Administrative practices of health professionals and use of artesunate-amodiaquine by community members for treating uncomplicated malaria in southern Ghana: implications for artemisinin-based combination therapy deployment.

OBJECTIVE: To investigate the use of artemisinin-based combination and monotherapy by community members and the administrative practices of health professionals in treating malaria in Ghana. METHOD: This study is a community-based cross-sectional survey in 11 rural and urban areas in southern Ghana. Using the interviewer method, close-ended questionnaires were administered to community members. Similar questionnaires were also administered in health facilities, community pharmacies and licensed chemical shops. RESULTS: A total of 1085 individuals comprising 959 non-health professionals and 126 health professionals were interviewed. Fifty-seven per cent of the community members visit pharmacies/drug stores as the first point of call when they suspect malaria. According to the participating drug sellers, artemether-lumefantrine (AL) is the most prescribed/sold anti-malarial drug (59.2%), followed by dihydroartemisinin (35%), sulfadoxine-pyrimethamine (33.0%) and artesunate-amodiaquine (AS-AQ) (27.2%). The majority of customers who visit pharmacies or drug stores without prescription have their anti-malarial drug selected by the shop attendant; in situations like that, dihydroartemisinin and artesunate monotherapies are sold just as AS-AQ and AL. Chloroquine is still sold by some drug vendors, 5 years after its proscription. CONCLUSION: Whereas the use of AS-AQ and AL are acceptable, the frequent use of dihydroartemisinin and artesunate monotherapy threatens the future of ACTs.

Plasmodium falciparum isolates from southern Ghana exhibit polymorphisms in the SERCA-type PfATPase6 though sensitive to artesunate in vitro.

BACKGROUND: In 2005, Ghana replaced chloroquine with artemisinin-based combination therapy as the first-line treatment for uncomplicated malaria. The aim of this work was to determine for the first time, polymorphisms in the putative pfATPase6 and pftctp, pfmdr1, pfcrt genes in Ghanaian isolates, particularly at a time when there is no report on artemisinin resistance in malaria parasites from Ghana. The sensitivity of parasite isolates to anti-malaria drugs were also evaluated for a possible association with polymorphisms in these genes. METHODS: The prevalence of point mutations in the above Plasmodium falciparum genes were assessed from filter-paper blood blot samples by DNA sequencing. In vitro drug sensitivity test was carried out on some of the blood samples from volunteers visiting hospitals/clinics in southern Ghana using a modified version of the standard WHO Mark III micro-test. RESULTS: All successfully tested parasite isolates were sensitive to artesunate; while 19.4%, 29.0% and 51.6% were resistant to quinine, amodiaquine and chloroquine respectively. The geometric mean of IC50 value for artesunate was 0.73 nM (95% CI, 0.38-1.08), amodiaquine 30.69 nM (95% CI, 14.18-47.20) and chloroquine 58.73 nM (95% CI, 38.08-79.38). Twenty point mutations were observed in pfATPase6 gene, with no L263E and S769N. All mutations found were low in frequency, except D639G which was observed in about half of the isolates but was not associated with artesunate response (p = 0.42). The pftctp gene is highly conserved as no mutation was observed, while CVIET which is chloroquine-resistant genotype at codon 72-76 of the pfcrt gene was identified in about half of the isolates; this was consistent with chloroquine IC50 values (p = 0.001). Mutations were present in pfmdr1 gene but were not associated with artemisinin response (p = 1.00). CONCLUSION: The pfATPase6 gene is highly polymorphic with D639G appearing to be fixed in Ghanaian isolates. These may just be spontaneous mutations as all parasite isolates that were tested displayed satisfactory in vitro response to artesunate. However, there is no improvement in susceptibility of the parasites to chloroquine five years after its proscription.

Human leptospirosis cases and the prevalence of rats harbouring Leptospira interrogans in urban areas of Tokyo, Japan.

