Trichinosis, also known as trichinellosis, is a parasitic disease caused by roundworms of the Trichinella genus. During the initial infection, invasion of the intestines can result in diarrhea, abdominal pain, and vomiting. Migration of larvae to muscle, which occurs about a week after being infected, can cause swelling of the face, inflammation of the whites of the eyes, fever, muscle pains, and a rash. Minor infection may be without symptoms. Complications may include inflammation of heart muscle, central nervous system involvement, and inflammation of the lungs.
Trichinosis is mainly spread when undercooked meat containing Trichinella cysts is eaten. Wild meat is more likely to contain the parasite. In North America this is most often bear, but infection can also occur from pork, boar, and dog meat. Several species of Trichinella can cause disease, with T. spiralis being the most common. After the infected meat has been eaten, the larvae are released from their cysts in the stomach. They then invade the wall of the small intestine, where they develop into adult worms. After one week, the females release new larvae that migrate to voluntarily controlled muscles, where they form cysts. The diagnosis is usually based on symptoms and confirmed by finding specific antibodies in the blood, or larvae on tissue biopsy.
The best way to prevent trichinosis is to fully cook meat. A food thermometer can verify that the temperature inside the meat is high enough. Infection is typically treated with antiparasitic medication such as albendazole or mebendazole. Rapid treatment may kill adult worms and thereby stop further worsening of symptoms. Both medications are considered safe but have been associated with side effects such as bone marrow suppression. Their use during pregnancy or in children under the age of 2 years is poorly studied but appears to be safe. Treatment with steroids is sometimes also required in severe cases. Without treatment, symptoms typically resolve within three months.
Worldwide, about 10,000 trichinosis infections occur a year. At least 55 countries including the United States, China, Argentina, and Russia have had recently documented cases. While trichinosis does occur in the tropics, it is actually less common there. Rates of trichinosis in the United States have decreased from about 400 cases per year in the 1940s to 20 or fewer per year in the 2000s. The risk of death from infection is low.
Signs and symptoms The great majority of trichinosis infections have either minor or no symptoms and no complications. The two main phases for the infection are enteral (affecting the intestines) and parenteral (outside the intestines). The symptoms vary depending on the phase, species of Trichinella, the quantity of encysted larvae ingested, age, sex, and host immunity.
Enteral phase A large burden of adult worms in the intestines promotes symptoms such as nausea, heartburn, dyspepsia, and diarrhea from two to seven days after infection, while small worm burdens generally are asymptomatic. Eosinophilia presents early and increases rapidly.
Parenteral phase The severity of symptoms caused by larval migration from the intestines depends on the number of larvae produced. As the larvae migrate through tissue and vessels, the body's inflammatory response results in edema, muscle pain, fever, and weakness. A classic sign of trichinosis is periorbital edema, swelling around the eyes, which may be caused by vasculitis. Splinter hemorrhage in the nails is also a common symptom.John D. and William A. Petri. Markell and Voge's Medical Parasitology. 9th ed. Philadelphia: Saunders, 2006.
They may very rarely cause enough damage to produce serious neurological deficits (such as ataxia or respiratory paralysis) from worms entering the central nervous system (CNS), which is compromised by trichinosis in 10–24% of reported cases of cerebral venous sinus thrombosis, a very rare form of stroke (three or four cases per million annual incidence in adults). Trichinosis can be fatal depending on the severity of the infection; death can occur 4–6 weeks after the infection, and is usually caused by myocarditis, encephalitis, or pneumonia.
Cause
The classical agent is T. spiralis (found worldwide in many carnivorous and omnivorous animals, both domestic and sylvatic (wild), but seven primarily sylvatic species of Trichinella also are now recognized:
Species and characteristics T. spiralis is most adapted to swine, most pathogenic in humans, and is cosmopolitan in distribution. T. britovi is the second-most common species to infect humans; it is distributed throughout Europe, Asia, and northern and western Africa, usually in wild carnivores, crocodiles, birds, wild boar, and domesticated pigs. T. murrelli also infects humans, especially from black bear meat; it is distributed among wild carnivores in North America. T. nativa, which has a high resistance to freezing, is found in the Arctic and subarctic regions; reservoir hosts include polar bears, Arctic foxes, walruses, and other wild game. T. nelsoni, found in East African predators and scavengers, has been documented to cause a few human cases. T. papuae infects both mammals and reptiles, including crocodiles, humans, and wild and domestic pigs; this species, found in Papua New Guinea and Thailand, is also nonencapsulated. T. pseudospiralis infects birds and mammals, and has demonstrated infection in humans; it is a nonencapsulated species. T. zimbabwensis can infect mammals, and possibly humans; this nonencapsulated species was detected in crocodiles in Africa.
