Muskuläre Sarkozystose nach Malaysiareise – Eine Fallserie aus Deutschland mit 40 Patienten von 2011–2014

 

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Seit 2011 wurde weltweit bei über 100 Besuchern der Insel Tioman, Malaysia, die Verdachtsdiagnose einer muskulären Sarkozystose gemeldet, einer bislang nur sporadisch beobachteten parasitären Erkrankung. Ursächlich ist vermutlich Sarcocystis nesbitti. Ausbruchsursache sowie Therapie sind unklar. Die Diagnosesicherung erfordert den mikroskopischen Zystennachweis im Muskelbiopsat. Studienziel war die systematische Beschreibung der diagnostisch wegweisenden Symptome, Laboruntersuchungen und des Therapieansprechens.

Die 40 Fälle aus 6 tropenmedizinischen/infektiologischen Zentren Deutschlands hatten zumeist einen Aufenthalt im Nordwesten der Insel Tioman und zeigen einen charakteristischen 2-phasigen Krankheitsverlauf mit initialem Fieber und später prolongierten Myalgien, Eosinophilie und CK-Erhöhung. Bei einer Schwangeren trat eine fetale Wachstumsretardierung auf. Eine Steroidstoßtherapie ist in der Spätphase rasch beschwerdelindernd. Bei möglichst frühzeitiger Cotrimoxazoltherapie war die Beschwerdedauer kürzer (0,7 vs. 3,0 Monate; p = 0,03), möglicherweise kann damit die Muskelinvasion der Parasiten verhindert werden.

Bei Fieber nach Malaysiaaufenthalt sollte die Sarkozystose differenzialdiagnostisch bedacht werden. Die Infektionsquelle erscheint konzentriert auf den Nordwesten Tiomans. Weitere Untersuchungen, inklusive zur Frühdiagnostik und Therapie, sind notwendig.

Since 2011, over 100 travelers to the island of Tioman, Malaysia, have been diagnosed worldwide with suspected muscular sarcocystosis, a previously only sporadically observed parasitic disease. Sarcocystis nesbitti is the presumptive causative agent. Source of the infection and therapy remain unclear. The final diagnosis requires the microscopic identification of cysts in muscle biopsies. Study goal was the systematic description of characteristic symptoms, laboratory investigations and treatment response.

The 40 cases from 6 centers for tropical medicine/infectiology in Germany had mostly stayed in the north-west of the island Tioman. They showed a characteristic biphasic development with initial fever and later prolonged myalgia, eosinophilia, and CK-elevation. In a pregnant woman fetal growth retardation was noted. Systemic steroid therapy leads to a rapid symptomatic relief. The duration of symptoms was shorter when cotrimoxazole treatment was initiated as early as possible (0.7 vs. 3.0 months, p = 0.03), possibly preventing muscular invasion by the parasite.

In fever after travel to Malaysia, the differential diagnosis should also include sarcocystosis. Source of infection appears to be concentrated in north-west of Tioman Island. Further studies are needed, including investigations for early diagnosis and treatment.

