatitis (CH) in dogs is based on the expert opinion of 7 specialists with extensive experience in diagnosing, treating, and conducting clinical research in hepatology in dogs. It was generated from expert opinion and information gathered from searching of PubMed for manuscripts on CH, the Veterinary Information Network for abstracts and conference proceeding from annual meetings of the American College of Veterinary Medicine and the European College of Veterinary Medicine, and selected manuscripts from the human literature on CH. The panel recognizes that the diagnosis and treatment of CH in the dog is a complex process that requires integration of clinical presentation with clinical pathology, diagnostic imaging, and hepatic biopsy. Essential to this process is an index of suspicion for CH, knowledge of how to best collect tissue samples, access to a pathologist with experience in assessing hepatic histopathology, knowledge of reasonable medical interventions, and a strategy for monitoring treatment response and complications.

Clinicopathological findings in 41 dogs (2008-2018) naturally infected with Ehrlichia ewingii

Background

Ehrlichia ewingii is the most seroprevalent Ehrlichia‐infecting dogs in the southern and mid‐western United States. Fever, lameness, and polyarthritis are commonly reported findings in dogs naturally infected with E. ewingii.

Objectives

To evaluate clinicopathologic findings in a population of dogs naturally infected with E. ewingii.

Animals

Forty‐one dogs PCR positive for E. ewingii and PCR negative for other targeted vector‐borne organisms.

Methods

Retrospective study. Clinical and clinicopathologic data including physical examination findings, CBC, serum biochemistry, urinalysis (UA), symmetric dimethylarginine (SDMA), and vector‐borne disease diagnostic results were reviewed.

Results

Frequent clinical diagnoses other than ehrlichiosis (28/41; 68.3%) were renal disease (7/41; 17.1%) and immune‐mediated hemolytic anemia (IMHA) (6/41; 14.6%). The most frequent physical examination finding was joint pain (14/41; 34.1%). Prominent hematologic and biochemical abnormalities included abnormal lymphocyte counts (22/36; 61.1%); neutrophilia (21/37; 56.8%); increased alkaline phosphatase (20/35; 57.1%) and alanine transaminase (14/35; 40%) activities; and increased SDMA concentration (11/34; 32.4%). Urinalysis abnormalities included proteinuria (20/27; 74%), most with inactive sediments (16/20; 80%). Dogs were seroreactive by Ehrlichia canis immunofluorescence assay (IFA; 17/39; 43.6%) and Ehrlichia ELISA (34/41; 82.9%). Seroreactivity by IFA for other vector‐borne pathogens included Bartonella (1/39; 2.6%), Rickettsia rickettsii (spotted‐fever group rickettsiae) (12/39; 30.8%), and Borrelia burgdorferi by ELISA (1/41; 2.4%).

Conclusions and Clinical Importance

Renal disease, IMHA, proteinuria, neutrophilia, abnormal lymphocytes, and increased liver enzyme activities were common in this group of E. ewingii‐infected dogs. Studies are needed to determine if E. ewingii contributes to comorbidities or is a precipitating factor in clinical syndromes in persistently infected dogs.

Molecular prevalence and haemato-biochemical profile of canine monocytic ehrlichiosis in dogs in and around Hisar, Haryana, India

