BRIEF COMMUNICATIONS
519
Results
Microscopical examination of the smears prepared from the internal organs and blood did not show any amastigotes. Amastigotes were found in two of the smears prepared from the ear scrapings of 50 rodents. Both were R. opimus from northern Khorassan. In the smears prepared from the sore of M. persicus, considerable numbers of amastigotes were seen. The organisms were morphologically similar to Leishmania tropica major. The habitat of the infected M. persicus had been along a stony fence on a flat plain with Artemisia and Astragalus at an altitude of 1100 m. This place is located near Zanganeh village, 37 km east of Marand city in Azerbaijan, north-western Iran, which is not considered to be an endemic area for human cutaneous leishmaniasis. It seems that in this area the infection is limited to wildlife (rodents). It is recommended that further studies be carried out in this area. This is most probably the first report of the natural occurrence of leishmaniasis in M. persicus.
ANSARI, N., & FAGHIH, M. A. (1953). Annls. Parasit. hum. camp.,28,241. & MOFIDI, CH. (1950). Bull. Sot. Path. exot., 43, 601. GHORBANI, M., HAFIZI, A., & SHEGERFCAR, T. (1973). Pahlavi Med. J., 4,389. GUNDERS, A. E., FONER, A., & MONTILLIO, B. (1968). Nature, Lond., 219, 85. NADIM, A., & FAGHIH, M. A. (1968). Trans. R. Sot. trop. Med. Hyg., 62, 534. -, & SEYEDI-RASHTI, M. A. (1971). Acta Med. Iranica, 14, 99. -, -, & MESGHALI, A. (1968). 3. trop. Med. Hyg., 71, 238. PETRISVEVA, I?. A. (1971). Bull. WZdHlth Org., 44, 567. SEYEDI-RASHTI, M. A., & NADIM, A. (1967). Bull. Sot. Path. exot., 60, 510.
HUMAN
INFECTIONS
H. E. SHORTT,
WITH BABESIA
F.R.S., I.M.S.(RET.)
Although the babesias, using the term in a wide sense to include various genera which are still inadequately separated, are probably the most widely distributed blood parasites of mammals it was long believed that man was immune to their attacks. The first reported human infection was that of a farmer in Yugoslavia whose fatal illness, in 1957, was at first thought to be malaria. This was later definitely diagnosed as a case of babesiosis, the source of infection being, presumably, his cattle which showed a high rate of infestation with Babesiabovis.Investigation brought to light the fact that 11 years previously the man had undergone splenectomy after a motor car accident (SKRABALO and DEANOVIC, 1957). The next recorded case was in California in 1966. This man also was diagnosed as malaria, was treated as such for 15 weeks with chloroquine and recovered. Investigation again disclosed that 2 years previous to this illness the man had undergone splenectomy as treatment for hereditary spherocytosis, a condition in which the red blood cells show an abnormality which is transmitted as a Mendelian dominant. In this case babesiosis was diagnosed when blood parasites showing “cross” patterns in the red blood cells were found (SCHOLTENS et al., 1966). The third confirmed case of human babesiosis occurred in County Galway, Ireland, in 1967. A deep sea fisherman and his family on holiday by caravan spent 4 or 5 days in August on the shore of Lough Corrib. Shortly after his return home the became acutely ill and died within a week. This case was ably described in detail in a paper by FITZPATRICK et al. (1969), who cdnsidered the diagnosis at the time of death to be blackwater fever due to Plasmodiumfaiciparum, probably caused by a blood transfusion the patient had had about 34 months previously after an operation for a perforated duodenal ulcer. This diagnosis appeared to be justified by the fact that blood slides showed “intra-erythrocytic” inclusions presumed to be malaria parasites. Enquiry revealed that this operation had been complicated by injury to the spleen, which had been removed. The absence of any malarial pigment in the blood films or in the internal organs at autopsy led to doubt as to the correctness of the diagnosis and blood films
520
BRIEF COhtMUNICATIONS
