Sarcocystis nesbitti infection in human skeletal muscle: possible transmission from snakes

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.

Molecular detection of Toxoplasma gondii, Neospora caninum and Sarcocystis spp in tissues of Sus scrofa slaughtered in southern Brazil

The aim of this study was to determine the presence of deoxyribonucleic acid (DNA) from Toxoplasma gondii, Sarcocystis spp. and Neospora caninum, in tissues of wild boars slaughtered in southern Brazil. A total of 156 samples were collected from different organs of 25 wild boars, and DNA from at least one of the protozoa investigated was detected in 79 samples. To differentiate between infectious agents, restriction fragment length polymorphism was performed using the restriction enzymes DdeI and HpaII. For N. caninum, conventional PCR was performed with specific primers. The DNA of at least one of the studied pathogens was detected in each animal: 26.58% for T. gondii, 68.36% for Sarcocystis spp. and 5.06% for N. caninum. Coinfection between T. gondii and Sarcocystis spp. occurred in 14 animals, between T. gondii and N. caninum in only one male animal, between Sarcocystis spp. and N. caninum in a female, while co-infection with the three agents was equally observed in only one male animal. Considering the high frequency of detection and its zoonotic risk, especially T. gondii, it appears that wild boars can be potential sources of transmission of infectious agents and the adoption of monitoring measures in these populations should be prioritized.

Sarcocystis moreliae sp. nov. in the imported green tree python Morelia cf. viridis (Reptilia, Pythonidae)

Species of Sarcocystis use various vertebrates as intermediate or definitive hosts in their life cycles. One of these is snakes, whose role as intermediate hosts for these protozoans is scarce; in fact, there are six records, but only three with molecular characterization. An imported green tree python was involved in the morphological and molecular characterization (four loci) of a new species of Sarcocystis localized in skeletal muscles. Sarcocystis moreliae sp. nov. has a type 1 sarcocyst with a smooth wall and is genetically similar (at the 18S rRNA gene) to two unnamed species of Sarcocystis found in Lytorhynchus diadema from Oman and Varanus salvator macromaculatus from Malaysia, but their detailed comparison is impossible. The new species showed lower similarity to its congeners in other loci (28S rRNA, ITS1, and cox1). This is the first morphological and genetic characterization of a Sarcocystis species in snakes of the genus Morelia, particularly M. viridis, using four loci, but more data are needed to fill the knowledge gap about snakes as intermediate hosts of Sarcocystis.

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.

Unusual Site of Oral Sarcocystosis in the Tongue

Sarcocystis is an intracellular protozoan parasite that manifests as a sarcocyst within the muscle fibers of an intermediate host. Sarcocystis commonly affects animals; in fact, cases of sarcocystosis involving human hosts are rare and often undiagnosed. The two types of Sarcocystis species that may infect and utilize humans as a definitive host are S. hominis and S. suihominis, both of which predominantly involve the gastrointestinal system. The low prevalence of intestinal sarcocystosis among humans is rarely accompanied by symptoms, except for individuals who ingest large amounts of the parasite. This study presents an unusual case of tongue sarcocystosis, a site that has not been previously reported, that was treated successfully with oral Albendazole for two weeks.

Molecular Epidemiology, Species Distribution, and Zoonotic Importance of the Neglected Meat-Borne Pathogen Sarcocystis spp. in Cattle (Bos taurus): A Global Systematic Review and Meta-analysis

BACKGROUND

Sarcocystis species are diverse apicomplexan parasites, though only two zoonotic species (S. hominis and S. heydorni) circulate between cattle and humans. Due to the importance of cattle in the human food chain and to prevent the consequences of parasitosis in humans, the first global systematic review and meta-analysis on molecular epidemiology, species distribution, and zoonotic significance of Sarcocystis infection in cattle was performed.

