The case is a TIA (transient ischemic attack). The basic etiological study includes echodoppler of supra-aortic trunks +/- cerebral arteries, echocardiogram and directed blood analysis.

61-year-old male, smoker and hypertensive, who comes to the emergency department for sudden loss of strength and tingling sensation in the right hand lasting about 15 minutes, with almost complete recovery afterwards. ECG: sinus rhythm at 93 bpm. In relation to the most probable diagnosis, indicate the FALSE answer:

A probable cause is an arterioarterial embolism due to detachment of a carotid plaque.

Doppler ultrasound of supra-aortic trunks is not very useful for diagnosis.

A cranial CT scan is necessary to assess the impact on the brain parenchyma.

Surgical treatment is indicated if imaging tests reveal carotid stenosis >70%.

Stroke

When a stroke has been diagnosed, various other studies may be performed to determine the underlying cause. With the current treatment and diagnosis options available, it is of particular importance to determine whether there is a peripheral source of emboli. Test selection may vary since the cause of stroke varies with age, comorbidity and the clinical presentation. The following are commonly used techniques: an ultrasound/doppler study of the carotid arteries (to detect carotid stenosis) or dissection of the precerebral arteries; an electrocardiogram (ECG) and echocardiogram (to identify arrhythmias and resultant clots in the heart which may spread to the brain vessels through the bloodstream); a Holter monitor study to identify intermittent abnormal heart rhythms; an angiogram of the cerebral vasculature (if a bleed is thought to have originated from an aneurysm or arteriovenous malformation);

Carotid ultrasonography

Doppler ultrasound allows for assessment of carotid arterial blood flow. Blood flow velocity is increased in areas of stenosis compared to normal. Therefore doppler imaging substantially aids in the diagnosis of carotid artery stenosis by ultrasound. Internal carotid artery (ICA) is located posterolateral, and larger when compared to the external carotid artery (ECA). ICA has low resistive pattern (difference between the blood velocities during heart systole and diastole) when compared to ECA. Besides, ECA can be differentiated from the ICA by tapping superficial temporal artery of the same side. This will generate a saw-like appearance on ECA doppler. Temporary reversal of the direction of flow during early diastole in ECA is normal. ICA peak systolic velocity more than 125m/sec and diastolic velocity more than 40 m/sec signifies stenosis. Vertebral artery also has low resistive pattern similar to ICA.

Syncope (medicine)

Imaging Echocardiography and ischemia testing may be recommended for cases where initial evaluation and ECG testing is nondiagnostic. For people with uncomplicated syncope (without seizures and a normal neurological exam) computed tomography or MRI is not generally needed. Likewise, using carotid ultrasonography on the premise of identifying carotid artery disease as a cause of syncope also is not indicated. Although sometimes investigated as a cause of syncope, carotid artery problems are unlikely to cause that condition. Additionally an electroencephalogram (EEG) is generally not recommended. A bedside ultrasound may be performed to rule out abdominal aortic aneurysm in people with concerning history or presentation.

Transient ischemic attack

Surgery If the TIA affects an area that is supplied by the carotid arteries, a carotid ultrasound scan may demonstrate stenosis, or narrowing, of the carotid artery. For people with extra-cranial carotid stenosis, if 70-99% of the carotid artery is clogged, carotid endarterectomy can decrease the five-year risk of ischemic stroke by approximately half. For those with extra-cranial stenosis between 50-69%, carotid endarterectomy decreases the 5-year risk of ischemic stroke by about 16%. For those with extra-cranial stenosis less than 50%, carotid endarterectomy does not reduce stroke risk and may, in some cases, increase it. The effectiveness of carotid endarterectomy or carotid artery stenting in reducing stroke risk in people with intra-cranial carotid artery stenosis is currently unknown.

Transient ischemic attack

Vessels in the head and neck may also be evaluated to look for atherosclerotic lesions that may benefit from interventions, such as carotid endarterectomy. The vasculature can be evaluated through the following imaging modalities: magnetic resonance angiography (MRA), CT angiography (CTA), and carotid ultrasonography/transcranial doppler ultrasonography. Carotid ultrasonography is often used to screen for carotid artery stenosis, as it is more readily available, is noninvasive, and does not expose the person being evaluated to radiation. However, all of the above imaging methods have variable sensitivities and specificities, making it important to supplement one of the imaging methods with another to help confirm the diagnosis (for example: screen for the disease with ultrasonography, and confirm with CTA). Confirming a diagnosis of carotid artery stenosis is important because the treatment for this condition, carotid endarterectomy, can pose significant risk to the patient, including

Carotid artery stenosis

The common carotid artery is the large vertical artery in red. The blood supply to the carotid artery starts at the arch of the aorta (bottom). The carotid artery divides into the internal carotid artery and the external carotid artery. The internal carotid artery supplies the brain. Plaque often builds up at that division and causes a narrowing (stenosis). Pieces of plaque can break off and block the small arteries above in the brain, which causes a stroke. Plaque can also build up at the origin of the carotid artery at the aorta. Diagnosis Carotid artery stenosis is usually diagnosed by color flow duplex ultrasound scan of the carotid arteries in the neck. This involves no radiation, no needles and no contrast agents that may cause allergic reactions. This test has good sensitivity and specificity.

[Diagnosis of brain death by multislice CT scan: angioCT scan and brain perfusion].

BD was diagnosed by clinical examination, electroencephalogram (EEG), Transcranial Doppler (TCD) and multislice CT of 64 detectors. Initially, a brain perfusion study was performed. This was followed by supra-aortic trunk and brain artery angiography with acquisition of images using 0.5 mm slices, from the origin of the aortic root to the vertex. In all the patients, BD diagnosis was verified by clinical examination, EEG and TCD. Brain perfusion never detected brain blood flow. The angioCT through internal carotid arteries and vertebral arteries demonstrated complete absence of intracranial circulation, observing circulation of the external carotid artery branches. Sensitivity and specificity of the method compared with clinical examination was 100%. These findings demonstrate that the study of brain perfusion and brain angiography by multislice CT scan is a rapid and minimally invasive technique, that is easily available and that shows the absence of brain blood flow through the four vascular trunks. This technique makes it possible to made the diagnosis of BD with high diagnostic safety. Its use has special interest in patients with clinical diagnostic difficulty due to treatment with sedative drugs and serious metabolic alterations.

[Transient paraparesis as a manifestation of left carotid stenosis].

Paraparesis caused by a cerebrovascular disorder is infrequent, although it is seen in infraction of both anterior cerebral arteries (ACA), in vertebrobasilar insufficiency syndromes or in infarction of the border zones of the anterior circulation. Male aged 52 years, right handed, with a history of high blood pressure, who visited because of two episodes of transient paraparesis that lasted 5 minutes and 15 hours. During the last episode the presence of paraparesis and left Babinski sign were observed. Complementary explorations conducted to test for medullar pathology were negative. Cranial MRI showed only bilateral lacunar infarctions in deep territories. Four months later, the patient presented an episode of motor aphasia and paresthesia of the right lower limb, which remitted spontaneously in 10 minutes. Echo Doppler exploration of the supra aortic trunks showed significant stenosis of the left internal carotid artery (LICA) and occlusion of the right artery (RICA). Arteriography of the supra aortic trunks revealed a 99% stenosis of the RICA and 95% of the LICA, with vascularisation of both ACA dependent on the LICA. A left carotid endarterectomy was performed and the patient has remained asymptomatic to date. In our patient, both ACA depended on the flow from the LICA. We therefore consider that the symptoms of transient paraparesis were secondary to the left carotid stenosis, either due to a haemodynamic or an artery to artery embolic mechanism.

[Syncope in a general population: etiologic diagnosis and follow-up. Results of a prospective study].