Thirteen patients with leptospirosis were identified, as confirmed by laboratory analysis during the last 5 years in our laboratory, who came from urban areas of Tokyo, Japan. All of the patients came into contact with rats before the onset of illness. Seventeen per cent of Norway rats captured in the inner cities of Tokyo carried leptospires in their kidneys. Most of these rat isolates were Leptospira interrogans serovar Copenhageni/Icterohaemorrhagiae. Antibodies against these serovars and their DNA were detected in the patients. This suggests that rats are important reservoirs of leptospirosis, and that rat-borne leptospires occur in urban areas of Tokyo.

Prolactin evokes lactational transmission of larvae in mice infected with Toxocara canis.

We investigated the trans-lactational maternal-neonatal transmission of Toxocara canis larvae in mice, with particular interest in the role of prolactin in their migration to the mammary gland. Two female mice were infected with 300 T. canis eggs soon after delivery of 27 offspring. After 1 week of breast-feeding, seven larvae were recovered from 4 of 13 offspring. After 2 weeks of lactation, 101 larvae were recovered from all the remaining offspring. Daily prolactin administration (5 microg) was performed 2 weeks before T. canis infection and continued until 2 weeks after infection in six non-pregnant female mice, which resulted in larval accumulation in the mammary gland. Furthermore, prolactin administration in female mice that had been infected with T. canis 4 weeks prior to prolactin treatment induced migration of larvae into the mammary gland. These findings suggest that prolactin is a promoting factor contributing to lactational transmission of T. canis larvae in mice.

A familial case of visceral toxocariasis due to consumption of raw bovine liver.

We present 3 adult cases of visceral toxocariasis from the same family, who each consumed thin slices of raw bovine liver weekly, and developed eosinophilia and multiple small lesions in their livers and lungs. Serological examinations using the larval excretory-secretory product of Toxocara canis strongly indicated infection with Toxocara species larvae. The patients responded well to treatment with albendazole. Ingestion of raw liver from paratenic animals is considered to be a common transmission route of human toxocariasis, especially in adults.

IL-33/ST2 contributes to severe symptoms in Plasmodium chabaudi-infected BALB/c mice.

It has been reported that IL-33 contributes to potentiation of Th2 inflammatory diseases and protection against helminth infection. Increased plasma IL-33 levels have been observed in patients with severe falciparum malaria, however, the role of IL-33 in malaria remains unclear. Here we report that IL-33 enhances inflammatory responses in malaria infection. ST2-deficiency altered severity of inflammation in the liver and serum levels of pro-inflammatory cytokines such as TNF-α and IL-6, and IL-13 that is a Th2 cytokine during Plasmodium chabaudi infection. IL-13-deficient mice have similar phenotype with ST2-deficient mice during P. chabaudi infection. Furthermore, ST2- and IL-13-deficiency reduced mortality from P. chabaudi infection. These results indicate that IL-33/ST2 can induce production of proinflammatory cytokines, such as TNF-α and IL-6, through production of IL-13 in P. chabaudi-infected BALB/c mice, suggesting that IL-33/ST2 play a critical role in inflammatory responses to malaria infection. Thus, these findings may define a novel therapeutic target for patients with severe malaria.

Toxocariasis in Japan.

Toxocariasis has long been considered a parasitic disease affecting pet owners and children who often play in sandboxes at public parks. Recent cases of this animal-borne infection, however, indicate that its clinical manifestations and etiologies are changing. In this article, we will describe the critical characteristic features of toxocariasis alongside the contributions of Japanese researchers to a better understanding of the disease.

A familial case of visceral larva migrans after ingestion of raw chicken livers: appearance of specific antibody in bronchoalveolar lavage fluid of the patients.