METHODS

For this aim, four international English databases (PubMed, Scopus, Google Scholar, and Web of Science) were systematically searched till 20th September 2021, and random-effect models were drawn to calculate total estimates and their 95% confidence intervals (CIs).

RESULTS

Finally, 44 papers from 21 countries were qualified for this review which examined 8526 cattle regarding Sarcocystis infection, rendering a total prevalence of 62.7% (95% CI 53-71.5%). Globally, 12 Sarcocystis spp. have been reported from cattle, including S. cruzi, S. hominis, S. hirsuta, S. rommeli, S. heydorni, S. bovifelis, S. bovini, S. sinensis, S. gigantea, S. fusiformis, S. hjorti and S. tenella. Among them, S. cruzi (37 studies), S. hominis (22 studies) and S. hirsuta (19 studies) were the 3 most common species, with 76.4% (95% CI 64.8-85%), 30.2% (95% CI 19.3-44%) and 8.7% (95% CI 3.8-18.6%), respectively. However, molecular identification was not performed in 48.4% (95% CI 27.3-70.1%) of the positive samples.

CONCLUSION

Despite the zoonotic significance of Sarcocystis spp., particularly S. hominis, the epidemiology and distribution of Sarcocystis infection in cattle remains unclear and demands more extensive researches around the world.

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.

New Insights into Gastrointestinal and Pulmonary Parasitofauna of Wild Eurasian lynx (Lynx lynx) in the Harz Mountains of Germany

The Eurasian lynx (Lynx lynx) represents an endangered wild felid species. In Germany, it currently occurs in three isolated populations in and around the Harz Mountains, the Palatinate Forest and the Bavarian Forest. Lynx parasitic infections affect animal health and might have an influence on population performance. Therefore, we investigated the protozoan and helminth fauna of free-ranging Eurasian lynx of the Harz population with emphasis on zoonotic parasites. Individual scat samples (n = 24) were collected from wild animals between 2019 and 2021 in the Harz National Park and surrounding areas. In total, 15 taxa of endoparasites were detected, including seven nematodes (i.e., Aelurostrongylus abstrusus, Angiostrongylus spp., Uncinaria stenocephala, Toxascaris leonina, Toxocara cati, Cylicospirura spp. and Capillaria spp.), one cestode (Diphyllobothriidae) and one trematode (Heterophylidae) as well as six protozoans (i.e., Cystoisospora rivolta, Cystoisospora felis, Toxoplasma gondii/Hammondia spp., Sarcocystis spp., Giardia intestinalis and Cryptosporidium spp.). Moreover, first-stage larvae (L1) of spurious lungworm, Protostrongylus pulmonalis, originating from lagomorph preys were identified. This work represents the first report on patent A. abstrusus and Angiostrongylus spp. infections in wild German Eurasian lynxes. Some of the identified parasites represent relevant pathogens for lynxes, circulating between these carnivorous definitive hosts and a variety of mammalian and invertebrate intermediate hosts, e.g., Sarcocystis spp., T. gondii/Hammondia spp., T. cati, T. leonina, A. abstrusus and Angiostrongylus spp., while others are considered exclusively pathogenic for wild felids (e.g., Cylicospirura spp., C. rivolta, C. felis). This study provides insights in the occurrence of zooanthroponotically relevant metazoan (i.e., T. cati and U. stenocephala) and protozoan (i.e., G. intestinalis) species in free-ranging lynx. The present work should be considered as a baseline study for future monitoring surveys on endoparasites circulating in wild Eurasian lynx for appropriate management practices in lynx conservation strategies in Europe.

