Accelerating Progress beyond the MDG-era through addressing endemic zoonoses in the East African Community Member States

Accelerating Progress beyond the MDG-era through addressing endemic zoonoses in the East African Community Member States

by | Jul 29, 2016 | My Write Ups, Zoonoses

Accelerating Progress beyond the MDG-era through addressing endemic zoonoses in the East African Community Member States

1.1 Introductory statement

This blog post will initially provide an overview of the achievements and “pending issues” of the Millennium Development Goals (MDGs) and the opportunities that the Sustainable Development Goals (SDGs) present to the East African Community (EAC) Member States so as to accelerate progress beyond the MDGs. Secondly, it will propose priority zoonotic diseases to be targeted (that will act as a model of controlling the other zoonotic diseases) and lastly, provide recommendations on adequate measures to improve their surveillance, prevention and control.

1.2 Overview

1.2.1 Transition from Millennium Development Goals to Sustainable Development Goals

The eight MDGs[4] adopted on 18th September 2000 have guided development efforts for fifteen years (2000 to 2015), with a clear focus on poverty and on developing nations. The EAC Member States comprise of Kenya, Uganda, Tanzania, Burundi and Rwanda[1] (Figure 1), all of which are classified as developing countries and lower income economies, except Kenya which was recently re-classified as a lower-middle income economy[5]. Three of the 8 MDGs focused directly on health (MDG-4, MDG-5 and MDG-6), with the goal of reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases, respectively. The MDG Report 2015: “Assessing Progress in Africa toward the Millennium Development Goals”[6] highlights important success stories from the MDGs in Africa.

Figure 1: EAC Member States

Figure 1: EAC Member States

Contrary to the success stories, there are “pending issues” that cannot be overlooked especially with respect to the EAC Member States. The MDGs were compartmentalized to specific health goals which drove resources to specific types of programmes. This is very evident from the MDG country progress reports from the EAC Member States i.e. Kenya[7], Uganda[8], Tanzania[9], Burundi[10], and Rwanda[11], all of which provide elaborate documentation on the progress made and statistics on TB, Malaria and HIV/AIDS forgetting the “other neglected and endemic diseases”. Therefore a  key lesson from the MDGs for the EAC Member States is that endemic zoonotic diseases are a great burden to human and animal health[12] characterized by lack of reliable data which undermines the ability to set goals, optimize investments, decisions, and measure progress[13].

The 17 Sustainable Development Goals (SDGs)[14], originally conceptualized as “The Future We Want” on September 2012[15] were adopted on September 2015[14] after a series of inclusive and consultative meetings (Figure 2).

Figure 2: The origin and evolution of SDGs [2]

Figure 2: The origin and evolution of SDGs [2]

In contrast to the 3 MDGs focused on health, only 1 out of the 17 proposed SDGs focus on health framed broadly as: to ensure healthy lives and promote well-being for all at all ages. Based on the ‘Alma Ata Declaration’[16] defining health as, “A state of complete physical, mental and social well-being”, it therefore means that health priorities may also be sustained through several of the other SDGs, namely: Goal 8, Goal 11, Goal 16 and Goal 10. The SDGs therefore spur transformative change towards sustainable development, addressing systemic barriers to social, economic and environmental progress[17] at the global, regional and national level and between different sectors. They thus form the basis of a more comprehensive and integrated development agenda and requiring far-reaching change in domestic policy and action [2, 18].

1.1 Zoonoses as a platform of addressing the SDG goal 3, target 3.3 & 3.d

1.1.1 Burden of zoonotic diseases in the EAC Member States

Outbreaks of endemic zoonotic diseases in the EAC Member States, such as anthrax and rabies have considerable impact on the health care systems at the local level and adversely affect livelihoods. The burden of zoonotic diseases in this region remains poorly defined[13], in part, because of weak surveillance and health information systems and also because endemic zoonoses are not considered of high priority within both the human and animal health sectors[3].

The increasing burden of zoonotic diseases in the EAC Member States can be attributed to several factors[3, 12]. The intensification of farming, for example, leads to closer relationships between individual animals, generating opportunities for more rapid mutations as organisms move from host to host, while also providing a structured way for those pathogens to enter highly ordered food chains that branch out and reach very large numbers of people[19]. At the same time development of antimicrobial resistance poses an increasing burden in the treatment of some of the zoonotic diseases in the region[20].