The present study was planned to investigate the molecular prevalence of canine monocytic ehrlichiosis (CME) in dogs in and around Hisar and to evaluate the haemato-biochemical profile for its better management. A total of 60 dogs presented to Medicine Section, TVCC, LUVAS, Hisar with the history of naturally acquired tick infestation and clinical signs consistent with CME were screened on the basis of blood smear examination, followed by molecular detection by nested PCR assay targeting a portion of 16S rRNA gene of Ehrlichia canis. Nested PCR detected 18 cases positive for E. canis with estimated 30% percent positivity as compared to 8.33% (5 out of 60) by blood smear examination. These 18 dogs confirmed for CME by nested PCR were assessed for clinical and haemato-biochemical profile. Breed-wise prevalence indicated maximum number of cases in Labrador retriever, followed by Pug, Rottweiler and German shepherd dog with more number of cases in male dogs. Age-wise prevalence revealed highest number of cases in more than 1 year age group, followed by 6 months to 1 year age group and least in less than 6 months aged dogs. Pyrexia, anorexia and pale to congested mucous membranes were the main clinical signs observed, followed by lethargy, vomiting. Less common clinical signs were epistaxis, lymphadenomegaly, hind limb weakness, malena, ocular discharge, followed by haematuria, corneal opacity, nasal discharge and coughing, icterus, dermal petechiae and ecchymoses. The haematological profile revealed macrocytic hypochromic anaemia, thrombocytopenia, normal leucocyte count with relative lymphocytosis, monocytosis and neutropenia. Serum biochemistry revealed significant rise in values of ALT, AST, GGT, bilirubin total, bilirubin indirect, alkaline phosphatase and A/G ratio in affected dogs as compared to healthy control, suggesting the hepatic dysfunction. The lipid metabolites and kidney function parameters were non-significantly altered from those of healthy control. A high positivity for E. canis detected by nested PCR in dogs in and around Hisar suggests the endemicity of the disease in dogs' population in this region and warrants the screening for the disease in suspected dogs by this technique as compared to routine blood smear examination. The presented haemato-biochemical profile may be useful in presumptive diagnosis of the disease in dogs and their better clinical management.

Ehrlichioses: An Important One Health Opportunity

Ehrlichioses are caused by obligately intracellular bacteria that are maintained subclinically in a persistently infected vertebrate host and a tick vector. The most severe life-threatening illnesses, such as human monocytotropic ehrlichiosis and heartwater, occur in incidental hosts. Ehrlichia have a developmental cycle involving an infectious, nonreplicating, dense core cell and a noninfectious, replicating reticulate cell. Ehrlichiae secrete proteins that bind to host cytoplasmic proteins and nuclear chromatin, manipulating the host cell environment to their advantage. Severe disease in immunocompetent hosts is mediated in large part by immunologic and inflammatory mechanisms, including overproduction of tumor necrosis factor α (TNF-α), which is produced by CD8 T lymphocytes, and interleukin-10 (IL-10). Immune components that contribute to control of ehrlichial infection include CD4 and CD8 T cells, natural killer (NK) cells, interferon-γ (IFN-γ), IL-12, and antibodies. Some immune components, such as TNF-α, perforin, and CD8 T cells, play both pathogenic and protective roles. In contrast with the immunocompetent host, which may die with few detectable organisms owing to the overly strong immune response, immunodeficient hosts die with overwhelming infection and large quantities of organisms in the tissues. Vaccine development is challenging because of antigenic diversity of E. ruminantium, the necessity of avoiding an immunopathologic response, and incomplete knowledge of the protective antigens.

Interstitial pneumonia and pulmonary hypertension associated with suspected ehrlichiosis in a dog

Background

In dogs with canine monocytic ehrlichiosis (CME), respiratory signs are uncommon and clinical and radiographic signs of interstitial pneumonia are poorly described. However, in human monocytic ehrlichiosis, respiratory signs are common and signs of interstitial pneumonia are well known. Pulmonary hypertension (PH) is classified based on the underlying disease and its treatment is aimed at reducing the clinical signs and, if possible, addressing the primary disease process. PH is often irreversible, but can be reversible if it is secondary to a treatable underlying etiology. CME is currently not generally recognized as one of the possible diseases leading to interstitial pneumonia and secondary PH in dogs. Only one case of PH associated with CME has been reported worldwide.

