A PCR Test Using the Mini-PCR Platform and Simplified Product Detection Methods Is Highly Sensitive and Specific to Detect Fasciola hepatica DNA Mixed in Human Stool, Snail Tissue, and Water DNA Specimens.

Fasciola hepatica has a complex lifecycle with multiple intermediate and definitive hosts and influenced by environmental factors. The disease causes significant morbidity in children and its prevalent worldwide. There is lack of data about distribution and burden of the disease in endemic regions, owing to poor efficacy of the different diagnostic methods used. A novel PCR-based test was developed by using a portable mini-PCR® platform to detect Fasciola sp. DNA and interpret the results via a fluorescence viewer and smartphone image analyzer application. Human stool, snail tissue, and water samples were used to extract DNA. Primers targeting the ITS-1 of the 18S rDNA gene of Fasciola sp. were used. The limit of detection of the mini-PCR test was 1 fg/µL for DNA samples diluted in water, 10 fg/µL for Fasciola/snail DNA scramble, and 100 fg/µL for Fasciola/stool DNA scramble. The product detection by agarose gel, direct visualization, and image analyses showed the same sensitivity. The Fh mini-PCR had a sensitivity and specificity equivalent to real-time PCR using the same specimens. Testing was also done on infected human stool and snail tissue successfully. These experiments demonstrated that Fh mini-PCR is as sensitive and specific as real time PCR but without the use of expensive equipment and laboratory facilities. Further testing of multiple specimens with natural infection will provide evidence for feasibility of deployment to resource constrained laboratories.

Concomitantly Diagnosed Disseminated M kansasii Infection and Hairy Cell Leukemia With Review of Pathophysiology.

The association between Hairy Cell Leukemia (HCL) and non-tuberculous mycobacterial infections (NTMs) is well described, most notably Mycobacterium kansasii. The exact pathophysiology is not known. We report a case of a 31-year-old male with concomitantly diagnosed HCL and disseminated M kansasii infection who presented with rash, pancytopenia, and bulky axillary lymphadenopathy. The M kansasii was initially diagnosed through use of cell-free DNA detection and confirmed by bone marrow and lymph node cultures. Hairy Cell Leukemia was diagnosed with peripheral flow cytometry and confirmed via the same bone marrow sample. His HCL was put into remission with a single course of cladribine and rituximab chemotherapy; however, his M kansasii infection persisted for 6 months despite aggressive antimicrobial and surgical therapy. It was finally controlled using high-dose rifampin in combination with azithromycin and ethambutol. This case highlights the known link between HCL and M kansasii. Furthermore, it hints at potential causes beyond chemotherapy-induced immunocompromise. Notable possibilities include HCL cells acting as sanctuary sites for M kansasii to evade the immune system, and subclinical M kansasii infections causing NLRP3 inflammasome overactivation to trigger the oncogenic transformation to HCL. More research into the pathophysiologic link between HCL and M kansasii infections would allow for more effective prevention, diagnosis, and treatment of these severe atypical infections which are the major cause of morbidity in the cladribine era of HCL treatment.

Fragility Fractures Unveil the Hidden Dragon: A Case of Osteitis Fibrosa Cystica and Secondary Hyperparathyroidism in End-Stage Renal Disease Post-Trauma.

Secondary hyperparathyroidism is a prevalent complication of end-stage renal disease (ESRD), arising from chronic renal insufficiency leading to disturbed calcium metabolism. This disruption triggers hypersecretion of the parathyroid gland, characterizing the condition. Osteitis fibrosa cystica (OFC), a rare complication of untreated secondary hyperparathyroidism, results in benign resorptive bone lesions and the formation of cystic cavities within bones. Our case report describes a 46-year-old incarcerated Hispanic male with a 17-year history of end-stage renal disease and secondary hyperparathyroidism. The patient initially presented with a traumatic right elbow injury. Further diagnostic evaluation revealed an 8 cm destructive process involving the distal humerus, initially suspected as malignancy but confirmed as OFC through bone biopsy. Management involved orthopedic surgery performing an open reduction and internal fixation (ORIF) of the affected limb, with subsequent consideration for inpatient parathyroidectomy. Imaging studies, including magnetic resonance imaging (MRI) and computed tomography (CT) scans, elucidated a 6 × 5.5 cm soft tissue mass, further confirmed as a brown tumor. The case underscores the complexities of diagnosing OFC, often misinterpreted in radiologic studies, and highlights the multidisciplinary approach involving orthopedics, otolaryngology, and nephrology in managing this intricate scenario. The objective is to explore clinical manifestations and treatment challenges of OFC and secondary hyperparathyroidism triggered by trauma in end-stage renal disease, emphasizing the need for continued awareness and precise diagnostic strategies in resource-rich areas.

