Imported human fascioliasis, United Kingdom.
Fascioliasis was defined as a positive Fasciola immunofluorescent antibody test with a screening titer of 1:32 and either compatible clinical or radiologic features consistent with the disease. We obtained clinical and radiologic information from the referring physician. Clinical features of both acute and chronic infection include fever, upper abdominal pain, malaise, eosinophilia, and impaired liver function; therefore, distinguishing between the 2 phases can be difficult. Fifty percent of chronic infection is subclinical (1,2). Compatible radiologic features are capsular enhancement with contrast, hypodense nodular areas, and low-density serpiginous lesions (2). Our analysis comprised 11 cases (Table). Two patients were white British, both of whom had recently traveled to sub-Saharan Africa. Cases from the preceding 10 years diagnosed in our laboratory were all in persons with histories of travel to fascioliasis-endemic areas. Therefore, these cases do not provide firm evidence of indigenous zoonotic transmission within England and Wales.
Nine patients originated from Somalia, Ethiopia, or Yemen. Few cases have previously been reported from this area (3), although Ethiopian migrants have been shown to have an egg positivity of 0.4% on routine screening (4). Patients 5 and 6 had not returned to Africa for >20 years, suggesting that they acquired their infection in Europe. Therefore, a risk factor may exist that is specific to this ethnic group within the United Kingdom.
Six cases were diagnosed at 1 hospital. All 6 patients reported current or past use of locally bought khat, a leaf chewed for its stimulant properties. It is imported fresh to the United Kingdom from Africa and is an ideal environment for the survival of Fasciola cercariae. It is used most commonly by migrants from the Horn of Africa and Yemen and has been reported in association with acute fascioliasis in the United Kingdom (5). Use of imported khat may explain the apparently higher incidence of fascioliasis in this ethnic group residing in the United Kingdom.
Despite the described parallel rise in human and veterinary fascioliasis, none of these cases provide clear evidence that recent human cases resulted from zoonotic transmission within the United Kingdom. Most cases occurred in migrants from the Horn of Africa and Yemen, some of whom may have acquired Fasciola spp. in their country of origin; other cases appear likely to have been acquired in the United Kingdom, possibly due to use of imported khat. Physicians need a heightened awareness of fascioliasis when investigating impaired liver function or abnormal abdominal imaging in migrants or travelers from high-risk areas.
Meera A. Chand, Joanna S. Herman, David G. Partridge, Kirsten Hewitt, and Peter L. Chiodini
Author affiliations: Hospital for Tropical Diseases, London, UK (M.A. Chand, J.S. Herman, P.L. Chiodini); Royal Hallamshire Hospital, Sheffield, UK (D.G. Partridge); Health Protection Agency Centre for Infections, London (K. Hewitt); and London School of Hygiene and Tropical Medicine, London (P.L. Chiodini)
(1.) Marcos LA, Terashima A, Gotuzzo E. Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis. Curr Opin Infect Dis. 2008;21:523-30.
(2.) Marcos LA, Tagle M, Terashima A, Bussalleu A, Ramirez C, Carrasco C, et al. Natural history, clinicoradiologic correlates and response to triclabendazole in acute massive fascioliasis. Am J Trop Med Hyg. 2008;78:222-7.
(3.) Control of foodborne trematode infections. Report of a WHO study group. World Health Organ Tech Rep Ser. 1995;849:1-157.
(4.) Nahmias J, Greenberg Z, Djerrasi L, Giladi L. Mass treatment of intestinal parasites among Ethiopian immigrants. Isr J Med Sci. 1991;27:278-83.
(5.) Doherty JF, Price N, Moody AH, Wright SG, Glynn MJ. Fascioliasis due to imported khat. Lancet. 1995;345:462. DOI: 10.1016/S0140-676(95)90450-6
Address for correspondence: Meera A. Chand, Hospital for Tropical Diseases, Mortimer Market, Capper Street, London WC1E 6JB, UK; email: firstname.lastname@example.org
Table. Characteristics of human fascioliasis case-patients during enhanced surveillance, United Kingdom, January 1, 2008-January 31, 2009 * Case Age, Country Years since no. y/sex of origin migration Other travel 1 45/F Yemen 7 Yemen regularly 2 44/M Somalia 16 Ethiopia 2007 3 34/F Ethiopia 3 S. Africa regularly 4 44/F Somalia 7 Somalia 2004, Netherlands 5 54/F Somalia 21 (to None Netherlands), 4 (to UK) 6 43/M Somalia 28 (to India), None 21 (to UK) 7 28/F UK -- Uganda 2007-2008 8 67/M UK -- Kenya 2008, prior world travel 9 38/M Ethiopia 10 Ethiopia 2006 10 28/M Ethiopia Unknown Unknown 11 47/F Somalia 16 (to Unknown Yemen), 6 (to UK) Eosinophil Abnormal Case Risk Clinical count, liver no. factor features x (10.sup.9]/L) function 1 Khat Abdominal 8.4 Yes use pain 2 Khat Fever, 3.4 Yes use abdominal pain 3 Khat Fever, 11.4 No use abdominal pain 4 Khat Abdominal 8.3 No use pain 5 Khat Anorexia 8.4 No use 6 Khat Fever 1.0 Yes use 7 -- Abdominal 1.84 Yes pain, hepatomegaly 8 -- Malaise, 0.04 Yes abdominal pain 9 -- Abdominal 18.7 Yes pain, fever 10 -- Fever, <0.04 Yes gram-negative sepsis; new HIV diagnosis 11 Khat Abdominal 16.8 Yes use pain, fever Case no. Hepatic imaging IFAT ([dagger]) 1 Mixed-density 1:128 liver lesion (CT) 2 Serpiginous 1:64 lesion (MRI) 3 Heterogeneous 1:128 lesion (USS) 4 Heterogeneous 1:128 lesion (USS) 5 Low-density 1:32 lesion (CT) 6 Heterogeneous 1:128 lesion (USS) 7 Hepatomegaly 1:512 with large mixed cystic and solid lesion (USS) 8 Multiple 1:256 gallstones (MRCP) 9 Normal (USS, 1:128 MRCP) 10 Lesion in 1:64 hepatic vein 11 Low-density 1:256 lesion (CT) * IFAT, immunofluorescent antibody test; CT, computed tomography; MRI, magnetic resonance imaging; USS, ultrasound scan, MRCP, magnetic resonance cholangiopancreatography. ([dagger]) Titer of IFAT (screening titer 32).
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|Author:||Chand, Meera A.; Herman, Joanna S.; Partridge, David G.; Hewitt, Kirsten; Chiodini, Peter L.|
|Publication:||Emerging Infectious Diseases|
|Date:||Nov 1, 2009|
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