Anisakiasis presenting to the ED: clinical manifestations, time course, hematologic tests, computed tomographic findings, and treatment.

BACKGROUND: The prevalence of anisakiasis is rare in the United States and Europe compared with that in Japan, with few reports of its presentation in the emergency department (ED). This study describes the clinical, hematologic, computed tomographic (CT) characteristics, and treatment in gastric and small intestinal anisakiasis patients in the ED. METHODS: We retrospectively reviewed the data of 83 consecutive anisakiasis presentations in our ED between 2003 and 2012. Gastric anisakiasis was endoscopically diagnosed with the Anisakis polypide. Small intestinal anisakiasis was diagnosed based on both hematologic (Anisakis antibody) and CT findings. RESULTS: Of the 83 cases, 39 had gastric anisakiasis and 44 had small intestinal anisakiasis based on our diagnostic criteria. Although all patients had abdominal pain, the gastric anisakiasis group developed symptoms significantly earlier (peaking within 6 hours) than the small intestinal anisakiasis group (peaking within 48 hours), and fewer patients with gastric anisakiasis needed admission therapy (5% vs 57%, P<.01). All patients in the gastric and 40 (91%) in the small intestinal anisakiasis group had a history of raw seafood ingestion. Computed tomographic findings revealed edematous wall thickening in all patients, and ascites and phlegmon of the mesenteric fat were more frequently observed in the small intestinal anisakiasis group. CONCLUSIONS: In the ED, early and accurate diagnosis of anisakiasis is important to treat and explain to the patient, and diagnosis can be facilitated by a history of raw seafood ingestion, evaluation of the time-to-symptom development, and classic CT findings.

Anisakis simplex: current knowledge.

Anisakiasis, firstly described in 1960s in the Netherlands, is a fish-borne parasitic disease caused by the consumption of raw or undercooked fish or cephalopods contaminated by third stage (13) larvae of the Anisakidae family, in particular Anisakis simplex (As), A. pegreffii and Pseudoterranova decipiens. Every year, approximately 20,000 cases of anisakiasis were reported worldwide, over 90% are from Japan and most others in Spain, the Netherlands and Germany, depending on the habits of fish consuming. Live As larvae can elicit i) a parasitic infection of the digestive tract or, occasionally, other organs, causing erosive and/or haemorrhagic lesions, ascites, perforations until granulomas and masses, if larva is not removed, and ii) allergic reactions, as anaphylaxis, acute/chronic urticaria and angioedema. Like other parasite infestations, As larva induces an immune adaptive response characterised by T-lymphocyte proliferation with polyclonal and monoclonal (responsible for As allergic symptoms) IgE production, eosinophilia and mastocytosis. Several As allergens, many of which thermostable, were described In particular the major allergen Ani s 1 and Ani s 7 could characterized a past or a recent infection. There is a general agreement that an active infection is required to initiate allergic sensitivity to Anisakis. Until now, the only effective treatment for anisakiasis is the endoscopic removal of live larvae and the best protection against anisakiasis is to educate consumers about the dangers of eating raw fish and to recommend avoiding the consumption of raw or inadequately thermally treated marine fish or cephalopods.

Should the host reaction to anisakiasis influence the treatment? Different clinical presentations in two cases.

Gastrointestinal anisakiasis is a parasitic infection occurring in people that consume raw or inadequately cooked fish or squid. It is frequently characterized by severe epigastric pain, nausea and vomiting caused by the penetration of the larvae into the gastric wall. Acute gastric anisakiasis with severe chest discomfort is rarely reported in Italy. On the other hand, gastro-allergic anisakiasis with rash, urticaria and isolated angioedema or anaphylaxis is a clinical entity that has been described only recently. Also, if patients usually develop symptoms within 12 hours after raw seafood ingestion, not always endoscopic exploration can promptly identify the Anisakis larvae. Moreover, some authors consider the prevailing allergic reaction as a natural and effective defense against the parasitic attack. We report two cases of peculiar manifestations of anisakiasis in both acute and chronic forms (severe chest discomfort and anaphylactoid reaction).

[Epidemiology and nosology of anisakiosis, a rather rare helminthozoonosis in Central Europe--two case reports]. / Epidemiologie und Nosologie der Anisakiose, einer in Mitteleuropa selten diagnostizierten Helminthozoonose--zwei Fallberichte.