Demographic Characteristics and Low Iron Status Markers Are Associated with Hemoglobin Levels and Anemia among Children Living at High Elevation in Cusco, Peru.

Anemia is a complex condition associated with diet, chronic infections, and blood loss. Children living at high altitudes have higher absolute hemoglobin levels due to hypoxemia. However, they are exposed to repeated infections and dietary limitations. We conducted a cross-sectional study to identify factors affecting the hemoglobin concentration in children living in high-altitude rural communities in the Anta province of Peru. All children 3-16 years of age attending public schools were invited to participate. We enrolled children 3-16 years old in schools and visited their homes to collect demographic, socioeconomic, medical history, and anthropometric data. Children provided blood and stool samples for complete blood counts, iron status markers, and helminth infection testing. Among the 2,000 children enrolled, the mean age was 9.9 (±3.4) years, 1,004 (50.2%) were female, and the median residence altitude was 3,398 (interquartile range 3,35-3,497) meters. The mean hemoglobin level was 15 (±1.15) mg/dL; 320 (16%) had anemia as defined by WHO. Children with anemia were more likely to have lower serum iron levels (odds ratio [OR] 2.8 [95% CI 2.2-3.6], P <0.001) and serum transferrin saturation (OR 2.8 [95% CI 2-3.9], P <0.001). Younger age (OR 0.85 [95% CI 0.82-0.89], P <0.001), stunting (OR 0.68 [95% CI 0.59-0.79], P <0.001), education of the mother (OR 0.94 [95% CI 0.91-0.98], P <0.005), and low eosinophils (OR 0.49 [95% CI 0.26-0.9], P = 0.022) were associated with anemia. Helminth infections were not associated with anemia. Anemia among children at high altitude is multifactorial, but iron deficiency is a contributing factor. Further studies are needed to evaluate iron status and anemia in children living at high altitudes.

An Update on the Pathogenesis of Fascioliasis: What Do We Know?

Fasciola hepatica is a trematode parasite distributed worldwide. It is known to cause disease in mammals, producing significant economic loses to livestock industry and burden to human health. After ingestion, the parasites migrate through the liver and mature in the bile ducts. A better understanding of the parasite's immunopathogenesis would help to develop efficacious therapeutics and vaccines. Currently, much of our knowledge comes from in vitro and in vivo studies in animal models. Relatively little is known about the host-parasite interactions in humans. Here, we provide a narrative review of what is currently know about the pathogenesis and host immune responses to F. hepatica summarizing the evidence available from the multiple hosts that this parasite infects.

Vacuoles in the Breast: A Histologic Clue for an Unusual Presentation of an Atypical Organism.

Infections with nontuberculous mycobacteria (NTM) are increasing in prevalence worldwide, and this group of organisms is emerging as significant clinical pathogens. We present a case of a 58-year-old female with persistent furuncles of the breast who was found to have an NTM infection. This case is unique for the lack of risk factors for NTM in the patient's history, the location of the infection in the breast, and the close cooperation needed across disciplines to arrive at the diagnosis. This multi-disciplinary discussion considers the classic clinical presentation of NTM, it is a characteristic morphological appearance on histopathology, the differential diagnosis, treatment, and the ultimate outcome of the case. This case report and discussion will assist both clinicians and pathologists in the diagnosis of this important infectious disease.

Geospatial analysis of the associations between environmental contamination with livestock feces and children with chronic fascioliasis in the Anta province of Cusco, Peru.