Zoonotic Sarcocystis

Apicomplexan species in the genus Sarcocystis form tissue cysts, in their intermediate hosts, similar to those established in chronic toxoplasmosis. More than 200 species are known, but just a few are known to threaten human health owing to infection in livestock species. Intestinal sarcocystosis occurs when people consume raw or undercooked beef contaminated with Sarcocystis hominis or S. heydorni or undercooked pork contaminated with S. suihominis. Those infections may cause mild enteritis, but most infections are thought to be asymptomatic. People also become dead-end (intermediate) hosts for non-human Sarcocystis spp. after accidentally ingesting sporocysts, leading to extraintestinal sarcocystosis. The clinical spectrum may range from asymptomatic muscle cysts to a severe, acute, eosinophilic myositis associated with systemic symptoms with peripheral eosinophilia. Most human cases have been described from Southeast Asia, but Sarcocystis parasites have a worldwide distribution, especially where livestock is raised, and human infections in other areas have been described but may be underrecognized.

Infection survey and morphological characteristics of Sarcocystis spp. in naturally infected Tibetan sheep from Qinghai in northwestern China

Sarcocystosis is a parasitic disease caused by intracellular coccidian protozoans that belong to the genus Sarcocystis. These parasites can cause diseases of the nervous system, abortion and economically significant losses in host animals. Previous studies have reported that Sarcocystis is found in mammals, birds and reptiles, while molecular and morphological studies of infected Tibetan sheep have not been performed in the Qinghai region. The aim of this study was to determine the prevalence of Sarcocystis spp. in Tibetan sheep in Qinghai, northwestern China. The results showed that in 1155 samples, sarcocysts from unspecified species were found in 50% (577/1155) of the sheep tissues by microscopy detection. The positive rates of sarcocysts in the diaphragmatic, esophageal and cardiac muscles were 78.4% (175/223), 29.1% (207/711), and 88.2% (195/221), respectively. Ultrastructural features were exclusively observed in Sarcocystis gigantea in the esophageal tissues. The specific architecture was characterized as a space between the two layers of the original capsule wall, which was filled with fiber bundles and tissue fluid. Cauliflower-like protrusions of the original capsule wall were observed toward the outer surface of the capsule. Prominent protrusions contained fibers and matrix. In addition, the Sarcocystis 18S rRNA genes from 6 esophageal tissue samples were cloned, sequenced, and aligned to related sequences from GenBank. All 5 S. gigantea sequences examined in this study were grouped into the same cluster and belonged to the same genotype. The other 5 Sarcocystis tenella sequences were obtained from cardiac muscle and diaphragm muscle and belonged to the same clade. Overall, this study revealed a high infection rate of Sarcocystis in Tibetan sheep in the region. The results of this study may provide a reference for further research investigating the sarcocystosis epidemic in Qinghai, China.

Molecular phylogeny of Sarcocystis fayeri (Apicomplexa: Sarcocystidae) from the domestic horse Equus caballus based on 18S rRNA gene sequences and its prevalence

Sarcocystosis is a parasitic disease caused by an intracellular protozoan parasite Sarcocystis belonging to the phylum Apicomplexa. These parasites have a requisite two-host life cycle. Recently, there are many Sarcocystis species that identified morphologically. In the present study, diaphragmatic muscle samples from the domestic horse (Equus caballus) were examined for Sarcocystis infection. The natural infection with sarcocysts was recorded to be 62·5% for only microcysts in the infected muscles. Molecular analysis using the 18S rRNA gene was conducted to swiftly and accurately identify the recovered species. Studies on the expression of the 18S rRNA gene have confirmed that the present parasite isolates belong to the Sarcocystis genus. The sequence data showed significant identities (>80%) with archived gene sequences from species within the Sarcocystidae family, and a dendrogram showing the phylogenetic relationship was constructed. The most closely related species were the previously described Sarcocystis fayeri and Sarcocystis bertrami. The current data showed that the present species was identified as S. fayeri and deposited in GenBank (accession number MF614956.1). This study highlights the importance of the genetic data in the exact taxonomy within sarcocystid species.

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.