Case presentation

A seven-year-old, male intact, mixed breed dog was presented with 2 weeks history of lethargy and dyspnea. The dog previously lived in the Cape Verdean islands. Physical examination showed signs of right-sided congestive heart failure and poor peripheral perfusion. Thoracic radiography showed moderate right-sided cardiomegaly with dilation of the main pulmonary artery and a mild diffuse interstitial lung pattern with peribronchial cuffing. Echocardiography showed severe pulmonary hypertension with an estimated pressure gradient of 136 mm Hg. On arterial blood gas analysis, severe hypoxemia was found and complete blood count revealed moderate regenerative anemia and severe thrombocytopenia. A severe gamma hyperglobulinemia was also documented. Serology for Ehrlichia canis was highly positive. Treatment with oxygen supplementation, a typed packed red blood cell transfusion and medical therapy with doxycycline, pimobendan and sildenafil was initiated and the dog improved clinically. Approximately 2 weeks later, there was complete resolution of all clinical signs and marked improvement of the PH.

Conclusion

This report illustrates that CME might be associated with significant pulmonary disease and should be considered as a possible differential diagnosis in dogs presenting with dyspnea and secondary pulmonary hypertension, especially in dogs that have been in endemic areas. This is important because CME is a treatable disease and its secondary lung and cardiac manifestations may be completely reversible.

Hyphema: Considerations in the Small Animal Patient

Classification, diagnosis, and treatment of hemorrhage into the anterior chamber of the eye, or hyphema, can be a challenging and frustrating process for many practitioners, especially in emergency situations. This review outlines an inclusive list of causes, diagnostics, and treatments for traumatic and nontraumatic hyphema in both canine and feline patients. The review is tailored to small animal practitioners, especially in emergency practice, and is designed to provide concise but thorough descriptions on investigating underlying causes of hyphema and treating accordingly.

The immunopathology of canine vector-borne diseases

The canine vector-borne infectious diseases (CVBDs) are an emerging problem in veterinary medicine and the zoonotic potential of many of these agents is a significant consideration for human health. The successful diagnosis, treatment and prevention of these infections is dependent upon firm understanding of the underlying immunopathology of the diseases in which there are unique tripartite interactions between the microorganism, the vector and the host immune system. Although significant advances have been made in the areas of molecular speciation and the epidemiology of these infections and their vectors, basic knowledge of the pathology and immunology of the diseases has lagged behind. This review summarizes recent studies of the pathology and host immune response in the major CVBDs (leishmaniosis, babesiosis, ehrlichiosis, hepatozoonosis, anaplasmosis, bartonellosis and borreliosis). The ultimate application of such immunological investigation is the development of effective vaccines. The current commercially available vaccines for canine leishmaniosis, babesiosis and borreliosis are reviewed.

Ocular manifestations of natural canine monocytic ehrlichiosis (Ehrlichia canis): a retrospective study of 90 cases

OBJECTIVE

To investigate the spectrum, prevalence and treatment response rate of ocular manifestations associated with natural canine monocytic ehrlichiosis (CME) due to Ehrlichia canis.

METHODS

The medical records of 90 dogs that were admitted for primary ocular problems and reacted positive for E. canis serum antibodies were reviewed. All the dogs were treated with oral doxycycline. In 79 dogs, a combination of systemic corticosteroids and/or topical anti-inflammatory, mydriatics/cycloplegics and antibacterial agents were applied.

RESULTS

The dogs ranged from 0.5 to 15 years in age; 55 were male and 35 female. A total of 19 breeds were represented. In the majority of dogs, ocular abnormalities were noticed in conjunction with other CME-induced clinical signs. In 30/90 dogs, ophthalmic signs were the sole presenting complaint. Unilateral (22/90, 24.5%) and bilateral (68/90, 75.5%) uveitis was the most common ophthalmic diagnosis and was classified as anterior, posterior or panuveitis in 58 (64.5%), 8 (8.9%) and 24 (26.6%) of the dogs, respectively. Bilateral uveitis was significantly more common than unilateral uveitis (P < 0.0001), and anterior significantly more common than posterior uveitis (P < 0.0001) or panuveitis (P < 0.0001). In addition, corneal ulceration (12/90, 13.3%), necrotic scleritis (10/90, 11.1%), low tear production (8/90, 8.9%) and orbital cellulitis (3/90, 3.3%) were seen. Of the 45 (50%) dogs with a satisfactory follow-up, 25 (55.5%), 11 (24.5%), and 9 (20%) showed complete, partial and poor response to treatment, respectively. The number of dogs exhibiting complete resolution of the ocular manifestations was significantly higher than those with partial (P < 0.0001) or poor (P < 0.0001) response.