1.1.2 Suggested priority diseases to target

In the EAC Member States, several zoonotic diseases of neglected populations conspire to hinder the health of people and the animals they depend on for their livelihoods which are transmitted in many ways.  For the scope of this report let us focus on four:

  • Brucellosis is an important source of morbidity in all EAC Member States. It causes a chronic debilitating disease in humans and often misdiagnosed thus wrongly treated[21]. Misdiagnosis is expensive; individuals incur significant expenses in failing to acquire diagnosis and treatment, and fail to conduct their daily activities by being unwell. Across the EAC Member States, brucellosis is still a very common but often neglected disease, and constitutes a major under-reported problem[22]. Geographical distribution depends upon local food habits, milk processing methods, animal husbandry types and standards of personal and environmental hygiene. Cattle, sheep and goats harbour this bacterium, which they transmit to each other and humans through milk or through contaminated aborted materials[19].
  • Rabies is a well-known, but nonetheless, neglected zoonotic infection, caused by the rabies virus and a public health problem in the region. For example in Kenya it is estimated that 2000 human deaths occur annually due to rabies[23]. It is transmitted and maintained mostly in domestic dog populations (though in areas with a wildlife interface, the epidemiology may get more complex), which transmit the infection to humans through bites. It is best controlled by vaccinating the dog reservoir to prevent disease from developing if infection occurs, but a human vaccine is available both as a pre- and post-exposure course, and effective and timely delivery of the vaccine will minimize mortality (but the human vaccine is very costly). Lack of cooperation between the health and veterinary sectors often impedes progress in the control of rabies. Limited accessibility to modern rabies vaccine, lack of public awareness and insufficient political commitment are the major problems in EAC Members States[23].
  • Cysticercosis is a disease caused by the tapeworm Taenia solium. It has a relatively complex lifecycle, involving pigs eating Taenia egg-carrying human faeces that contaminates the environment, humans eating undercooked pork meat, and environmental contamination with eggs that can encyst in humans. The greatest problem with solium is that it may cause a neurological disease called neurocysticercosis in people who are infected with tapeworm eggs; in the EAC Member States, it is the single largest cause of acquired epilepsy in humans[24, 25].
  • Anthrax is a disease caused by the spore-forming bacteria Bacillus anthracis, that is classified as a category ‘A’ agent by the CDC [26]. Anthrax is a very serious zoonotic disease of livestock and wild animals because it can potentially cause the rapid loss of a large number of animals in a very short time. It is estimated that 1 livestock case equals 10 human cutaneous and enteric cases [27]. A recent (July 2015) outbreak of the disease in Nakuru County in Kenya killed over one hundred buffaloes and 2 rhinos.

1.2 Conclusion and recommendations

Many factors involved in prevention and control of zoonotic infections in the EAC Member States cannot be addressed by the livestock or health sector alone.  To effectively address the proposed priority zoonoses (to act as a model to control other zoonoses and infections) it will entail focusing transmission control, prevention and burden reduction in animals so as to accrue the benefits of control and prevention  in humans as documented by other studies in Chad[28] and Mongolia[29]. This, in turn, requires a One Health approach, involving joint surveillance, control and policy management by veterinary, medical and other sectors[30]. The outstanding opportunity that is at hand is there is already a working model of a One Health office in Kenya[3], this model offers a “success story” that can be adopted to suit the needs of the other EAC Member States in addressing the priority zoonotic diseases and others as well. The good thing is that, the model will utilize the existing medical and veterinary workforce within the respective countries (Figure 3).

Figure 3: Potential One Health Coordination model among EAC Member States (modified from ZDU[3])

Figure 3: Potential One Health Coordination model among EAC Member States (modified from ZDU[3])

For these suggested priority diseases many aspects of their basic biology are well understood, and the transmission of the pathogens has been controlled in many countries. The outstanding issues that the EAC Member States need to address to effectively deploy intervention efforts, are:

  • High-level commitment and the ability of national programmes to mobilize the necessary resources and to strengthen collaboration with the pre-existing funding agencies and organisations from the MDG era e.g. the World Health Organization[31] among others to scale up intervention strategies in order to cope with the common challenges in the control of zoonoses.
  • Create multisectoral committees responsible for surveillance and control of zoonoses. These committees should be empowered to coordinate zoonosis control activities at national level and be provided with adequate budget. The committees should comprise members from all sectors and the community involved in zoonoses surveillance and control, particularly public health and veterinary services.
  • Develop national integrated surveillance systems with an open policy of cross sharing information among the EAC Member States on occurrence, distribution and disease burden. These integrated surveillance systems to be linked to the National statistics system to complement monitoring the SDGs[32].
  • Update veterinary and health professions educational curricula according to current knowledge and practical needs for control of zoonotic diseases, with emphasis on multisectoral and community led approaches
  • Diagnostic facility strengthening by deploying, and in some cases developing, new and better tools to diagnose the infections in humans and animals esp. for brucellosis, and cysticercosis (because accurate and efficient detection is key to both delivering cure and also to gathering good surveillance data)
  • Finally and most importantly, develop key indicators (reflecting each country socio-economic context and political priorities[18]) so as to measure progress in the work of controlling the four priority zoonotic diseases.

