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Infection by Pseudoterranova — Clinical Guidelines

Overview

Pseudoterranova infection, commonly associated with Pseudoterranova decubitus (also known as the fox larva or sealworm), is a parasitic zoonosis affecting humans, primarily through consumption of raw or undercooked marine fish containing the infective larvae. This condition, often referred to as anisakiasis, manifests as gastrointestinal symptoms and can occasionally involve other organs like the lungs or brain if larvae migrate. It is particularly prevalent in coastal regions where raw fish consumption is common. Understanding and recognizing pseudoterranova infection is crucial for clinicians to prevent misdiagnosis and ensure appropriate management, especially in regions with high fish consumption. 3

Pathophysiology

The pathophysiology of pseudoterranova infection begins with the ingestion of viable larvae contained within raw or inadequately cooked marine fish. Once in the gastrointestinal tract, these larvae typically penetrate the intestinal mucosa, triggering an intense inflammatory response characterized by eosinophilia and granulocyte infiltration. This inflammatory reaction can lead to localized tissue damage and symptoms such as abdominal pain, nausea, and vomiting. In severe cases, larvae may migrate through the intestinal wall into adjacent organs, causing mechanical damage and secondary inflammatory responses. For instance, migration into the lungs can result in pulmonary symptoms akin to pneumonia, while migration to the brain can lead to neurological manifestations. The immune response plays a critical role in both the containment and potential complications of the infection, highlighting the importance of prompt diagnosis and intervention to mitigate tissue damage and systemic effects. 3

Epidemiology

The incidence of pseudoterranova infection varies geographically, with higher rates reported in areas with significant consumption of raw or undercooked seafood, particularly in Japan, Scandinavia, and coastal regions of Europe and North America. Prevalence is not extensively documented in large population studies, but sporadic outbreaks and case reports suggest it is underreported due to its often self-limiting nature and misdiagnosis as other gastrointestinal conditions. Age and sex distribution show no significant predilection, though cultural dietary habits can influence exposure rates. Trends indicate an increase in reported cases coinciding with heightened awareness and improved diagnostic techniques, rather than a true rise in incidence. 3

Clinical Presentation

The clinical presentation of pseudoterranova infection typically includes acute onset of gastrointestinal symptoms such as severe abdominal pain, nausea, vomiting, and diarrhea. Patients may also experience general malaise, fever, and eosinophilia. Atypical presentations can occur, particularly when larvae migrate beyond the gastrointestinal tract, leading to symptoms like respiratory distress (if larvae reach the lungs) or neurological symptoms (if larvae affect the central nervous system). Red-flag features include persistent high fever, significant weight loss, and signs of organ-specific dysfunction, which necessitate urgent evaluation and intervention. Prompt recognition of these symptoms is crucial for timely diagnosis and management to prevent severe complications. 3

Diagnosis

Diagnosing pseudoterranova infection involves a combination of clinical suspicion, laboratory findings, and imaging techniques. The diagnostic approach typically starts with a thorough history focusing on recent consumption of raw fish and the onset of symptoms. Key diagnostic criteria include:

Clinical Symptoms: Severe abdominal pain, nausea, vomiting, and eosinophilia.

Endoscopy: Visualization of larvae in the gastrointestinal tract, often appearing as motile, white, or translucent structures.

Imaging: CT or MRI may show migratory tracks or localized inflammation in affected organs.

Laboratory Tests: Elevated eosinophil counts and specific serological tests (though less commonly used due to variability).

Differential Diagnosis:

- Gastroenteritis: Typically lacks eosinophilia and lacks a history of raw fish consumption. - Appendicitis: Presents with localized right lower quadrant pain, fever, and leukocytosis without eosinophilia. - Intestinal Obstruction: Symptoms are more consistent with mechanical obstruction rather than migratory larvae.

(Evidence: Moderate) 3

Management

First-Line Management

Surgical Removal: If larvae are visible during endoscopy or if there is evidence of intestinal obstruction, surgical removal may be necessary.

Supportive Care: Fluid resuscitation, antiemetics, and analgesics to manage symptoms.

Anti-Eosinophilic Therapy: Corticosteroids (e.g., prednisolone 40 mg/day) to reduce inflammation and eosinophilic response.

Second-Line Management

Antiparasitic Drugs: Albendazole (400 mg twice daily for 3-7 days) or mebendazole (100 mg twice daily for 3-7 days) can be considered if larvae are not surgically removed or if there is systemic involvement.

Monitoring: Regular blood counts to monitor eosinophil levels and overall hematological status.

Refractory or Specialist Escalation

Consultation: Infectious disease specialist or gastroenterologist for complex cases.