We report a familial case of visceral larva migrans (VLM) caused by Toxocara canis larvae. Patient 1 was a 45-year-old man who presented to our university hospital complaining of mild fever, general fatigue, and headache. Patient 2 was a 71-year-old man and was the father of Patient 1; he presented complaining of cough and hyper-viscous white sputum. Laboratory data from both patients showed extensive eosinophilia, their chest X-ray findings revealed multiple pulmonary infiltrates, and their bronchoalveolar lavage fluid (BALF) showed an elevated eosinophil count. The diagnosis of VLM was made based on a positive result in a serological test using T. canis larval excretory-secretory both in the serum and BALF. T. canis larvae were identified in meat that was prepared from chicken taken from the same source as that ingested. This is the first report to identify antibodies in BALF in patients with VLM.

Development of membrane-based tests for the detection of urinary antigens and antibodies in human toxoplasmosis: preliminary studies in Ghanaian patients.

Two membrane-based ELISA systems were used in detecting Toxoplasma antigens and anti-Toxoplasma antibodies in urine samples collected from 54 ophthalmology (22 suggestive active and 32 suggestive past infection) patients and 26 pregnant women attending obstetrics/gynaecology clinic (OGP), suspected of toxoplasmosis by eye examination, past medical records and questionnaire, respectively, in Ghana from mid-February to April 2002. The antigen detecting ELISA was able to demonstrate antigen in 100% (22/22) ophthalmology (active infection) and 62.5% (20/32) ophthalmology (past infection) patients, and 42% (11/26) of OGP which included 3 that were sero-negative prior to and during this study, giving an overall prevalence of 66.3% (53/80). The urinary antigen positive samples also included 6 that were negative for both the Dye Test (DT) and latex agglutination test (LAT). Antigen was not detected in the urine of 22 normal (sero-negative for antibodies to Toxoplasma) individuals. The membrane-based urinary antibody detecting sandwich ELISA also detected anti-Toxoplasma antibodies in 100% (22/22) of ophthalmology (active infection) and 81.3% (26/32) of ophthalmology (past infection) patients, a total of 89% (48/54); and 80.8% (21/26) of OGP with an overall prevalence of 86.3% (69/80), including 7 ophthalmology patients' samples that were sero-negative for both DT and LAT. Antibody sero-positivity of the samples was determined by DT as 87% (47/54) in ophthalmology patients and 73.1% (19/26) in pregnant women, LAT as 85.2% (46/54) and 65.4% (17/26), and an overall prevalence as 82.5% (66/80) and 78.8% (63/80), respectively. The membrane-based ELISA systems appear promising but need to be investigated further for its efficacy as reliable diagnostic tests.

The effect of free and polyethylene glycol-liposome-entrapped albendazole on larval mobility and number in Toxocara canis infected mice.

As part of our exploratory drug research on the larva migrans that causes roundworm in dogs and cats, this study was carried out to clarify the effect of free and liposome-entrapped (LE) albendazole in Toxocara canis infected mice. In infected mice, evaluation of mobility and number of larva were examined in detail in the brain, skeletal muscle and liver. Larva mobility was evaluated by using the relative mobility (RM) value. Albendazole was LE as one of the drug delivery systems (DDSs). Polyethylene glycol (PEG) was added to the liposome in order to avoid evoking a response by the reticuloendothelial system (RES). By using the albendazole PEG-LE delivery system, it was possible to target the larvae in the mouse brain and liver resulting in a decrease in the number of larvae. In the skeletal muscle of the infected mice, the intraperitoneal dosages of PEG-LE albendazole did not cause a complete decrease in the number of larvae, even though free albendazole did cause the number to decrease. Therefore, it is necessary to take into consideration the migrating stage of the larvae before the initiation of any drug administration.

Fatal Baylisascaris larva migrans in a colony of Japanese macaques kept by a safari-style zoo in Japan.