Syncope is a common clinical problem in a general population. A prospective study was performed, in our hospital, to evaluate the incidence of the disease and to standardize the diagnostic and clinical management. 194 patients aged 10-92 years were recruited during one year. The diagnostic produce followed the three standard stages: First stage clinical evaluation (a complete history, physical and neurological examination, a base-line laboratory evaluation, a 12-lead electrocardiogram, carotid sinus stimulation); Second stage non invasive investigation (echocardiogram, 24-hour electrocardiographic monitoring, electroencephalography, Doppler echocardiography of epiaortic vessels, head-up tilt test, head CT scan); third stage invasive investigation (electrophysiologic study). Diagnosis was, sometimes, difficult because of the sporadic and transitory nature of the syncope. The etiological diagnosis were the following: cardiovascular causes 68.55% (cardiac 31.95%, reflex syncope 36.59%). Non-cardiovascular causes 10.82% (metabolic 5.15%, neurologic 3.5%, different 2.06%). Unknown cause 20.61%. Diagnosis was determined at the following stages: ist stage 63.40% (complete history and physical examination alone 4072%), 2nd stage 14.43%, 3rd stage 1.54%. The mean follow-up period was 21.71 +/- 6.22 months. Over this period 17 (8.76) patients died; all aged (> 65 years) end in this aged the incidence is 18.08%. If we look at patients with correct diagnosis of syncope (183 patients) the mortality rate is 8.19% (if we consider those aged > 65 the rate is 17.44%). The mortality rate of cardiac syncope of unknown (28.88% for aged > 65 years). 2 deaths among syncope of unknown cause. 17.48% had 1 or more episodes of recurrent syncope during this follow-up period with little prevalence for patients with syncope of unknown origin. Other major cardiovascular events was 18.03% in all patients with little prevalence for cardiac cause of syncope. 1) Frequently an accurate history, a physical examination and a standard ECG are enough to formulate a correct diagnosis. 2) Head-up tilt test must be considered in patients with a unknown diagnosis, before starting invasive investigation. 3) Prognosis is dependent on the specific cause. Since cardiac syncope has a serious prognosis, when it is not treated correctly, it can even lead to sudden death.

Amaurosis fugax

If laboratory tests are abnormal, a systemic disease process is likely, and, if the ophthalmologic examination is abnormal, ocular disease is likely. However, in the event that both of these routes of investigation yield normal findings or an inadequate explanation, noninvasive duplex ultrasound studies are recommended to identify carotid artery disease. Most episodes of amaurosis fugax are the result of stenosis of the ipsilateral carotid artery. With that being the case, researchers investigated how best to evaluate these episodes of vision loss, and concluded that for patients ranging from 36 to 74 years old, "...carotid artery duplex scanning should be performed...as this investigation is more likely to provide useful information than an extensive cardiac screening (ECG, Holter 24-hour monitoring, and precordial echocardiography)." Additionally, concomitant head CT or MRI imaging is also recommended to investigate the presence of a “clinically silent cerebral embolism.”

[Clinical diagnostic of brain death and transcranial Doppler, looking for middle cerebral arteries and intracranial vertebral arteries. Agreement with scintigraphic techniques].

The Real Ordinance 2070/1999 meant an important modification in the legislation, when including transcranial Doppler (TCD) in explorations to confirm the clinical diagnosis of brain death (BD). Habitually for their employment in the diagnosis of BD, we look for blood flow signal from the middle cerebral arteries (MCA) and the basilar artery (BA). To check the effectiveness of the TCD like test of BD, looking for both middle cerebral arteries (MCA) and both intracranial vertebral arteries (VA), instead of the BA, and taking as Gold Standard cerebral scintigraphic techniques. . We present 25 patients diagnosed clinically with BD; on these TCD was carried out to confirm BD. Later on we proceeded to carry out cerebral scintigraphic techniques in all these cases. As statistical tool the test of c2 is used with confidence interval of 95%. In 24 of the 25 cases, the TCD was effective in confirming the diagnosis of BD. In the remaining patient, a false positive result was obtained, since the TCD didn't reveal flow in the infratentorial compartment, as contrary to the cerebral scintigraphic techniques which showed the presence of residual flow at this level; this residual flow disappeared in 36 hours. This patient was hemodynamically unstable during TCD exploration. In our results the TCD obtains a reliability of 100% when confirming the absence of blood flow in the supratentorial compartment; nevertheless the false positive result obtained at the infratentorial level, warns us to be cautious in accepting the flow from the VA as a test of absence of flow at the infratentorial compartment, especially in those patients with hemodynamic instability.

Brugada syndrome (BS) and syncope: a complex therapeutic issue.

A 66 year-old man was brought to the emergency room (ER) for syncope and sphincter incontinence; syncope duration was about 15 min. Similar short duration episodes had been referred by his relatives during the last months, following small traumas; no seizures had been registered. Patient told he was affected with BS, having already been diagnosed 5 years before, after performing an electrocardiogram (ECG) highly suggestive for it. He had performed an electrophysiologic study, which had not shown any sustained ventricular arrhythmias after scheduled stimulation. This finding together to the lack of symptoms had suggested a conservative treatment, notwithstanding that familiar history documented his father's sudden death. Patient was also affected with hypertension and gastroesophageal reflux disease. Clinical examination did not suggest any significant findings. Laboratory tests, supra aortic Doppler ultrasound, electroencephalogram (EEG) and brain CT were normal. ECG showed sinus rhythm with a heart frequency of 82 bpm, QRS axis was normal, as well as atrioventricular conduction. ST coved-type elevation with right bundle branch block pattern and repolarization abnormalities were found. Holter ECG and Doppler echocardiography were also performed. The onset of syncope in presence of BS suggested the evaluation of this case report together with electrophysiolgists and neurologists. Therefore, an implantable cardioverter defibrillator (ICD) was implanted through left subclavian vein. He was discharged eight days after hospitalization, diagnosis was "Syncope in patient affected with BS, hypertension". Arrhythmogenic risk stratification is necessary; the indication for implanting this device is obvious in symptomatic patients, whereas it is controversial in patients presenting only ECG patterns of BS. In conclusion, the above mentioned case report rises remarkable diagnostic and therapeutic issues. The finding of BS in a patient with syncope indicates the opportunity of implanting a defibrillator and only clinical experience and common opinions may help doctors in taking the most appropriated, often difficult, decisions.

[Ultrasonographic control of cerebral blood flow in patients with stenosis of brachiocephalic arteries before and after carotid endarterectomy].

The authors studied the parameters of arterial and venous blood flow in patients presenting with haemodynamically significant atherosclerosis of the carotid arteries before and after carotid endarterectomy, as well as while carrying out functional tests. Comparing the indices of arterial blood flow in the Study Group consisting of 52 patients and the Control Group comprising 15 apparently healthy volunteers at rest prior to the operation revealed statistically significant differences of volumetric parameters of blood flow in the internal carotid artery. The obtained results showed that the breath-holding test was accompanied and followed by increased velocity of blood flow in the middle cerebral artery (MCA) on the side contralateral to stenosis, with the reactivity index (RI) amounting to 0.98±0.20, which statistically significantly differed from the RI in the Control Group patients (1.28±0.13). The forced respiration test demonstrated a decrease in the volumetric indices of blood flow in the MCA on the side of stenosis, as well as an increase of the maximum end-diastolic velocity of blood flow on the side contralateral to stenosis. The test with sublingual administration of nitroglycerin appeared to result in reduced blood flow in the MCA. The supratrochlear test demonstrated decreased velocity of blood flow in the supratrochlear artery. Studying the venous link of cerebral vessels after the operation showed that statistically significant differences were revealed only on the side contralateral to stenosis as compared with the values prior to revascularization. An increase of blood flow in the internal jugular veins after the operation on the side contralateral to the operation was apparently suggestive of an adequate distribution of blood flow through the main vessels of the brain.

[The Doppler test: its practical importance in the study of lesions of the supra-aortic trunks].

Ultrasonography by the Doppler effect is of indisputable use in the investigation of lesions of the supra-aortic trunks leading to the brain. It allows a direct study of the extracranial carotidian and vertebral axes, and gives an idea of the intracerebral circulation. It detects the main lesions affecting them, provided that such lesions have hemodynamic repercussions. The Doppler does not replace arteriography, but is a complementary exam making it possible to decide on or to dismiss the need for it. Its harmlessness and simplicity make it a standard exam in cerebral vascular pathology.

Syncope (medicine)

A medical history, physical examination, and electrocardiogram (ECG) are the most effective ways to determine the underlying cause. The ECG is useful to detect an abnormal heart rhythm, poor blood flow to the heart muscle and other electrical issues, such as long QT syndrome and Brugada syndrome. Heart related causes also often have little history of a prodrome. Low blood pressure and a fast heart rate after the event may indicate blood loss or dehydration, while low blood oxygen levels may be seen following the event in those with pulmonary embolism. More specific tests such as implantable loop recorders, tilt table testing or carotid sinus massage may be useful in uncertain cases. Computed tomography (CT) is generally not required unless specific concerns are present. Other causes of similar symptoms that should be considered include seizure, stroke, concussion, low blood oxygen, low blood sugar, drug intoxication and some psychiatric disorders among others. Treatment depends on the

[Carotid endarterectomy without angiography].