Two cases of anisakiosis are reported. Two male patients (54 and 58 years old) had spent their holidays in Alaska for salmon fishing at the end of July 2006 and consumed the self caught cold smoked salmon. Back in Austria both patients suffered from abdominal pain within 6 and 15 days respectively, after consumption and received in-patient treatment (patient 1: subileus; patient 2: ileus). Patient 1 received aprednisolon alone and recovered within 3 days, patient 2, however, was treated surgically (ileus) and suffered from an ARDS and an insufficiency of anastomosis during postoperative intensive therapy, additionally he received hydrocortisone. Both patients recovered completely. The diagnosis of anisakiosis was primarily based on the common anamnesis (consumption of cold smoked salmon) and the detection of eosinophilia in the differential blood picture. The diagnosis was confirmed by the detection of specific antibodies against Anisakis antigen in the serum of patient 1, the morphological determination and molecularbiological characterization (PCR, sequence analysis) of Anisakis simplex s. str. larvae found in parts of the consumed salmon as well as by the detection of Anisakis DNA in the resected ileum by a nested PCR. These two cases of anisakiosis are the first documented cases in Austria.

Garlic oil as a fight against histological and oxidative stress abnormalities in Wistar rats after oral inoculation of Anisakis spp. Type II (L3) (Nematoda) / [O uso do óleo de alho na luta contra anormalidades histológicas e de estresse oxidativo em ratos Winstar após inoculação oral de Anisakis spp. Tipo II (L3) (Nematoda)]

The consumption of inadequately thermally treated fish is a public health risk due to the possible propagation of Anisakis larvae and their antigenic proteins, the causative agent of the zoonotic disease anisakidosis. The present study demonstrated the physiological and histopathological changes that accompanied an oral inoculation of crude extracts from fresh and thermally treated Anisakis Type II (L3) in Wistar albino rats. Nematode worms were isolated from the marine fish Dicentrarchus labrax. They were examined and taxonomically identified using light and scanning electron microscopy. The study was performed in 6 rat groups: a control group (I), a garlic oil (GO) inoculated group (II), a fresh L3 inoculated group (III), a thermally treated L3 inoculated group (IV), a fresh L3 + GO inoculated group (V), and a thermally treated L3 + GO inoculated group (VI). It was observed that rats inoculated with fresh and thermally treated L3 crude extracts showed abnormal oxidative stress markers associated with the destruction of normal architecture of spleen and thymus. GO produced a protective effect in rat groups inoculated with L3 extracts + GO administration via the amelioration of oxidative stress markers, which was confirmed by the marked normal structure of the organs' histology. Cooking of L3 infected fish induced severe physiological and histopathological alterations compared to uncooked infected fish. The administration of garlic before and after fish eating is recommended to avoid the dangerous effect of anisakids, even if they are cooked.(AU)

O consumo de peixes tratados termicamente de forma inadequada é um risco à saúde pública devido à possível propagação das larvas de Anisakis e suas proteínas antigênicas, o agente causador da doença zoonótica anisakidose. O presente estudo demonstrou as alterações fisiológicas e histopatológicas que acompanharam a inoculação oral de extratos brutos de Anisakis Tipo II (L3) frescos e termicamente tratados em ratos Wistar albinos. Vermes nematoides foram isolados do peixe marinho Dicentrarchus labrax e foram examinados e identificados taxonomicamente usando microscopia óptica e eletrônica de varredura. O estudo foi realizado em 6 grupos de ratos: grupo controle (I), grupo inoculado com óleo de alho (GO) (II), grupo inoculado com L3 fresco (III), grupo inoculado com L3 tratado termicamente (IV), grupo inoculado com L3 + GO fresco (V), e grupo inoculado com L3 + GO tratado termicamente (VI). Observou-se que ratos inoculados com extrato bruto L3 fresco e tratado termicamente mostraram marcadores de estresse oxidativo anormais associados à destruição da estrutura normal do baço e do timo. GO produziu um efeito protetor em grupos de ratos inoculados com extrato L3 + administração de GO através da melhoria dos marcadores de estresse oxidativo, que foi confirmada pela marcante estrutura normal da histologia dos órgãos. O cozimento de peixes infectados com L3 induziu alterações fisiológicas e histopatológicas graves quando comparado com peixes infectados não cozidos. Recomenda-se a administração de alho antes e depois da ingestão do peixe para evitar o efeito perigoso dos anisakídeos, mesmo se cozidos.(AU)

Anisakidosis: report of 25 cases and review of the literature.

Anisakidosis (previously known as anisakiasis) is a disease caused by the accidental ingestion of larval nematodes (Anisakis and sometimes Pseudoterranova) in raw fish. Two groups of patients are studied: 5 clinical cases and 20 serological diagnoses. 55 French cases are already published. Most of them complained of acute symptoms, which occurred within 12 h of eating the seafood meal--epigastric pain, occlusion, diffuse abdominal pain, and appendicitis. Larvae were attached to the gastric mucosa (25 cases), including an inflammatory response (erythema, oedema ulceration). Diagnosis of anisakiasis is made by gastroscopy which allows removal of the worms, and cures the patients. In gastro-intestinal tract X-rays, oedema in the mucosa, pseudo tumour formation, and filling defects (worm) were observed. In chronic infections, cases with intermittent feelings of ill health and abdominal pain, lasting from several weeks to months, were misdiagnosed as another intestinal disease. Positive serological reactions are helpful, and surgery is necessary for resection of the lesion; diagnosis is made histologically by an eosinophilic granuloma, and the presence of a larva with Y shaped lateral cords. Infestation rate is high in fishes: cod (88%), rock fish (86%), herring (88%), salmon, mackerel. Public health education should discourage the eating of raw fish. Thorough cooking to 70 degrees C or adequate freezing to -20 degrees C for 72 h are the best preventive measures. Such legislation is only in force in the Netherlands, where cases have decreased dramatically.