Fasciola hepatica is a neglected parasitic infection with significant human health and livestock industry impact. The Andean Altiplano harbors an estimated 50% of the Fasciola's world infection burden. There is scarce data regarding the spatial associations between different Fasciola hosts. In this project, we aimed to determine the geospatial relationships between Fasciola eggs passed in feces of different livestock species and the risk of infection among each household as a unit. We used data from a cross-sectional study evaluating children and livestock feces for Fasciola infection around households in three districts of Anta province, in the Cusco region of Peru. Each sample was geographically tagged and evaluated for fascioliasis using microscopy methods. A total of 2070 households were included, the median age was 9.1 years (6.7-11.8), 49.5% were female, and 7.2% of the households had at least one infected child. A total of 2420 livestock feces samples were evaluated. The infection rate in livestock samples was 30.9%. The highest infection rate was found in sheep with 40.8%, followed by cattle (33.8%), and swine (26.4%). The median distance between a household with an infected child to a positive animal sample was 44.6 meters (IQR 14.7-112.8) and the distance between a household with no infected children to a positive animal sample was 62.2 meters (IQR 18.3-158.6) (p = 0.025). The multivariable logistic regression adjusted by presence of poor sanitation, unsafe water consumption, altitude, and presence of multiple infected children per household demonstrated an association between household infection and any cattle feces at a 50 meters radius (Uninfected: OR 1.42 (95%CI 1.07-1.89), p = 0.017. Infected: OR 1.89 (95%CI 1.31-2.73), p = 0.001), positive cattle feces at a 100 meters radius (OR 1.35 (95% CI 1.08-1.69), p = 0.008), and negative cattle feces at a 200 meters radius (OR 1.08 (95% CI 1.01-1.15), p = 0.022). We identified potential hot and cold spots for fascioliasis in the Anta province. An association between environmental contamination with feces from different livestock species and infected children in rural households was found in our study. Local health authorities may apply this strategy to estimate the risk of infection in human populations and apply targeted interventions.

A Comparison of the Risk for Chronic Fascioliasis between Children 3 to 5 Years and Children 6 to 12 Years of Age in the Cusco Region of Peru.

School-age children bear the highest burden of fascioliasis in endemic countries. Few studies have addressed Fasciola in preschool children. We performed a secondary data analysis using two Fasciola databases from Cusco, Peru, comparing preschoolers with elementary school children. We included 2,630 children, 50% were female, the median age was 8.4 years (interquartile range [IQR] 6.1-10.5), and 15% (396/2,630) were < 5 years of age. Children < 5 years were less likely to be infected with Fasciola hepatica (P = 0.008) and Hymenolepis nana (P < 0.001) and more likely to have anemia (P < 0.001) and a lower median height for age Z (HAZ) score (P = 0.002). Fascioliasis was less common in younger children, but this group may be at higher risk for chronic complications caused by fascioliasis.

Triclabendazole Treatment Failure for Fasciola hepatica Infection among Preschool and School-Age Children, Cusco, Peru1.

We conducted a retrospective cohort study of children who had chronic fascioliasis in the highlands of Peru to determine triclabendazole treatment efficacy. Children passing Fasciola eggs in stool were offered directly observed triclabendazole treatment (>1 doses of 10 mg/kg). Parasitologic cure was evaluated by using microscopy of stool 1-4 months after each treatment. A total of 146 children who had chronic fascioliasis participated in the study; 53% were female, and the mean ± SD age was 10.4 ± 3.1 years. After the first treatment, 55% of the children achieved parasitologic cure. Cure rates decreased after the second (38%), third (30%), and fourth (23%) treatments; 17 children (11.6%) did not achieve cure after 4 treatments. Higher baseline egg counts and lower socioeconomic status were associated with triclabendazole treatment failure. Decreased triclabendazole efficacy in disease-endemic communities threatens control efforts. Further research on triclabendazole resistance and new drugs to overcome it are urgently needed.

Comparison of Liver Condemnation and Bile Microscopy As Tools to Estimate Fasciola hepatica Prevalence and Burden in the Anta Province of Cusco in Peru.

