Acute Muscular Sarcocystosis: an international investigation among ill travelers returning from Tioman Island, Malaysia, 2011 and 2012

Authors: ESPOSITO, DOUGLAS - Centers For Disease Control And Prevention (CDC) - United States; STICH, AUGUST - Medical Mission Hospital; EPELBOIN, LOIC - Pierre And Marie Curie University; MALVY, DENIS - Hôpital Saint-André; HAN, PAULINE - Centers For Disease Control And Prevention (CDC) - United States; BOTTIEAU, EMMANUEL - Institute Of Tropical Medicine; DA SILVA, ALEXANDRE - Centers For Disease Control And Prevention (CDC) - United States; ZANGER, PHILIPP - Eberhard-Karls University; SLESAK, GUNTHER - Tropenklinik; VAN GENDEREN, PERRY J. - Harbour Hospital,institute For Tropical Diseases; Rosenthal, Benjamin; Fayer, Ronald

Submitted to: Clinical Infectious Diseases
Publication Type: Peer Reviewed Journal
Publication Acceptance Date: 8/1/2014
Publication Date: 8/4/2014
Publication URL: http://cid.oxfordjournals.org/content/early/2014/09/17/cid.ciu622.long
Citation: Esposito, D.H., Stich, A., Epelboin, L., Malvy, D., Han, P., Bottieau, E., Da Silva, A., Zanger, P., Slesak, G., Van Genderen, P.J., Rosenthal, B.M., Fayer, R. 2014. Acute Muscular Sarcocystosis: an international investigation among ill travelers returning from Tioman Island, Malaysia, 2011 and 2012. Clinical Infectious Diseases. DOI:10.1093/cid/ciu622.

Interpretive Summary: Sarcocystis is a protozoan parasite affecting a wide range of hosts including livestock and humans. The life cycle and disease aspects were discovered by ARS scientists several years ago and those related publications have served in large part as a guide for diagnosing and determining the sources of the disease in humans. In the present study ARS scientists have served as advisors to the Centers for Disease Control involving an international outbreak of human disease caused by Sarcocystis. Affected persons, mostly from Europe, were on holiday in Malaysia and returned home with symptoms remarkably similar to those reported in cattle and sheep by ARS scientists. Advice was provided on potential routes and sources of infection and the likely source was determined to be ingestion of water or ice contaminated with snake feces. The thoroughly documented manuscript provides an excellent diagnostic guide for physicians caring for patients living in or traveling from locations where sanitation is poor.

Technical Abstract: Two provider-based traveler-focused networks allowed for the detection of a large outbreak of acute muscular sarcocystosis (AMS). Clinicians evaluating travelers returning ill from Malaysia with fever and myalgia noted the biphasic aspect of the disease, the later onset of elevated CPK and eosinophilia, and the possibility for relapses. Sixty-eight patients met the case definition; 62 probable and six confirmed. All but two patients resided in Europe; all traveled to Tioman Island on holiday, mostly during the summer months. The most frequent symptoms reported were myalgia (100%), fatigue (91%), fever (82%), headache (59%), and arthralgia (29%); onset clustered during two distinct periods: early during the second and late during the sixth weeks after departing from the island. Blood eosinophilia and elevated serum creatinine phosphokinase levels were observed beginning during the fifth week post-departure. Sarcocystis nesbitti DNA was recovered from one biopsy sample.