Taxonomy Kingdom: Animalia Phylum: Nematoda Class: Adenophorea Order: Trichurida Family: Trichinellidae Genus: Trichinella
Lifecycle
The typical lifecycle for T. spiralis involves humans, pigs, and rodents. A pig becomes infected when it eats infectious cysts in raw meat, often porcine carrion or a rat (sylvatic cycle). A human becomes infected by consuming raw or undercooked infected pork (domestic cycle). In the stomach, the cysts from infected undercooked meat are acted on by pepsin and hydrochloric acid, which help release the larvae from the cysts into the stomach. The larvae then migrate to the small intestine, and burrow into the intestinal mucosa, where they molt four times before becoming adults.
30 to 34 hours after the cysts were originally ingested, the adults mate, and within five days produce larvae. Adult worms can only reproduce for a limited time because the immune system eventually expels them from the small intestine. The larvae then use their piercing mouthpart, called the "stylet", to pass through the intestinal mucosa and enter the lymphatic vessels, and then enter the bloodstream.
The larvae travel by capillaries to various organs, such as the retina, myocardium, or lymph nodes; however, only larvae that migrate to skeletal muscle cells survive and encyst. The larval host cell becomes a nurse cell, in which the larva will be encapsulated, potentially for the life of the host, waiting for the host to be eaten. The development of a capillary network around the nurse cell completes encystation of the larva. Trichinosis is not soil-transmitted, as the parasite does not lay eggs, nor can it survive long outside a host.
Diagnosis Diagnosis of trichinosis is confirmed by a combination of exposure history, clinical diagnosis, and laboratory testing.
Exposure history An epidemiological investigation can be done to determine a patient's exposure to raw infected meat. Often, an infection arises from home preparation of contaminated meat, in which case microscopy of the meat may be used to determine the infection. Exposure determination does not have to be directly from a laboratory-confirmed infected animal. Indirect exposure criteria include the consumption of products from a laboratory-confirmed infected animal or sharing of a common exposure with a laboratory-confirmed infected human.
Clinical diagnosis Clinical presentation of the common trichinosis symptoms may also suggest infection. These symptoms include eye puffiness, splinter hemorrhage, nonspecific gastroenteritis, and muscle pain. The case definition for trichinosis at the European Center for Disease Control states, "at least three of the following six: fever, muscle soreness and pain, gastrointestinal symptoms, facial edema, eosinophilia, and subconjunctival, subungual, and retinal hemorrhages."
Laboratory testing Blood tests and microscopy can be used to aid in the diagnosis of trichinosis. Blood tests include a complete blood count for eosinophilia, creatine phosphokinase activity, and various immunoassays such as ELISA for larval antigens.
In some cases, muscle biopsies are performed, where "0.2 to 0.5 grams of human or animal skeletal muscle tissue is collected and examined for Trichinella larvae via artificial digestion or histological analysis."
Prevention
Legislation Laws and rules for food producers may improve food safety for consumers, such as the rules established by the European Commission for inspections, rodent control, and improved hygiene. A similar protocol exists in the United States, in the USDA guidelines for farms and slaughterhouse responsibilities in inspecting pork.United States Department of Agriculture – Food Safety and Inspection Service. "NSS NRTE/RTE Establishment Responsibilities." (2006).
Education and training Public education about the dangers of consuming raw and undercooked meat, especially pork, may reduce infection rates. Hunters are also an at-risk population due to their contact and consumption of wild game, including bears. As such, many states, such as New York, require the completion of a course in such matters before a hunting license can be obtained.New York State Department of Environmental Conservation – Hunting Licenses <www.dec.ny.gov/permits/6094.html>
Meat testing Testing methods are available for both individual carcasses and monitoring of the herds. Artificial digestion method is usually used for the testing of individual carcasses, while the testing for specific antibodies is usually used for herd monitoring.
Food preparation Larvae may be killed by the heating or irradiation of raw meat. Freezing is normally only effective for T. spiralis, since other species, such as T. nativa, are freeze-resistant and can survive long-term freezing. All meat (including pork) can be safely prepared by cooking to an internal temperature of or higher for 15 seconds or more. Wild game: Wild game meat must be cooked thoroughly (see meat preparation above). Freezing wild game does not kill all trichinosis larval worms, because the worm species that typically infests wild game can resist freezing. Pork: Freezing cuts of pork less than 6 inches thick for 20 days at 5 °F (−15 °C) or three days at −4 °F (−20 °C) kills T. spiralis larval worms; but this will not kill other trichinosis larval worm species, such as T. nativa, if they have infested the pork food supply (which is unlikely, due to geography).
Pork can be safely cooked to a slightly lower temperature, provided that the internal meat temperature is at least as hot for at least as long as listed in the USDA table below. Nonetheless, allowing a margin of error for variation in internal temperature within a particular cut of pork, which may have bones that affect temperature uniformity, is prudent. In addition, kitchen thermometers have measurement errors that must be considered. Pork may be cooked for significantly longer and at a higher uniform internal temperature than listed below to be safe.
Internal Temperature Internal Temperature Minimum Time (°F) (°C) (minutes) 120 49 1260 122 50.0 570 124 51.1 270 126 52.2 120 128 53.4 60 130 54.5 30 132 55.6 15 134 56.7 6 136 57.8 3 138 58.9 2 140 60.0 1 142 61.1 1 144 62.2 Instant