Fascioliasis is a zoonotic infection linked to significant economic losses in the livestock industry. Infection prevalence and estimated financial burden vary across locations owing to different diagnostic tests used. The accuracy of liver condemnation to estimate the prevalence and costs of fascioliasis has seldom been evaluated. We performed a pilot study to determine the prevalence and burden of Fasciola hepatica infection among cattle slaughtered at the municipal abattoir in the Anta province of the Cusco highlands in Peru. We compared liver condemnation with bile microscopy for the diagnosis of infection and prediction of carcass weight. Data were collected from 2009 slaughtered cattle for 1 year. The overall prevalence of Fasciola infection by bile microscopy was 62.5% (1247/2009). A higher prevalence was observed after the rainy season from March to August than from September to February (p < 0.01). Fascioliasis prevalence during the first 6 months was 77.4% (714/923), combining the results of condemnation and microscopy. Bile microscopy diagnosed more infections than liver condemnation (62.7% (579/923) versus 55.4% (511/923), McNemar test p < 0.01). The agreement of the bile microscopy testing with liver condemnation was fair (κ = 0.247). Animal age, gender, breed, and liver condemnation predicted carcass weight [F (df 4, 704) = 61.1, p < 0.001]. Liver condemnation and bile microscopy are complementary tools for evaluation of the prevalence and burden of fascioliasis in livestock. Large scale studies are warranted to confirm our results.

Fasciola hepatica Infection Risk for Adult Household Members Living with Children with Fascioliasis in Cusco, Peru.

Fasciola hepatica is highly prevalent in the highlands of Peru. School-age children have the greatest risk of infection. Mass treatment of at-risk populations has been proposed to control the infection and prevent complications. However, the decreasing effectiveness of triclabendazole raises concerns regarding this strategy. Previous studies reported aggregation of Fasciola infection among family members. This study aimed to determine the risk of fascioliasis among household members living with Fasciola-infected children identified through school-based testing. We conducted a cross-sectional study including adult members of households where children with and without fascioliasis were identified. Demographic, epidemiological, and socioeconomic information was collected. One blood sample was drawn to test for Fasciola antibodies, and three stool samples were collected for microscopy for Fasciola ova. We tested 326 adults from 213 households. Of these adult subjects, chronic fascioliasis (24 of 326, 7.4%) was the most common helminth infection. Thirty-nine subjects (12.7%) tested positive for Fasciola antibodies. Combining microscopy and serum antibody tests, 13.2% (43 of 326) had evidence of Fasciola infection. One third (104 of 326, 31.9%) of the participants lived with at least one child infected with Fasciola hepatica. Adults with fascioliasis were four times more likely to live with an infected child. Poverty and diet were associated with increased risk of Fasciola infection. Adults with fascioliasis were significantly more likely to live with Fasciola-infected children.

Murine Typhus Infection in Pregnancy: Case Series and Literature Review.

Murine typhus is a flea-borne disease of worldwide distribution with a recent reemergence in the United States of America. There are limited data about the presentation, treatment, and outcomes in the pregnant population. We report on two cases of murine typhus during pregnancy and review the literature to compile previously reported cases. A comprehensive search was performed via the PubMed database for published articles between 1990 and 2020. Seven articles met the criteria of symptomatic pregnant murine typhus infection. A total of 37 patients were identified. Patients frequently presented with a prolonged duration of fevers prior to presentation, headache, and elevated hepatic transaminases. The diagnosis was predominantly based on serology. Treatment varied. Overall, the pregnancy outcome was favorable. Murine typhus can mimic other pregnancy-related pathologies. More exclusive and large-scale studies are needed to learn more of murine typhus during pregnancy.

Persistent Infection Versus Type 2 Immunological Reaction in Lepromatous Leprosy.

The distinction between persistent infection and immunologic reactions in leprosy is often difficult but critically important since their management is different. We present the case of a 51-year-old Vietnamese female who presented in 2015 with areas of erythema and skin infiltration on face and chest, as well as edema on her hands and feet. Skin biopsy was consistent with lepromatous leprosy. She was treated with rifampin, clarithromycin, and levofloxacin for 2 years. Her lower extremity edema was attributed to type 2 immunological reaction for which she was started on prednisone and methotrexate, but she was lost to follow-up for 19 months. She presented with new skin lesions and pain on her extremities. New biopsies revealed an intense neutrophilic infiltrate in the dermis and acid-fast bacilli focally within cutaneous nerve twigs. As compared with the initial biopsy, the inflammatory infiltrates were diminished and the bacilli had a degenerating appearance. These findings were consistent with type 2 immunological reaction. The patient was treated with thalidomide with improvement in the appearance of the skin lesions. A follow-up biopsy showed lack of neutrophilic infiltrates and decreased number of bacilli. This case illustrates the importance of differentiating between persistent infection and immunologic reactions in leprosy. Clinicians should be aware of these complications. A high index of suspicion and accurate interpretation of skin biopsy results are essential for appropriate diagnosis.