Muskuläre Sarkozystose nach Malaysiareise: eine Fallserie aus Deutschland

 

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Zusammenfassung

Hintergrund: Seit 2011 wurde weltweit bei ca. 100 Besuchern der Insel Tioman, Malaysia, die Verdachtsdiagnose einer muskulären Sarkozystose gemeldet, einer bislang nur sporadisch beobachteten parasitären Erkrankung. Ausbruchsursache sowie Therapie sind unklar. Die Diagnosesicherung erfordert den mikroskopischen Zysten-Nachweis im Muskelbiopsat. Studienziel war die systematische Beschreibung der diagnostisch wegweisenden Symptome, Laboruntersuchungen und des Therapieansprechens.

Methodik: Systematische Fallserie.

Ergebnisse: Die 26 Fälle aus fünf tropenmedizinischen Zentren Deutschlands zeigen einen charakteristischen zweiphasigen Krankheitsverlauf: zwei Wochen nach Urlaubsmitte (min. 7,5/ max. 22 Tage) tritt uncharakteristisches knapp einwöchiges Fieber mit Kopfschmerz auf, nach zweiwöchiger überwiegender Beschwerdefreiheit folgen ca. 6 Wochen andauernde (min. 7/ max. 207 Tage), starke Myalgien (6,5, Skala 0–10), Fieber, Erhöhung der Kreatinkinase (CK; bis 3,5-fach) und Eosinophilie (2,9-fach). Eine von zwei Muskelbiopsien zeigte eine Sarkozystose-typische Zyste, bei 6 von 7 untersuchten Patienten war mittels ELISA ein Anstieg Sarcocystis-spezifischer Antikörper nachweisbar. Behandlungsversuche mit systemischen Glukokortikoiden und Albendazol, oder Ivermectin erbrachten zumeist deutliche Beschwerdebesserungen. Bei einem Patienten entwickelte sich nach frühzeitiger Cotrimoxazol-Therapie keine zweite Erkrankungsphase. Alle Patienten hatten Aufenthalte im Nordwesten der Insel Tioman.

Folgerungen: Die Muskelsarkozystose verläuft zweiphasig mit initialem Fieber und später prolongierten Myalgien, Eosinophilie und CK-Erhöhung. Eine Steroidstoßtherapie ist in der Spätphase beschwerdelindernd. Frühzeitige Cotrimoxazol-Gabe verhindert möglicherweise die parasitäre Muskelinvasion. Bei Fieber nach Malaysia-Aufenthalt sollte Sarkozystose differenzialdiagnostisch bedacht werden. Die Infektionsquelle erscheint konzentriert auf den Nord-Westen Tiomans. Weitere Untersuchungen, inklusive zur Früh-Diagnostik und Therapie sind notwendig.

Abstract

Background: Since 2011, about 100 travellers to the island of Tioman, Malaysia, have been diagnosed worldwide with suspected muscular sarcocystosis, a previously only sporadically observed parasitic disease. Source of infection and therapy remain unclear. Final diagnosis requires microscopic identification of cysts in muscle biopsies. The study objective was a systematic description of characteristic symptoms, laboratory investigations and treatment response.

Methods: Systematic case series.

Results: The 26 cases of 5 centers for tropical medicine in Germany showed a characteristic biphasic development: symptoms began in general 2 weeks after mid-holidays (min. 7.5, max. 22 days) with unspecific fever and headaches lasting for almost 1 week. After an asymptomatic period of 2 weeks, severe myalgia (6.5, scale 0–10) and fever developed and lasted for about 6 weeks (min. 7, max. 207 days), accompanied by creatin-phosphokinase(CK)-elevation (up to 3.5 times), and eosinophilia (2.9 times). One out of two muscle biopsies revealed a cyst typical for sarcocystosis. In 6 out of 7 patients an increase in Sarcocystis-specific antibody concentration could be demonstrated by ELISA. Treatment with systemic steroids and albendazole, or ivermectin resulted in significant symptomatic improvement in most of the patients. One patient was treated early with cotrimoxazole and subsequently did not develop a second phase of the disease. All patients had stayed in the North-West of the island Tioman.

Conclusions: Muscular sarcocystosis develops in a biphasic pattern with initial fever and later prolonged myalgia, eosinophilia, and CK-elevation. Steroids achieve symptomatic relief in the late phase. Early cotrimoxazole-therapy could possibly prevent parasitic muscle invasion. In fever after travel to Malaysia differential diagnosis should include sarcocystosis. The source of infection appears to be located in North-West of Tioman. Further studies are needed, including addressing early diagnosis and treatment.

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