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SASTM Newsflash - Sarcocystosis - Malaysia: (Tioman Island) travel related: 2012


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Update on sarcocystis-like illness after visiting Tioman Island, Malaysia


An outbreak of muscular sarcocystis-like illness has been evidenced since summer 2011 among travelers after visiting Tioman Island, Malaysia. As of November 2012, GeoSentinel working with TropNet, has been notified of 100 reported patients with suspected _Sarcocystis_ species.


Starting in summer 2011, 35 patients were identified by early 2012 and travelled there mostly during July and August 2011. The epidemic is currently ongoing, with a 2nd wave of 65 reported new diseased travelers returning since summer 2012. A cluster of 12 patients returning from Peninsular Malaysia since late August 2012 were seen and followed in Bordeaux, France.


In the period of September-October 2012, 12 patients (7 male, 5 female; aged 11-46 years) were referred to the Division of tropical medicine, University Hospital Center, Bordeaux, France, with febrile myalgia, unexplained blood eosinophilia, elevated CPK levels, and negative trichinellosis serology.


Cases spent their vacation from 26 Jul to 25 Aug 2012 on the east coast of peninsular Malaysia. All patients belonged to a tourist group from southwestern France. The group was composed of 4 families. Of note, the 3 members of one family did not participate in the optional 4-day trip on Tioman Island and were instead moving on the neighboring Perhentian place. Almost all patients presented high-grade fever, fatigue, headache, moderate-to-severe myalgia, and arthralgia.


Three cases experienced febrile illness for more than 14 days. 2 patients had suffered from diarrhoea and extensive maculo-papular rash. A muscle biopsy from one patient revealed intense myositis, but no intramuscular cysts. Half of patients healed using usual antalgic treatments. 6 patients were given empirically albendazole 400 mg twice a day for 7 days and oral prednisone (0.5 mg/kg/day) for 3 days tapered over 2 days. 6 weeks later, 4 patients have still not recovered and were experiencing prolonged asthenia and myalgia. The patients were effectively treated with additional prednisone 0.5 mg/kg/day for 5 days and decreasing dosage over 14 days. By February 2012, one patient relapsed with musculoskeletal complaints. All patients were reported to GeoSentinel for lab and epidemiological investigation, and TropNet was informed.


The cluster of 12 diseased travelers living in southwestern France mainly contributes to the 65 patients returning from Malaysia who represent the 2nd wave of an outbreak of acute muscular sarcocystis-like illness. With little known about the disease, our experience suggests that late and prolonged manifestations may occur and short-term corticosteroid course could benefit symptomatic patients.


In Malaysia, the 1st sparse cases of human muscular sarcocystosis were noted in the late 1970's and an overall seroprevalence of nearly 20 percent was reported in 1991.  Thereafter, a cluster of symptomatic apparent cases was evidenced, affecting up to 7 of 15 US servicemen on maneuvers in a Malaysian jungle.


In the recent outbreaks in Malaysia, human muscular sarcocystosis is seen as a possible emerging foodborne zoonosis. The source of infection, specific species, and life cycle are to be elucidated, and the definitive animal host to be identified. Herein, humans are thought to become accidental intermediate hosts for zoonotic species by ingesting fecally-contaminated food or water material. Strikingly, it should be stressed that cats and macaques are numerous in Tioman Island and neighboring places, and are good candidates as infected predator animals. Overall, international travelers should be aware of the risk of acquiring this infection through genuine food habits.


Communicated by Pro-Med Mail



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