Duplex scanning has emerged as an accurate noninvasive method of evaluating patients with extracranial cerebrovascular disease; it has research, clinical and economic implications. The risks associated with cerebral angiography are numerous and well-known. During 1990-1995, 227 carotid endarterectomies (CEA) were performed without preoperative arteriography in 192 patients. 91% were performed under local anesthesia. Indications for surgery without angiography were: renal insufficiency (in 5), allergy to contrast material (11), and need for urgent surgery (25). In 81% CEA was performed due to the preference of both the neurologist and surgeon. In only 2 cases there was a discrepancy in duplex evaluation. 3 patients had postoperative strokes (total stroke rate 1.56%), only 1 of which was disabling (0.52%). 2 died during the immediate postoperative period (mortality 1.04%): 1 on the 2nd postoperative day due to asphyxia caused by a huge neck hematoma which appeared suddenly after discharge (related death, 0.52%); the other died several days after coronary surgery which followed CEA (unrelated death). Our study confirms that patients with well-defined symptoms, appropriate physical findings, and concurrent CT and duplex scans, can safely undergo CEA without preoperative angiography. It is extremely important however, that the duplex scan be a reliable study from a laboratory which has validated its results by sequential comparison of previous duplex and angiographic data. Angiography remains appropriate in patients with atypical symptoms; with conflicting findings between history, physical and duplex data; when there is proximal disease; or in an asymptomatic patient when the duplex scan suggests total occlusion.

Embolic stroke of undetermined source

Diagnosis ESUS is a diagnosis of exclusion based on radiological and cardiological examinations. For exclusion of haemorrhagic or lacunar strokes CT or MRI imaging is needed. Both procedures also allow detection of embolic pattern of ischemic lesions. 12-lead ECG and cardiac monitoring for at least 24 h with automated rhythm detection are mandated to exclude atrial fibrillation; echocardiography (TTE and/or TEE) is used to detect other major-risk cardioembolic sources (e.g., intracardiac thrombi, or ejection fraction <30%). For imaging of both the extracranial and intracranial arteries supplying the area of brain ischaemia, examination methods like catheter, MR/CT angiography or cervical duplex plus transcranial Doppler ultrasonography are required. They allow an exclusion of large vessel stenosis (≥ 50%).

Evaluation by Magnetic Resonance Imaging of Silent Brain Infarcts in Preoperative and Postoperative Asymptomatic Carotid Surgery.

To report the prevalence of silent brain infarcts (SBI) at magnetic resonance imaging (MRI) before and after surgery for asymptomatic high grade carotid stenosis. This is a single center retrospective observational study. Asymptomatic patients who underwent carotid endarterectomy between October 2012 and October 2014 were included. The preoperative assessment included a Doppler and a computed tomographic (CT) scan dating less than 3 months. A neurological examination was performed during the anesthesia consultation and in the 15 days before surgery. An MRI angiography was performed the day before and 3 days after surgery and was analyzed by an independent neuroradiologist. Preoperative analysis focused on the presence of ischemic events at MRI. The type of plaque, the supra aortic trunk lesions, and the quality of the circle of Willis were analyzed using Doppler and CT scanning. Postoperatively, we searched for signs of postoperative ischemic events at MRI. Forty-one patients were included (85.4% of men), and the mean age was 72.4 ± 8.3 years. We noted 7 (17.1%) contralateral stenoses (>50%) and 2 (4.9%) contralateral thromboses, 6 (14.6%) vertebral stenoses, and 7 (17.1%) abnormalities of the circle of Willis. The morphological analysis described 6 unstable plaques including 4 ulcerated, 1 pseudodissection, and 1 intraplaque hemorrhage. Preoperatively, we noted the presence of 21 (51.2%) ischemic lesions including 9 (21.9%) multiple lacunar ischemic events and 12 (29.3%) silent arterial territory infarcts. Eversion was performed for all patients except for 6 (14.6%), for whom a bypass was necessary. No deaths or major complications were observed in the 30 postoperative days. Postoperatively, MRI showed 3 (7.3%) asymptomatic recent ischemic strokes, 1 ipsilateral middle cerebral artery (MCA) stroke, and 2 contralateral (cerebellar and MCA) strokes. Patients with asymptomatic significant carotid stenosis show many preoperative SBI indicating a significant embolic risk. It is difficult to conclude about intraoperative embolic risk, but we hope that more data could demonstrate the importance of MRI for the preoperative evaluation of carotid plaques and brain parenchyma, to identify high-risk embolic patients.

[Common carotid artery thrombosis--clinical and radiological evaluation].

Common carotid artery thrombosis (CCAT) is not common. We studied 4 patients with CCAT to clarify the clinical and radiological features of this disorder. Case 1 had only episodes of TIA. Case 2 was diagnosed by chance as having CCAT at the time of admission due to cerebellar infarction. On the contrary, Cases 3 and 4 were admitted because of disturbance of consciousness and hemiparesis. Case 4 died soon after his stroke because of complications. We evaluated cases 1, 2 and 3 using head CT, head MRI, neck MRI, MR angiography, SPECT and cerebral angiography. Case 4, who was evaluated with head CT and cerebral angiography, was autopsied to confirm the occlusion of the common carotid artery. The clinical severity of CCAT varies from asymptomatic to severe, because each differs in the time taken for complete occlusion of the common carotid artery; the development of collateral circulation; and hemodynamics of the brain. As for the collaterals their contribution is variable; for example, the thyrocervical and other arteries function as the bypass. We can diagnose CCAT easily and noninvasively using MR angiography and neck MRI based on disappearance of the flow void in the common carotid artery or internal carotid artery. On physical examination, it is important to detect faded pulsation of the superficial temporal artery that is ipsilateral to the occluded common carotid artery.

[A case report of thoracic aortic and common carotid artery dissecting aneurysm diagnosed by duplex ultrasound examination].

A 61-year-old man was admitted to our hospital because of sudden consciousness disturbance, aphasia and right-side hemiparesis. On admission his blood pressure was 124/74mmHg, and his pulse was a regular rate of 46 beats per minute. Electrocardiogram was normal. Thirty minutes after the onset brain computed tomographic (CT) scan showed no abnormality. Fifty minutes after the onset cervical ultrasound examination with color-coded Doppler demonstrated a subintimal dissection with a false channel of the left common carotid artery. Eighty minutes after the onset thoracic CT scan demonstrated the false lumen in ascending and descending thoracic aortic artery. Cervical CT scan showed a dissection with a false channel of the left common carotid artery. We could diagnose him as cerebral infarction due to thoracic aortic and common carotid artery dissection by means of ultrasound examination within 80 minutes after the onset. He spontaneously and fully recovered three days later. We emphasize the usefulness of noninvasive technique such as cervical ultrasound examination with color-coded Doppler in the diagnosis and follow-up of common carotid artery dissection.

[What studies should be done in syncope?].

Fainting (short loss of consciousness) is a frequent reason for a consultation in a general practitioner's or cardiologist's office. Four main causes are recognized commonly: cardial with auriculo-ventricular block and arrhythmias, vascular in particular vaso-vagal syncopes, neurologic and other causes. In 38 to 47% of the patients no etiology is found: these are syncopal attacks of unknown origin. The first diagnostic step comprises noninvasive investigations. A 24-hour recording of the ECG or a 'long strip' improve the diagnostic rate by 10%. They are particularly useful for sick sinus syndromes. The head-up tilt-test has been developed recently. It is very useful for detection of vagovasal syncope and permits to understand the pathophysiology and the therapeutic consequences of these disorders. This test plays a particular role for the diagnosis of syncopes of unknown causes and shows in 24 to 75% of the cases pathologic results. Patients at high risk for ventricular arrhythmia can be recognized by ECG with high amplification. Doppler investigation of the neck vessels, however, seems to be of low diagnostic value in syncopes. Invasive measures are the last line resort. Electrophysiologic studies provide criteria that are well defined. They are useful for detection of ventricular dysrhythmias and conduction disorders. This latter approach is reserved to patients with negative noninvasive tests and in particular with cardiopathy. The approach to syncope and the power of noninvasive and invasive tests is thus well established. However, in a certain number of patients the cause for fainting is not disclosed. Fortunately mortality is low in this particular group.