[Gastric anisakidosis: personal experience]. / L'anisakidosi gastrica: esperienza personale.

Anisakidosis is a parasitic disease of the human gastrointestinal tract caused by ingestion of marine nematode larvae such as anisakis simplex or, rarely, Pseudoterranova, present in raw or undercooked fish. Frequent sites of involvement by anisakis are the stomach, small intestine, rarely the colon, or the peritoneum, liver, pancreas, lung and tonsils, anisakidosis is a self-limiting disease; the symptoms arise 12-24 hours after ingesting raw fish and include nausea, diarrhoea, and severe abdominal pain, but also anaphylactic reactions. At the site of penetration, anisakis causes marked oedema, eosinophilic infiltration and granuloma formation. There are haematological abnormalities such as marked leukocytosis of the peripheral blood, eosinophilia, and positive PCR and serum antibodies to the larva's surface antigens. The diagnosis of anisakidosis can be made by endoscopy, radiology and US, but the disease is often diagnosed at surgical intervention. In the gastric form of anisakidosis, EGIDS has both a diagnostic role and a therapeutic one because it is possible to remove the worm using biopsy forceps. We report on one case of gastric anisakidosis, in a women, hospitalised for intense epigastric pain and vomiting after ingesting raw fish. She underwent gastroscopy. A worm was extracted from the gastric mucosa using biopsy forceps. This was followed by clinical improvement. The worm was identified by its macroscopic and microscopic characteristics as an anisakis larva. At laboratory examination, marked leukocytosis and eosinophilia of the patient's peripheral blood were observed 3-4 days after ingestion of anisakis.

[Angina-like chest pain due to gastric anisakiasis]. / Dolor torácico como manifestación inicial de anisakiasis gástrica.

The chest pain is one of the most common reasons for consultation of the patients seen in the emergency services of hospitals. Still being the acute coronary syndrome one of the first causes to confirmed by its important repercussions, we do not have to forget other reasons. We report a case of acute anginalike chest pain due to gastric anisakiasis. The larvae of Anisakis in the gastric mucosa were found and extracted endoscopically. Gastric anisakiasis should be included in the differential diagnosis of acute chest pain.

[Anisakiasis: a borderline disorder]. / Anisakiasi: una patologia di confine.

Anisakis simplex is a nematode which can parasitize many different kinds of fish or cephalopods (codfish, salmon, tuna, mackerel, hake, etc). Anisakis simplex can cause different diseases in humans. The human being acquires the larvae by eating raw or undercooked seafood. Acute anisakiasis is probably caused by an inflammatory and/or allergic response in the digestive tract mucosa with abdominal pain. It can also induce IgE-mediated reactions with several clinical manifestations ranging from urticaria/angioedema to anaphylaxis. Chronic anisakiasis results from abscesses or eosinophilic granulomas caused by parasite invasion. This later form can mimic appendicitis, duodenal ulcer, inflammatory bowel diseases and intestinal obstruction. An early gastroduodenoscopy can confirm the diagnosis and prevent the complications. Serodiagnosis of anisakiasis is difficult since many Anisakis antigens show cross-reativity complications. In fact many people have high IgE titles in the absence of obvious allergic reactions to seafoods. As preventive measures heating for 10 min over 65 degrees C or freezing (minus 20 degrees for 24 h) destroys the infectivity of the larval stage but not always prevent allergic reactions.

Intestinal anisakiasis treated successfully with conservative therapy: importance of clinical diagnosis.

Intestinal anisakiasis is not only a rare parasitic disease, but is also difficult to diagnose. The symptoms are not specific and are often very severe and abrupt, and the findings of clinical imaging are very remarkable. Therefore, intestinal anisakiasis is often misdiagnosed as acute abdomen or intestinal obstruction and is treated surgically. However, if intestinal anisakiasis could be diagnosed correctly, it is well treated conservatively. We experienced three cases of intestinal anisakiasis, which were diagnosed correctly and treated successfully with conservative therapy. A correct clinical history and imaging interpretation helped us diagnose intestinal anisakiasis correctly and thus treat the patients successfully with conservative therapy.