Molecular differentiation of cattle Sarcocystis spp. by multiplex PCR targeting 18S and COI genes following identification of Sarcocystis hominis in human stool samples

Sarcocystis spp. are protozoan parasites which can infect a wide range of vertebrates, including humans; the latter can act as definitive hosts for two cattle Sarcocystis spp.: Sarcocystis hominis and Sarcocystis heydorni. Reports of intestinal sarcocystosis are well documented in the literature, but PCR-based methods have been scarcely used to identify Sarcocystis species in human stools, and have been limited to the molecular analysis of 18S ribosomal RNA (18S rRNA) gene sequences. Since the mitochondrial cytochrome c oxidase subunit I (COI) gene is one of the most promising tools for distinguishing between closely related Sarcocystis spp., and taking into account the lack of publicly available S. hominis COI sequences, in the present study we obtained the first partial COI sequence of S. hominis from human stool samples of patient with gastrointestinal symptoms. We designed specific COI primers to develop a multiplex PCR method for the identification of Sarcocystis spp. in cattle. The submission of the COI sequence described herein and the unambiguous identification of S. hominis through the application of the new multiplex PCR is important for determining the prevalence of this zoonotic Sarcocystis spp. in meat and the risk for consumers.

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.

Genetic diversity of Hepatozoon (Apicomplexa) from domestic cats in South Africa, with a global reassessment of Hepatozoon felis diversity

Genetic diversity within partial 18S rRNA sequences from Hepatozoon protozoan parasites from domestic cats in South Africa was assessed and compared against published data to assess global biogeographic patterns. Multiple distinct haplotypes of Hepatozoon felis were identified, as well as an unrelated Hepatozoon lineage. Hepatozoon felis genetic diversity globally is very high, indicating a likely complex of species. The recently described Hepatozoon apri from wild boars is closely related to some lineages of H. felis. Sarcocystis and Babesia parasites were also detected. Since Hepatozoon felis is apparently a species complex, potential differences between genetically distinct forms need to be assessed. The finding of an unrelated Hepatozoon indicates that felids can be infected by more species of Hepatozoon than currently known, and that trophic interactions may increase the number of Hepatozoon species found in carnivores. Genetic screening again is demonstrated to identify previously unrecognised parasites from vertebrate hosts.

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.

Oxidative stress and hepatic injury induced in mice fed a Sarcocystis hirsuta cyst extract

We studied the toxic effects of a Sarcocystis hirsuta cyst extract fed to mice. Degenerative changes were found in mice gavage-fed fresh, frozen, and heat-treated S. hirsuta cyst extract. There were increases in the levels of serum aspartate aminotransferase and alanine aminotransferase as well as hepatic and brain malondialdehyde (MDA) levels along with concomitant decreases in catalase (CAT) and superoxide dismutase (SOD) activities of mice receiving fresh and frozen S. hirsuta extracts. Gavage feeding of heat-treated S. hirsuta cyst extract had no effects on liver enzymes or brain MDA content, but the liver MDA level did increase. Mice in the heat-treated cyst group showed reduced CAT and SOD activities as well as increased hepatic MDA levels compared to those in the control group. These results indicate that an extract of S. hirsuta cyst can induce oxidative stress and hepatic injury, even after heat treatment.

An update on sarcocystosis in one-humped camels (Camelus dromedarius)

Sarcocystis spp. are intracellular coccidian parasites which infect domestic and wild animals and birds, resulting in considerable economic losses in production animals, and public health concerns worldwide. Sarcocystis spp. have an indirect life cycle where wild and/or domestic canine species primarily serve as definitive hosts and several domestic and wild animals (such as camels) act as intermediate hosts. In Northern Africa, the Middle East, Central Asia and China, camel meat is preferred due to cultural and religious traditions as well as its lower cholesterol/fat content than other red meat. However, camel meat quality could be downgraded by the presence of sarcocysts. To date, two Sarcocystis spp. have been reported from camels, including Sarcocystis ippeni (forms microscopic sarcocysts) and Sarcocystis cameli (forms both macroscopic and microscopic sarcocysts). Sarcocystosis is usually asymptomatic, though significant pathogenic effects have also been reported in camels. Despite the high occurrence of sarcocystosis in camels, little is known about various aspects of the disease in these animals. This paper provides a comprehensive review of the existing knowledge on the taxonomy, pathogenesis, epidemiology and diagnosis of Sarcocystis spp. infecting camels and it also highlights areas for further research that could enhance our understanding about sarcocystosis in camels.