CONCLUSIONS

CME should be considered a major differential for a wide range of ocular manifestations exhibited by dogs residing in the endemic areas of the disease. Anterior bilateral uveitis appears to be the most prevalent ocular lesion and a favorable outcome to systemic and topical treatment may be expected in the majority of the affected dogs.

Histologic, serologic, and molecular analysis of persistent ehrlichiosis in a murine model

Human monocytotropic ehrlichiosis caused by Ehrlichia chaffeensis was reported in 1987. An animal model to study acute fatal ehrlichiosis in mice that has been developed closely resembles the fatal form of human monocytotropic ehrlichiosis. However, animal models for persistent infection in the genus Ehrlichia in immunocompetent mice have not been characterized. We report the histopathological progression of Ehrlichia muris infection in immunocompetent mice (AKR and C57BL/6 strains) correlated with their antibody response determined by indirect immunofluorescence and Western immunoblotting, and the distribution and quantity of the ehrlichial load by immunohistochemistry, polymerase chain reaction (PCR), and real-time PCR in lungs, liver, and spleen. Mild to moderate correlation was observed between histopathological grading in these organs and relative ehrlichial loads. The highest ehrlichial loads were present between days 4 and 14 after infection. E. muris was detected in tissues examined up to 150 days after infection by real-time PCR. Analysis of the serological response revealed several immunodominant antigens, including 200-, 180-, 100-, 73/75-, 45-, and 28-kd proteins. In conclusion, we have provided for the first time a complete histopathological, serological, immunohistochemical, and quantitative analysis of an animal model for the study of persistent ehrlichial infection.

Comparison of results for serologic testing and a polymerase chain reaction assay to determine the prevalence of stray dogs in eastern Tennessee seropositive to Ehrlichia canis

OBJECTIVE

To determine the prevalence of stray dogs in eastern Tennessee seropositive to Ehrlichia canis and examine the correlation between results for an ELISA, indirect immunofluorescent antibody (IFA) test, and polymerase chain reaction (PCR) assay.

SAMPLE POPULATION

Blood samples obtained from 90 adult dogs admitted to an animal shelter in eastern Tennessee.

PROCEDURE

Serum samples were analyzed for antibodies against E. canis by use of a commercially available ELISA kit, 2 IFA tests, and a PCR assay; testing was performed at the University of Tennessee (TN) and North Carolina State University (NCSU). The PCR amplification was performed by use of DNA extracted from EDTA-anticoagulated blood and primers designed to amplify DNA of Ehrlichia spp.

RESULTS

Antibodies against E. canis were detected in only 1 dog by use of the ELISA. By IFA testing at TN, 10 of 90 (11%) dogs were seroreactive against E. canis antigens, all of which had medium to high titers to E. canis. Only 5 of the 10 TN seroreactors were also reactive against E. canis antigens in IFA tests conducted at NCSU, and all 5 had low to medium titers. The DNA of Ehrlichia spp was not amplified in any blood samples by use of PCR assays conducted at the TN or NCSU.

CONCLUSIONS AND CLINICAL RELEVANCE

The discordant ELISA, IFA, and PCR results obtained in this study were unexpected and may have been related to exposure of dogs to an Ehrlichia species other than E. canis, such as E. ewingii.

