TWiP 163 letters | This Week in Parasitism

Paul writes:

Halzoun is the local name of a buccopharyngeal infection occurring in Lebanon, probably caused by pentastomida larvae of Linguatula serrata (dog tongue worm) which wander into the throat of the human host after ingestion of infected raw liver or lymph nodes from sheep or goats’. Wikipedia

—

Paul J. Brindley, Ph.D

Brindley lab

Research Center for Neglected Diseases of Poverty, Department of Microbiology, Immunology & Tropical Medicine, School of Medicine & Health Sciences, The George Washington University

Bjorn writes:

Hi Doctors

I will be brief:

If the meat was the source, and we’re only looking at parasites, then the clinical signs fits neither tapeworms (Neither beef nor pork tapeworm) nor trichinosis, and using the “when hearing hoofbeats, look for horses” heuristic, the obvious choice is … Toxoplasma gondii: The world’s most successful parasite 🙂

This parasite can infect essentially any mammalian cell, so it stands to reason that it can also infect epithelial cells in the throat too, and indeed the PD6E page 146 does list pharyngitis and lymphadenopathy as possible consequences of an T. Gondii infection. I am sure a _much_ longer list of differentials and ways to distinguish between them can be made, but I won’t do that 🙂

I won’t elaborate much on treatment, except to say that if the lady is immune competent, is not pregnant and do not plan to get pregnant in the immediate future, this infection will probably clear itself, and no medication is indicated. If any of the above criteria _are_ present PD6E lists a variety of drugs, but there also seems to be a set of tricky tradeoffs that needs to be done to determine the best treatment, or if if lack of treatment is the best option so I won’t even try to elaborate.

I guess I am now a long time listener of TwIP (four years or so). It continues to be a joy to listen to you. You also serve as a healthy reminder that there is an interesting world out there that with other things in it than telecommunications software, which is what I usually spend my days developing and thinking about.

All the best.

Bjørn

John writes:

Hello Doctors of TWiP,

My guess for the case from TWiP 162 of the woman who visited Lebanon and ate the raw meat dish is Toxoplasmosis, probably acquired by eating Chekov’s raw meat dish.

I base my guess on a video that I recently watched from the Parasitic Diseases playlist (starring a couple of likely lads, both of whom had eerily familiar voices) .

( https://www.youtube.com/watch?v=eL0X_C6azmY&t=684)

The particular section of the video that stood out was: [excerpt from the transcript so the translation is a little wonky]

“What you ate for dinner might have been something that looked like this rack of lamb or a rare steak.

That’s the way we usually acquire the infection, so by ordering our meals rare or medium rare (in this case a rack of lamb) but of course a lot of us like our steaks not well-done.

You order a hamburger medium rare you’re running a risk at that point of acquiring toxoplasmosis and that’s why it’s such a ubiquitously distributed infection in humans. Some statistics will serve to point that for instance in France by the time you reach the age of 20 about 80% of the population has some evidence of being infected with

Toxoplasma gondii and that’s true for a lot of other countries as well.”

Those are the sage words of Dr. Despommier from the Toxoplasmosis video.

The symptoms of posterior cervical lymphadenopathy and sore throat are common with toxo, though Dr. Google surprised me when it showed me that the posterior cervical lymph nodes are actually in the neck. That was not where I was expecting them to be based on the name. It turns out that I don’t know my posterior cervix from my elbow. If I had remembered Daniel’s audio presentation, he mentioned “lymph nodes in the neck” but Vincent’s text notes mention “posterior cervical lymph nodes”.

The “Parasitic Diseases 6ed” pdf has a differential diagnosis table (table 11.2, p146) to help distinguish between various other causes of lymphadenopathy.

Dr. Griffiths didn’t mention many other symptoms (general malaise, low grade fever). More rare parasitic possibilities that also cause lymphadenopathy are lyme disease and tularaemia but there was no mention of tick exposure and no mention of a rash or bite ulcers. An IgM test can determine if the toxoplasma antibody is present since the patient had the potential exposure to toxo within the previous 3 weeks.

I’ll refrain from offering treatment options as I have already demonstrated my medical weaknesses enough for one day and who knows how I might suggest the medicine would be administered.

Thanks for the great podcast, book and lecture series and season’s greetings to you and yours and all the best in the new year.

Regards,

John Mullin,

Limerick, Ireland, where it is a crisp, clear 0 degrees C tonight.

Kendra writes:

Dear TWiP professors,

Hello from Casper, Wyoming. It is sunny and 33°F or 1°C. My guess for TWiP Case Study 162 is Toxoplasmosis gondii. A Toxoplasmosis gondii infection is usually asymptomatic, however, it can cause enlarged lymph nodes particularly the cervical nodes and can cause a low-grade fever. It may be transmitted by eating raw meat which contain pseudocysts. It is possible she became infected after eating the raw kibbeh. Serologic testing to measure IgG can determine toxoplasmosis infection. Treatment for toxoplasmosis is a combination of pyrimethamine and sulfadiazine.

Best,

Kendra

References

Parasite Diseases Sixth Edition Dickson D. Despommier, Daniel O. Griffin, Robert W. Gwadz, Peter J. Hotez, Charles A. Knirsch

https://www.sciencedirect.com/topics/medicine-and-dentistry/cervical-lymphadenopathy

Lang, S., & Kansy, B. (2014). Cervical lymph node diseases in children. GMS current topics in otorhinolaryngology, head and neck surgery, 13, Doc08. doi:10.3205/cto000111

Acquired toxoplasmosis of a submandibular lymph node in a 13-year-old boy: case report Badri Azaz, DMD Isaac Milhem, DMD Oscar Hasson, DMD Gina Kirsch, DMD http://www.aapd.org/assets/1/25/Azaz-16-05.pdf

https://www.cdc.gov/parasites/toxoplasmosis/diagnosis.html

Adam writes:

Hi!

