Emerg Infect DisEIDEmerging Infectious Diseases1080-60401080-6059Centers for Disease Control and Prevention19891898285723609-051110.3201/eid1511.090511Letters to the EditorImported Human Fascioliasis, United KingdomChandMeera A.HermanJoanna S.PartridgeDavid G.HewittKirstenChiodiniPeter L.Hospital for Tropical Diseases, London, UK (M.A. Chand, J.S. Herman, P.L. Chiodini)Royal Hallamshire Hospital, Sheffield, UK (D.G. Partridge)Health Protection Agency Centre for Infections, London (K. Hewitt)London School of Hygiene and Tropical Medicine, London (P.L. Chiodini)Address for correspondence: Meera A. Chand, Hospital for Tropical Diseases, Mortimer Market, Capper Street, London WC1E 6JB, UK; email: meera.chand@nhs.net112009151118761877Keywords: Fasciola spp.fascioliasiszoonosiskhatparasiteseosinophiliaUnited Kingdomletter

To the Editor: We initiated enhanced surveillance for human fascioliasis after a reported increase in livestock cases in the United Kingdom. From January 1, 2008, through January 31, 2009, 11 human cases were confirmed by the reference laboratory for England and Wales, compared with 6 cases during the preceding 10 years. The Scottish reference laboratory detected no human cases during the study period.

Fascioliasis was defined as a positive Fasciola immunofluorescent antibody test with a screening titer of 1:32 and either compatible clinical or radiologic features consistent with the disease. We obtained clinical and radiologic information from the referring physician. Clinical features of both acute and chronic infection include fever, upper abdominal pain, malaise, eosinophilia, and impaired liver function; therefore, distinguishing between the 2 phases can be difficult. Fifty percent of chronic infection is subclinical (1,2). Compatible radiologic features are capsular enhancement with contrast, hypodense nodular areas, and low-density serpiginous lesions (2). Our analysis comprised 11 cases (Table). Two patients were white British, both of whom had recently traveled to sub-Saharan Africa. Cases from the preceding 10 years diagnosed in our laboratory were all in persons with histories of travel to fascioliasis-endemic areas. Therefore, these cases do not provide firm evidence of indigenous zoonotic transmission within England and Wales.

Characteristics of human fascioliasis case-patients during enhanced surveillance, United Kingdom, January 1, 2008–January 31, 2009*
Case no.Age, y/sexCountry of originYears since migrationOther travelRisk factorClinical featuresEosinophil count, x109/L)Abnormal liver functionHepatic imagingIFAT†
145/FYemen7Yemen regularlyKhat useAbdominal pain8.4YesMixed-density liver lesion (CT)1:128
244/MSomalia16Ethiopia 2007Khat useFever, abdominal pain3.4YesSerpiginous lesion (MRI)1:64
334/FEthiopia3S. Africa regularlyKhat useFever, abdominal pain11.4NoHeterogeneous lesion (USS)1:128
444/FSomalia7Somalia 2004, NetherlandsKhat useAbdominal pain8.3NoHeterogeneous lesion (USS)1:128
554/FSomalia21 (to Netherlands),
4 (to UK)NoneKhat useAnorexia8.4NoLow-density lesion (CT)1:32
643/MSomalia28 (to India), 21 (to UK)NoneKhat useFever1.0YesHeterogeneous lesion (USS)1:128
728/FUKUganda 2007–2008Abdominal pain, hepatomegaly1.84YesHepatomegaly with large mixed cystic and solid lesion (USS)1:512
867/MUKKenya 2008, prior world travelMalaise, abdominal pain0.04YesMultiple gallstones (MRCP)1:256
938/MEthiopia10Ethiopia 2006Abdominal pain, fever18.7YesNormal (USS, MRCP)1:128
1028/MEthiopiaUnknownUnknownFever, gram- negative sepsis; new HIV diagnosis<0.04YesLesion in hepatic vein1:64
1147/FSomalia16 (to Yemen),
6 (to UK)UnknownKhat useAbdominal pain, fever16.8YesLow-density lesion (CT)1:256

*IFAT, immunofluorescent antibody test; CT, computed tomography; MRI, magnetic resonance imaging; USS, ultrasound scan, MRCP, magnetic resonance cholangiopancreatography.
†Titer of IFAT (screening titer 32).

Nine patients originated from Somalia, Ethiopia, or Yemen. Few cases have previously been reported from this area (3), although Ethiopian migrants have been shown to have an egg positivity of 0.4% on routine screening (4). Patients 5 and 6 had not returned to Africa for >20 years, suggesting that they acquired their infection in Europe. Therefore, a risk factor may exist that is specific to this ethnic group within the United Kingdom.

Six cases were diagnosed at 1 hospital. All 6 patients reported current or past use of locally bought khat, a leaf chewed for its stimulant properties. It is imported fresh to the United Kingdom from Africa and is an ideal environment for the survival of Fasciola cercariae. It is used most commonly by migrants from the Horn of Africa and Yemen and has been reported in association with acute fascioliasis in the United Kingdom (5). Use of imported khat may explain the apparently higher incidence of fascioliasis in this ethnic group residing in the United Kingdom.

Despite the described parallel rise in human and veterinary fascioliasis, none of these cases provide clear evidence that recent human cases resulted from zoonotic transmission within the United Kingdom. Most cases occurred in migrants from the Horn of Africa and Yemen, some of whom may have acquired Fasciola spp. in their country of origin; other cases appear likely to have been acquired in the United Kingdom, possibly due to use of imported khat. Physicians need a heightened awareness of fascioliasis when investigating impaired liver function or abnormal abdominal imaging in migrants or travelers from high-risk areas.

Suggested citation for this article: Chand MA, Herman JS, Partridge DG, Hewitt K, Chiodini PL. Imported human fascioliasis, United Kingdom [letter]. Emerg Infect Dis [serial on the Internet] 2009 Nov [date cited]. Available from http://www.cdc.gov/EID/content/15/11/1876.htm

ReferencesMarcos LA, Terashima A, Gotuzzo E Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis.Curr Opin Infect Dis 2008;21:52330 10.1097/QCO.0b013e32830f981818725803Marcos LA, Tagle M, Terashima A, Bussalleu A, Ramirez C, Carrasco C, Natural history, clinicoradiologic correlates and response to triclabendazole in acute massive fascioliasis.Am J Trop Med Hyg 2008;78:222718256419Control of foodborne trematode infections. Report of a WHO study group.World Health Organ Tech Rep Ser 1995;849:11577740791Nahmias J, Greenberg Z, Djerrasi L, Giladi L Mass treatment of intestinal parasites among Ethiopian immigrants.Isr J Med Sci 1991;27:278832050509Doherty JF, Price N, Moody AH, Wright SG, Glynn MJ Fascioliasis due to imported khat.Lancet 1995;345:462 10.1016/S0140-6736(95)90450-67853987