History of Spirometra Erinaceieuropaei

A uncommon species of tapeworm known as Spirometra Erinaceieuropaei is typically found in nations in eastern and southeastern Asia like Japan, Thailand, South Korea, Vietnam, and China (Zhang, Cui and Liu). Rudolphi collected the tapeworm larvae from a European hedgehog in 1819, whereas dogs were given adult forms raised from larvae discovered in Chinese hedgehogs. Rudolphi identified these larvae as the erinaceieuropaei species. The cestode Spirometra Erinaceieuropaei's plerocercoid larva can infect both domestic animals and people. The Spirometra Erinaceieuropaei's primary hosts are carnivores like dogs and cats, however in humans, the plerocercoid larvae do not reach adulthood. Sequencing its genome showed that it contains around ten times more DNA than any other tapeworm sequenced so far, which could explain its ability to invade many different species. Over 8 to 14 days the released unembyronated eggs embryonate in water and eventually hatch and the hatched eggs release coracidia which parasitize copepod and finally grow into procercoid larvae. (Bennett, Mok and Gkrania-Klotsas). The development of the plerocercoid larvae also known as sparganum occurs in a vertebrate host such as frog, snake after ingestion and remain in the tissues of the host. Once the host organism is ingested, the infectious larval stage is passed on to the organism. In humans, plerocercoid larvae also known as spargana can cause a severe parasitic disease known as sparganosis by lodging itself in the subcutaneous tissues, muscles as well as invade eyes, the central nervous system and the abdominal cavity (Farrar, Hotez and Junghanss). The sparganum in humans have a flat body with a longitudinal median groove and is transversely wrinkled (Zhang, Cui and Liu). Consumption of raw flesh of both the snakes and frog infected with the spargana, utilization of flesh of snake or frog for the treatment of eye inflammation or skin ulcers as a poultice on an open wound and drinking contaminated water infested with cyclops containing procercoids can lead to infection.

Pathophysiology of Spirometra Erinaceieuropaei

When the larvae migrate to the superficial muscles such as the abdominal wall, chest wall, scrotum, lower extremities and subcutaneous connective tissues a subcutaneous sparganosis occurs. Under the skin, a lesion appears accompanied with a palpable, rubber-like and irregular lump that resembles a movable lipoma cyst that grows slowly becoming itchy, inflamed and very painful. Without any significant symptoms other than pain the nodules may persist for months, and sometimes clephantitis may appear in sites associated with the lymph channels (D. Liu). Subcutaneous nodules can form in labia, scrotum, ureter, epididymis, groin and the urinary bladder in cases of genital sparganosis and sometimes it may appear tumor-like. Damage or malfunction of the tissues such as the breast, abdominal cavity, pericardium, pleura and intestine dues to the migration and growth of the larvae results from visceral sparganosis. Intestinal perforation, as well as obstruction, can be caused by sparganosis. When the larvae migrate to the orbit and the conjunctiva, it causes ocular sparganosis. In the posterior pole, the larvae may induce exophthalmoses, protrusion of the eyeball, periorbital edema and lagophthalmia which results in the excessive watering of the eye, eye pain, drooping of the upper eyelid, swelling of the eyelids irritation, cornea ulcer and orbital cellulitis. However, these symptoms can lead to blindness if the ocular sparganosis is left untreated (D. Liu). Cerebral sparganosis may appear as a cerebral hemorrhage due to the movement and growth of larvae in the cerebral hemispheres especially the frontal parietal lobes and cerebellum. The invasion of the spargana in the spine or brain can result in some various neurological symptoms. The invasion of the spargana in the subcutaneous regions and tissues such as the bones cause proliferative sparganosis which undergoes continuous branching and budding producing a large number of plerocercoids in a single site that results to a fatal human sparganosis. Proliferative sparganosis starts with an open, tumor-like subcutaneous nodule due to the ulceration in the shoulder, neck or thigh and spread further to other parts muscles, internal organs such as lung and muscles.

Clinical signs of Spirometra Erinaceieuropaei

Clinical symptoms of Spirometra Erinaceieuropaei depend on the site of entry and size of lesions and the signs range from mild or asymptomatic signs such as subcutaneous swelling to severe signs such as hemiparesis, eosinophilia and seizure. After the first week of inoculation of the larvae in the soft tissue, tunnel-like structures appear in two weeks and patients with human sparganosis experience an inflammatory cell infiltration (D. Liu). Between 4 weeks and six months post infection, a fibroblast proliferation occurs. Plerocercoid larvae located in some vital organs and central nervous system can lead to headaches, blindness, seizures, epilepsy, paralysis and sometimes death. The patient may experience deafness or vertigo if the spargana are situated at the inner ear. The migration of the larvae in the subcutaneous tissues is painless and led to the development of nodular mass or cyst however the patient may also experience some abnormal skin sensations such as tingling and numbness.

Global Epidemiology of Spirometra Erinaceieuropaei

According to the epidemiological data suggest that the increase in consumption raw flesh of freshwater frogs and snakes contribute to the growth in the effects of sparganosis on human health. By 2015 more than 300 cases of the human sparganosis have been reported globally and about 300 cases of human sparganosis by 2003 and 19 of the cases were ocular sparganosis. Throughout North America sparganosis occurs in animals and sparganosis human cases are rare however the first case of human infection in the United States was reported in 1908. In 1882 the first case of human sparganosis was reported in Xiamen of Fujian province, China. However, the two earliest cases of spargana in Hong Kong were reported in 1962, and they were subcutaneous infections. Most cases of Sparganosis occur in Eastern and Southeastern Asia; however, sparganosis is world spread as other cases have been reported in about 39 countries. South America, Africa, Australia Greece and the United States have published a considerate number of sparganosis cases and drinking contaminated water is the common cause of spargana infection. In Europe, where 2 cases in France and 5 in Italy the seven cases of sparganosis were reported by 2002. About 37 cases of sparganosis in Ethiopia and South Sudan present worms emerging from open wounds suggesting a diagnosis of dracunculiasis (D. Liu).

Human spargana is endemic in countries such as India, Thailand, Vietnam, Japan, China and South Korea as most locals consume raw or inadequately cooked frog or snake flesh as most of the people consider it a delicacy (Zhang, Cui and Liu). Since 1999 China has the largest number of sparganosis cases in the world with 27 out of 34 provinces in China reporting about 1000 cases of human sparganosis of which 10% of these cases occur in Guangdong Province. Also, the local cases have increased in recent years, and sparganosis has even been termed as emerging enzootic diseases in several districts of China (D. Liu). Between 1943 and 2010, approximately 52 cases of human sparganosis were reported in Thailand. In Thailand sparganosis is not only caused by the consumption of contaminated food but also the local tradition of using frog flesh, probably contaminated with sparganum, as treatment of sore eyes.

Sociologic and Ecologic Factors that Impact its Emergence or Reemergence of Spirometra Erinaceieuropaei in China

The practice of consuming wild frog flesh as a delicacy commonly in the southern Guangdong province has made sparganosis an emerging zoonotic disease as well as a public health challenge in China. Epidemiological investigations have found that spargana infections in frogs are very common in China.

In a recent survey, the prevalence in frogs was on average 22.2%, ranging from 3.2% to 90.9%. Approximately 25% of local wild frogs found in Guangdong province were infected with spargana according to a 2009 survey (Wang, Li and Hua). About half of local food restaurants in Guangzhou serve wild-caught snakes as many locals enjoy consuming the half cooked snake as well as completely raw snake flesh, skin or gall bladder assuming the high risk of infections related to parasites leading to annual trade volumes of about 3612 tons (Lia, Songb and Lic).

Between 2006 and 2008 Henan Province reported 20 cases of sparganosis while Guangdong reported cases between 2000 and 2002 and these cases were caused by the unusual act of swallowing live tadpoles (Cui, Lin and Zhang). According to a recent study, Henan Province reported, 11.93% of tadpoles are infected with plerocercoids, and 3.53% of cyclops are infected with procercoids. Locals in some provinces in China swallow snake sacs or sometimes live tadpoles as a method to reduce fever. The Hainan Island, China practice the Chinese custom of applying a raw split frogs to sores on the hands or inflamed eyes that facilitate the entry of larvae causing ocular sparganosis. Consumption of rats, pigs, ducks and hens has been recorded as to create sparganosis in China (Lia, Songb and Lic). Dogs and cats also play a significant role in the emergence of sparganosis to human especially homesteads that keep them as pets.



Conclusion

Given that human sparganosis is an emerging zoonotic parasitic infection, clinicians may consider it in the differential diagnosis of mass lesions with undetermined etiology. Sparganosis not only poses a grave threat to human health but also causes significant economic losses. However, knowledge regarding the distribution of the pathogen of this disease, the genetic characteristics of its populations about local environmental conditions is valuable for the prevention and control of sparganosis in humans. Drinking water contaminated with infected copepods or the consumption of under-cooked or raw flesh humans can acquire sparganosis (Lia, Songb and Lic). Education on food safety to the general public, including avoiding the consumption of untreated water and undercooked frog and snake meat is highly recommended (Lia, Songb and Lic). Regular treatment of cestodiasis in animals such as dogs and cats is recommended as a preventive measure against sparganosis by eliminating the infectious source.

The cultural practice of application of raw flesh and skin of snakes or frogs on open wound should be regulated, or more caution is practiced. To protect the ecological environment countries should prohibit the illegal killing and trading of native wild frogs and snakes. Moreover, authorities should apply more effort to ensure the reduction in hunting and sale of all native species. Other more efficient and safe treatment methods for fever should be utilised.

Although the parasitic drug praziquantel has comprehensive coverage against several cestodes and trematodes, its efficacy in the treatment of sparganosis remains uncertain. Surgical intervention for complete worm removal should be used whenever feasible.



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