My guess for the case in TWiP 162 is toxoplasmosis. It’s the only relevant parasite I know of that cases low grade fever and lymphadenopathy.

Best regards,

Adam,

Halmstad, Sweden (where it’s sunny, clear sky and no wind, -5 degrees C).

Brandon writes:

Dear Doctors of Awesome,

This is my second e-mail submission, my first submission was shortly after discovering TWiP about 3 years ago. At that time, I had omitted Dr. Griffin from the e-mail. This was not intentional but only due to the fact that I had only listened to the first 10 episodes for which Dr. Griffin was not a part of. Due to the nature of my schedule which includes working full time developing analytical assays in the animal health industry, part time graduate student at the University of Nebraska Lincoln, and in the beginning stages of starting a company to develop novel treatments and diagnostics for people and animals that are envenomed by snakes, spiders, and scorpions, I always find that my attempts to answer the case studies are on the wrong side of time.

Although I am in awe of the detailed responses many of the listeners provide, my guess is going to be straight to the point with not much of a differential. I believe the woman has toxoplasmosis caused by Toxoplasma gondii. The combination of raw meat consumption along with fairly mild symptoms of someone who appears to be immunocompetent from the information provided lead me to immediately consider T. gondii. Majority of immunocompetent adults who acquire T. gondii are asymptomatic, but those that do show symptoms typically present with enlarged lymphnodes in the cervical area and occasionally a low grade fever. The fact that many are asymptomatic would explain why she exhibited symptoms while her husband did not and was probably exposed in the past since he has consumed this raw meat meal throughout his life. Diagnosis can be confirmed through either PCR or looking at IgM antibody response within 2 weeks or IgG antibody response after 2 weeks. Due to the mild symptoms, no treatment is necessary. It was not mentioned or asked if the patient was pregnant. If the patient is indeed pregnant than treatment would be necessary to prevent infection of the fetus. The treatment that can be provided to someone who is pregnant with a T. gondii infection is spiramycin, a macrolide antibiotic.

Thank you for your contribution to science communication. I look forward to starting my own podcast about venomous animals by the end of the year due in part by inspiration from listening to the TWiX podcasts.

Brandon Russell

Lincoln, NE

Kevin writes:

A raw deal.

Young woman, ate raw meat in Lebanon three weeks ago. Presents with pharyngitis, posterior cervical adenopathy and low grade fever. Previously healthy. The case notes did not specify if the raw meat was wild or domesticated, nor did it speciate the flesh: was it pork, beef, lamb, goat, horse, poultry or reptile? (see endnotes) Case also states that her raw meal may have been washed down with some local liquor. Patient didn’t become ill until approximately three weeks after consuming the suspect food.

This case, alas, has opened numerous digressive byways leading into theological territory (Islamic, Judaic and Christian), animal husbandry, gastronomy and the arcana of herbology. I will endeavor to spare the listener these tangential excesses and refer them to the endnotes, which if not a remedy for insomnia, will (as a Buddhist mantra) temporarily banish thought.

Most electronic medical records have a query field for a patient’s religion. This information, with all due respect to the pieties of holistic medicine, is often irrelevant. An important exception might be knowing that a surgical patient is a Jehovah’s Witness, since this faith prohibits blood transfusion. In our case however, knowing whether our patient was a Christian or devout Muslim could provide important clues to the diagnosis. More on this later.

Gastronomy part I: Lebanese raw flesh dishes could be the following:

1.kibbeh nayeh (nayyeh)—Kibbeh nayeh is usually made of minced raw lamb or beef, combined with bulgur, pureed onion and spices. The word nayeh (nayyeh) means raw or uncooked in Arabic.

The Oliason outbreak report (REF) states that kebbeh nayyeh is “a special kind of Lebanese salad prepared for celebrations such as Christmas and New Year.” In Oliason’s paper, the kibbeh was prepared with pork, which would only be used in Christian villages. Some sources state that this dish is traditionally served with arak (more on this below).

kubeniye–a local Lebanese specialty described in Haim’s 1997 paper. This may just be a dialect or transliteration of the more common term kibbeh nayeh. An internet food site simply translates kube niye as “raw meat”. Raw pork is known to be used for kubeniye, as it was in Haim’s report.
Sawda nayyeh (alternate spelling: sawda nayeh) or Asbeh Nayyeh raw lamb liver with spices. Sawda nayyeh is best paired with the Lebanese home made liquor arak according to wikibooks (ref)

These are the traditional and likely possibilities. Our patient’s exposure was certainly due to either pork, beef, lamb or a mixture thereof. Other types of raw meat are more likely in an Asian location.

Gastronomy part II: The liquor:

The overwhelming probability is that the local hooch consumed was arak , a distilled alcoholic beverage in the range of 40-50% alcohol (80-100 Proof) made from grape derived alcohol and aniseed (arak, Arabic for sweat, juice). Arak has been known to associate with the textbook PD6 (see endnote ‘A Terminal Curiosity’). It is regarded as the national drink of Lebanon, and is consumed widely in the Middle East. The taste is similar to the Greek ouzo, anisette, or Pernod (i.e. imitation absinthe). It is imbibed diluted with very cold water in a ratio of one part arak and two parts water. The case notes suggest that the our patient’s host assured her that the alcoholic drink would neutralize any adverse consequences of eating raw flesh. See references for putative health or pharmacologic effects of anise seeds (Pimpinella anisum) and the principal ingredient in its volatile oil: anethole. Is the conjunction of alcoholic beverages and parasitic disease coincidental or just a function of the ubiquity of both- I submit for your consideration the confluence of alcohol and parasites that occurs in TWiP 159 (toddy and amoeba) and TWiP 156 (Babesia and scotch).

Theological considerations:

US Department of State- religious demography of Lebanon (2016): 37% Christian, 57% Muslim, the remainder being Druze, Jews, Hindus, Buddhists etc. Statistics may give a slight edge in predicting the likelihood of pork consumption in our patient.