were sent to Mr. P. G. Shute of the Malaria Reference Centre, Horton. As he considered the erythrocytic inclusions atypical of malaria he consulted Professor I?. C. C. Garnham of the London School of Hygiene and Tropical Medicine who identified the inclusions as B. divergens.The presumption was obvious that the infection had been acquired during the short holiday at Lough Corrib. A year later, Professor Garnham and colleagues went to the exact locality to investigate the local conditions. By a happy coincidence this visit resulted in the initiation of an experiment, carried out to investigate the possibility of the local origin of the infection. Fortuitously, in the very area concerned, there had been located for a fortnight a large detachment of the Irish army in connection with a film production and the men must “inevitably often” (sic) have been attacked by ticks. 10 ml. of blood were taken from each of 37 individuals. The blood was heparinized in bulk, placed in ampoules, packed in ice and flown to London from Shannon airport. It was subsequently taken to the Central Veterinary Laboratories, Weybridge, and was inoculated into 2 splenectomized calves, 3 splenectomized mice and 2 splenectomized rats. Without going further into the details of this experiment which were taken from the paper by GARNHAM et al. (1969), it may be said that the results, so far as detecting any Babesiaparasites or symptoms of Babe& infection, were entirely negative. In addition to these operations a large number of nymphs and adult ticks &odes ricinus)collected from the area were also taken to Weybridge and placed on the left ear of a splenectomized calf while 71 clean adults were placed on the right ear in an attempt to pick up any infection transmitted by the feral ticks. No infection with Babesiaoccurred in any of the mammals or ticks. This experiment was meticulous in conception, planning and procedure and the negative results could be explained in ways other than specifically because there was no Babesiainfection in the blood of the soldiers or in the ticks. Certain points in connection with the experiment call for mention, not with its execution but with some of the original assumptions. In the first place was it correct to state that all the men were “inevitably often” bitten by ticks? In the second place the assumption seems to have been made that the infection in the human case was due to the cattle parasite B. divergens,a point which will now be discussed. By the courtesy of Mr. I?. G. Shute of the Malaria Reference Laboratory, Horton, Surrey, I was able to examine a blood slide from the human case. After careful examination of the slide I came to the conclusion that the infection was due not to B. divergensbut to the Babesiucommonly found in small British mammals (rodents and insectivora), B. microti, thereby greatly enlarging the possible sources of infection. GARNHAM and BRAY (1959) have shown that a primate, the chimpanzee, when splenectomized, may be infected with B. divergens,the cattle parasite, and the first human case reported illustrates the fact that man also, when so deprived, is susceptible to B. bovis of cattle. Further evidence of other possible sources of infection, and I believe this to have been an example in the Irish patient, is provided by the following experiment. In the course of a study of Babes&zinfections in small British mammals SHORTT and BLACKIE (1965) recovered Babe& from the mole (T&pa europaea).This was passaged for some time in multimammate rats (Mustomys sp.) and blood from this strain was then inoculated intravenously and intraperitoneally into a monkey (Macaca mulattu), which had been splenectomized two years previously. Three weeks later Babesiaappeared in the peripheral blood. This infection increased to produce a heavy parasitaemia which persisted at fluctuating but lower levels for some months after which the monkey, still showing parasites, passed out of my possession. I am indebted to Dr. J. R. Baker for looking after this arrival during my temporary absence in Africa and for informing me by letter when the infection first appeared. Subsequent to the reports of the 3 human infections mentioned above, in all of which the subjects had previously been splenectomized, 2 further cases occurring in the United States have been brought to my attention by Professor M. Yoeli, in which no previous splenectomy had been performed. The first subject (WESTERN et al., 1970) was a 59 year old widow who went to her summer home on holiday in Nantucket Island, Massachusetts. In mid-May 1969 she found a tick deeply imbedded in her supra-sternal notch and with some difficulty removed it. On 12 July she was seen by a physician and advised to enter hospital in New Brunswick. In hospital her temperature ranged between 385°C and 395°C per rectum. On 14 July she was referred to the Malaria Surveillance Unit for the National Communicable Disease Center as a possible case of introduced falciparum malaria. Blood smears sent to the National Malaria Repository of the Center showed infection of 1% of the red cells with ring-shaped and tetrad parasites characteristic of some Babesiasp. By inoculation of blood into a hamster and a splenectomized monkey the organism was established in each and was considered to be a rodent species, probably B.