Carotid bruit

A carotid bruit is a vascular murmur sound (bruit) heard over the carotid artery area on auscultation during systole. Associated conditions It may occur as the result of carotid artery stenosis (though some disagree); however, most carotid bruits, particularly those found in younger or asymptomatic patients, are not related to any disease and are termed "innocent carotid bruits". A carotid bruit is unlikely to be heard if the stenosis occludes less than 40% of the diameter of the artery. Likewise, a stenosis of greater than 90% may not be heard, as the flow may be too low. Many carotid bruits are discovered incidentally in an otherwise asymptomatic patient. The presence of a carotid bruit alone does not necessarily indicate the presence of stenosis, and the physical examination cannot be used to estimate the degree of stenosis, if present; therefore, any bruit must be evaluated by ultrasound or imaging.

Aortic aneurysm

The diagnosis of an abdominal aortic aneurysm can be confirmed at the bedside by the use of ultrasound. Rupture may be indicated by the presence of free fluid in the abdomen. A contrast-enhanced abdominal CT scan is the best test to diagnose an AAA and guide treatment options. Only 10–25% of patients survive rupture due to large pre-and postoperative mortality. Annual mortality from ruptured aneurysms in the United States is about 15,000. Most are due to abdominal aneurysms, with thoracic and thoracoabdominal aneurysms making up 1% to 4% of the total. Aortic rupture An aortic aneurysm can rupture from wall weakness. Aortic rupture is a surgical emergency and has a high mortality even with prompt treatment. Weekend admission for a ruptured aortic aneurysm is associated with increased mortality compared with admission on a weekday, and this is likely due to several factors including a delay in prompt surgical intervention.

[History of neurovascular ultrasonography].

History of diagnostic ultrasound begins with the Austrian physicist Christian Doppler, who described in 1842 the Doppler principle. 40 years later, the Curies discovered the reverse piezoelectric effect that produces ultrasound. The first ultrasonic devices were designed at the beginning of the 20th century and were used among other things for detection of submarines. Development during World War II permitted the construction of the first transcranial (1940) and extracranial (1949) ultrasound imaging units. Continuous-wave Doppler sonography was introduced in clinical practice 20 to 30 years later. Due to its high validity, this technique has become the standard method for evaluation of extracranial occlusive cerebrovascular disease. Further ultrasonic developments like duplex and color duplex sonography have increased the diagnostic possibilities but did not replace continuous-wave sonography in many European ultrasound laboratories. Transcranial ultrasound studies are performed by means of pulsed-wave Doppler or color duplex sonography. It is likely that power Doppler and transpulmonary contrast agents will further increase diagnostic confidence in neurovascular ultrasound. The search for a source of arterio-arterial embolism in case of ocular and cerebral ischemia remains the main indication for neurovascular ultrasonography. Additional indications are repetitive studies in dissection, vasospasm, endovascularly treated vascular malformations and stenoses, intracranial pressure monitoring, examination of cerebrovascular reactivity in suspicion of hemodynamic ischemia, and diagnostic work-up of cough syncope, pulsatile tinnitus and cardiac right-left shunt.

Innominate Artery Stenosis Presenting With Migratory Digital Ischemia.

Atherosclerotic lesions of the supra-aortic trunk vessels, including the innominate artery, subclavian artery, or the common carotid artery, tend to present either as low-flow state distal to the lesion or as embolic events. The risk of embolic cerebrovascular event complicates the management of this condition via a pure endovascular approach. A combined operative-endovascular intervention may be a valuable approach in order to reduce the risk of intraoperative stroke and prevent future embolic events. An 84-year-old female presented at the emergency department (ED) with a 4-month history of migratory digital cyanotic lesions across various fingers on her right hand. The lesion eventually progressed into dry gangrene on her right middle finger. Selective angiography of the aortic arch vessels demonstrated significant atherosclerotic plaque burden throughout her supra-aortic vessels and a segmental stenosis at the proximal innominate artery. A right carotid cut down was performed to allow clamping of the carotid artery so as to minimize the risk of intraoperative stroke from plaque manipulation. Retrograde balloon angioplasty was performed, and stent was placed across the stenotic segment. The patient tolerated the procedure well and had an uneventful postoperative course. She was discharged on postoperative day 3. At 2-week follow-up, she has had no progression of her digital ischemia nor other focal cranial nerve deficits. Migratory digital ischemia is a rare presentation of atherosclerotic disease of the supra-aortic vessels. It represents a challenging situation for endovascular intervention due to concern about plaque dislodgment during the procedure. A retrograde balloon-stent angioplasty following distal carotid control with an open approach may be safe and effective in selected patients.

Outcome for patients with carotid stenosis undergoing carotid endarterectomy, the cerebral condition followed by extra/intracranial ultrasound examinations.

Seventy-six patients undergoing carotid endarterectomy were studied to estimate the effect of operation, evaluate the accessible methods of examination and disclose the complications owing to the operation. In addition, the hypothesis that the pulsatility index in MCA measured by the Doppler method could disclose severe ischemia and risk of complications during endarterectomy was tested. The study was a prospective study of patients operated at the University Hospital in Odense in the years 1991-1996. Data collected included demographics, operative indications, complications, follow-up extra/transcranial Doppler examinations, cerebrovascular reactivity investigations, recurrent symptoms and deaths. Concerning the carotid stenosis, a fairly good correlation was found between the results of extracranial Doppler examinations, Duplex and carotid angiography. Serious complications after surgery were few. One patient, who had a coronary by-pass operation consecutive to the endarterectomy, died 3 weeks after the operation, owing to a hematothorax. Five patients (7%) suffered a stroke. Only 2 patients needed rehabilitation, and they came out with minor disturbances in the use of a hand. Recurrent stenosis in excess of 69% emerged in 3% of the patients. All were hemodynamically insignificant. One patient had a new TIA during the observation time of 3-60 months. After the operation she had a thrombosis in the operated carotid artery. Thus our results, a perioperative stroke rate of 7% and a mortality rate of 1%, are in line with the average results in multicenter trials. In addition a PI below 0.60 in the MCA seemed to be a warning of the risk of postoperative cerebral hyperemia.

[Value of the carotid compression test for the diagnosis of cerebrovascular disorders].

The carotid compression tests have been performed in 1940 outpatients and 233 hospitalized patients with clinical signs and symptoms of cerebrovascular disturbances. The frequency of EEG slowing, positivity of the compression tests and carotis sinus hypersensitivity was in patients with local neurological signs: 36%, 22.5%, and 24.8%, while the corresponding numbers for patients without neurological signs were: 24.6%, 21.8%, 14.7%. On the basis of the carotis angiography the following groups of the patients could be formed: Thrombosis of the internal carotid artery (A), thrombosis of the anterior or medial cerebral artery (B), carotis stenosis (C), other vascular pathological signs of the arteries (D), normal angiography (E). They were compared with the control group of patients with vertebrobasilar insufficiency (F). The frequency of EEG slowing (A = 92%, B = 72%, C = 58.9%, D = 57%, E = 40%, F = 22.5%). The percentage of the positivity of carotid compression tests (A = 54%, B = 32%, C = 46%, D = 26%, E = 12%) and occurrence of carotis sinus hypersensitivity (A = 26.8%, B = 16%, C = 17.7%, D = 10.8%, E = 11.3%, F = 6.9%) were proportionate to the pathological morphological signs. The results of the compression tests may give indication for detailed clinical investigation, and are helpful in the estimation of the functional capacity of the carotid arteries in the cerebral circulation.

[A case with cerebral embolism due to the recurrence of thrombotic valve five years after the reoperation].