If the patient is a devout Muslim it is highly unlikely that she consumed pork (unless their butcher was unscrupulous). Islamic prohibitions of pork consumption parallel Judaic proscriptions as stated in Leviticus 11:7. The Koranic injunction: “Forbidden to you (for food) are: dead meat, blood, the flesh of swine, and that on which hath been invoked the name of other than Allah.” Al-Qur’an 5:3. On the other hand, if she was an orthodox Muslim, presumably she would not partake of arak. If the patient is Christian, she is at risk for the illness that is described in Haim’s 1997 paper.

Differential diagnosis; parasitological considerations or The Erection of the Straw Man

Viral (see ref) and bacterial food borne illnesses always come to mind when raw meat comes up. These diseases are acknowledged only to be dispensed with. CDC.gov will provide a comprehensive list of culprits. Parasitic diseases to consider here: protozoans, cestodes, nematodes.

Toxocara: A theoretical possibility (see reference which describes visceral larval migrans associated with ingestion of infected meat in Brazil). Unlikely here.

Ascaris: In a manner analogous to toxocara, it is possible that ingestion of infectious larva in undercooked or raw paratenic host meat could result in human infection. More than a long-shot here.

Taenia solium: A possibility whenever undercooked infected pork is ingested. I would not expect an acute presentation such as our patient exhibits. Insufficient to account for out patient’s presentation.

Taenia saginata: Can be acquired by ingesting undercooked beef. Generally asymptomatic. Not a consideration in our case.

Echinococcus- This infection is acquired when humans eat the ova excreted by dogs (definitive host). Contaminated leafy greens/vegetables is a typical route of infection. It is the dogs who eat the raw meat (often liver and other organs) and become parasitized by the adult. Not a consideration here.

Sarcocystis: acquired by eating undercooked or raw meat. Clinical manifestations: nausea, diarrhea and GI symptoms. Review from 2015 states that no cases are described from the Mid-East. (see REF). Not relevant.

Mesocystoides: Rare ( I do not mean undercooked, I mean rarely described) There has been a number of reports in Japan where many of the infections are related to the eating of raw snake meat. No implied judgement: Is there no raw flesh that is not consumed in Japan?

Trichinella: Trichinellosis (sometimes called trichinosis) is well documented in Lebanon from consumption of wild boar and more commonly farmed hogs. Several outbreak reports from Lebanon are referenced below. I think that it is unlikely that our patient was exposed to raw hog meat. It is more likely from a demographic perspective that this patient was consuming Halal meat (beef or lamb) which has almost no potential to transmit trichinella (references addressing the theoretical potential are below). Our patient does not exhibit the common clinical presentation for trichinella which is fever, myalgia and periorbital edema The Olaison review states that 91% of cases reported periorbital edema. Clinical suspicion would be raised if patient had eosinophilia, diagnosis would be via PCR, or ELISA with confirmatory Western blotting.

Toxoplasmosis: Ingestion of tissue cysts (bradyzoites) in undercooked or uncooked meat. 80-90% of acute infections in the immunocompetent host are asymptomatic. Presentation is similar to an acute viral syndrome/ mononucleosis-like illness with fever, malaise, myalgias, cervical adenopathy, pharyngitis. One cohort review states that 88% of acutely infected patients had cervical adenopathy. These descriptions closely parallel our patient’s clinical complaints. Less common is hepatosplenomegaly and ocular involvement. Toxoplasma seroprevalence in Lebanon is extremely high compared to the United States; approx 80% IgG positive in Lebanon vs 9% in US. These figures alone attest to the high probability of exposure to this parasite in Lebanon. According to PD6 diagnosis is via PCR or serology for IgG and IgM. If not pregnant our patient can

be treated with pyrimethamine and sulfadiazine. If Pharma-Bro’s pyrimethamine is too expensive an alternative is trimethoprim sulfa or atovaquone. I submit that our patient is suffering from acute toxoplasmosis.

Wishing all New Year greetings and untainted meat.

ENDNOTES, REFERENCES AND A TERMINAL CURIOSITY

Gastronomy references:

From the menu of the Ishbilia Restaurant, 8-9 William Street, Knightsbridge, LONDON SW1X 9HL,

Tel. 0207 2357788

Kibbeh Nayeh (n) £12.00

Lamb tartar blended with cracked wheat, spring onion, fresh mint, cumin, topped with mixed nuts and olive oil.

Habrah Nayeh (n) £12.50

Tartar of lamb served with a side of garlic sauce.

Fatayel Ghanam £13.00

Diced prime cut of raw lamb fillet. (Not available Sat/Sun)

Sawda Nayeh £12.50

Diced raw lamb liver served with a selection of spices. (Not available Sat/Sun)

Ishbilia Nayeh Platter (n) £45.00

A selection of the above specialities accompanied with assorted spices and garlic sauce. (Not available Sat/Sun)

https://www.tripadvisor.com/ShowUserReviews-g293986-d1371269-r176673693-Fakhreldin_Restaurant- Amman_Amman_Governorate.html#

This is a review of a Lebanese restaurant in Jordan. The reviewer praises the raw meat dishes.

http://www.onplatestillhungry.com/story/raw-lamb-in-lebanon-kibbeh-nayeh

“…feasting on Kibbeh, variety of lamb dishes unique to Lebanon, including raw lamb liver and drinking arak — national Lebanese alcohol — till the sun goes down….We also had raw lamb fillet simply cut into

small pieces, eaten with salt, black pepper, chili powder, marjoram and cumin.”

https://www.sainsburysmagazine.co.uk/lifestyle/food/10-things-you-never-knew-about-lebanese-food

“Traditionally, the national dish of Lebanon, Kibbeh Nayyeh, (a raw lamb mince dish with bulgur wheat and spices), is eaten with Arak – a very strong aniseed-based alcoholic drink. The alcohol content is supposed to kill the bacteria in the raw meat – that’s what I was told.”