References

  1. EAC. The East African Community. 2015; Available from: http://www.eac.int/.
  2. Weitz, N., et al., Sustainable Development Goals for Sweden: Insights on Setting a national Agenda in Working Paper 2015-10. 2015, Stockholm Environmental Institute: Sweden.
  3. ZDU, Zoonotic Disease Unit: National One Health Strategic Plan 2012-2017, Ministry of Health and L.a.F. Ministry of Agriculture, Editors. 2012, The Zoonotic Diseases Unit Nairobi. p. 1-46.
  4. UN, Resolution adopted by the General Assembly-United Nations Millennium Declaration, G. Assembly, Editor. 2000, United Nations: Geneva.
  5. Bank, W., Country and Lending Groups. 2015.
  6. UNDP, MDG Report 2015: Lessons learned in implementing the MDGS, in Assessing progress in Africa toward the Millennium Development Goals. 2015, United Nations Economic Commission for Africa, African Union, African Development Bank and United Nations Development Programme.
  7. UNDP, Millennium Development Goals: Status Report for Kenya 2013, in Country MDG Progress Reports. 2014, Ministry of Devolution and Planning: Nairobi. p. 1-56.
  8. UNDP, Millennium Development Goals: Report for Uganda 2013, in Country MDG Progress Reports. 2014.
  9. UNDP, Millennium Development Goals 2014-Tanzania, in Country MDG Progress Reports. 2014.
  10. UNDP, Système des Nations Unies au Burundi et Gouvernement du Burundi 2012, in Country MDG Progress Reports. 2012, United Nations Development Programme: Burindi. p. 1-131.
  11. UNDP, Millennium Development Goals: Final Progress Report, Rwanda 2013, in Country MDG Progress Reports. 2014: Rwanda p. 1-117.
  12. Delia, G., Mapping of poverty and likely zoonoses hotspots. 2012, Department for International Development, UK: Nairobi, Kenya. p. 1-119.
  13. Hotez, P.J. and A. Kamath, Neglected tropical diseases in sub-saharan Africa: review of their prevalence, distribution, and disease burden. PLoS Negl Trop Dis, 2009. 3(8): p. e412.
  14. UN, Resolutions adopted by General Assembly on 25 September 2015, G. Assembly, Editor. 2015, United Nations. p. 1-35.
  15. UN General Assembly, The Future We Want, G. Assembly, Editor. 2012, United Nations: Rio de Janeiro.
  16. ICPHC, Declaration of Alma-Ata, A.-A. International Conference on Primary Health Care, USSR, 6-12 September 1978, Editor. 1978.
  17. Kumar, G., et al., A Transformative Post-2015 Development Agenda. 2014, Independent Research Forum (IRF2015): London.
  18. Porsch, L., T. Kafyeke, and J. Yuan, How to measure the Sustainable Development Goals in central Europe?, NETGREEN, Editor. 2015. p. 1-25.
  19. Microbiology Society, Comment: Zoonoses in Africa. Microbiology Society’s online magazine-Microbiology Today, 2015(November 2015).
  20. Kimang’a Andrew, N., A situational analysis of antimicrobial drug resistance in Africa: Are we losing the battle. Ethiop J Health Sci, 2012. 22(2): p. 1-9.
  21. McDermott, J.J. and S.M. Arimi, Brucellosis in sub-Saharan Africa: epidemiology, control and impact. Vet Microbiol 2002. 90: p. 111–34.
  22. Welburn, S.C., et al., The Neglected Zoonoses – The Case for Integrated Control and Advocacy. Clinical Microbiology And Infection: The Official Publication Of The European Society Of Clinical Microbiology And Infectious Diseases, 2015.
  23. ZDU, Kenya Strategic Plan for the Elimination of Human Rabies in kenya 2014-2030, Ministry of Health and L.a.F. Ministry of Agriculture, Editors. 2014, Zoonotic Diseases unit.
  24. Phiri, I.K., et al., The emergence of Taenia solium cysticercosis in Eastern and Southern Africa as a serious agricultural problem and public health risk. Acta Tropica, 2003. 87(1): p. 13-23.
  25. Ngowi, H.A., et al., Taenia Solium Cyticercosis in eastern and Southern Africa: An Emerging Problem in Agriculture and Public Health. 2004. 35(1): p. 266-270.
  26. CDC. Bioterrorism Agents/Diseases. Emergency Preparedness and Response 2015 [cited 2015 23 Nov 2015]; Available from: http://emergence\y.cdc.gov/agent/agentlist.asp.
  27. ZDU. Anthrax Outbreak Response, Nakuru COunty-February 2014. Outbreaks 2015 [cited 2015 23 Nov 2015]; Available from: http://zdukenya.org/outbreaks/.
  28. Zinsstag, J., et al., Potential of cooperation between human and animal health to strengthen health systems. The Lancet, 2005. 366(9503): p. 2142-2145.
  29. Batsukh, Z., et al., One Health in Mongolia. Current Topics In Microbiology And Immunology, 2013. 366: p. 123-37.
  30. Zinsstag, J., et al., One Health: The Theory and Practice of Integrated Health Approaches. 2015: CAB International.
  31. WHO, Neglected tropical diseases, in Closer intersectoral collaboration using existing tools can defeat zoonoses affecting humans. 2015, World Health Organisation Online.
  32. SDSN, Data for development: An Action Plan to Finance the Data Revolution for Sustainable Development. 2015, Sustainable Development Solutions Network, Open Data Watch.

