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Home Eurosurveillance Weekly Release  2007: Volume 12/ Issue 29 Article 4
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Eurosurveillance, Volume 12, Issue 29, 19 July 2007
Articles

Citation style for this article: Schmiedel S, Kramme S. Cluster of trichinellosis cases in Germany, imported from Poland, June 2007. Euro Surveill. 2007;12(29):pii=3240. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3240

Cluster of trichinellosis cases in Germany, imported from Poland, June 2007

S Schmiedel (sschmiedel@bni.uni-hamburg.de)1, S Kramme2

1. University Medical Centre, Hamburg, Germany
2. Bernhard-Nocht institute for Tropical Medicine, Hamburg, Germany

In this article we describe the clinical presentation of a cluster of trichinellosis cases in a German family.
Trichinellosis is caused by Trichinella spiralis and other closely related species and has a worldwide distribution. Humans, as well as other mammalian species, become infected when eating raw or undercooked contaminated meat [1]. Over the last years no reports of trichinellosis in domestic animals were documented in Germany, while cases have been reported from Lithuania and Poland until 2004 [2].

Treatment and clinical development
Two patients, father and daughter, presented to our infectious disease clinic at the end of June, complaining of severe muscle pain, abdominal pains, swelling of the face and low grade fever. They reported visiting the town of Bytow in Poland about four weeks earlier where they bought and consumed pork meet and sausage in a local butchery. On the way, they also bought sausage in the city of Nowogard in West-Pomerania.

Trichinellosis was suspected on the basis of the clinical presentation and history. A marked eosinophilia was detected in both patients and the father also showed highly elevated liver (ALAT/ASAT 259/348 U/L) and muscular (CK 6000 U/L) enzymes as a sign of hepatitis and rhabdomyolysis. Both patients were treated with albendazole. Due to the severity of symptoms the father was also given prednisolone.

The patient informed us that his wife had been admitted to a hospital with fever, diarrhoea, abdominal pain and myalgias and was treated with broad spectrum antibiotics. She was transferred to our hospital with signs of hepatitis and rhabdomyolysis, and eosinophilia (eosinophils 51%, 6300/µl). Her electrocardiogramme (ECG) on the day of admission was normal, but when albendazol and prednisolon treatment was started on the next day, the ECG showed irregularities. On the same evening, she collapsed, had a cardiac arrest and had to be resuscitated. She was transferred to the intensive care unit where she was monitored until the antiparasitic therapy had been completed.

The clinical diagnosis was confirmed by serological testing in all three patients on 28 June (two days after collection of samples). All patients showed elevated anibody titres against T. spiralis in enzyme-linked immunosorbent assay (ELISA) and immunoblot. The commercial ELISA (DRG Diagnostic) uses an excretory-secretory antigen obtained from T. spiralis larvae whereas the Western Blot contains crude larval extract antigen.
These results may also support an infection with Trichinella spp. other than T. spiralis. Due to the clear clinical picture, together with the serological results, further diagnostic procedures were not initiated. The Trichinella species that caused the infection was therefore not identified.
After completion of antiparasitic therapy all three patients fully recovered.

Discussion
The clinical picture of trichinellosis is directly related to the number of larvae ingested and has two clinical stages: the intestinal stage and the muscular stage. Larval migration into the muscles can cause facial oedema, subungual, conjunctival and retinal haemorrhages, muscle pain, weakness, and fever [3]. The tropism of T. spiralis for striated muscle can cause the myocardium to be affected in 21–75% of infected patients. Complications such as cardiac arrhythmias are considered the most common cause of death associated with trichinellosis [4]. T. spiralis-associated myocarditis is not caused by direct invasion and encystation of larvae in the myocardium but is probably induced by an inflammatory response resulting in eosinophilic myocarditis [5].

The clinical suspicion of trichinellosis is based on the epidemiology associated with the typical clinical presentation and the presence of eosinophilia. Confirmation is based on serology and, if those results are equivocal, on muscle biopsy. The treatment consists of the administration of albendazole or mebendazole in conjunction with steroids for severe cases.

References:
  1. Pozio E, Gomez Morales MA, Dupouy-Camet J. Clinical aspects, diagnosis and treatment of trichinellosis. Expert Rev Anti Infect Ther. 2003;1(3):471-82.
  2. EFSA. First Community Summary Report on Trends and Sources of Zoonoses, Zoonotic Agents and Antimicrobial resistance in the European Union in 2004. Available from: http://www.efsa.eu.int/science/monitoring_zoonoses/reports/1277_fr.html
  3. Akar S, Gurler O, Pozio E, Onen F, Sari I, Gerceker E, et al. Frequency and severity of musculoskeletal symptoms in humans during an outbreak of trichinellosis. J. Parasitol. 2007;93(2):341-4.
  4. Franco-Paredes C, Rouphael N, Méndez J, Folch E, Rodríguez-Morales AJ, Santos JI, Hurst JW. Cardiac manifestations of parasitic infections. Parasitic myocardial disease. Clin Cardiol. 2007;30(5):218-22.
  5. Andy JJ, O’Connell JP, Daddario RC, Roberts WC: Trichinosis causing extensive ventricular mural endocarditis with superimposed thrombosis. Evidence that severe eosinophilia damages endocardium. Am J Med. 1977;63(5):824–829.

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