A colony of Japanese macaques (Macaca fuscata fuscata) kept by a safari-style zoo in Japan experienced 9 sporadic cases of fatal neurological diseases, such as epilepsy and posterior paralysis, during the 12 yr from 1989 to 2001. This macaque colony consisted of approximately 30 animals, on average, during this period, and the macaques shared their living space with II American black bears (Ursus americanus) harboring zoonotic roundworms (Baylisascaris transfuga). Close to this enclosure, a cote for 2-3 raccoons (Procyon lotor) was placed, and raw sewage from this cote ran into a shallow drain in the area for macaques and bears. However, fecal examinations in recent years did not detect the infection of raccoons with zoonotic roundworms (Baylisascaris procyonis). Postmortem histological examination of the latest 2 ill macaques detected multifocal malacia in the brain; 2 ascarid larvae of 60 microm maximum width were encapsulated in the cerebrum and lungs of 1 of the animals. To determine the causative ascarid species of the fatal larva migrans, we analyzed 2 additional encapsulated Baylisascaris larvae collected from formalin-fixed lungs by morphological and molecular approaches. This sporadic outbreak is the second record of Baylisascaris larva migrans in animals in Japan.

Following the migration of a Toxocara larva in the retina by optical coherence tomography and fluorescein angiography.

BACKGROUND: The Toxocara larva is known to migrate across the retina, but the layer in which it migrates and its effect on the retina has been unknown. CASE: An ocular Toxocara infection was diagnosed by an immunological test on a vitreous sample from a patient with a retinal lesion that had migrated. Optical coherence tomography (OCT) and fluorescein angiography (FA) were used in this investigation. OBSERVATIONS: Many small lesions were first detected in the peripheral retina, and vitrectomy was performed because of vitreous haze. Two peripapillary lesions were found during the vitrectomy. OCT of one lesion demonstrated a highly reflective mass located in the nerve fiber layer, and FA showed dye leakage from the lesion as well as hyperfluorescence of the disc. Three weeks later, another lesion was found in the macular area, and OCT and FA findings were the same as for the first lesions. Fluorescein leakage was also observed along the presumed path of the migrating larva. CONCLUSIONS: The movement of the lesion from the peripapillary area to the macular area suggested that a Toxocara larva had migrated across the retina. OCT images indicated that the larva moved in the nerve fiber layer, and FA showed that it caused severe inflammation along its pathway.

The high prevalence of asymptomatic Toxocara infection among schoolchildren in Manado, Indonesia.

We performed a serological survey of Toxocara canis infection in junior high school students from three districts in northern Sulawesi. Almost all of the 117 subjects from two rural districts near Manado allowed dogs in their houses, and there was an 84.6% prevalence of T. canis infection in this group. Fifty-three subjects (45.3%) had serum samples with a high titer of specific anti-Toxocara antibody. By contrast, 41 students tested in one urban district showed a 12.2% prevalence. To confirm the clinical symptoms of visceral larva migrans (VML) and ocular larva migrans (OLM) caused by Toxocara, we administered a questionnaire survey, serological liver function tests, and an ophthalmoscopic examination in 34 subjects having high anti-Toxocara antibodies. One rural district showed a high prevalence; 58 out of 71 subjects (81.7%) had a high titer of anti-Toxocara antibodies according to a plate-ELISA test, although none showed clinical signs. Five of these subjects exhibited hypereosinophilia. These results indicated that T. canis infection in northern Sulawesi is latent in many more cases than previously estimated, and suggest that people living in environments polluted by Toxocara eggs become easily infected with T. canis and show a high prevalence of infection.

Molecular identification of Anisakis and Hysterothylacium larvae in marine fishes from the East China Sea and the Pacific coast of central Japan.