Sarcocystosis in South American camelids: The state of play revisited

Members of the genus Sarcocystis (Apicomplexa: Sarcocystidae) are intracellular protozoan parasites that infect a wide range of domestic and wild animals, resulting in economic losses in production animals worldwide. Sarcocystis spp. have indirect life-cycles where canids and felids serve as main definitive hosts while a range of domestic and wild animals serve as intermediate hosts, including South American camelids (SACs) such as alpacas, llamas and guanacos. These animals primarily occur in South American countries on Andean, elevated plains but in recent years, alpacas and llamas have become emerging animal industries in other parts of the world such as Australia, Europe and the USA due to their high-quality fiber, meat and hides. For instance, alpaca meat is becoming popular in many parts of the world due to its lower cholesterol content than other red meat, thereby it has the potential of a valuable product for both local and international markets. However, SAC meat can be degraded and/or even condemned due to the presence of macroscopic sarcocysts in skeletal muscles, leading to significant economic losses to farmers. The infection is generally asymptomatic, though highly pathogenic or even fatal Sarcocystis infections have also been reported in alpacas and llamas. Despite the economic importance of sarcocystosis in SACs, little is known about the life-cycle of parasites involved, disease transmission, epidemiology, pathogenesis, diagnosis, control and public health significance. This review article provides an in-depth analysis of the existing knowledge on the taxonomy, epidemiology, clinicopathology and diagnosis of Sarcocystis in SACs, highlights knowledge gaps and proposes future areas of research that could contribute to our better understanding of sarcocystosis in these animals.

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.

Molecular characterization of the ribosomal DNA unit of Sarcocystis singaporensis, Sarcocystis zamani and Sarcocystis zuoi from rodents in Thailand

Sarcocystis species are heteroxenous cyst-forming coccidian protozoan parasites with a wide host range, including rodents. In this study, Sarcocystis spp. samples were isolated from Bandicota indica, Rattus argentiventer, R. tiomanicus and R. norvegicus across five provinces of Thailand. Two major groups of Sarcocystis cysts were determined in this study: large and small cysts. By sequence comparisons and phylogenetic analyses based on the partial sequences of 28S ribosomal DNA, the large cysts showed the highest identity value (99%) with the S. zamani in GenBank database. While the small cysts could be divided into 2 groups of Sarcocystis: S. singaporensis and presupposed S. zuoi. The further analysis on 18S rDNA supported that the 2 isolates (S2 and B6 no.2) were as identified as S. singaporensis shared a high sequence identity with the S. singaporensis in GenBank database and the unidentified Sarcocystis (4 isolates, i.e., B6 no.10, B6 no.12, B10 no.4 and B10 no.7) showed 96.3–99.5% identity to S. zuoi as well as high distinct identity from others Sarcocystis spp. (≤93%). The result indicated that these four samples should be S. zuoi. In this study, we provided complete sequence of internal transcribed spacer 1 (ITS1), 5.8S rDNA and internal transcribed spacer 2 (ITS2) of these three Sarcocystis species and our new primer set could be useful to study the evolution of Sarcocystis.