 

7

Updates direct to your Email

Enter your email address to receive notifications of new posts and opportunities by email.

Join 7,243 other subscribers

Post categories

Oral cysticercosis: A contribution of dentists & clinicians to One Health?

Oral cysticercosis: A contribution of dentists & clinicians to One Health?

by | Jul 31, 2015 | My Write Ups, Zoonoses

Oral cysticercosis: A contribution of dentists & clinicians to One Health?

Historical account

Cysticercosis was first described by Johannes Udalric Rumler in 1555 but the connection between tapeworms and cysticercosis in man was still a mystery. In 1855, Kuchenmaister established that human cysticercosis is indeed caused by the larval stage, Cysticercus cellulosae, of the pork tapeworm, Taenia solium[14].

Epidemiology

Cysticercosis is prevalent in several parts of the world. It is endemic and one of the leading causes of acquired epilepsy[10] in developing countries, mainly in parts of Asia, Africa, Latin America and Eastern Europe. This is especially in those areas with uncontrolled free range pig production, poor sanitation and where humans and animals live in close contact[1]. Its incidence is also increasing in developed countries as a result of migration of infected persons and frequent travel to and from endemic areas[27].

In man, cysticercosis frequently involves many parts of the body including the brain (causing fatal neurocysticercosis), subcutaneous tissues, heart, liver, lungs, peritoneum, skeletal muscles and the eye. Although oral involvement by cysticercosis is common in swine, this location is a very rare occurrence in humans[17, 27, 1] where it presents as a component of disseminated cysticercosis and often a diagnostic challenge to clinicians [14].

A literature review conducted in 2012 by Krishnamoorthy and colleagues  [14], revealed 69 cases of oral cysticercosis characterized by a cystic swelling as the only evidence of the disease. They further found that any region of the oral cavity can be involved but review of literature suggested that the tongue was the preferred site comprising 46.37% of the 69 cases, followed by labial and buccal mucosa, with one case documented involving the gingival tissue from India [17]. However, some authors postulate that the muscular activity and high metabolic rate of the oral region may prevent lodging of the cysticerci in the tongue[5]. Other authors have also noted that intraorally, the favored sites for the development of cysticerci are the tongue, labial mucosa (lips), buccal mucosa (cheeks) and the floor of the mouth, however, correct and precise diagnosis is infrequently established [20, 6, 23, 13, 29, 7, 12]

How does man get infected?

Man is the definitive host for the adult pork tapeworm (Taenia solium) while the pig serves as an intermediate host. Human beings are infected by either:

  1. Eating uncooked, partially cooked or inadequately frozen pork containing viable Cysticercus cellulosae.
  2. Ingesting food or water contaminated by infected human faeces containing Taenia solium eggs which further explains cases of cysticercosis in vegetarians [11]
  3. Autoinfection by regurgitation of eggs into the stomach after reverse peristalsis[20, 3, 24]

In the human body the larval form (Cysticercus cellulosae) penetrates the intestinal mucosa and is then distributed through the blood vessels and lymphatics to the various parts of the body where they develop into cysticerci completing the life cycle.

What are the clinical signs?