Between April 1972 and May 1990, a total of 300 patients in our institution underwent insertion of a Björk-Shiley aortic valve prosthesis, and development of a thrombosed valve was observed only in 4 female cases. It was considered that the thrombosed valves in all 4 cases were caused by inadequacy of the anticoagulant agents. As reoperative procedures, thrombectomy, resection of the excessive granulation under the valve, and a method of turning the opening direction of the valve 180 degrees were used. These procedures were reported previously. One case died late in the day after the operation, while the remaining 3 cases progressed favorably. Although control of one of these three cases was favorably maintained after reoperation, a restriction of 43.2 degrees of the opening angle of the valve was again observed by valve-fluoroscopy performed in the 3rd postoperative year. However, progress of this patient was observed on an outpatient basis because flow velocity at the position of aortic valve was also within normal range. This was shown Doppler's test using ultrasonic waves and the patient showed no symptoms. However, this patient was admitted to our institute due to sudden right hemiplegia on May 1990 in the 5th year after reoperation. The cerebral embolism due to the recurrent thrombosed valve was diagnosed because a low density in the middle cerebral area was observed by CT, and increase of the opening angle of the valve (compared with that at ambulation) was also noted by valve-fluoroscopy. The hemiplegia remained even though this patient was saved from death. (ABSTRACT TRUNCATED AT 250 WORDS)

Radiology

Because ultrasound imaging techniques do not employ ionizing radiation to generate images (unlike radiography, and CT scans), they are generally considered safer and are therefore more common in obstetrical imaging. The progression of pregnancies can be thoroughly evaluated with less concern about damage from the techniques employed, allowing early detection and diagnosis of many fetal anomalies. Growth can be assessed over time, important in patients with chronic disease or pregnancy-induced disease, and in multiple pregnancies (twins, triplets, etc.). Color-flow Doppler ultrasound measures the severity of peripheral vascular disease and is used by cardiologists for dynamic evaluation of the heart, heart valves and major vessels. Stenosis, for example, of the carotid arteries may be a warning sign for an impending stroke. A clot, embedded deep in one of the inner veins of the legs, can be found via ultrasound before it dislodges and travels to the lungs, resulting in a potentially

[Ultrasonic diagnosis in the area of the carotid and vertebrobasilar circulation].

At present the duplex ultrasonic method is the best non-invasive examination method of the carotid and vertebrobasilar circulation. It was developed by a combination of the Doppler method with two-dimensional imaging in real time. It makes it possible to evaluate all stages of the stenotic process, the size and surface of plaques, the lumen of the vessels, occlusions. It provides a comprehensive picture of the morphology and function of vessels. The introduction of transcranial Doppler ultrasonography by R. Aaslid in 1982 made it possible to examine also basal intracranial arteries. Examination by ultrasound makes it possible to diagnose vascular changes in still asymptomatic patients; it helps to establish the correct diagnosis, offers the possibility to evaluate the therapeutic effect as well as terminal conditions-cerebral death.

[A 62-year-old man with an acute onset of consciousness disturbances].

We report a 62-year-old man who developed coma and died in a fulminant course. The patient was well until May 1, 1996 when he noted chillness, tenderness in his shoulders, and he went to bed without having his lunch and dinner. In the early morning of May 2, his families found him unresponsive and snoring; he was brought into the ER of our hospital. He had histories of hypertension, gout, and hyperlipidemia since 42 years of the age. On admission, his blood pressure was 120/70, heart rate 102 and regular, and body temperature 36.3 degrees C. His respiration was regular and he was not cyanotic. Low pitch rhonchi was heard in his right lower lung field. Otherwise general physical examination was unremarkable. Neurologic examination revealed that he was somnolent and he was only able to respond to simple questions such as opening eyes and grasping the examiner's hand, but he was unable to respond verbally. The optic discs were flat; the right pupil was slightly larger than the left, but both reacted to light. He showed ptosis on the left side, conjugate deviation of eyes to the left, and right facial paresis. The oculocephalic response and the corneal reflex were present. His right extremities were paralyzed and did not respond to pain Deep tendon reflexes were exaggerated on the right side and the plantar response was extensor on the right. No meningeal signs were present. Laboratory examination revealed the following abnormalities; WBC 18,400/ml, GOT 131 IU/l GPT 50 IU/l, CK616 IU/l, BUN 30 mg/dl, Cr 2.1 mg/ dl, glucose 339 mg/dl, and CRP 27.4 mg/dl. ECG showed sinus tachycardia and ST elevation in II, III and a VF leads and abnormal q waves in I, V5, and V6 leads. Chest X-ray revealed cardiac enlargement but the lung fields were clear. Cranial CT scan revealed low density areas in the left middle cerebral and left posterior cerebral artery territories. The patient was treated with intravenous glycerol infusion and other supportive measures. At 2: 10 AM on May 3, he developed sudden hypotension and cardiopulmonary arrest. He was pronounced dead at 3:45 AM. The patient was discussed in a neurological CPC, and the chief discussant arrived at the conclusion that the patient had acute myocardial infarction involving the inferior and the true posterior walls and left internal carotid embolism from a mural thrombus. Post mortem examination revealed occlusion of the circumflex branch of the left coronary artery due to atherom plaque rupture and myocardial infarction involving the posterior and the lateral wall with a rupture in the postero-lateral wall. Marked atheromatous changes were seen in the left internal carotid, the middle cerebral and the basilar arteries; the left internal carotid and the middle cerebral arteries were almost occluded by thrombi and blood coagulate. The territories of the left middle cerebral and the occipital arteries were infarcted; but the left thalamic area was spared. The neuropathologist concluded that the infarction was thrombotic origin not an embolic one as the atherosclerotic changes were severe. Cardiac rupture appeared to be the cause of terminal sudden hypotension and cardiopulmonary arrest. It appears likely that a vegetation which had been attached to the aortic valve induced thromboembolic occlusion of the left internal carotid artery which had already been markedly sclerotic by atherosclerosis. It is also possible that the vegetations in the aortic valve came from mural thrombi at the site of acute myocardial infarction, as no bacteria were found in those vegetations.

[Internal carotid artery dissection in the neurologist's practice - a case study].

Dissection of the interior carotid artery is rare in the general population. It can however be a potentially life-threatening condition. In the group of patients below 45 years of age, it constitutes a fairly common cause of cerebral stroke. The study describes the case of a patient with the right interior carotid artery dissection, sustained most probably in the course of work. The patient was admitted to hospital for a severe headache of a few days' duration accompanied by Horner's syndrome on the right side. Promptly undertaken diagnostic procedures allowed for immediate diagnosis and application of the right treatment. The check-up examinations performed showed a healed artery and withdrawal of the neurological syndrome. The case emphasizes the role of prompt diagnosis and treatment in preventing the development of more serious complications. The article refers also to the standards of treating the dissection of the interior carotid artery which still arouse controversies.


Anisakis simplex is a parasite frequently found in fish. To avoid reactions with this parasite, a diet free of fresh and raw fish (anchovies in vinegar, smoked, salted fish, sushi, etc.) should be followed. Deep-frozen fish or fresh fish previously frozen at -20ºC for at least 5 days before cooking can be consumed, as long as it is cooked at high temperatures >60ºC (roasted, fried, etc.), avoiding raw, grilled or microwaved preparations. It is recommended to consume preferably the tails because the larvae of the parasite are usually close to the viscera of the head.

A 35-year-old patient consults to confirm a suspected allergy to Anisakis simplex. She has previously suffered a clinical picture of gastrointestinal anisakiasis after eating fish. The tests performed show specific IgE levels of 10 KU/l against Anisakis simplex. Which of the following would be the dietary recommendation for this patient?

He cannot eat any fish, crustaceans, mollusks or cephalopods.

He can eat fresh fish cooked on the grill.

You can eat fresh marinated or cold smoked fish.

Freezing protects against allergy to Anisakis simplex.

Allergic reactions to Anisakis simplex have been described following ingestion of fish and were thought to be possible even if seafood is frozen or well-cooked. This study aimed to confirm, by challenge test, that dead A. simplex larvae are not able to trigger allergic reactions in patients with proven hypersensitivity to this parasite. Simple-blind, placebo-controlled, oral challenge tests with frozen A. simplex larvae were performed in 12 patients who had suffered severe anaphylactic reactions after ingestion of seafood and diagnosed of A. simplex hypersensitivity by skin prick test and specific IgE. If no reaction appeared, they were told to eat frozen seafood. 63 patients who had suffered urticaria or urticaria/angioedema by demonstratred hypersensitivity to A. simplex were also advised to eat frozen seafood. All of them were reevaluated 6 months later. All patients tolerated the dead larvae challenge test. After eating previously frozen seafood at least two times per week, all patients, including those who had suffered anaphylactic reactions and those who had only presented cutaneous manifestations, remained asymptomatic. Anisakis simplex-allergic patients tolerate ingestion of dead larvae. It is probable that these patients can eat frozen fish and that a seafood-free diet is not necessary.

Occupational disease due to Anisakis simplex in fish handlers.

