Acute Muscular Sarcocystosis: An International Investigation Among Ill Travelers Returning From Tioman Island, Malaysia, 2011-2012

• Type of Material: Article
• Authors: Douglas H. Esposito, Centers for Disease Control and Prevention; August Stich, Medical Mission Hospital; Loic Epelboin, Université Pierre et Marie Curie; Denis Malvy, University Hospital Center, Bordeaux; Pauline V. Han, Centers for Disease Control and Prevention; Emmanuel Bottieau, Institute of Tropical Medicine, Belgium; Alexandre da Silva, Centers for Disease Control and Prevention; Philipp Zanger, University of Tubingen; Gunther Slesak, Tropenklinik Paul-Lechler-Krankenhaus; Perry J.J. van Genderen, Harbor Hospital; Benjamin M. Rosenthal, US Department of Agriculture; Jakob P. Cramer, University Medical Center Hamburg-Eppendorf; Leo G. Visser, Leiden University; Jose Munoz, University of Barcelona; Clifton P. Drew, Centers for Disease Control and Prevention; Cynthia S. Goldsmith, Centers for Disease Control and Prevention; Florian Steiner, Charite Medical University of Berlin; Noemie Wagner, University Hospitals of Geneva; Martin P. Grobusch, University of Amsterdam; D. Adam Plier, University of Alabama Birmingham; Dennis Tappe, Bernhard Nocht Institute for Tropical Medicine; Mark J. Sotir, Centers for Disease Control and Prevention; Clive Brown, Centers for Disease Control and Prevention; Gary W. Brunette, Centers for Disease Control and Prevention; Ronald Fayer, US Department of Agriculture; Frank von Sonnenburg, University of Munich; Andreas Neumayr, Swiss Tropical and Public Health Institute; Phyllis E Kozarsky, Emory University
• Language: English
• Date: 2014-11-15
• Publisher: Oxford University Press (OUP): Policy B - Oxford Open Option C
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2014, Oxford University Press
• Final Published Version (URL): http://dx.doi.org/10.1093/cid/ciu622
• Title of Journal or Parent Work: Clinical Infectious Diseases
• ISSN: 1058-4838
• Volume: 59
• Issue: 10
• Start Page: 1401
• End Page: 1410
• Grant/Funding Information: This work was supported by the CDC.
• Keywords: travel; MONKEY; PENINSULAR MALAYSIA; Immunology; Infectious Diseases; PULAU TIOMAN; Microbiology; OUTBREAK; Malaysia; Science & Technology; INFECTION; SPP.; sarcocystosis; infectious disease outbreak; Life Sciences & Biomedicine; NESBITTI; parasitic disease
• Research Categories: Health Sciences, Immunology

Abstract

Background: Through 2 international traveler-focused surveillance networks (GeoSentinel and TropNet), we identified and investigated a large outbreak of acute muscular sarcocystosis (AMS), a rarely reported zoonosis caused by a protozoan parasite of the genus Sarcocystis, associated with travel to Tioman Island, Malaysia, during 2011-2012. Methods: Clinicians reporting patients with suspected AMS to GeoSentinel submitted demographic, clinical, itinerary, and exposure data.We defined a probable case as travel to Tioman Island after 1 March 2011, eosinophilia (<5%), clinical or laboratory-supported myositis, and negative trichinellosis serology. Case confirmation required histologic observation of sarcocysts or isolation of Sarcocystis species DNA from muscle biopsy. Results: Sixty-eight patients met the case definition (62 probable and 6 confirmed). All but 2 resided in Europe; all were tourists and traveled 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 2 distinct periods: "early" during the second and "late" during the sixth week after departure from the island. Blood eosinophilia and elevated serum creatinine phosphokinase (CPK) levels were observed beginning during the fifth week after departure. Sarcocystis nesbitti DNA was recovered from 1 muscle biopsy. Conclusions: Clinicians evaluating travelers returning ill from Malaysia with myalgia, with or without fever, should consider AMS, noting the apparent biphasic aspect of the disease, the later onset of elevated CPK and eosinophilia, and the possibility for relapses. The exact source of infection among travelers to Tioman Island remains unclear but needs to be determined to prevent future illnesses.