In humans cysticercosis can develop in various organs and tissues. The larval form (Cysticercus cellulosae) commonly presents as a cyst in the cerebral tissue (brain), meninges, subcutaneous tissue, muscle and the eye [3, 19, 13, 15]. However, it is not commonly considered in the diagnosis of swellings of the maxillofacial region including the oral cavity and cheek muscles.

Most oral presentations of cysticercosis are in the form of painless, well-circumscribed, soft swellings or cystic nodules[12], that may persist or rupture and heal uneventfully[11]. Therefore, oral cysticercosis is a diagnostic challenge to a clinician due to:

  1. The condition mimics other oral nodular lesions like mucoceles, or a benign tumor of mesenchymal origin, such as a lipoma, fibroma, hemangioma, granular cell tumor, or a minor salivary gland adenoma[22]. However, the high intraluminal pressure in oral cysticercosis helps to differentiate it from lipoma and hemangioma.
  2. Cysticercosis is rarely included in the pre-operative differential diagnosis due to relative rarity of the lesion, inadequate knowledge of oral manifestations of parasitic infections and negligence while taking medical history[26].

Generally, the clinical symptoms of cysticercosis depend on the site and the number of cysticerci in the body. Cysticerci are well tolerated in the tissues when they are alive but evoke an inflammatory reaction in the surrounding tissue on  death. During invasion there may be no symptoms or mild muscular pain and fever. Central nervous system involvement may result to the potentially fatal neuro-cysticercosis[9].

Examples of oral cysticercosis case presentation and presumptive diagnosis: 

1. JoshiExample one, Joshi and colleagues (2014)[12]: An 18 year old male from Central India with an asymptomatic solitary cystic nodule in the right mucobuccal fold of upper arch. The patient reported that the lesion was present since 5-6 years with no associated pain. Intra oral examination revealed that the nodule as spherical in shape, 2 x 2 cm in size, firm, smooth surfaced and mobile. Noted in the alveolar mucosa mainly in mucobuccal fold of maxillary right canine region. There was no much change in the size and other features of the lesion in due course. The patient was otherwise healthy without any systemic signs and symptoms.

Example two, Bhatia and colleagues (2014)[1]: A case of eight year old Hindu female and a resident of a slum in Mumbai. The patient came with a swelling inside the oral cavity on the right buccal mucosa since one year which gradually increased in size. On local examination the swelling was non tender, firm and mobile measuring 1 x 0.5cm.

WanjariExample three, Wanjari and colleages (2013)[28]: Clinical presentation for both (2) cases was of diffuse, nontender, soft to fluctuant swelling. Case 1 showed involvement of the right cheek in the lower third of the face in line with the outer canthus of the right eye; however, intraorally overlying mucosa was intact and normal in colour. While case 2 revealed involvement of right labial mucosa in relation to maxillary right anterior region. No submandibular or cervical lymphadenopathy was detected in both cases.

Example four, Venkatraman and colleagues (2013)[27]: A 23 year old male presented with a swelling on the right lateral border of the tongue. The patient reported that the lesion was present since 4 years with no associated pain. Intra oral examination revealed that the lesion was spherical in shape, 2×2 cm in size, firm, compressible, smooth surfaced and mobile within the soft tissue of the tongue.

ChunturiExample five, Chunduri and colleagues(2013) [2]: A 17 year old Indian male presented with a nodule in the right lower lip. Clinical examination revealed a well circumscribed, mobile nodule approximately 1.5 cm in diameter with intact overlying mucosa. The lesion was painless and had been present for about six months, and was slowly growing.

Nervos SantosExample six, Neves Santos and colleagues (2013)[21]: A 21-year-old woman from Poções County (Bahia, Brazil) reported to a private dental center with the chief complaint of a painless nodule on the right side of her tongue that had been present for the past two years. The nodule had increased in size to approximately 3.5 cm in maximum diameter, and clinical examination showed a firm nodule that was covered with normal mucosa. No cervical or submandibular lymphadenopathy was observed. A complete blood count, liver function tests and renal function tests were all normal. A preliminary diagnosis of lipoma was made.

 

 

Krishnamoorthy

Example seven, Krishnamoorthy and colleagues (2012)[14]: A 12-year-old girl with a nodular swelling on the lower lip. She first noticed it 2 months ago. The swelling was painless, remained unchanged in size, and caused a little difficulty while eating and talking. On examination there was a solitary, spherical, well-defined swelling in the lower labial mucosa present on the left side of the midline which measured approximately 1.5 X 1.5 cm. The mucosa over the swelling was normal. On palpation it was not tender, but was tense and nonfluctuant. Differential diagnoses of mucocele, lipoma, and fibroma were considered.