Here we go again with the putative protective effects of arak.

https://www.npr.org/sections/thesalt/2013/02/06/171301501/why-lebanese-love-their-raw-kibbeh

source https://en.wikibooks.org/wiki/Cookbook:Cuisine_of_Lebanon

kubeniye, a mix of raw beef, cooked beef and bulgur,Amy Spiro July 20, 2015, The Jerusalem Post.

The “kube Niye”( raw meat ) was a gourmet dish I will never forget , and all the rest was heaven on earth! I was told they have another branch in Lebanon and maybe in Paris, I’m not sure, but if they do, I’ll be the first one knocking on their elegant wooden door..!

torisashi-Japanese word describing raw chicken (source: Wikipedia)

Torisashi is a Japanese dish of chicken cut into strips and only cooked long enough to sear the outer layer, leaving the inside pink.There are many risks associated with consuming torisashi as the inside is left raw.

Chicken sashimi, difficult to imagine, but it is served in Japanese restaurants. “It’s popular in Japan, where raw chicken – often referred to as chicken tartare or chicken sashimi – is found on many menus.” https://www.independent.co.uk/life-style/food-and-drink/chicken-sashimi-eat-risk-food-poisoning-bacteria- salmonella-campylobacter-experts-a7935591.html

Bickerstaff’s brainstem encephalitis after an outbreak of Campylobacter jejuni enteritis, Masahiro Mori et al, Journal of Neuroimmunology 196 (2008) 143–146

In order to demonstrate that the eating of raw chicken is not some fictional internet meme, see M Mori J Neuroimmuno referenced above:

Twenty-eight patients suffered Campylobacter jejuni enteritis after eating raw chicken

Horse sashimi most common is basashi–horse sashimi

How arak is made: http://sidchidiac.com/oil/making-arak.htm

variant spellings of arak: (or arrak, arack, aracke and other variant spellings)

Wikipedia on arak:

The word arak comes from Arabic ʿ araqع,ر ق meaning ‘perspiration’.[5] (I note that this is a very poor

translation, which would more accurately be termed sweat or juice) “Arak is commonly served with mezza, which may include dozens of small traditional dishes. In general, arak drinkers prefer to consume it this way, rather than alone. It is also consumed with raw meat dishes or barbecues, along with garlic sauce.”

Herbology references:

Question: Are these legitimate avenues of research that buttress contentions that Arak may mitigate or negate the dangers of raw meat consumption? RE: Anise….(Pimpinella anisum), volatile oil principal component: anethole

Medicinal uses of anise (Pimpinella anisum): https://www.thealternativedaily.com/13-medicinal-uses-anise-seed/

Claimed benefits of anise seed extract including “relieving lice and scabies” and “may increase libido”: https://www.botanical-online.com/english/anisemedicinalproperties.htm

Investigation of Biochemical Effect of Phenols Extract Isolated from Coriandrum sativum Seeds Against Echinococcus granulosus Parasite in Vitro, Abbas Dawwas Matter Al-Maliki

JOURNAL OF THI-QAR SCIENCE م جلة علوم ذ يقار Chemistry Department – College of Education – University of Basrah,Iraq

The article referenced below remarks on the antihelminthic effect of anise seed (Pimpinella anisum)–

A significant decreasing for Echinococcus granulosus protoscolices viability , was recorded by using alcoholic extract of Pimpinella anisum and Plantajo major.

Medicinal uses of anise (Pimpinella anisum): https://www.thealternativedaily.com/13-medicinal-uses-anise-seed/

Herbal Medicine and Parasitic Diseases Samia E. Etewa1, PUJ (Parasitologists United Journal) Vol. 4, No. 1, 2011–Pimpinella anisum; Anise (Al-Yanson)

“The active constituents in anise, particularly the terpenoid anethole, are in its volatile oil. Its uses for medication in parasitic diseases are due to its insecticidal and repellent effects. The acaricidal activity of anise seed oil against house dust mites Dermatophagoides farinae and D. pteronyssinus was about 8.4 and 6.7 times more toxic than benzyl benzoate, respectively. Besides its acaricidal activity, it was highly effective as both larvicidal and ovicidal against different mosquito spp. As Anopheles, Aedes and Culex. Moreover, its spray preparation had significant cure rates against head louse infestations.”

Anthelmintic activity of anethole, carvone, carvacrol, thymol, linalool, limonene, eucalyptol, vanillin, cinnamaldehyde and eugenol in in vitro tests, L Katiki 1,et al Planta Med 2014; 80 – P1L14

Screening of some Palestinian medicinal plants for antibacterial activity, T. Essawi et al, Journal of

Ethnopharmacology 70 (2000) 343–349

Commonly cited uses of Pimpinella anisum: “Helps in headaches and cold, Used as insecticides, Decreases coughing and chest pain. Pimpinella anisum…did not show any antibacterial activity.”

Theological references:

US Dept State: religious demography of Lebanon: https://www.state.gov/j/drl/rls/irf/2016/nea/268902.htm

“EVERYONE under the sky. Whether one goes to salafi inclined madhabis or la madhabis, all the way to sufi based madhabis, ALL concede that raw meats are HALAL (permissible). Yes halal. And yes, you did read correctly, RAW. I will end with this point concluding this section further below.”https://medium.com/@alboriqee/the-proper-fiqh-determination-on-eating-red-meat-beef-steaks-3f78a32c32c9

Parasitology references:

Transmission of common food borne viruses by meat products, Branko Velebita,,Procedia Food Science 5 (2015 ) 304 – 307

Highlights norovirus, hepatitis A, hepatitis E

[[Microbiological analysis of samples of crude kibbeh reveals the presence of enteropathogenic bacteria]].

Rodríguez-Roque SM1, Attie-Habelrih MG1, Figueroa-Espinosa RA2, Thomas LE2, Escalona-Pacheco AJ2, Báez- Ramírez EA2.Salud Publica Mex. 2018 Jan-Feb;60(1):105-106. doi: 10.21149/8703.

https://www.fsis.usda.gov/wps/portal/fsis/topics/recalls-and-public-health-alerts/recall-case- archive/archive/2013/FSIS-RC-008-2013

The 7 case-patients consumed raw beef kibbeh on December 7, 2012, and December 8, 2012. This reports a salmonella outbreak associated with kibbeh.