A Review of Zoonotic Infection Risks Associated with the Wild Meat Trade in Malaysia

The overhunting of wildlife for food and commercial gain presents a major threat to biodiversity in tropical forests and poses health risks to humans from contact with wild animals. Using a recent survey of wildlife offered at wild meat markets in Malaysia as a basis, we review the literature to determine the potential zoonotic infection risks from hunting, butchering and consuming the species offered. We also determine which taxa potentially host the highest number of pathogens and discuss the significant disease risks from traded wildlife, considering how cultural practices influence zoonotic transmission. We identify 51 zoonotic pathogens (16 viruses, 19 bacteria and 16 parasites) potentially hosted by wildlife and describe the human health risks. The Suidae and the Cervidae families potentially host the highest number of pathogens. We conclude that there are substantial gaps in our knowledge of zoonotic pathogens and recommend performing microbial food safety risk assessments to assess the hazards of wild meat consumption. Overall, there may be considerable zoonotic risks to people involved in the hunting, butchering or consumption of wild meat in Southeast Asia, and these should be considered in public health strategies.

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.

Molecular evidence of Sarcocystis species in captive snakes in Japan

Sarcocystis nesbitti, using snakes as the definitive host, is a causative agent of acute human muscular sarcocystosis in Malaysia. Therefore, it is important to explore the distribution and prevalence of S. nesbitti in snakes. Nevertheless, epizootiological information of S. nesbitti in snakes remains insufficient because few surveys have assessed Sarcocystis infection in snakes in endemic countries. In Japan, snakes are popular exotic pet animals that are imported from overseas, but the degree of Sarcocystis infection in them remains unclear. The possibility exists that muscular sarcocystosis by S. nesbitti occurs in contact with captive snakes in non-endemic countries. For a total of 125 snake faecal samples from 67 snake species collected at animal hospitals, pet shops and a zoo, this study investigated the presence of Sarcocystis using polymerase chain reaction (PCR) for the 18S ribosomal RNA gene (18S rDNA). Four (3.2%) faecal samples were positive by PCR. Phylogenetic analysis of the 18S rDNA sequences obtained from four amplification products revealed one isolate from a beauty snake (Elaphe taeniura), Sarcocystis zuoi, which uses rat snakes as the definitive host. The isolate from a Macklot's python (Liasis mackloti) was closely related with unidentified Sarcocystis sp. from reticulated pythons in Malaysia. The remaining two isolates from tree boas (Corallus spp.) were closely related with Sarcocystis lacertae, Sarcocystis gallotiae and unidentified Sarcocystis sp. from smooth snakes, Tenerife lizards and European shrews, respectively. This report is the first of a study examining the distribution of Sarcocystis species in captive snakes in Japan.

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.

Acute muscular sarcocystosis: an international investigation among ill travelers returning from Tioman Island, Malaysia, 2011-2012

BACKGROUND

Through 2 international traveler-focused surveillance networks (GeoSentinel and TropNet), we identified and investigated a large outbreak of acute muscular sarcocystosis (AMS), a rarely reported zoonosis caused by a protozoan parasite of the genus Sarcocystis, associated with travel to Tioman Island, Malaysia, during 2011-2012.

METHODS

Clinicians reporting patients with suspected AMS to GeoSentinel submitted demographic, clinical, itinerary, and exposure data. We defined a probable case as travel to Tioman Island after 1 March 2011, eosinophilia (>5%), clinical or laboratory-supported myositis, and negative trichinellosis serology. Case confirmation required histologic observation of sarcocysts or isolation of Sarcocystis species DNA from muscle biopsy.

RESULTS

Sixty-eight patients met the case definition (62 probable and 6 confirmed). All but 2 resided in Europe; all were tourists and traveled mostly during the summer months. The most frequent symptoms reported were myalgia (100%), fatigue (91%), fever (82%), headache (59%), and arthralgia (29%); onset clustered during 2 distinct periods: "early" during the second and "late" during the sixth week after departure from the island. Blood eosinophilia and elevated serum creatinine phosphokinase (CPK) levels were observed beginning during the fifth week after departure. Sarcocystis nesbitti DNA was recovered from 1 muscle biopsy.