Diagnosis of oral cysticercosis  

Diagnosis of human oral cysticercosis (including other forms of tissue cysticercosis) is impaired by its polymorphic clinical presentations. Excisional biopsy coupled with sections stained with Haematoxylin & Eosin, is the only confirmatory diagnostic procedure for the condition, which demonstrates the presence of the larva in the tissue or the scolex in the cystic lesion. However, other investigations must be considered to detect the disease in the diverse tissues that may be affected, using: Fine Needle Aspiration (FNA), serology, radiologic imaging techniques such as Computer Tomography (CT) or Magnet Resonance Imaging (MRI) and advanced molecular techniques as tools for conformational diagnosis[5][7].

Criteria for diagnosing oral cysticercosis as proposed by Krishnamoorthy and colleagues is: [14]:

  • A compatible clinical presentation
  • FNA aspirated material showing a speck of pearly white content also by[17, 27]
  • Histopathologic demonstration of the parasite on biopsy
  • Cystic lesions with scolex on imaging (muscular cysticercosis)
  • Positive epidemiological factors like household contact, endemic region or travel to or from an endemic area

Examples of oral cysticercosis definitive diagnoses: 

JoshiExample one, Joshi and colleagues (2014)[12]: Microscopically, the excised tissue showed a thin fibrous connective tissue capsule adjacent to a cystic cavity containing a duct like tubal segments that was lined by a homogeneous membrane typical of cysticercosis cellulosae (larval form of Taenia solium); Cyst wall and outer fibrous tissue was presenting in many papillary projections along with numerous inflammatory cell infiltrations and macrophages.

BhatiaExample two, Bhatia and colleagues (2014)[1]: External fibrous capsule with mononuclear cell infiltrate comprised of lymphocytes, histocytes and plasma cells. A double layered membrane consisting of an outer acellular hyaline eosinophilic layer and an inner sparsely cellular layer with aggregates of eosinophils was seen. The cyst contained larval form of T. Solium. The cephalic extremity of larva (scolex) with suckers could be identified suggesting the diagnosis of cysticercosis of right buccal mucosa.

WanjariExample three, Wanjari and colleagues (2013)[28]: Histopathological examination of excisional biopsy specimen revealed external dense, fibrous capsule derived from host tissue surrounding a cystic cavity which contained larval stage of T solium-cysticercus cellulosae. capsule showed intense inflammatory infiltrate consisting of plasma cells and few eosinophils. The larva consisted of a scolex, where suckers and duct-like invaginated segment could be identified at the caudal end. A digitiform coating of homogenous eosinophillic membrane was evident lining the cystic area. A final diagnosis of oral cysticercosis was made. MRI and CT scan were negative which ruled out neurocysticercosis (NCC).

Example four, Venkatramana and colleagues (2013)[27]: Histopathology of the excised tissue revealed a thin capsule of fibrous connective tissue surrounding a cystic cavity, which contained cysticercosis cellulosae (larval form of Taenia solium). The larva composed of a duct like tubal segments that was lined by a homogeneous membrane. Cyst wall and outer fibrous tissue was infiltrated with numerous inflammatory cells, macrophages and few foreign body type giant cells. Based on these findings, a diagnosis of cysticercosis was made

ChunduriExample five, Chunduri and colleagues (2013[2]: Microscopic examination revealed double glycoprotein membrane tissue surrounding a cystic cavity which contained Cysticercus cellulosae. The capsule showed intense inflammatory infiltrate, consisting mainly of lymphocytes and plasma cells. The larva was composed of a scolex, where a sucker could be identified, and a duct-like invaginated segment at the caudal end. No areas of dystrophic calcification were present in the specimen. Based on these findings, a diagnosis of cysticercosis was made.

Neves SantosExample six, Neves Santos and colleagues (2012)[21]: histological sections revealed the presence of a cystic lesion containing a serrated larva (C. cellulosae) with a cuticle and well-defined areolar and cellular layers as well as a cystic capsule exhibiting predominantly mononuclear inflammation. The final diagnosis was cysticercosis of the tongue.

KrishnamoorthyExample seven, Krishnamoorthy and colleagues (2012)[14]: A fine-needle aspiration (FNA) was performed. The aspirate was a clear fluid but the report was not conclusive. Hence the lesion was excised under local anesthesia which was a smooth well-encapsulated mass. Hematoxylline and eosin (H/E) stained sections showed a cystic mass containing the cysticercus cellulosae surrounded by dense fibrous capsule infiltrated with inflammatory cells, mainly lymphocytes and plasma cells. The inner aspect of the capsule was a double-layered membrane in which larval form of T. solium were seen. Larva showed the presence of suckers and caudal to it duct-like invagination segment lined by homogenous membrane. No areas of dystrophic calcifications were present in the tissue specimen. The final diagnosis of cysticercosis of the lip was made.