Toxocara spp. seroprevalence in sheep from southern Brazil, Rassier GL, Parasitol Res.2013Sep;112(9):3181-6.

The main risk factor for humans is the ingestion of the eggs from contaminated soil; however, infection can also occur through the ingestion of contaminated raw or undercooked infected meat from paratenic hosts. There are reports of human toxocariasis associated with the consumption of pork, lamb, poultry, meat or viscera, and raw cattle liver.

Larva migrans syndrome caused by Toxocara and Ascaris roundworm infections in Japanese patients

Yoshida, Eur J Clin Microbiol Infect Dis. 2016; 35: 1521–1529. Open access

A very large study that looked at over 900 patients diagnosed with Toxocara or Ascaris infection. Symptoms often pulmonary, ocular, or neurologic, as well as asymptomatic.

“More than two-thirds of the patients whose dietary habits were recorded had a history of ingesting raw or undercooked animal meat. LMS caused by Toxocara or Ascaris is primarily a disease of adult males in Japan, who probably acquired infections by eating raw or undercooked animal meat/liver.” “Humans acquire infection with these ascarid nematodes by ingesting embryonated eggs contaminating the soil or vegetables, or eating raw/undercooked paratenic host meat, such as chicken and beef, in which infective larvae reside. After the ingestion of eggs or infected meat, third-stage larvae invade intestinal mucosa, and migrate to various tissues and organs through blood or lymph vessels, eliciting potent immune responses with eosinophilic inflammation” “We found that, among 480 patients whose dietary habits were recorded, 326 patients (67.9 %) had a history or habit of ingesting raw or undercooked animal meat and/or liver. Consumed meat included chicken, beef, horse, wild boar and wild dear. Furthermore, when we took a close look at the seven patients younger than 10 years old, a 2-year-old girl had a history of ingesting slices of raw duck meat with her family”

Human Infections with Sarcocystis Species, Ronald Fayer, Douglas H. Esposito, Jitender P. Dubey Clinical Microbiology Reviews Feb 2015, 28 (2) 295-311 OPEN ACCESS

Massive review. “Humans with intestinal sarcocystosis (Fig. 1) have been identified worldwide, with the exception of Africa and the Middle East, although such infections likely occur there given customs of eating raw or undercooked meat in those areas.”

Mesocestoides lineatus, Anastasia Bowman, Jun 16, 2014 http://www.aavp.org/wiki/cestodes/cyclophyllidea/mesocestoididae/mesocestoides-lineatus/ Here follows a Brazilian study describes some disease transmission by kibbeh ingestion!

Outbreak of Acute Toxoplasmosis, Anapolis, E Renoiner et al Goias State-Brazil, 2006

wahis2-devt.oie.int/doc/ged/D3728.PDF

After several participants of a barbecue in Anápolis, Goías State, had suspected AT, an investigation was conducted to identify infection source, risk factors and recommend prevention and control measures.

… a retrospective cohort study…706 participants, 612(87%)…. 61(10%)… Attack rate was 19.4%, of which 59(97%) were symptomatic. Symptoms included malaise(88%), fever(85%), headache(81%), lymphadenopathy (78%), myalgia(68%), and arthralgia(59%). Median incubation period was eight days(range:2-27), and median symptom duration was 46 days(range:26-58). Persons consuming a traditional dish of raw beef (Kibbeh) prepared at one location had an attack rate of 19%, a 10-fold increase compared to unexposed persons (95%CI=4.2-24.9; p=0.01). Of six pregnant women, two had AT. During follow-up one infant was born with three brain calcifications.

Toxoplasmosis as a travel risk.,Sepúlveda-Arias, J. C.,et al Travel Medicine and Infectious Disease, 12(6), 592–601.(2014). doi:10.1016/j.tmaid.2014.05.007

Seroprevalence of Anti-Toxoplasma gondii Antibodies Among Lebanese Pregnant Women, Nahouli H, Vector Borne Zoonotic Dis. 2017 Dec;17(12):785-790. doi: 10.1089/vbz.2016.2092. Epub 2017 Oct 24.

The seroprevalence of anti-T. gondii IgG among the screened pregnant women in Lebanon is the highest in the Arab region. 82% IgG seropositivity among 2,400 women tested. (Compare this to the age adjusted seroprevalence in US women (ages 15-44) which was 9%. (CDC statistic 2009-10)

Seroprevalence of Toxoplasma antibodies among individuals tested at hospitals and private laboratories in Beirut, Bouhamdan SF, J Med Liban. 2010 Jan-Mar;58(1):8-11.

The toxoplasma IgG seropositivity showed significant (p<0.05) increasing correlation with advanced age, for example, from 9% at < or = 5 yrs to 78% at 46-50 yrs, and 94% at > or = 51 yrs.

An outbreak of trichinosis in Lebanon.

Olaison L1, Ljungström I.Trans R Soc Trop Med Hyg. 1992 Nov-Dec;86(6):658-60. Unable to get full text. ReprintrequestedviaResearchGateon11/28/18.doi10.1016/0035-9203(92)90178-F Abstractbelow:

In 1982 an outbreak of trichinosis occurred in an area of south Lebanon consisting of 4 villages, including 6440 persons. In 267 households, involving 2456 persons, typical clinical signs of Trichinella spiralis infection could be recognized among household members. Twenty-one of these households, including 193 persons, were randomly chosen for further studies. Nearly half of the household members (46%) had clinical symptoms consistent with acute trichinosis. 12 of 16 tested persons had high anti-Trichinella antibody titres (12 positive by indirect immunofluorescence (IIF) and 11 by enzyme-linked immunosorbent assay). Class- specific antibodies, IIF-immunoglobulin (Ig) G, IgM and IgA, were detected in most tested cases. Of the remaining 4 seronegative cases, 3 had a duration of clinical symptoms < or = 12 d. High peripheral eosinophilic counts (> 20%) were noted in 8 of 16 cases. In total, 15 of 16 cases were positive by one or more of these tests. The outbreak constituted one of the most extensive single outbreaks reported with a calculated > 1000 clinical cases. The cause was attributed to consumption of raw pork meat, an ingredient of kebbeh nayyeh, a favourite Lebanese dish.