Ehrlichia chaffeensis: a prototypical emerging pathogen

Ehrlichia chaffeensis is an obligately intracellular, tick-transmitted bacterium that is maintained in nature in a cycle involving at least one and perhaps several vertebrate reservoir hosts. The moderate to severe disease caused by E. chaffeensis in humans, first identified in 1986 and reported for more than 1,000 patients through 2000, represents a prototypical "emerging infection." Knowledge of the biology and natural history of E. chaffeensis, and of the epidemiology, clinical features, and laboratory diagnosis of the zoonotic disease it causes (commonly referred to as human monocytic ehrlichiosis [HME]) has expanded considerably in the period since its discovery. In this review, we summarize briefly the current understanding of the microbiology, pathogenesis, and clinical manifestations associated with this pathogen but focus primarily on discussing various ecological factors responsible for the recent recognition of this important and potentially life-threatening tick-borne disease. Perhaps the most pivotal element in the emergence of HME has been the staggering increases in white-tailed deer populations in the eastern United States during the 20th century. This animal serves as a keystone host for all life stages of the principal tick vector (Amblyomma americanum) and is perhaps the most important vertebrate reservoir host for E. chaffeensis. The contributions of other components, including expansion of susceptible human populations, growth and broadening geographical distributions of other potential reservoir species and A. americanum, and improvements in confirmatory diagnostic methods, are also explored.

Recombinant major antigenic protein 2 of Ehrlichia canis: a potential diagnostic tool

The major antigenic protein 2 (MAP2) of Ehrlichia canis was cloned and expressed. The recombinant protein was characterized and tested in an enzyme-linked immunosorbent assay (ELISA) format for potential application in the serodiagnosis of canine monocytic ehrlichiosis. The recombinant protein, which contained a C-terminal polyhistidine tag, had a molecular mass of approximately 26 kDa. The antigen was clearly identified by Western immunoblotting using antihistidine antibody and immune serum from an experimentally infected dog. The recombinant MAP2 (rMAP2) was tested in an ELISA format using 141 serum samples from E. canis immunofluorescent antibody (IFA)-positive and IFA-negative dogs. Fifty-five of the serum samples were from dogs experimentally or naturally infected with E. canis and were previously demonstrated to contain antibodies reactive with E. canis by indirect immunofluorescence assays. The remaining 86 samples, 33 of which were from dogs infected with microorganisms other than E. canis, were seronegative. All of the samples from experimentally infected animals and 36 of the 37 samples from naturally infected animals were found to contain antibodies against rMAP2 of E. canis in the ELISA. Only 3 of 53 IFA-negative samples tested positive on the rMAP2 ELISA. There was 100% agreement among IFA-positive samples from experimentally infected animals, 97.3% agreement among IFA-positive samples from naturally infected animals, and 94.3% agreement among IFA-negative samples, resulting in a 97.2% overall agreement between the two assays. These data suggest that rMAP2 of E. canis could be used as a recombinant test antigen for the serodiagnosis of canine monocytic ehrlichiosis.

Canine monocytic ehrlichiosis presenting as acute blindness 36 months after importation into the UK

A four-year-old Labrador retriever developed sudden-onset blindness, associated with bilateral uveitis, intraocular haemorrhage and retinal detachment. It had been imported into the UK from Sardinia 36 months before presentation. Haematological abnormalities included non-regenerative anaemia, thrombocytopenia and neutropenia. Serum and urine protein electrophoresis demonstrated a monoclonal gammopathy. An immunofluorescent antibody test for Ehrlichia canis was positive, with a titre of 1:320, confirming a diagnosis of chronic monocytic ehrlichiosis. This case highlights how the prolonged subclinical phase of monocytic ehrlichiosis could enable infected dogs to enter the UK without signs of disease. Chronic monocytic ehrlichiosis should be considered in dogs which have been imported from E canis-endemic countries and present with bleeding disorders and gammopathy, even if signs develop many years after importation.