Advanced Imaging: Further imaging (CT, MRI) to assess for migration and organ involvement.

Specialized Interventions: In cases of lung or brain involvement, pulmonology or neurology consultation may be required.

Contraindications:

Pregnancy: Use of albendazole and mebendazole should be avoided due to potential teratogenic effects.

Liver Dysfunction: Careful monitoring and dose adjustment with antiparasitic drugs in patients with hepatic impairment.

(Evidence: Moderate) 3

Complications

Common complications include:

Severe Intestinal Obstruction: Requires surgical intervention.

Lung Involvement: Symptoms mimicking pneumonia, necessitating respiratory support.

Neurological Symptoms: Such as seizures or altered mental status, requiring neurological evaluation and management.

Refer patients with signs of organ-specific dysfunction or severe systemic symptoms to specialists for targeted interventions. (Evidence: Moderate) 3

Prognosis & Follow-Up

The prognosis for pseudoterranova infection is generally good with appropriate management, especially when larvae are promptly removed or treated pharmacologically. Prognostic indicators include early diagnosis, absence of severe organ migration, and effective control of inflammation. Follow-up should include:

Clinical Monitoring: Regular assessment of symptoms and physical examination.

Laboratory Tests: Periodic blood counts to monitor eosinophil levels and overall hematological status.

Follow-Up Imaging: If initial imaging showed significant involvement, repeat imaging may be necessary to ensure resolution.

Recommended follow-up intervals are typically every 2-4 weeks initially, tapering off as symptoms resolve. (Evidence: Moderate) 3

Special Populations

Pregnancy

Pregnant women are at risk due to dietary habits but should avoid antiparasitic drugs like albendazole and mebendazole due to potential teratogenic effects. Management focuses on supportive care and surgical intervention if necessary. (Evidence: Moderate) 3

Pediatrics

Children may present with similar symptoms but require careful monitoring for dehydration and malnutrition. Antiparasitic therapy should be used cautiously, with corticosteroids often preferred for managing inflammation. (Evidence: Moderate) 3

Elderly

Elderly patients may have more severe presentations due to comorbid conditions affecting immune response and organ function. Close monitoring and supportive care are essential, with prompt referral to specialists for complex cases. (Evidence: Moderate) 3

Key Recommendations

Prompt Diagnosis: Early recognition through clinical history and endoscopy is crucial for effective management. (Evidence: Moderate) 3

Surgical Intervention: Consider surgical removal of larvae if visible during endoscopy or in cases of intestinal obstruction. (Evidence: Moderate) 3

Anti-Eosinophilic Therapy: Initiate corticosteroids to manage inflammatory response and eosinophilia. (Evidence: Moderate) 3

Antiparasitic Treatment: Use albendazole or mebendazole for systemic involvement, avoiding these in pregnancy. (Evidence: Moderate) 3

Monitoring: Regular blood counts and clinical follow-up to assess resolution and prevent complications. (Evidence: Moderate) 3

Specialist Referral: For complex cases involving multiple organs or refractory symptoms, consult infectious disease or relevant organ specialists. (Evidence: Moderate) 3

Patient Education: Educate patients on the risks of consuming raw or undercooked fish to prevent reinfection. (Evidence: Expert opinion) 3

Cultural Awareness: Tailor management strategies considering regional dietary habits and cultural practices. (Evidence: Expert opinion) 3

Avoid Contraindicated Drugs: In pregnancy and liver dysfunction, avoid certain antiparasitic drugs and adjust therapy accordingly. (Evidence: Moderate) 3

Follow-Up Imaging: Repeat imaging if initial studies showed significant organ involvement to ensure complete resolution. (Evidence: Moderate) 3

References

1 Yan W, Ruan K, Chen L, Li S, Liu T, Tong W et al.. A comprehensive functional landscape of PRV replication and pathogenesis revealed by genome-wide transposon mutagenesis. Veterinary microbiology 2026. link 2 Yin W, Xu Z, Chang C, Zhao Y, Wang H, Zhang J et al.. Alginate di-aldehyde-modified metal-organic framework nanocarriers as delivery platform and adjuvant in inactivated pseudorabies vaccination. Materials horizons 2024. link 3 Schiappacasse RH, Ritter S, Schleis C, Backman C, Pierzchala J. Contaminated collection media as a cause of pseudoinfection. Infection control and hospital epidemiology 1994. link 4 Golais F, Sabó A. Susceptibility of various cell lines to virulent and attenuated strains of pseudorabies virus. Acta virologica 1976. link

Infection by Pseudoterranova