Differential diagnoses for oral cysticercosis

Oral cystucercosis is usually misdiagnosed as a mucocele, sialocyst or a benign tumor of mesenchymal origin such as lipoma, fibroma, hemangioma, lymphangioma, granular cell tumor  [16, 27], benign salivary gland neoplasms[8] and parasitic cysts e.g. hydatid cyst. Stool examination is usually carried out to rule out parasitic cysts [28].

Treatment

Oral cysticerci, being usually localized and superficial lesions, are easy to excise and have good prognosis. Simple surgical excision is often all that is required to ensure complete removal of the lesion without any postoperative complications in such cases[5]. Lesions involving the muscles like the masseter may be treated conservatively with antiparasitic therapy[18]. Unlike the neurocysticercosis or orbital cysticercosis which are severe in their clinical presentations, the oral cysticercosis are usually well tolerated. However, it is important to exclude the presence of the parasite in other sites through a detailed case study and systematic investigations [14]. Praziquantel and albendazole are used to treat cysticercosis, especially in patient with disseminated cysticercosis or where surgical excision is risky or not possible, such as in neurocysticercosis[4].

Control and prevention

Transmitted via the orofecal route, cysticercosis is potentially eradicable. To prevent and eradicate human cysticercosis supportive measures such as improvement in the sanitary conditions, pork inspection, consumption of boiled water, well washed vegetables, mass education about personal hygiene should be undertaken along with medical treatment (by a registered and approved medical practitioner) which includes larvicidal drugs, corticosteroids, and surgical procedure for removal of the cyst[25, 28].

The role of the dental clinician?

The illustrations above clearly tell us the critical role that clinicians and especially dentists have in the control  of not only oral cysticercosis but cysticercosis as a Neglected Tropical Disease. The patient diagnosis of oral cysticercosis could act as a “sentinel” and insight to further investigate and control the problem in the family or community at large.

It is clear that oral cysticercosis should be considered in the differential diagnosis of intraoral solitary swellings especially in endemic areas. In endemic countries a lesion can be first referred for a FNA which is cost-effective, quick, and reliable. Expensive investigations, like immunological tests and CT, can be undertaken only in the absence of a definitive pathological diagnosis. As much as the histopathological findings of the excised swelling are diagnostic of the lesion a detailed evaluation should be done to exclude the presence of the parasite at other sites[14, 2].