An outbreak of Trichinella spiralis infection in southern Lebanon, Haim M et al, Epidemiol Infect. 1997;119:357–62.

A frequently cited paper. An estimated 200 cases of trichinellosis were described in a Southern Lebanese village, population approx 800-1000. Raw pork was the cause of the outbreak.

Blondheim DS, Klein R, Ben-Dror G, Schick G. Trichinosis in southern Lebanon. Isr J Med Sci. 1984;20:141–4.PubMed
Matossian RM, Rebeiz J, Stephan E. Serodiagnosis by fluorescent antibody staining of an outbreak of trichinosis in Lebanon. Ann Trop Med Parasitol. 1975;69:387–92.PubMed

Trichinellosis: a worldwide zoonosis, Jean Dupouy-Camet, Veterinary Parasitology 93 (2000) 191–200

mention of mutton as a cause of trichinosis

Trichinosis, By William J. Foreyt USGS National Wildlife Health Center, US Dept of the Interior, US Geological Survey, 2013 OPEN ACCESS at https://pubs.usgs.gov/circ/1388/pdf/cir1388.pdf

A beautiful 70 page monograph on all things trichina.

Experimental trichinosis in sheep, H J Smith and K E Snowdon, Can J Vet Res. 1989 Jan; 53(1): 112–114.

Sheep are averse to eating muscle tissue. Trichinella has low infectivity for sheep, even when given large innocula.

New aspects of human trichinellosis: the impact of new Trichinella species, F Bruschi, K D Murrell, The Postgraduate Medical Journal, v78;915, 2002

“Recent reports also indicate that infected herbivores (horses, sheep, goats, and cattle) have been the source of outbreaks, a new variation on the traditional model of trichinellosis epidemiology.” No reference is given for a sheep associated trichinella outbreak.

Unusual meats involved in transmission of trichinella: Horsemeat….Other unusual meats have also been involved in human cases (Soule, 1991): bears (in Greenland, Canada, USA, Japan, Eastern Europe and China), walrus in Canada and Alaska (Margolis et al., 1979), cougar in USA (Dworkin et al., 1996), foxes in Italy (Pozio, personal communication), mutton in China (Wang et al., 1998), warthog in Africa (Kefenie and Bero, 1992) and dog in China and Slovakia. A recent outbreak, involving some 340 patients in central Slovakia, was related to the consumption of home-made dogmeat sausages (Dubinsky et al., 1999). Although, bovines could be exceptionally infected (Murrell, 1994), they have never been involved in outbreaks.

Trichinella spiralis in a South American sea lion (Otaria flavescens) from Patagonia, Argentina Pasqualetti, M.I., Fariña, F.A., Krivokapich, S.J. et al. Parasitol Res (2018) 117: 4033. https://doi.org/10.1007/s00436-018-6116-z

This is the first report of a Trichinella species infecting marine mammals from South America.

A TERMINAL CURIOSITY

Arak in flagrante delicto with PD6.

Carlo writes:

Hi TWiP team,

I am writing on behalf of my inpatient medicine team (residents, interns, and medical students) who worked together on this case.

To summarize the case study of the patient with the woman who was born in Palestine who moved to NY that presented with a sore throat and posterior cervical lymphadenopathy who had a recent trip to Lebanon where she ate some raw meat dish. The differential includes toxoplasmosis, kala-azar, acute filarial lymphadenitis, onchodermatitis, Loa Loa, mansonella ozzardi, as well as mansonella streptocerca. The most likely diagnosis likely being Toxoplasmosis as her main complaint is the lymphadenopathy and she had a recent exposure to a raw meat dish. Toxoplasmosis can be found almost anywhere in the world, so the travel history does not influence the differential as much here. Visceral leishmaniasis could be possible given her travel history but it is often not associated with raw meat consumption. The epidemiology does not make sense for acute filarial lymphadenitis. Additionally, filiariasis usually leads to inguinal lymphadenopathy. Onchodermatitis is more prevalent in Africa and would show enlarged inguinal or femoral lymph nodes. Loa Loa can also lead to lymphadenopathy but it is transmitted by a mosquito bite and it is more prevalent in central and west Africa. Mansonella ozzardi is associated with exposure to South and Central America. Finally, Mansonella streptocerca would be more consistent with axillary or inguinal lymphadenopathy and it is prevalent in Central Africa.

Apart from parasitic infections, it would also be important to consider some viral infections like acute HIV, EBV, CMV, as well as other viral infections.

Looking forward to the next episode!

Carlo

John writes:

TWIP Trio,

Greetings from Creighton University in Omaha, NE where we’re expecting significant snow this weekend.

Once I heard that the woman visited Lebanon and ate raw meat, I immediately thought of halzoun. The swollen lymph nodes and sore throat are consistent with symptoms of a halzoun (moderate to severe pharyngitis, itchiness of throat and nose, nasal congestion and discharge and lacrimation (Khalil et al 2013)). The parasite responsible for this disease, however, remains unknown. Initially, halzoun was attributed to Fasciola hepatica. Wikipedia and other sources believe halzoun is caused by the pentastomida larvae of Linguatula serrata (dog tongue worm). The 6th edition of Parasitic Diseases remains noncommittal, but does cite Khalil et al 2013, which found evidence for Dicrocoelium dendriticum as being the causative agent:

https://www.sciencedirect.com/science/article/pii/S0001706X12003324?via%3Dihub

Treatment includes removal of the worm, saline nasal washings and anti-allergy medicines.

