Increasing Risk Factors for Imported and Domestic Gnathostomiasis in the United States

Gnathostomiasis is a foodborne zoonotic helminthic infection, commonly described in Asia and Latin America, which may follow the consumption of raw fish, eels, amphibians, and reptiles infected with muscle-encysted larvae of Gnathostoma species nematodes. After an inoculum of as little as one infective larva and an incubation period of months to years, most infections are characterized by intermittent migratory swellings due to subdermal larval migration. Less commonly, larval migration to the central nervous system may result in radiculomyelopathy or eosinophilic meningoencephalitis with high fatality rates; or larval migration to the eye with resulting blindness in untreated cases. Since the US now supports a zoonosis of Gnathostoma species with infective larvae encysted in imported and domestic fish and eels that may be consumed raw as exotic ethnic dishes, the objectives of this review were to describe the biology and life cycle of Gnathostoma nematodes and the behavioral risk factors for gnathostomiasis; and to describe the clinical manifestations, diagnosis, management, and prevention of human gnathostomiasis. Since the eradication of gnathostomiasis is very unlikely given the global distribution of Gnathostoma nematodes and the increasingly exotic culinary tastes of US residents and travelers to endemic regions, the only effective strategies for gnathostomiasis include: (1) educating citizens in the US and travelers abroad in endemic areas that fish, eels, frogs, snakes, and chicken must be cooked thoroughly first and not eaten raw or marinated; and (2) seeking medical care immediately for evaluation of migratory subcutaneous swellings. The combination of international travel and increased immigration from Asia and Latin America to the US has resulted in greater popularity of exotic ethnic cuisine, especially raw seafood dishes. The ethnic cuisine industry is supported by domestic aquaculture that produces fish-farmed tilapia and trout, and by increased importation of live freshwater species, such as Asian swamp eels (Monopterus spp.).1 Although raw seafood dishes are typically prepared with saltwater species, freshwater species, which harbor more parasites, are also used in these dishes, such as limejuice marinated tilapia or trout ceviche and eel-sashimi and sushi.2 In 2014, biologists from the US Geological Survey detected Gnathostoma species infective-stage larvae in nearly 30 percent of imported Monopterus species Asian swamp eels and in 4.5 percent of locally-caught Monopterus species freshwater swamp eels in three states.1 The investigators concluded that consumption of imported swamp eels from Gnathostoma-endemic regions of Asia could transmit gnathostomiasis to humans in the US.1 In addition, the release of live imported swamp eels or the disposal of their offal after filleting has introduced more Gnathostoma larvae into open and fish-farmed freshwaters infecting more native species.1 Since the US has all of the components to support Gnathostoma's life cycle, a zoonosis of infective Gnathostoma species, such as G. spinigerum and others, has become established in the US and will increase the risks of gnathostomiasis in humans consuming native, wildcaught, or farmed fish in ethnic dishes.1 As a result, the objectives of this review were to describe the biology and life cycle of Gnathostoma nematodes and the behavioral risk factors for gnathostomiasis; and to describe the clinical manifestations, diagnosis, management, and prevention of human gnathostomiasis.