Anisakis is a marine nematode. Its larvae can be found encysted in several species, both in the abdominal cavity and in the adjacent musculature. The most commonly affected commercial species are hake, whiting, cod, and mackerel. The prevalence in fish varies according to the fishing area and the size of the host. Until now only three species have been confirmed to be involved in human anisakiasis, the most common ones being A. simplex sensu stricto (s.s.) and A. pegreffii, and anecdotally, A. physeteris. Infestation in humans occurs when they eat raw or undercooked parasitized fish or cephalopods (pickled, cold-smoked, salted, semi-preserved, prepared in certain Asian styles like sushi or sashimi, ceviche). The majority of anisakiasis cases have been described by Japanese authors. However, over the last few years there has been an increase in the number of cases reported in other countries including Italy and Spain. It is estimated that its incidence in the European Union is 0.32/100,000, and in the Basque Country (Spain), this parasite is responsible for 10% of anaphylaxis cases and 32% of urticaria cases in adults aged 40-60 years, around 300 cases/year. Anisakis-related disease in the work environment (occupational disease) is less common. We present three cases of the occupational disease in Spain due to a type I hypersensitivity to Anisakis simplex in individuals who handle fish (one fishmonger, one supermarket employee, and one chef).

Fish as food

Parasite infection by raw fish is rare in the developed world (fewer than 40 cases per year in the United States), and involves mainly three kinds of parasites: Clonorchis sinensis (a trematode/fluke), Anisakis (a nematode/roundworm) and Diphyllobothrium (a cestode/tapeworm). Infection risk of Anisakis is particularly higher in fishes which may have lived in a river or estuary, such as salmon (sa ke in Japanese cuisine) or mackerel (sa ba in Japanese cuisine). Such parasite infections can generally be avoided by boiling, grilling, preserving in salt or vinegar, or deep-freezing. In Japan, it is common to eat raw salmon and ikura (roe), but these foods are frozen overnight prior to eating to prevent infections from parasites, particularly Anisakis. Vegetarianism Since fish is animal flesh, the Vegetarian Society has stated that vegetarian diets cannot contain fish.

[Human diseases caused by Anisakis simplex].

Anisakis simplex is a parasitic worm. It infects marine mammals that feed on fish and cephalopods, its intermediary hosts. Human disease is caused by accidental ingestion of Anisakis larvae. Upon consumption of contaminated fish, cuttlefish or squid, human may develop two distinct clinical pictures: Anisakiasis is provoked by living larvae penetrating the digestive mucosa. Allergy is caused by IgE-mediate hypersensitivity to living or dead larvae in a previously sensitized individual. Anisakiasis may manifests with violent epi gastric pain, acute abdomen or eosinophilic gastroenteritis. The larvae may be visualized by endoscopy or histology. The main Anisakis allergens are not denaturated by heat or cold and resist to digestion. Allergy diagnosis relies on careful history and detection of specific IgE.

[Allergy to Anisakis simplex].

Anisakis simplex is a parasite, belonging to the Anisakidae family. The life cycle of the parasite can include one or more intermediary hosts, their final hosts being marine mammals or large fish, in which the larvae develop until the adult stage is reached. Man is an accidental host who acquires the larvae by eating raw or undercooked fish. Since the mid-50s, when the first case studies were published in Holland and Japan, new cases have been emerging in different countries including Spain. Parasitization of man by the living larva is known as anisakiasis, principally giving rise to digestive symptomology, with other rare cases described of invasion of other organs such as the lung, the liver, the spleen, the pancreas, etc. Clinical pictures of allergy to IgE mediated anisakis simplex have also been described: reactions by thermostable antigens of the parasite that develop in spite of the fish being cooked or frozen, and an acute digestive parasitization with allergic symptoms called gastro-allergic anisakiasis. In the diagnosis of anisakiasis and/or allergy to Anisakis, the antecedent of the prior ingestion of fish as well as the clinical accompaniment can form basic data of considerable orientational value, and endoscopy can reveal the presence of the larvae and make possible their extraction. Besides, in cases of allergy the detection test for specific IgE facing Anisakis simplex, and cutaneous tests with fish should be carried out. The best treatment for avoiding this parasitization is prophylactic, avoiding the consumption of raw or undercooked fish, while a fish free diet is necessary in cases of true allergy to the thermostable proteins of the parasite.

Investigation of Anisakis larvae in different products of ready-to-eat fish meat and imported frozen fish in Turkey.

Globalization opens new market areas and affects food consumption habits, resulting in rapid and remarkable cultural change. Food habits such as consumption of raw fish meat have become popular, resulting in increased risk of emerging infectious diseases. Anisakis simplex sensu stricto (s.s) and A. pegreffii are the most common and important fish-borne zoonotic nematodes responsible for human anisakiasis, which occurs through the consumption of raw or undercooked fish as well as cooked fish due to their heat-stable allergens. Here, we investigated the prevalence, intensity, and abundance of Anisakis larvae in imported fish and ready-to-eat local fish products in Turkey. A total of 205 ready-to-eat fish products, 100 imported frozen Atlantic salmon (Salmo salar) fillets, and 100 imported frozen whole Atlantic mackerel (Scomber scombrus) were sampled from supermarkets, sushi restaurants, and fish markets. All samples were individually examined using a pepsin digestion technique. In total, 602 Anisakis type I larvae were recovered from 98/100 mackerel. No larvae were found in ready-to-eat products or frozen Atlantic salmon fillets. Overall, 8.8% of the larvae were found in the muscle tissue. The overall mean intensity and abundance of infection in mackerel were 6.14 and 6.02, respectively. The larvae were molecularly identified and their phylogenetic relationships with the relevant Anisakis sequences in GenBank were investigated. For this purpose, a subsample of randomly selected 100 Anisakis larvae were analyzed with PCR-RFLP of the ITS region. The larvae were identified as A. simplex (s.s.) (n = 87) and hybrids (n = 13). ITS and cox2 gene regions of all hybrids and randomly selected 50 A. simplex (s.s.) larvae were sequenced for species confirmation and phylogenetic analyses. No intraspecific nucleotide variation was found among the ITS sequences of either species. Seven and three haplotypes, respectively, were identified for A. simplex (s.s.) and hybrid species according to DNA polymorphism of the cox2 gene. Hybrids in our study clustered within the common A. simplex (s.s.) clade in the cox2 phylogenetic tree indicating the dominance of A. simplex (s.s) in the catching area of Atlantic mackerel. Consequently, our study indicates high occurrence of A. simplex (s.s.) larvae with an overall 98.0% prevalence in imported Atlantic mackerel, and highlights the importance of these fish as potential reservoirs for human allergic anisakiasis in Turkey and possibly in other countries.

[Eosinophilic esophagitis associated with recurrent urticaria: is the worm Anisakis simplex involved?].

Anisakis simplex, a fish parasite of the nematode family, typically infects marine mammals such as whales, dolphins and seals. Human anisakiasis, which is acquired by eating raw or insufficiently heated fish or squid, has gained world-wide importance. Infestation with living larvae caused by eating parasitised fish results in acute upper abdominal pain, nausea and vomiting and may be confused with acute abdomen due to appendicitis and other inflammatory abdominal disorders. Extraintestinal organ manifestations are rare. Endoscopically, inflammation, oedema, erosions and ulcerations may be found. The parasite can been found in up to 50% of patients. Histologically, an eosinophilic inflammation is typical. Acute anisakiasis may be prevented by thorough cooking or deep-freezing the parasitised fish for at least 48 h. IgG-antibodies specific for Anisakis simplex are thought to represent an immunological host reaction against parasitic antigens. More recently, allergic reactions to Anisakis ingestion or exposure, such as urticaria, anaphylaxis and even occupational asthma, have been reported. These allergic reactions may also occur when the fish has been properly cooked, and hence these allergens are thought to be heat-stable. Such cases may be diagnosed by skin tests and the determination of specific Anisakis-IgE. However, the specificity of IgE is low, since they may also be present in exposed asymptomatic individuals. Since the eliciting allergens are temperature-stable, prophylactic dietetic measures are indicated. We report a case from Switzerland acquired during a holiday in Portugal. The patient suffered from recurrent dysphagia and urticaria, and histologically eosinophilic oesophagitis was found. IgG-antibodies and a positive skin prick test to Anisakis simplex support its aetiologic role for the symptoms.