CONCLUSIONS

Clinicians evaluating travelers returning ill from Malaysia with myalgia, with or without fever, should consider AMS, noting the apparent biphasic aspect of the disease, the later onset of elevated CPK and eosinophilia, and the possibility for relapses. The exact source of infection among travelers to Tioman Island remains unclear but needs to be determined to prevent future illnesses.

Suspected new wave of muscular sarcocystosis in travellers returning from Tioman Island, Malaysia, May 2014

In May 2014, six patients presented in Germany with a Sarcocystis-associated febrile myositis syndrome after returning from Tioman Island, Malaysia. During two earlier waves of infections, in 2011 and 2012, about 100 travellers returning to various European countries from the island were affected. While the first two waves were associated with travel to Tioman Island mostly during the summer months, this current series of infections is associated with travel in early spring, possibly indicating an upcoming new epidemic.

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

Background

From the 17^th to 19^th January 2012, a group of 92 college students and teachers attended a retreat in a hotel located on Pangkor Island, off the west coast of Peninsular Malaysia. Following the onset of symptoms in many participants who presented to our institute, an investigation was undertaken which ultimately identified Sarcocystis nesbitti as the cause of this outbreak.

Methodology/Principal Findings

All retreat participants were identified, and clinical and epidemiological information was obtained via clinical review and self-reported answers to a structured questionnaire. Laboratory, imaging and muscle biopsy results were evaluated and possible sources of exposure, in particular water supply, were investigated. At an average of 9–11 days upon return from the retreat, 89 (97%) of the participants became ill. A vast majority of 94% had fever with 57% of these persons experiencing relapsing fever. Myalgia was present in 91% of patients. Facial swelling from myositis of jaw muscles occurred in 9 (10%) patients. The median duration of symptoms was 17 days (IQR 7 to 30 days; range 3 to 112). Out of 4 muscle biopsies, sarcocysts were identified in 3. S. nesbitti was identified by PCR in 3 of the 4 biopsies including one biopsy without observed sarcocyst. Non-Malaysians had a median duration of symptoms longer than that of Malaysians (27.5 days vs. 14 days, p = 0.001) and were more likely to experience moderate or severe myalgia compared to mild myalgia (83.3% vs. 40.0%, p = 0.002).

Conclusions/Significance

The similarity of the symptoms and clustered time of onset suggests that all affected persons had muscular sarcocystosis. This is the largest human outbreak of sarcocystosis ever reported, with the specific Sarcocystis species identified. The largely non-specific clinical features of this illness suggest that S. nesbitti may be an under diagnosed infection in the tropics.

Sarcocystis species are protozoan organisms that have been associated with disease in animals but less frequently so in humans. Following a retreat on Pangkor Island off Peninsular Malaysia, a number of persons presented to our hospital with prolonged fever and muscle pain that was initially difficult to attribute to a known infectious cause. Investigations, including muscle biopsies and PCR, showed that this outbreak was most likely due to Sarcocystis nesbitti infection. The most common clinical features were fever and myalgia that was relapsing-remitting in more than half the patients. Some patients had visible swelling of muscle groups, including of the face, with magnetic resonance imaging also demonstrating inflammation in these muscles. Herein, we present the clinical and investigation findings in 89 symptomatic persons in the largest reported outbreak of human muscular sarcocystosis to date. Our findings provide insights and suggestions for the most appropriate forms of investigation, treatment and possible source of infection.

Current status of epidemiology and diagnosis of human sarcocystosis

Species of Sarcocystis are Apicomplexan parasites requiring intermediate and definitive hosts to complete their life cycle. Humans are one of many natural host species and may serve as both intermediate and definitive hosts. However, the extent and public health significance of human Sarcocystis infection are incompletely known. In this minireview, we provide an update on the epidemiology and diagnosis of human sarcocystosis and propose some tools that could contribute to a better understanding of the clinical significance and epidemiology of Sarcocystis infections.