If my entry is chosen and the Red Mother book is still available, then I would like a copy of that.

peace

—

John Shea, SJ, Ph.D.

Jesuit Community Creighton University

Omaha, NE

Jacquelyn writes:

Hello TWiP hosts,

Here’s my guess for the case from episode 162 of the woman in her late 30’s who recently visited Lebanon. Her recent dietary adventures immediately made me think of a Toxoplasma gondii infection. Her non-specific presentation of posterior cervical LAD, sore throat, fatigue, and headache would also align with this. According to PD6, the few patients who are symptomatic present with low grade fever and enlarged cervical lymph nodes. The dish she likely tried was kibbeh nayyeh, traditionally made with raw lamb or beef. Both are intermediate hosts for T. gondii that could have been harboring tissue cysts. Given that her husband has eaten that dish since childhood, he’s likely already infected, explaining his lack of symptoms.

Other things on the differential would include infectious mononucleosis or lymphoma, but the short course of her symptoms (and the name of this podcast) make me think those are less likely. Serology could be done for confirmation with either IgM or IgG antibodies. It appears (per UpToDate) that IgG Ab could be detected ~2 weeks after infection. Assuming she’s immunocompetent (only her HIV status was mentioned), no therapy is needed. If she’s pregnant, she may need pyrimethamine & sulfadiazine to protect the fetus.

I was introduced to your podcast by a classmate last year and decided to listen to every episode in order before throwing my hat into the ring for case studies. I’ve finally caught up! I was hoping to be able to deliver a wider differential, but this case seems fairly toxo-esque to me.

Jacquelyn DeVries

UCSD School of Medicine | Class of 2021

Mycheala writes:

Dear Great Doctors,

You pronounce my name Ma-kay-la.

It’s been about 2 years since I last emailed in. In that time I quit my job as a Veterinary Microbiologist in Ireland and I went traveling and teaching English in Korea.

I got back to Ireland a few months ago and have just landed myself a new job as a Microbiologist in an orthopaedic manufacturing company, and you guys have been part of my journey the whole time.

Listening to TWIP, TWIM, TWIV, Immune, urban agriculture and all the rest has kept me in touch with my scientific side and even HELPED land me my new job, so thank you very much.

For the case study, I would like to throw my hat in the ring although my parasitology is very rusty.

My guess is Toxoplasma gondii,

T gondii is a worldwide parasite that, wherever cats are, it will be. Infection is acquired by transferring the eggs to the mouth by touching the eggs and touching your face, or also from eating contaminated undercooked (in this case raw) meat.

Usually infection doesn’t cause symptoms, but some people can get swollen lymph nodes, lymphadenopathy, fever, a vague ill feeling and a sore throat (all symptoms from the woman mentioned). Less often, other organs can be affected in people with weakened immune systems.

Diagnosis blood test to detect antibodies, or a stool sample under a microscope.

Treatment with pyrimethamine plus sulfadiazine and leucovorin.

Keep up the wonderful, I’ll be listening every week/month as the episodes come out.

Happy Christmas and have a wonderful New year! I hope it snows this year as our whole country gets shut down so we can stay toasty in bed

From Mycheala in a cold wet Co. Cork in Ireland.

Hannah writes:

Dear TWiPanosomes,

I’m a bit behind on my podcasts, so I hope this gets to you in time! I think the Palestinian woman has contracted Toxoplasma gondii, most likely from eating raw meat while on holiday. According to Parasitic Diseases 6th Edition, acute acquired toxoplasmosis in an immunocompetent patient, when symptomatic, is characterised in part by enlarged cervical lymph nodes. The parasite is commonly acquired through the consumption of raw/undercooked meat or cat faeces.

Speaking of interesting protozoan parasites, did you see this recent case report?

“Fatal Balamuthia mandrillaris brain infection associated with improper nasal lavage” https://www.sciencedirect.com/science/article/pii/S1201971218345259

A Seattle woman died from a brain infection with Balamuthia mandrillaris a year after using a neti pot with tap water and developing an unusual rash on her nose. They don’t have direct evidence that the neti pot was the source of her infection, however: looks like this assumption is based on the timing and the location of the rash (thought to have been caused by the amoebae), as well as the fact that other brain-eating amoebae can be acquired that way.

Cheers,

Hannah

P.S. I’m writing from beautiful Ottawa, Canada, where it’s -13.5°C outside (windchill -21°C), 21.5°C in my office, 25°C and 15°C in our fly incubators, and 0°C in the ice-water bath that I’m currently chilling live flies in.

Till writes:

Dear professors twip,

After venturing a guess for twip 160 I will try my second guess (this time sent from my private email address).

I believe the woman with cervical lymphadenopathy and fever from twip 162 is suffering from acute toxoplasmosis. As you explained in previous episodes, toxoplasmosis is usually asymptomatic in the far majority of cases. However, it may occasionally cause fever and lymphadenopathy in adults upon first infection, and the throat symptoms might also be a result of the acute infection. The mode of transmission (eating uncooked/raw meat) would also fit the diagnosis.

The prevalence of toxoplasmosis in Lebanon seems to be quite high with >80% of Lebanese pregnant women being IgG positive:

https://www.ncbi.nlm.nih.gov/m/pubmed/29064352/

Differentials include :

– other parasitic infections like African trypanosomiasis (can be dismissed since it is not endemic in Palestine/Lebanon) or Malaria

– non parasitic infections like systemic viral (CMV, EBV) or local bacterial (pharyngitis) infections.

– Of non infectious diseases, we have to consider malignant diseases (lymphoma) and

– autoimmune diseases (systemic lupus erythematosus, sarcoidosis).

Diagnosis could be obtained by different serological methods (ELISA, IFA) or by PCR from the serum.

Unless she has an underlying malignant or immunocompromising disease (other than HIV), we could expect a benign development and expect the patients symptoms to recede without lasting consequences.

However, the lymphadenopathy usually takes several weeks and sometimes months to regress.