References

  1. Bhatia, V., O., Natekar, A., A., and Valand, A., G., Paediatric Oral Cysticercosis: A Misdiagnosed and a Rare Entity. International Journal of Oral & Maxillofacial Pathology., 2014. 5(2): p. 26-28.
  2. Chunduri, N., S., Goteki, V., Gelli, V., and Madasu, K., Case Report: Oral Cysticercosis. SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH, 2013. 44(2).
  3. De Souza, P.E., Barreto, D.C., Fonseca, L.M., de Paula, A.M., Silva, E.C., and Gomez, R.S., Cysticercosis of the Oral Cavity: Report of Seven Cases. Oral Dis, 2000. 6: p. 253-5.
  4. Del Brutto, O.H., Sotelo, J., and Roman, G.C., Therapy for Neurocysticercosis: A Reappraisal. Clin Infect Dis, 1993. 17: p. 30-5.
  5. Delgado-Azañero, W.A., Mosqueda-Taylor, A., and Carlos-Bregni, R., Oral Cysticercosis: A Collaborative Study of 16 Cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2007. 103: p. 528-33.
  6. Dhaif, G.A. and Al-Hadi, A.A., Oral Cysticercosis: A Case Report. Saudi Dental J 2000. 2: p. 100-2.
  7. Dysanoor, S. and Pol, J., A Solitary Facial Nodular Swelling: A Case Report of Intramuscular Cysticercosis in Buccinator Muscle. Asian Pac J Trop Dis, 2013. 3(3): p. 235-9.
  8. Garcia, H.H. and Del Brutto, O.H., Taenia Solium Cysticercosis. Infect Dis Clin North Am, 2000. 14: p. 97-119.
  9. Garcia, H.H., Evans, C.A.W., and Nash, T.E., Current Consensus Guidelines for Treatment of Cysticercosis. Clin Microbiol Rev, 2002. 15: p. 747-56.
  10. Jay, A., Dhanda, J., and Peter, L., Short Communication-Oral Cysticercosis. Br J Oral Maxillofac Surg, 2007. 45: p. 331-4.
  11. Jay, A., Dhanda, J., Chiodini, P.L., Woodrow, C.J., Farthing, P.M., Evans, J., and Jager, H.R., Oral Cysticercosis. Br J Oral Maxillofac Surg, 2007. 45(4): p. 331-4.
  12. Joshi, J., Sharanesha, M.B., Jatwa, R., and Khetrapal, S., Oral Cysticercosis: A Diagnostic Difficulty. J Clin Diagn Res, 2014. 8(10): p. ZD24-5.
  13. Junior, H.M., Melo, F., M.R., and Nogueira, d., Santos L.A., Oral Cysticercosis. Braz J Oral Sci, 2006. 5: p. 1109-11.
  14. Krishnamoorthy, B., Suma, G.N., Dhillon, M., Srivastava, S., Sharma, M.L., and Malik, S.S., Encysted Tenia Solium Larva of Oral Cavity: Case Report with Review of Literature. Contemp Clin Dent, 2012. 3(Suppl 2): p. S228-32.
  15. Lee, K.H., Cepeda, L., and Miller, M., Mucoceles Not-Oral Cysticercosis and Minor Salivary Gland Adenocarcinoma: Two Case Reports. Dermatol Online J 2009. 15(S).
  16. Mahajan, S., Agrawal, P., Datarkar, A., Datarkar, and Borle, R., Oral Cysticercosis: A Case Report. J Maxillofac Oral Surg, 2009. 8(1): p. 85-87.
  17. Mazhari, N.J., Kumar, N., and Jain, S., Cysticercosis of the Oral Mucosa: Aspiration Cytologic Diagnosis. J Oral Pathol Med, 2001. 30: p. 187-9.
  18. Mittal, A., Das, D., Iyer, N., Nagaraj, J., and Gupta, M., Massester Cysticercosis-a Rare Case Diagnosed on Ultrasound. Dentomaxillofac Radiol, 2008. 37(113-16).
  19. Mohan, H., Infectious and Parasitic Diseases, in Textbook of Pathology, Mohan, P. and Mohan, T., Editors. 2005, Jaypee Brothers Medical Publishers Ltd: New Delhi, India. p. 195-6.
  20. Mukheh, S., Kacker, S.K., and Kapilla, K., Cysticercosis of the Oral Cavity—a Clinic Pathological Study of Ten and a Half Years. JIDA, 1986. 58: p. 257-9.
  21. Neves Santos, F., Neves Santos Soares, F., Leal Macedo, C., Oliveira de Souza, R., Rode Santos, A., Araújo Silva Gurgel, C., and Luciano Neves Santos, F., A Brazilian Case of Tongue Cysticercosis. Advances in Infectious Diseases, 2012. 02(04): p. 106-109.
  22. Nigam, S., Singh, T., Mishra, A., and Chaturvedi, u., Oral Cystivercosis-Report of Six Cases. 2000.
  23. Nigam, S., Singh, T., Mishra, A., and Chaturvedi, K.U., Oral Cysticercosis–Report of Six Cases. Rev Inst Med Trop Sao Paulo, 2005. 47(2): p. 95-8.
  24. Patel, K., Shah, M., and Patel, B., Subcutaneous Oral Cysticercosis. Natl J Community Med, 2011. 2: p. 311-13.
  25. Ribeiro, A.C., Luvizotto, M., Soubhia, A.M., Castro, A., and Paulo, A., Oral Cysticercosis: Case Report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2007. 104: p. 56-8.
  26. Singh, S., Chhabra, S., Aggarwal, G., Karla, R., Duhan, A., and Sen, R., Oral Cysticercosis- a Rare Presentation. Asian Pacific Journal of Tropical Medicine, 2011: p. 587-8.
  27. Venkatraman, J., Jain, A., and Parmar, P., Oral Cysticercosis-a Reare Case Report. Int J Cur Res Rev, 2013. 5(22): p. 89-93.
  28. Wanjari, S.P., Patidar, K.A., Parwani, R.N., and Tekade, S.A., Oral Cysticercosis: A Clinical Dilemma. BMJ Case Rep, 2013. 2013.
  29. Wilson, A., Mosqueda, A., Carlos, R., Antonio, M., and Contreras, E., Oral Cysticercosis: A Collab¬Orative Study of 16 Cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007. 103: p. 528-33.
7

Updates direct to your Email

Enter your email address to receive notifications of new posts and opportunities by email.

Join 7,243 other subscribers

Post categories