List of raw fish dishes

Parasite infection by raw fish is rare in the developed world (fewer than 40 cases per year in the U.S.), and involves mainly three kinds of parasites: Clonorchis sinensis (a trematode/fluke), Anisakis (a nematode/roundworm) and Diphyllobothrium (a cestode/tapeworm). Infection risk of anisakis is particularly higher in fishes which may live in a river such as salmon (sake) in Salmonidae or mackerel (saba). Such parasite infections can generally be avoided by boiling, burning, preserving in salt or vinegar, or freezing overnight. In Japan it is common to eat raw salmon and ikura, but these foods are frozen overnight prior to eating to prevent infections from parasites, particularly anisakis. See also Eating live seafood Lomi salmon List of fish dishes List of seafood dishes References Fish, Raw

Anisakis

Raising consumer and producer awareness about the existence of anisakid worms in fish is a critical and effective prevention strategy. Anisakiasis can be easily prevented by adequate cooking at temperatures greater than 60 °C or freezing. The FDA recommends all shellfish and fish intended for raw consumption be blast frozen to −35 °C or below for 15 hours or be regularly frozen to −20 °C or below for seven days. Salting and marinating will not necessarily kill the parasites, as in Italy where two-thirds of cases were attributed to anchovies marinated in lemon or vinegar. Humans are thought to be more at risk of anisakiasis from eating wild fish rather than farmed fish. Many countries require all types of fish with potential risk intended for raw consumption to be previously frozen to kill parasites. The mandate to freeze herring in the Netherlands has virtually eliminated human anisakiasis.

Anisakis

Anisakiasis is a human parasitic infection of the gastrointestinal tract caused by the consumption of raw or undercooked seafood containing larvae of the nematode Anisakis simplex. The first case of human infection by a member of the family Anisakidae was reported in the Netherlands by Van Thiel, who described the presence of a marine nematode in a patient suffering from acute abdominal pain. It is frequently reported in areas of the world where fish is consumed raw, lightly pickled, or salted. The areas of highest prevalence are Scandinavia (from cod livers), Japan (after eating sashimi), the Netherlands (by eating infected fermented herrings (maatjes)), Spain (from eating anchovies and other fish marinated in escabeche), and along the Pacific coast of South America (from eating ceviche). The frequency in the United States is unknown, because the disease is not reportable and can go undetected or be mistaken for other illnesses. Anisakiasis was first recognized in the 1960s.

Dietary recommendations for patients allergic to Anisakis simplex.

Anisakis simplex, a fish parasite, causes allergic urticaria, angioedema and anaphylactic shock through an IgE-mediated hypersensitivity mechanism. Consensus on the dietary recommendations that should be given to allergic patients is lacking. Our objective was to evaluate the usefulness of different types of diets in preventing further reactions in patients allergic to A. simplex. Twenty-eight adult patients, who had suffered an allergic episode caused by A. simplex were asked to follow one of the following three diets for a mean period of 13.16 months: a fish-free diet (diet 1; n = 19), a diet including fish frozen for more than 48 hours (diet 2; n = 9) and a diet with fresh fish (diet 3; n = 12). In all patients raw fish was excluded. Relapse rates and changes in total serum IgE and specific IgE to A. simplex were studied during the follow up. During the 13-month follow-up none of the patients developed anaphylaxis. Urticaria symptoms were present in 5.8 %, 11.1 % (n.s) and 33.3 % (p = 0.016) of patients following diets 1, 2 and 3, respectively. Total IgE decreased by 64 % (p < 0.05), 48 % (p < 0.05) and 39.4 % (p < 0.05), respectively. Specific IgE to A. simplex decreased by 50.7 % (p < 0.05), 54.1 % (p < 0.05) and 23.6 % (p < 0.05) after diets 1, 2 and 3, respectively. No statistically significant differences were found among the groups in variations in total and specific IgE. Patients allergic to A. simplex can eat fish that has been frozen at -20 C for 48 hours without risk of a severe allergic reaction. Long term decreases in specific and total IgE may not be good markers of eventual contact with A. simplex.

List of raw fish dishes

This article is about raw fish or shellfish. It includes marinated raw fish (soaked in a seasoned liquid) and raw fish which is lightly cured such as gravlax, but not fish which is fully cured (fermented, pickled, smoked or otherwise preserved). Raw fish dishes Health concerns Parasites in fish are a natural occurrence and common. Though not a health concern in thoroughly cooked fish, parasites are a concern when consumers eat raw or lightly preserved fish such as sashimi, sushi, ceviche, and gravlax. The popularity of such raw fish dishes makes it important for consumers to be aware of this risk. Raw fish should be frozen to an internal temperature of −20 °C (−4 °F) for at least 7 days to kill parasites. It is important to be aware that home freezers may not be cold enough to kill parasites.

Fish disease and parasites

Eating raw fish Though not a health concern in thoroughly cooked fish, parasites are a concern when human consumers eat raw or lightly preserved fish such as sashimi, sushi, ceviche, and gravlax. The popularity of such raw fish dishes makes it important for consumers to be aware of this risk. Raw fish should be frozen to an internal temperature of −20 °C (−4 °F) for at least 7 days to kill parasites. It is important to be aware that home freezers may not be cold enough to kill parasites.

[New data on anisakiasis].

Acute anisakiasis is generally due to the third-stage larvae of Anisakis simplex, and occasionally to other anisakidae. Human infection occurs through consumption of raw seafish, and especially herring, hake, black plaice and cod. Patients sensitized by prior consumption of parasitized fish develop, within a few hours, violent abdominal pain and an allergic reaction. Anisakis-induced urticaria is seen in about one in five cases. Preventive measures have reduced the number of cases. In France for example, the number of cases fell four-fold between 1977-1991 and 1992-2005. In 1990 Kasuya [1] reported chronic anisakiasis related to consumption of cooked parasitized fish. Seafish-induced urticaria might be an allergic response to Anisakis larval antigens rather than to the fish itself. Indeed, 11 patients with mackerel-related urticaria all had a positive reaction to Anisakis simplex larval antigen, while none reacted to mackerel antigen. A low-molecular-weight thermostable A. simplex allergen causes chronic urticaria, angioedema and even anaphylactoid reactions. Victims have a genetic predisposition (HLA class II alleles) that is uncommon in France and Germany but frequent in Japan. A number of cases have been observed in Spain, where fish is particularly popular. Immunoblotting shows cross-reactions between antigens of A. simplex and Toxocara canis, nematodes belonging to the same superfamily. At present, the only way to avoid contracting anisakiasis is not to eat raw or even cooked parasitized seafish.

Anisakis simplex: current knowledge.

Anisakiasis, firstly described in 1960s in the Netherlands, is a fish-borne parasitic disease caused by the consumption of raw or undercooked fish or cephalopods contaminated by third stage (13) larvae of the Anisakidae family, in particular Anisakis simplex (As), A. pegreffii and Pseudoterranova decipiens. Every year, approximately 20,000 cases of anisakiasis were reported worldwide, over 90% are from Japan and most others in Spain, the Netherlands and Germany, depending on the habits of fish consuming. Live As larvae can elicit i) a parasitic infection of the digestive tract or, occasionally, other organs, causing erosive and/or haemorrhagic lesions, ascites, perforations until granulomas and masses, if larva is not removed, and ii) allergic reactions, as anaphylaxis, acute/chronic urticaria and angioedema. Like other parasite infestations, As larva induces an immune adaptive response characterised by T-lymphocyte proliferation with polyclonal and monoclonal (responsible for As allergic symptoms) IgE production, eosinophilia and mastocytosis. Several As allergens, many of which thermostable, were described In particular the major allergen Ani s 1 and Ani s 7 could characterized a past or a recent infection. There is a general agreement that an active infection is required to initiate allergic sensitivity to Anisakis. Until now, the only effective treatment for anisakiasis is the endoscopic removal of live larvae and the best protection against anisakiasis is to educate consumers about the dangers of eating raw fish and to recommend avoiding the consumption of raw or inadequately thermally treated marine fish or cephalopods.

A Multicenter Study of IgE Sensitization to <i>Anisakis simplex</i> and Diet Recommendations.

Allergy to Anisakis simplex (s.) is spreading due to the increased consumption of raw, smoked or marinated fish. In man, Anisakis s. can directly attack the gastrointestinal mucosa, provoking a parasitosis known as anisakiasis, or giving rise to the formation of IgE and, finally, inducing IgE-mediated reactions like urticaria, angioedema and anaphylactic shock. During recent years, a dietary approach to Anisakis s. infestation has also been addressed. A total of 620 patients with urticaria, angioedema, or both and a history of anaphylaxis following consumption of raw, smoked or marinated fish were recruited, evaluated for specific IgE levels to Anisakis s. and subjected to Skin Prick test. Following 18 month fish-free diet, patients were reevaluated at 6, 12 and 18 months, respectively. Patients undergoing diet were selected among those who had a clinical history with multiple accesses to first aid. After 6-month fish-free diet, we recorded an improvement of symptoms and a remarkable reduction of specific IgE levels. The extension of the diet over 6 months in some cases resulted in a further reduction of specific IgE levels. Data obtained confirm the importance of a fish-free diet in patients with severe symptoms since a new antigenic exposure coincides with a relapse of symptoms and increased IgE levels. This last point should be kept in mind and carefully evaluated in patients at risk for anaphylaxis or angioedema.