521
BRIEF COMMUNICATIONS
CASE 1
Possible source of infection: Bull terrier and eight pups all carrying B. canis. Contact with dogs : Extremely close; ticks found on dog, pups and child. Age of case : 8 years. General symptoms : Headache, pains in legs, back and abdomen. Pyre& : 40-405°C falling in evening to 3%38”C, duration 4 days. Rigors : + + in evening. Haematuria: + on fourth day, had disappeared in one week. Examinations : Blood for parasites-negative. Other investigations : Brucella, typhoid, typhus, Leptospira, urine for organisms, all unrevealing, Treatment : At first antimalarial, without improvement. On day 4 a long acting sulphonamide. Final reszdt : Temperature normal from day 5.
albumen
+.
CASE 2
Possible source of infection : Dogs. Contact with dogs : Close. Age of case : Small child, exact age not known. General symptoms : All as in case 1 plus convulsions at height of fever. Pyrexia : 395°C. Rigors: + +. Haematuria : None. Examinations : Blood for parasites-negative. Other investigations : Albumen in urine, otherwise unrevealing. Treatment : Oral antibiotic. Duration of illness : 3 to 4 days.
Oral therapy with chloroquine phosphatewas initiated and continued for 30 days. On discharge from hospital chloroquine treatment was continued for 8 weeks. For about 2 months afterwards parasites were occasionallyseenbut the patient remained well without further medication (WESTERN et al., 1970). The secondsubject (CASSIDY et al., 1973) was a 48 year old woman also living on Nantucket Island. She had received a tick bite in mid August 1973 which becameinflamed and her physician had excised a local abscesscontaining the tick head. On 4 September 1973 she consulted her physician complaining of daily recurrent chills and fever, myalgia in her legsand side and moderately severedepression.Becauseof the history, Rocky Mountain spotted fever was suspectedand the patient was admitted to a local hospital. Treatmenr with tetracycline wasinitiated but without response.On 6 Septemberher temperature was40°C and examination of her peripheral blood revealed Babesia sp. Treatment with chloroquine phosphatewas started on 6 September with a prompt reduction in fever and no parasiteswere seenafter 17 September. She was dischargedon 28 September still on chloroquine medication. Whole blood inoculated into gerbils produced an infection of Babesia sp. The patient had not been splenectomizedand had had no immunosuppressivetherapy or other treatment known to predisposeto parasitic infection (C~SSIDY et al., 1973). The fact that probably at least3 of the definitely diagnosedcasesof human babestosisseemto have had origin in Babesia parasites of common widely disseminatedsmall mammalsgreatly widens the field of possiblesourcesof infection and this is further emphasized by the successful experimental infection describedabove of a monkey by one such parasite. The human and primate cases,natural and experimental, described here have been parasitized by bovine, murine and.talpine Babesia sp. If there is such a diversity of sourcesof infection the existence of undiagnosedhuman casesis a very real danger becauseit is possiblethat in whole subjects(not splenectomired) the infection may be ephemeraland so escapediagnosis.Two such casesreported to me may be quoted and their similarity is brought out by a comparisonof the findings in each asshown in the table. microti.
CASSIDY,
P., ANDERSON
A. E.,
& FIUMARA,
References N. J. (1973). Center for Disease Control
U.S. Dept. of Hlth, Educ.
0 Welfare, 22, 39. I?. C. C., & GRAY,
GARNHAM, R. S. (1959). J. Protozool, 6, 352. -, DONNELLY, J., HOOGSTRAAL, H., KENNEDY, C. K., & WALTON, FITZPATRICK, J. E. P., et al. (1969). Ibid., 4, 770. SCHOLTENS, R. G., BRAFF, E. H., HEALY, G. R. & GLEASON, N. (1966). SHORTT, H. E., & BLACKIE, E. J. (1965). J. trap. Med. Hyg., 68, 37. SKRABALO, Z., & DEANOVIC, Z. (1957). Documenta Med. geogr. trap., 9, WESTERN, K. A., et al. (1970). N. Engl. J. Med., 283, 854.