Anisakiasis is a human disease caused by the accidental ingestion of larvae belonging to the family Anisakidae. Three fish species, the small yellow croaker Pseudosciaena polyactis, the mackerel Pneumatophorus japonicus and the hairtail Trichiurus haumela are important source for food products in the East China Sea. The prevalence and the identification of Anisakidae larvae in these fishes will benefit the prevention and control of anisakiasis. In this study, fish samples were obtained from fish markers in the East China Sea and the Pacific coast of central Japan during April 2011 and July 2013. For species identification, the PCR-based restriction fragment length polymorphism (PCR-RFLP) analysis of the entire ITS region (ITS1, 5.8 S and ITS2) of nuclear ribosomal DNA (rDNA) was performed. In total, 2004 larvae were collected from 80 hairtail fish, 20 small yellow croaker, and 27 mackerel from the East China Sea and the Pacific coast of central Japan. High prevalence of Anisakidae larvae infection (116/122, 95.1%) was detected in the East China Sea. Seven species were identified belonging to the genera Anisakis (Nematoda: Anisakidae) and Hysterothylacium (Nematoda: Anisakidae). Anisakis pegreffii was the predominant species accounting for 84.8% of all larvae examined in East China Sea, while all Anisakidae larvae isolated from Japan were identified as Anisakis simplex sensu stricto (s.s.). In the East China Sea, A. simplex s.s. and Anisakis typica were 0.6% (4/619) and 1.5% (9/619) of the identified nematodes, respectively. Interestingly, one larva was identified as a recombinant genotype of A. simplex s.s. and A. pegreffii. In addition, four species of the genus Hysterothylacium, namely, Hysterothylacium amoyense (31/619, 5.0%), Hysterothylacium aduncum (10/619, 1.6%), Hysterothylacium fabri (21/619, 3.4%) and Hysterothylacium spp. (18/619, 2.9%) were also identified in the present study. This is a comprehensive epidemiological dataset for the family Anisakidae in the East China Sea. The identification of A. typica, recombinant genotype of A. simplex s.s. and A. pegreffii, H. amoyense and H. fabri is first reported in this area. The wide diversity and substantial geographical distributions of these nematodes will provide a foundation for future studies of Anisakidae family. The high prevalence of these nematodes in marine fishes off the East China Sea may pose considerable food safety problems, which is a potential cause of human anisakiasis.

Loiasis in a Japanese Traveler Returning from Central Africa.

We encountered a probable case of loiasis in a returned traveler from Central Africa. A 52-year-old Japanese woman presented to our hospital complaining of discomfort in her eyes and skin. She reported having frequently visited Central Africa over many years and having been extensively exposed to the rainforest climate and ecosystem. Although no microfilariae were found in her blood, there was an elevated level of IgG antibodies against the crude antigens of Brugia pahangi, which have cross-reactivity with Loa loa. She was treated with albendazole for 21 days, after which the antigen-specific IgG level decreased and no relapse occurred.

Optical coherence tomographic and angiographic findings of a case with subretinal toxocara granuloma.

PURPOSE: To study a case with a subretinal Toxocara granuloma. DESIGN: Interventional case report. METHODS: A patient with a exudative macular lesion, diagnosed as ocular toxocariasis, was examined with optical coherence tomography (OCT) and angiography before and after systemic corticosteroid and anthelminthic therapy. RESULTS: In OCT images, the macular granuloma initially appeared as a highly reflective mass protruding above the retinal pigment epithelium and showed dye leakage by angiography. Posttherapy, the lesion was no longer exudative, was less elevated, and was covered by the retinal pigment epithelium. There was reticular hyperfluorescence surrounded by a hypofluorescent rim in the angiograms. CONCLUSIONS: Subretinal Toxocara granuloma may have a presentation similar to idiopathic choroidal neovascularization (CNV) and should be included in the differential diagnosis of the idiopathic CNV.

Cerebellar ataxia due to Toxocara infection in Mongolian gerbils, Meriones unguiculatus.

We assessed the usefulness of gerbils as an experimental model for neurologic toxocarosis. Mongolian gerbils, Meriones unguiculatus, infected with Toxocara canis or Toxocara cati (1000 eggs/gerbil) showed progressive neurologic disorders from 50 days after infection in T. canis-infected gerbils or from 120 days after infection in T. cati-infected gerbils. The incidence of the onset was 6 of the 13 gerbils (49%) in the T. canis-gerbils and 5 of the 7 gerbils (71%) in the T. cati-gerbils. Histopathologically, the cerebellum was the most affected in both groups. We observed loss of Purkinje cells, glial nerve fibers, and nerve sheaths. We also found foci consisting of aggregated macrophages scattered in the white matter of the cerebellum. The affected gerbils showed ataxia and ultimately died of cachexia. Our findings suggest that irreversible neurologic toxocarosis in gerbils can be induced by infection with either T. canis or T. cati.

Larva migrans by Baylisascaris transfuga: fatal neurological diseases in Mongolian jirds, but not in mice.

Raccoon roundworms (Baylisascaris procyonis) and other Baylisascaris species cause patent or latent larva migrans (LM) in a variety of mammals and birds, including humans. It is not clear whether LM by Baylisascaris transfuga, roundworms of bears, is associated with clinical neurological disorders. To clarify this issue, ICR and BALB/c mice as well as Mongolian jirds (Meriones unguiculatus) were orally inoculated with 2,000-5,000 embryonated eggs of B. transfuga. In mice, the ascarid caused symptomatic LM of limited extent and duration, whereas the infection was fatal in jirds; i.e., they exhibited general signs such as severe depression and emaciation on days 8-11 postinfection (PI) and died, or they developed progressive and fatal neurological disorders after day 14 PI. Histological examination showed B. transfuga larvae in the brain of all mice and jirds examined, and the larvae collected from them developed to a size comparable with that of B. procyonis. There existed, however, critical differences in host reactions against larvae localized in the brain of mice and jirds; B. transfuga larvae found in mice were surrounded by granulomatous reactions and immobilized, whereas larvae found in jirds were free from any host reaction and mobile, causing extensive malacia.

[A case of severe eosinophilia in the acute phase of Opisthorchis viverrini infection].

A 26-year-old woman Japanese public official servant in Lao People's Democratic Republic was introduced to our hospital on December 12, 2002, because of two months duration of low grade fever and severe eosinophilia. There was no significant finding in physical examination. Laboratory tests showed leukocytosis (15,700/microliter) with severe eosinophilia (42%), and no abnormal lymphocyte was observed. Furthermore, elevation in alkaline phosphatase (748 IU/l), gamma-glutamyl transpeptidase (190 IU/l), leucine aminopeptidase (150 IU/l), and slight elevation in CRP (2.8 mg/dl) were pointed out. A computed tomographic scan of the abdomen obtained multiple cystic lesions in the right lobe of the liver. On parasitological study, a stool specimen examined by the formalin-ether concentration method revealed positive for Opisthorchis viverrini eggs. She was orally administered with 40 mg/kg of praziquantel a day for two consecutive days. Following check-up by medical-affairs official at Embassy of Japan in Lao PDR confirmed the normal eosinophil count and her fever disappeared. It was considered eosinophilia in this case was induced by acute phase of severe ophisthorchiasis.

[A case bilharziasis in a Japanese male].

Bilharziasis is an endemic disease distributed mostly in African countries and the Middle East, and causes severe disturbances of urinary tract secondarily. Although it used to be a very rare disease in Japan, modern human mobility and jet travel have brought this tropical disease into our country far from endemic areas. A 25-year-old Japanese male presented to our hospital with macroscopic hematuria. He had an experience of traveling to Malawi two years before. Cystourethroscopy demonstrated so-called 'bilharzial tubercles', many yellowish specks of mucosa at the posterior wall and dome of the bladder. The diagnosis of bilharziasis was made by detection of Schistosoma haematobium eggs in urine and histological specimen obtained by transurethral biopsy. In this case, radiographic and pathological examinations revealed neither obstructive uropathy nor urothelial malignancy. He was treated with praziquantel, and the disease is under good control.