Foodborne Trematodiasis and Opisthorchis felineus Acquired in Italy

To the editor: Opisthorchiasis comprises diverse clinical manifestations caused by infections with Opisthorchis felineus or O. viverrini liver flukes, which are transmitted by eating infected raw or undercooked fish and other aquatic products. In regions outside Western Europe where human opisthorchiasis is endemic, the disease is mainly described as being chronic and asymptomatic. Recent studies indicate cases of O. felineus infection in the Mediterranean region, particularly Italy (1–4). Patients with acute infection have signs/symptoms ranging from fever to hepatitis-like signs/symptoms (e.g., pain in upper right abdominal quadrant, weakness, fatigue, loss of appetite, diarrhea, weight loss); sign/symptom onset occurs ≈2–3 weeks after infection, depending on the number of ingested flukes (2–4).


Foodborne Trematodiasis and Opisthorchis felineus Acquired in Italy
To the Editor: Opisthorchiasis comprises diverse clinical manifestations caused by infections with Opisthorchis felineus or O. viverrini liver flukes, which are transmitted by eating infected raw or undercooked fish and other aquatic products. In regions outside Western Europe where human opisthorchiasis is endemic, the disease is mainly described as being chronic and asymptomatic. Recent studies indicate cases of O. felineus infection in the Mediterranean region, particularly Italy (1)(2)(3)(4). Patients with acute infection have signs/symptoms ranging from fever to hepatitis-like signs/symptoms (e.g., pain in upper right abdominal quadrant, weakness, fatigue, loss of appetite, diarrhea, weight loss); sign/symptom onset occurs ≈2 3 weeks after infection, depending on the number of ingested flukes (2)(3)(4).
Acute opisthorchiasis is a feature of O. felineus infection that is not often reported for other trematode infections. Opisthorchiasis is characterized by hepatosplenomegaly, abdominal tenderness, eosinophilia, chills, and fever (2) In August 2011, a 54-year-old woman in the Netherlands with no relevant medical history sought medical care for fever, chills, and myalgia lasting 2 weeks. Symptoms began after the patient returned from a vacation in Tuscany. Physical examination showed no abnormalities; her temperature was 37.4°C. Laboratory examinations showed eosinophilic leukocytosis, an elevated C-reactive protein level, and elevated liver enzyme levels (Table).
Opisthorchiasis was suspected because of the patient's travel history and report of eating carpaccio (Italian dish made with raw fish/meat) near Lake Bolsena (8). A fecal sample examined by microscopy was negative for eggs, cysts, and helminths. A serum sample was tested at Leiden University Medical Center by using an in-house immunofluorescence assay and ELISA with Fasciola spp. antigens, which are likely to show crossreactivity with other liver flukes (9). The immunofluorescence assay result was positive, but the ELISA result was negative.
To confirm the diagnosis of opisthorchiasis, we obtained another fecal sample 1 month later, and low numbers of Opisthorchis eggs were seen by microscopy. The sample was sent to Leiden University Medical Center, where in-house real-time PCR was performed using primers (Of350F 5′-CTC CGT TGT TGG TCC TTT GTC-

LETTERS
The patient had 2 travel companions with similar, but less severe, symptoms. Both had serology test results positive for Fasciola spp. For 1 traveler, microscopic examination revealed an Opisthorchis egg in a fecal specimen, and O. felineus real-time PCR was positive (threshold 25.1). All 3 patients were treated with praziquantel (25 mg/kg orally 3 times/d for 2 d) and completely recovered.
Foodborne trematodiasis is reemerging and occurring in developed regions (1)(2)(3). A total of ≈8.4 million persons worldwide have opisthorchiasis, of whom ≈325,000 are in Europe (1). Earlier reports of human infections around Lake Bolsena did not result in complete transmission control in the region, as illustrated by the current cases.
The reference standard for diagnosing opisthorchiasis is observation of eggs in feces by microscopy. However, the sensitivity of microscopy is low, particularly in the early disease stage because egg production starts 1-3 months after exposure (4,9), and the similarity of eggs of different trematodes hampers species-specific differentiation (1). In addition, sensitivity of microscopy is highly observer-dependent and varies with the microscopist's level of experience. Because most opisthorchiasis cases in Europe have low numbers of worms, at least 3 separate fecal samples should be obtained and thoroughly examined to rule out a positive diagnosis (4,9). If test results are negative, a fecal examination should be repeated after several weeks.
Specific Opisthorchis spp. serology tests are not available within the Netherlands, but because of known serologic cross-reactivity, antibody detection for Fasciola spp. can be performed if opisthorchiasis is suspected (9). For confirmation, an O. felineus-specific real-time PCR can be performed.
Although opisthorchiasis is not frequently reported in Europe, it should be considered in cases of unexplained acute febrile eosinophilic syndrome with cholestasis, especially when patients confirm the ingestion of raw or undercooked aquatic products. Furthermore, opisthorchiasis should be considered even without a relevant travel history to regions outside Europe where the disease is endemic.