G. A. (1969). Br. med. J., 4,768. Am. J. trop. Med. Hyg., 17, 6, 810. 11,
519
Results
Microscopical examination of the smears prepared from the internal organs and blood did not show any amastigotes. Amastigotes were found in two of the smears prepared from the ear scrapings of 50 rodents. Both were R. opimus from northern Khorassan. In the smears prepared from the sore of M. persicus, considerable numbers of amastigotes were seen. The organisms were morphologically similar to Leishmania tropica major. The habitat of the infected M. persicus had been along a stony fence on a flat plain with Artemisia and Astragalus at an altitude of 1100 m. This place is located near Zanganeh village, 37 km east of Marand city in Azerbaijan, north-western Iran, which is not considered to be an endemic area for human cutaneous leishmaniasis. It seems that in this area the infection is limited to wildlife (rodents). It is recommended that further studies be carried out in this area. This is most probably the first report of the natural occurrence of leishmaniasis in M. persicus.
ANSARI, N., & FAGHIH, M. A. (1953). Annls. Parasit. hum. camp.,28,241. & MOFIDI, CH. (1950). Bull. Sot. Path. exot., 43, 601. GHORBANI, M., HAFIZI, A., & SHEGERFCAR, T. (1973). Pahlavi Med. J., 4,389. GUNDERS, A. E., FONER, A., & MONTILLIO, B. (1968). Nature, Lond., 219, 85. NADIM, A., & FAGHIH, M. A. (1968). Trans. R. Sot. trop. Med. Hyg., 62, 534. -, & SEYEDI-RASHTI, M. A. (1971). Acta Med. Iranica, 14, 99. -, -, & MESGHALI, A. (1968). 3. trop. Med. Hyg., 71, 238. PETRISVEVA, I?. A. (1971). Bull. WZdHlth Org., 44, 567. SEYEDI-RASHTI, M. A., & NADIM, A. (1967). Bull. Sot. Path. exot., 60, 510.
HUMAN
INFECTIONS
H. E. SHORTT,
WITH BABESIA
F.R.S., I.M.S.(RET.)
Although the babesias, using the term in a wide sense to include various genera which are still inadequately separated, are probably the most widely distributed blood parasites of mammals it was long believed that man was immune to their attacks. The first reported human infection was that of a farmer in Yugoslavia whose fatal illness, in 1957, was at first thought to be malaria. This was later definitely diagnosed as a case of babesiosis, the source of infection being, presumably, his cattle which showed a high rate of infestation with Babesiabovis.Investigation brought to light the fact that 11 years previously the man had undergone splenectomy after a motor car accident (SKRABALO and DEANOVIC, 1957). The next recorded case was in California in 1966. This man also was diagnosed as malaria, was treated as such for 15 weeks with chloroquine and recovered. Investigation again disclosed that 2 years previous to this illness the man had undergone splenectomy as treatment for hereditary spherocytosis, a condition in which the red blood cells show an abnormality which is transmitted as a Mendelian dominant. In this case babesiosis was diagnosed when blood parasites showing “cross” patterns in the red blood cells were found (SCHOLTENS et al., 1966). The third confirmed case of human babesiosis occurred in County Galway, Ireland, in 1967. A deep sea fisherman and his family on holiday by caravan spent 4 or 5 days in August on the shore of Lough Corrib. Shortly after his return home the became acutely ill and died within a week. This case was ably described in detail in a paper by FITZPATRICK et al. (1969), who cdnsidered the diagnosis at the time of death to be blackwater fever due to Plasmodiumfaiciparum, probably caused by a blood transfusion the patient had had about 34 months previously after an operation for a perforated duodenal ulcer. This diagnosis appeared to be justified by the fact that blood slides showed “intra-erythrocytic” inclusions presumed to be malaria parasites. Enquiry revealed that this operation had been complicated by injury to the spleen, which had been removed. The absence of any malarial pigment in the blood films or in the internal organs at autopsy led to doubt as to the correctness of the diagnosis and blood films
520
BRIEF COhtMUNICATIONS
were sent to Mr. P. G. Shute of the Malaria Reference Centre, Horton. As he considered the erythrocytic inclusions atypical of malaria he consulted Professor I?. C. C. Garnham of the London School of Hygiene and Tropical Medicine who identified the inclusions as B. divergens.The presumption was obvious that the infection had been acquired during the short holiday at Lough Corrib. A year later, Professor Garnham and colleagues went to the exact locality to investigate the local conditions. By a happy coincidence this visit resulted in the initiation of an experiment, carried out to investigate the possibility of the local origin of the infection. Fortuitously, in the very area concerned, there had been located for a fortnight a large detachment of the Irish army in connection with a film production and the men must “inevitably often” (sic) have been attacked by ticks. 10 ml. of blood were taken from each of 37 individuals. The blood was heparinized in bulk, placed in ampoules, packed in ice and flown to London from Shannon airport. It was subsequently taken to the Central Veterinary Laboratories, Weybridge, and was inoculated into 2 splenectomized calves, 3 splenectomized mice and 2 splenectomized rats. Without going further into the details of this experiment which were taken from the paper by GARNHAM et al. (1969), it may be said that the results, so far as detecting any Babesiaparasites or symptoms of Babe& infection, were entirely negative. In addition to these operations a large number of nymphs and adult ticks &odes ricinus)collected from the area were also taken to Weybridge and placed on the left ear of a splenectomized calf while 71 clean adults were placed on the right ear in an attempt to pick up any infection transmitted by the feral ticks. No infection with Babesiaoccurred in any of the mammals or ticks. This experiment was meticulous in conception, planning and procedure and the negative results could be explained in ways other than specifically because there was no Babesiainfection in the blood of the soldiers or in the ticks. Certain points in connection with the experiment call for mention, not with its execution but with some of the original assumptions. In the first place was it correct to state that all the men were “inevitably often” bitten by ticks? In the second place the assumption seems to have been made that the infection in the human case was due to the cattle parasite B. divergens,a point which will now be discussed. By the courtesy of Mr. I?. G. Shute of the Malaria Reference Laboratory, Horton, Surrey, I was able to examine a blood slide from the human case. After careful examination of the slide I came to the conclusion that the infection was due not to B. divergensbut to the Babesiucommonly found in small British mammals (rodents and insectivora), B. microti, thereby greatly enlarging the possible sources of infection. GARNHAM and BRAY (1959) have shown that a primate, the chimpanzee, when splenectomized, may be infected with B. divergens,the cattle parasite, and the first human case reported illustrates the fact that man also, when so deprived, is susceptible to B. bovis of cattle. Further evidence of other possible sources of infection, and I believe this to have been an example in the Irish patient, is provided by the following experiment. In the course of a study of Babes&zinfections in small British mammals SHORTT and BLACKIE (1965) recovered Babe& from the mole (T&pa europaea).This was passaged for some time in multimammate rats (Mustomys sp.) and blood from this strain was then inoculated intravenously and intraperitoneally into a monkey (Macaca mulattu), which had been splenectomized two years previously. Three weeks later Babesiaappeared in the peripheral blood. This infection increased to produce a heavy parasitaemia which persisted at fluctuating but lower levels for some months after which the monkey, still showing parasites, passed out of my possession. I am indebted to Dr. J. R. Baker for looking after this arrival during my temporary absence in Africa and for informing me by letter when the infection first appeared. Subsequent to the reports of the 3 human infections mentioned above, in all of which the subjects had previously been splenectomized, 2 further cases occurring in the United States have been brought to my attention by Professor M. Yoeli, in which no previous splenectomy had been performed. The first subject (WESTERN et al., 1970) was a 59 year old widow who went to her summer home on holiday in Nantucket Island, Massachusetts. In mid-May 1969 she found a tick deeply imbedded in her supra-sternal notch and with some difficulty removed it. On 12 July she was seen by a physician and advised to enter hospital in New Brunswick. In hospital her temperature ranged between 385°C and 395°C per rectum. On 14 July she was referred to the Malaria Surveillance Unit for the National Communicable Disease Center as a possible case of introduced falciparum malaria. Blood smears sent to the National Malaria Repository of the Center showed infection of 1% of the red cells with ring-shaped and tetrad parasites characteristic of some Babesiasp. By inoculation of blood into a hamster and a splenectomized monkey the organism was established in each and was considered to be a rodent species, probably B.
521
BRIEF COMMUNICATIONS
CASE 1
Possible source of infection: Bull terrier and eight pups all carrying B. canis. Contact with dogs : Extremely close; ticks found on dog, pups and child. Age of case : 8 years. General symptoms : Headache, pains in legs, back and abdomen. Pyre& : 40-405°C falling in evening to 3%38”C, duration 4 days. Rigors : + + in evening. Haematuria: + on fourth day, had disappeared in one week. Examinations : Blood for parasites-negative. Other investigations : Brucella, typhoid, typhus, Leptospira, urine for organisms, all unrevealing, Treatment : At first antimalarial, without improvement. On day 4 a long acting sulphonamide. Final reszdt : Temperature normal from day 5.
albumen
+.
CASE 2
Possible source of infection : Dogs. Contact with dogs : Close. Age of case : Small child, exact age not known. General symptoms : All as in case 1 plus convulsions at height of fever. Pyrexia : 395°C. Rigors: + +. Haematuria : None. Examinations : Blood for parasites-negative. Other investigations : Albumen in urine, otherwise unrevealing. Treatment : Oral antibiotic. Duration of illness : 3 to 4 days.
Oral therapy with chloroquine phosphatewas initiated and continued for 30 days. On discharge from hospital chloroquine treatment was continued for 8 weeks. For about 2 months afterwards parasites were occasionallyseenbut the patient remained well without further medication (WESTERN et al., 1970). The secondsubject (CASSIDY et al., 1973) was a 48 year old woman also living on Nantucket Island. She had received a tick bite in mid August 1973 which becameinflamed and her physician had excised a local abscesscontaining the tick head. On 4 September 1973 she consulted her physician complaining of daily recurrent chills and fever, myalgia in her legsand side and moderately severedepression.Becauseof the history, Rocky Mountain spotted fever was suspectedand the patient was admitted to a local hospital. Treatmenr with tetracycline wasinitiated but without response.On 6 Septemberher temperature was40°C and examination of her peripheral blood revealed Babesia sp. Treatment with chloroquine phosphatewas started on 6 September with a prompt reduction in fever and no parasiteswere seenafter 17 September. She was dischargedon 28 September still on chloroquine medication. Whole blood inoculated into gerbils produced an infection of Babesia sp. The patient had not been splenectomizedand had had no immunosuppressivetherapy or other treatment known to predisposeto parasitic infection (C~SSIDY et al., 1973). The fact that probably at least3 of the definitely diagnosedcasesof human babestosisseemto have had origin in Babesia parasites of common widely disseminatedsmall mammalsgreatly widens the field of possiblesourcesof infection and this is further emphasized by the successful experimental infection describedabove of a monkey by one such parasite. The human and primate cases,natural and experimental, described here have been parasitized by bovine, murine and.talpine Babesia sp. If there is such a diversity of sourcesof infection the existence of undiagnosedhuman casesis a very real danger becauseit is possiblethat in whole subjects(not splenectomired) the infection may be ephemeraland so escapediagnosis.Two such casesreported to me may be quoted and their similarity is brought out by a comparisonof the findings in each asshown in the table. microti.
CASSIDY,
P., ANDERSON
A. E.,
& FIUMARA,
References N. J. (1973). Center for Disease Control
U.S. Dept. of Hlth, Educ.
0 Welfare, 22, 39. I?. C. C., & GRAY,
GARNHAM, R. S. (1959). J. Protozool, 6, 352. -, DONNELLY, J., HOOGSTRAAL, H., KENNEDY, C. K., & WALTON, FITZPATRICK, J. E. P., et al. (1969). Ibid., 4, 770. SCHOLTENS, R. G., BRAFF, E. H., HEALY, G. R. & GLEASON, N. (1966). SHORTT, H. E., & BLACKIE, E. J. (1965). J. trap. Med. Hyg., 68, 37. SKRABALO, Z., & DEANOVIC, Z. (1957). Documenta Med. geogr. trap., 9, WESTERN, K. A., et al. (1970). N. Engl. J. Med., 283, 854.
G. A. (1969). Br. med. J., 4,768. Am. J. trop. Med. Hyg., 17, 6, 810. 11,