• Literatur

• 1 Tappe D, Ernestus K, Rauthe S et al. Outbreak of acute muscular Sarcocystis-like infection in returning travelers from Tioman Island, Peninsular Malaysia, 2011: Description of the initial patient cluster and the first positive biopsy findings. J Clin Microbiol 2013; 51: 725-726
  CrossrefGoogle Scholar
• 2 Freedman D, Stich A, vonSonnenburg F. Sarcocystosis, human – Malaysia: Tioman Island. ProMed-mail 31. Oktober 2011. Im Internet: http://www.promedmail.org/direct.php?id=20111031. 3240
  Google Scholar
• 3 Centers for Disease Control and Prevention (CDC). Notes from the field: acute muscular sarcocystosis among returning travelers – Tioman Island, Malaysia, 2011. MMWR Morb Mortal Wkly Rep 2012; 61: 37-38
  Google Scholar
• 4 Esposito DH, Freedman DO, Neumayr A et al. Ongoing outbreak of an acute muscular Sarcocystis-like illness among travellers returning from Tioman Island, Malaysia, 2011–2012. Euro Surveill 2012; 17
  Google Scholar
• 5 Slesak G, Tappe D, Keller C et al. Muskuläre Sarko-zystose nach Malaysiareise: eine Fallserie aus Deutschland. Dtsch Med Wochenschr 2014; 139: 990-995
  Article in Thieme ConnectGoogle Scholar
• 6 Slesak G, Schäfer J. Verdacht auf Sarkozystose nach Malaysia-Urlaub. Dtsch Arztebl 2012; 109: 1688-1688
  Google Scholar
• 7 Slesak G, Schäfer J, Tappe D et al. Verlaufsbeobachtung zur invasiven muskulären Sarkozystose bei Malaysia-Reisenden nach Tioman-Aufenthalt 2011–2013. Bericht aus fünf tropenmedizinischen Zentren in Deutschland. Epidem Bull 2014; 22: 189-191
  Google Scholar
• 8 Dubey JP, Lindsay DS. Neosporosis, toxoplasmosis, and sarcocystosis in ruminants. Vet Clin North Am Food Anim Pract 2006; 22: 645-671
  CrossrefGoogle Scholar
• 9 Fayer R. Sarcocystis spp. in human infections. Clin Microbiol Rev 2004; 17: 894-902
  CrossrefGoogle Scholar
• 10 Krauss H, Weber A, Enders B, Schiefer HG, Slenczka W, Zahner H. Sarkosporidiose. In: Zoonosen. Von Tier zu Mensch übertragbare Infektionskrankheiten. 2. Aufl. Köln: Deutscher Ärzte-Verlag; 1997: 243-245
  Google Scholar
• 11 Arness MK, Brown JD, Dubey JP et al. An outbreak of acute eosinophilic myositis attributed to human Sarcocystis parasitism. Am J Trop Med Hyg 1999; 61: 548-553
  Google Scholar
• 12 Herbert IV, Smith TS. Sarcocystosis. Parasitol Today 1987; 3: 16-21
  CrossrefGoogle Scholar
• 13 Van den Enden E, Praet M, Joos R et al. Eosinophilic myositis resulting from sarcocystosis. J Trop Med Hyg 1995; 98: 273-276
  Google Scholar
• 14 AbuBakar S, Teoh BT, Sam SS et al. Outbreak of human infection with Sarcocystis nesbitti, Malaysia, 2012. Emerg Infect Dis 2013; 19: 1989-1991
  CrossrefGoogle Scholar
• 15 Italiano CM, Wong KT, AbuBakar S et al. Sarcocystis nesbitti causes acute, relapsing febrile myositis with a high attack rate: description of a large outbreak of muscular sarcocystosis in Pangkor Island, Malaysia, 2012. PLoS Negl Trop Dis 2014; 8
  Google Scholar
• 16 Esposito DH, Stich A, Epelboin L et al. Acute muscular sarcocystosis: an international investigation among ill travelers returning from Tioman Island, Malaysia, 2011–2012. Clin Infect Dis 2014; 59: 1401-1410
  CrossrefGoogle Scholar
• 17 Kan SP, Pathmanathan R. Review of sarcocystosis in Malaysia. Southeast Asian J Trop Med Public Health 1991; 22 (Suppl. 01) 129-134
  Google Scholar
• 18 Wong KT, Pathmanathan R. High prevalence of human skeletal muscle sarcocystosis in south-east Asia. Trans R Soc Trop Med Hyg 1992; 86: 631-632
  CrossrefGoogle Scholar
• 19 Kutty MK, Dissanaike AS. A case of human Sarcocystis infection in west Malaysia. Trans R Soc Trop Med Hyg 1975; 69: 503-504
  CrossrefGoogle Scholar
• 20 Kutty MK, Mohan Das A, Dissanaike AS. Sarcocystis infection in an Orang Asli: the second human case from Malaysia. Southeast Asian J Trop Med Public Health 1975; 6: 400-401
  Google Scholar
• 21 Pathmanathan R, Kan SP. Three cases of human Sarcocystis infection with a review of human muscular sarcocystosis in Malaysia. Trop Geogr Med 1992; 44: 102-108
  Google Scholar
• 22 Prathap K, Dissanaike AS. The fourth case of Sarcocystis infection in man in Malaysia. Southeast Asian J Trop Med Public Health 1978; 9: 452-453
  Google Scholar
• 23 Knobloch J, Lederer I, Mannweiler E. Species-Specific Immunodiagnosis of Human Echinococcosis with Crude Antigens. Eur J Clin Microbiol 1984; 3: 554-555
  CrossrefGoogle Scholar
• 24 Flaherty SA. Pain measurement tools for clinical practice and research. AANA J 1996; 64
  Google Scholar
• 25 Slesak G, Schäfer J, Langeheinecke A, Tappe D. Prolonged clinical course of muxcular sarcocystosis and effectiveness of cotrimoxazole among travelers to tioman island, malaysia, 2011–2014. Clin Infect Dis 2015; 60: 329-329
  CrossrefGoogle Scholar
• 26 Tappe D, Stich A, Langeheinecke A et al. Suspected new wave of muscular sarcocystosis in travelers returning from Tioman Island, Malaysia, May 2014. Euro Surveill 2014; 19
  Google Scholar
• 27 Dubey JP, Speer CA, Epling GP. Sarcocystosis in newborn calves fed Sarcocystis cruzi sporocysts from coyotes. Am J Vet Res 1982; 34: 445-447
  Google Scholar
• 28 Kirkpatrick CE, Hamir AN, Dubey JP et al. Sarcocystis in muscles of raccoons (Procyon lotor L.). J Protozool 1987; 34: 445-447
  CrossrefGoogle Scholar
• 29 Latif B, Vellayan S, Omar E et al. Sarcocystosis among wild captive and zoo animals in Malaysia. Korean J Parasitol 2010; 48: 213-217
  CrossrefGoogle Scholar
• 30 Mandour AM. Sarcocystis nesbitti n. sp. from the rhesus monkey. J Protozool 1969; 16: 353-354
  CrossrefGoogle Scholar
• 31 Stanek JF, Dubey JP, Oglesbee MJ et al. Life cycle of Sarcocystis neurona in its natural intermediate host, the raccoon, Procyon lotor. J Parasitol 2002; 88: 1151-1158
  CrossrefGoogle Scholar
• 32 Agerholm JS, Dubey JP. Sarcocystosis in a stillborn lamb. Reprod Domest Anim 2014; 49
  Google Scholar
• 33 Gottstein B, Pozio E, Nöckler K. Epidemiology, diagnosis, treatment, and control of trichinellosis. Clin Microbiol Rev 2009; 22: 127-145
  CrossrefGoogle Scholar
• 34 Lindsay DS, Dubey JP. Determination of the activity of pyrimethamine, trimethoprim, sulfonamides, and combinations of pyrimethamine and sulfonamides against Sarcocystis neurona in cell cultures. Vet Parasitol 1999; 82: 205-210
  CrossrefGoogle Scholar
• 35 Page CD, Schmidt RE, English J et al. Antemortem diagnosis and treatment of sarcocystosis in two species of psittacines. J Zoo Wildlife Med 1992; 23: 77-85
  Google Scholar
• 36 Stanford MR, Gilbert RE. Treating ocular toxoplasmosis – current evidence. Mem Inst Oswaldo Cruz, Rio de Janeiro 2009; 104: 312-315
  CrossrefGoogle Scholar
• 37 Cuturic M, Hayat GR, Vogler CA et al. Toxoplasmic polymyositis revisited: case report and review of literature. Neuromuscul Disord 1997; 7: 390-396
  CrossrefGoogle Scholar
• 38 El-Beshbishi SN, Ahmed NN, Mostafa SH et al. Parasitic infections and myositis. Parasitol Res 2012; 110: 1-18
  CrossrefGoogle Scholar
• 39 Tian M, Chen Y, Wu L et al. Phylogenetic analysis of Sarcocystis nesbitti (Coccidia: Sarcocystidae) suggests a snake as its probable definitive host. Vet Parasitol 2012; 183: 373-376
  CrossrefGoogle Scholar