Treatment is often only recommended for people with severe disease or an underlying condition that would let one expect the development of complications.

If we would treat, the drugs of choice would include pyrimethamine, sulfadiazine and Clindamycin.

Trimethoprim/sulfamethoxazole, which is the drug of choice for prevention, is not used for treatment.

Once again thank you for your super cool podcast, keep em coming!

Cheers, Till.

Madeeha writes:

Dear TWIP professors,

This is my first time writing in to your program. I have been a listener of TWIM and TWIV off and on for one year and recently started listening to TWIP. I am grateful to my colleague from work who mentioned the trio of podcasts during small talk when I started fellowship training in Infectious Diseases at the university of Maryland medical center last year. I think you all bring SO MUCH AWE and visceral joy to a listener like myself by sharing some papers that I would never come across on my own with my busy schedule.

In TWIM, I love the discussions of Dr. Swanson and Dr. Schaecter. That’s partly responsible for my late intro to TWIP. However, now that I have started listening to TWIP, this is all I want to hear on my drive to and from work. I have enjoyed these so much that I wanted to hazard a guess at this week’s case study. I am happy for the length of time that was available for the answer as I was able to go back to the beginnings of TWIP and listen to the episodes I thought were relevant based on the answers I thought for this case (hope I am not too late). I am thoroughly enjoying the historical back and forth between Dr. Racaniello and Dr. Despommier. I must confess that I feel a little bit like a I did when as a teenager I was on page 200 of “Gone with the Wind” and was so happy that there were another 800 to go. I am very happy that I have a treasure trove to explore and hopefully share when my daughter grows up (so she can develop a love for science).

I also browsed through the pdf copy of Parasitic Diseases, focusing on the section relevant to current case study. I love hard copies of books and I know I can buy it for myself but would REALLY LOVE a signed copy, if I am lucky enough to win one. Until then, will make do with the pdf which you have so kindly made available for free.

So, for our Palestinian born, now American patient who ate a “raw meat dish” in Lebanon and returned to develop low grade fever, sore throat which subsequently improved and posterior cervical lymphadenopathy in less than a week. Our pt is HIV negative. Interestingly, the husband is unaffected but he has eaten that dish for his whole life.

My immediate thought was Salmonella (non-typhi) given the raw meat meal – Salmonella live in the intestines of most food animals and contamination can occur during slaughter and processing (Ref: Mandell). The headache went with that diagnosis but then it starts to fall apart. Most important is the absence of GI symptoms or severe systemic illness. Swollen cervical LNs are not typically seen in Salmonella GE or enteric fever (pts have high grade fevers) although they do have abdominal/mesenteric lymph node swelling leading to abdominal pain and diarrheal illness, sometimes even perforation and ileus.

Other possible but unlikely differentials include EBV (mono) and acute CMV – the pt is missing the organomegaly (liver and spleen). Serology for IgM to both would help differentiate.

Lastly, the other diagnosis that initially popped in my head is going to be my final answer. My thoughts were further consolidated after a review of TWIPs 12 and 13 as well as Parasitic Diseases Pgs. 141 – 154. The pt most likely ate a dish of raw lamb/sheep or beef meat which Dr. Google calls Kibbeh Nayyeh which is very likely to harbor the culprit pathogen. Dr. Despommier’s detailed story (pardon me if I can’t recall it accurately) of the four medical students who ate incompletely cooked meat burgers at this one restaurant in New York and then developed “cervical lymphadenopathy”, malaise and sore throat (I think) was very fascinating and helpful. Our patient has acute toxoplasmosis in an immunocompetent host. Cervical lymphadenopathy and sore throat that resolves are seen in this illness. Diagnosis can be made by testing for toxoplasma serology. I do not know how useful PCR testing would be in this case but I would be extremely curious from a scientist viewpoint to check it and see if she has detectable toxo PCR in blood. I expect that she would not as the toxo should have already invaded the tissues and disappeared from the blood given that she is immunocompetent. We could biopsy her swollen lymph nodes and may see tachyzoites (or will they already have become bradyzoites?) in tissues or smears obtained from biopsy. However, given that toxo in immunocompetent pts is self-limiting, I would not subject our poor patient to any unnecessary procedures. No treatment is necessary as the disease is self-limiting in all immunocompetent hosts.

Thank you again.

Looking forward to your next podcast,

Madeeha

Dana writes:

Hello TWiP professors,

We are a group of 1st year medical students who are part of a Global Health educational track. Our assigned task was to listen to your podcast and submit a guess. Fortuitously, our medical school is located in Lebanon, Oregon so it was meant to be that we were given this particular assignment.

We believe the most likely diagnosis is an infection via Toxoplasma gondii ¹, which is most commonly transmitted from lamb, beef and pork 6. The patient likely contracted this when she consumed raw kibbeh², a customary Lebanese dish consisting of minced raw lamb or beef mixed with bulgur, spices, garlic, mint leaves, olive oil, and green onions. The most common symptoms in an otherwise healthy patient, like the one in this case, are described as flu-like. Symptoms include swollen lymph nodes, muscle aches, and fatigue over a period of weeks to months.¹ It can also be asymptomatic, which could explain why others who ate the same infected meat wouldn’t be ill.

Differential diagnosis would include an infection via Haemonchus contortus which is the most significant parasite of sheep and goats throughout the United States and the world.³ Her symptoms are consistent with the symptoms related to such an infection which include a general unwell feeling.⁴

Another possible diagnosis would include rhinovirus. While this could be unlikely, mainly due to the fact that this is a podcast about parasites, it is a common illness that could easily have produced the patients’ symptoms.5 The cold symptoms manifesting in close proximity to her trip, could simply be a coincidence. This diagnosis is supported by a decrease in the pharyngeal inflammation in subsequent exams. However, healthy individuals usually recover within 7-10 days

Sincerely,

Dana,
Steven, Alex, Vickie, Irene, and Chris

Our
references include: