title: Acute muscular sarcocystosis: an international investigation among ill travelers returning from Tioman Island, Malaysia, 2011-2012.
abstract: BACKGROUND
  Through 2 international traveler-focused surveillance networks (GeoSentinel and TropNet), we identified and investigated a large outbreak of acute muscular sarcocystosis (AMS), a rarely reported zoonosis caused by a protozoan parasite of the genus Sarcocystis, associated with travel to Tioman Island, Malaysia, during 2011-2012.
  
  
  METHODS
  Clinicians reporting patients with suspected AMS to GeoSentinel submitted demographic, clinical, itinerary, and exposure data. We defined a probable case as travel to Tioman Island after 1 March 2011, eosinophilia (>5%), clinical or laboratory-supported myositis, and negative trichinellosis serology. Case confirmation required histologic observation of sarcocysts or isolation of Sarcocystis species DNA from muscle biopsy.
  
  
  RESULTS
  Sixty-eight patients met the case definition (62 probable and 6 confirmed). All but 2 resided in Europe; all were tourists and traveled mostly during the summer months. The most frequent symptoms reported were myalgia (100%), fatigue (91%), fever (82%), headache (59%), and arthralgia (29%); onset clustered during 2 distinct periods: "early" during the second and "late" during the sixth week after departure from the island. Blood eosinophilia and elevated serum creatinine phosphokinase (CPK) levels were observed beginning during the fifth week after departure. Sarcocystis nesbitti DNA was recovered from 1 muscle biopsy.
  
  
  CONCLUSIONS
  Clinicians evaluating travelers returning ill from Malaysia with myalgia, with or without fever, should consider AMS, noting the apparent biphasic aspect of the disease, the later onset of elevated CPK and eosinophilia, and the possibility for relapses. The exact source of infection among travelers to Tioman Island remains unclear but needs to be determined to prevent future illnesses.
authors.forename: Douglas H
authors.initials: DH
authors.lastname: Esposito
authors.forename: August
authors.initials: A
authors.lastname: Stich
authors.forename: Loïc
authors.initials: L
authors.lastname: Epelboin
authors.forename: Denis
authors.initials: D
authors.lastname: Malvy
authors.forename: Pauline V
authors.initials: PV
authors.lastname: Han
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Bottieau
authors.forename: Alexandre
authors.initials: A
authors.lastname: da Silva
authors.forename: Philipp
authors.initials: P
authors.lastname: Zanger
authors.forename: Günther
authors.initials: G
authors.lastname: Slesak
authors.forename: Perry J J
authors.initials: PJ
authors.lastname: van Genderen
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Rosenthal
authors.forename: Jakob P
authors.initials: JP
authors.lastname: Cramer
authors.forename: Leo G
authors.initials: LG
authors.lastname: Visser
authors.forename: José
authors.initials: J
authors.lastname: Muñoz
authors.forename: Clifton P
authors.initials: CP
authors.lastname: Drew
authors.forename: Cynthia S
authors.initials: CS
authors.lastname: Goldsmith
authors.forename: Florian
authors.initials: F
authors.lastname: Steiner
authors.forename: Noémie
authors.initials: N
authors.lastname: Wagner
authors.forename: Martin P
authors.initials: MP
authors.lastname: Grobusch
authors.forename: D Adam
authors.initials: DA
authors.lastname: Plier
authors.forename: Dennis
authors.initials: D
authors.lastname: Tappe
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Sotir
authors.forename: Clive
authors.initials: C
authors.lastname: Brown
authors.forename: Gary W
authors.initials: GW
authors.lastname: Brunette
authors.forename: Ronald
authors.initials: R
authors.lastname: Fayer
authors.forename: Frank
authors.initials: F
authors.lastname: von Sonnenburg
authors.forename: Andreas
authors.initials: A
authors.lastname: Neumayr
authors.forename: Phyllis E
authors.initials: PE
authors.lastname: Kozarsky
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001706:Biopsy; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D004804:Eosinophils; D005260:Female; D005843:Geography; D006801:Humans; D062312:Islands; D007958:Leukocyte Count; D008296:Malaysia / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009132:Muscles / Q000469:parasitology / Q000473:pathology / Q000648:ultrastructure; D062486:Public Health Surveillance; D012307:Risk Factors; D012522:Sarcocystis / Q000235:genetics / Q000302:isolation & purification; D012523:Sarcocystosis / Q000175:diagnosis / Q000453:epidemiology* / Q000635:transmission; D014195:Travel; D055815:Young Adult
keywords: Malaysia; infectious disease outbreak; parasitic disease; sarcocystosis; travel
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