Sermon of Saint Anthony to the Fish

The greatest thing Vieira finds reprehensible about fish is that they eat one another ("So foreign a thing it is, not only to reason but to nature itself, that you live by eating one another, all you being created in the same element, all of you citizens of the same homeland, and all of you, finally, brothers"), noting on how big fish eating small fish is particularly perverse because the big ones cannot satisfy their hunger by eating the little ones one by one. He also remarks on how easily fish are tempted by just any old piece of cloth passing for bait dangling on a hook (Vieira here makes reference to the habits of the Portuguese orders of chivalry, overtly attacking the social elites). He then chastises specific fish on their particular vices:

Tolerability to dogfish in children with fish allergy.

Fish is a potent food allergen. The aim of this work is to demonstrate that dogfish, a small shark, has low allergenicity in both its clinical tolerance as well as its molecular structure. We present a study of 34 paediatric patients with IgE-mediated immediate reactions after eating fish. The diagnosis of several fish allergies was demonstrated by skin prick techniques and determination of specific IgE, in all the cases excluding sensitisation to Anisakis simplex. Open oral challenge test was checked with dogfish. Analysis was by SDS-PAGE of dogfish and other fish (megrim, shark, hake, sole, cod, anchovy and tuna) and Western-blot with "pool" of patients polysensitised sera against extracts of dogfish and other fish, and ELISA - inhibition with the "pool" sera. The prick-prick with raw dogfish was slightly positive in six patients, however cooked was negative in 34 cases. The specific IgE showed in the 34 cases class ≥2 for megrim, hake, sole, cod and anchovy, class 0 for tuna in 26 patients, class 0 for emperor in 18 patients and class 0 to Anisakis simplex in all cases. The IgE binding capacity for proteins of allergenic extracts of tested fish revealed, in immunoblotting, the absence of IgE-mediated recognition abstract dogfish by the "pool" of polysensitised patient sera. Testing in vivo and in vitro demonstrated the low allergenicity of dogfish. Dogfish brings an alternative to eating fish in polysensitised patients.

Dietary assessment in five cases of allergic reactions due to gastroallergic anisakiasis.

Anisakis simplex can cause allergic reactions in sensitized patients. Some of these reactions are related to acute parasitism, as is shown in gastroallergic anisakiasis (anisakiasis with digestive and predominantly allergic symptoms). At present, a nonseafood diet is recommended for all patients with any kind of A. simplex allergy. We wished to confirm the clinical suspicion that patients with allergic symptoms after ingestion of raw or undercooked seafood who are sensitized to A. simplex, and diagnosed with gastroallergic anisakiasis, can tolerate the ingestion of seafood when the parasites are dead and noninfective. We included patients diagnosed with gastroallergic anisakiasis (positive skin prick test or/and serum specific IgE to A. simplex, with one or more parasites found by gastroscopy in the stomach). Patients included in the study gave written, informed consent. Specimens of A. simplex about 2 cm long were selected, placed in capsules, and frozen at -20 degrees C for more than 48 h to make them noninfective. We administered 11 specimens to every patient at the hospital. If they tolerated the larvae, they were told to eat well-frozen seafood (-20 degrees C at least 48 h). After 6 months, the patients were re-evaluated. Five patients accepted the challenge with noninfective A. simplex larvae. All tolerated the noninfective larvae. After eating deep-frozen seafood for 6 months, no patient suffered a reaction. In gastroallergic anisakiasis, the antigens of the live parasite probably cause the allergic symptoms. Patients with this disease can tolerate deep-frozen seafood, in which the parasites are dead.

Shellfish allergy

Shellfish parasite The food-borne parasite Anisakis is a genus of nematodes known to be present in squid. Anisakis are directly infective to humans whenever infected squid (or marine fish) are consumed raw or slightly processed, causing a condition called anisakiasis. Symptoms from consuming live nematodes include severe abdominal pain, nausea, and vomiting. In addition, there can be an allergic reaction to Anisakis proteins, even if the food in question was frozen or cooked before being consumed, killing the nematodes, as some of the nematode proteins are resistant to cold and heat. Allergic reactions can include hives, asthma and true anaphylactic reactions.

Allergic reactions to anisakis simplex parasitizing seafood.

The ingestion of Anisakidae ssp larvae parasitized fish can cause anisakiasis. Allergic reactions after ingestion of safely cooked but parasitized fish have been reported. Twenty-three patients who suffered allergic reactions after seafood ingestion, with negative skin tests were studied. Anisakis simplex sensitization was assessed by skin prick test and/or specific serum Immunoglobulin E (IgE). Total serum IgE and specific IgE against the implicated seafood and Ascaris lumbricoides were also determined. Manifestations of Anisakis simplex allergy were urticaria/angioedema (18/23) patients and anaphylaxis (5/23). Gastric symptoms were also observed (3/23). Sea fish and shellfish were implicated. Raw and cooked seafood ingestion caused reactions. Total serum IgE ranged from 13 to 7200 KU/L. Specific IgE to Anisakis simplex was positive (> 0.35 KU/L) in all patients, and skin tests were positive in 20. Serum-specific IgE and skin tests to the involved seafoods were negative in every patient. Serum-specific IgE to Ascaris lumbricoides was negative in 13 patients. No association between total IgE and the eosinophil count (r < 0.1) was observed, but there was some association between total IgE and specific IgE to Anisakis simplex (r = 0.58). Anisakis simplex sensitization is the cause of allergic reactions after seafood ingestion. It is important to pay attention to this new "food allergy" to diagnose correctly the etiology of adverse food reactions.

Anisakis simplex, a relevant etiologic factor in acute urticaria.

Anisakis simplex, a parasite of fish and cephalopods, can induce IgE-mediated reactions. This study aimed to determine the etiologic role of A. simplex in patients affected by urticaria/angioedema (AE) or anaphylaxis. We studied 100 adult subjects suffering acute episodes of urticaria/AE, by anamnesis, prick tests with A. simplex and fish-mix extracts, and total and specific IgE to both A. simplex and cod. The following criteria of A. simplex allergy were considered: 1) urticaria/AE within 6 h after fish ingestion; 2) specific IgE to A. simplex; 3) positive prick test to A. simplex extract; 4) exclusion of other suspected causes. Double-blind, placebo-controlled food challenge was not carried out because ethical considerations forbid challenge with a parasite. Specific IgE to A. simplex (> 0.7 kU/l) was found in 22 subjects, but only eight were diagnosed as having A. simplex allergy. Other allergens were involved in 37 patients, and 55 cases were considered idiopathic. Specific IgE to fish (> 0.7 kU/l) was found in two patients, but only one was diagnosed as having fish allergy. We concluded that A. simplex is an important etiologic factor in acute urticaria. We suggest that it should be considered in cases of urticaria/AE or anaphylaxis, especially after fish ingestion.

Anisakis simplex

The allergic symptoms caused by A. simplex can be alleviated by anti-histamines, or other treatments that are commonly used for allergies. Prevention The elimination of raw or semi-cooked seafood is the most effective prevention method. According to FDA guidelines, seafood should be cooked at a temperature of at least 63° C, and fish should be stored at a maximum temperature of -20°C for 7 days or -35°C for 15 hours for safe consumption. However, the allergens in A. simplex cannot be removed by heating or freezing processes. See also List of parasites of humans References Further reading Parasitic nematodes of humans Parasitic nematodes of fish Parasitic nematodes of mammals Marine mammals Zoonoses Ascaridida Nematodes described in 1809 Taxa named by Karl Rudolphi

[Anisakiasis: a borderline disorder].

Anisakis simplex is a nematode which can parasitize many different kinds of fish or cephalopods (codfish, salmon, tuna, mackerel, hake, etc). Anisakis simplex can cause different diseases in humans. The human being acquires the larvae by eating raw or undercooked seafood. Acute anisakiasis is probably caused by an inflammatory and/or allergic response in the digestive tract mucosa with abdominal pain. It can also induce IgE-mediated reactions with several clinical manifestations ranging from urticaria/angioedema to anaphylaxis. Chronic anisakiasis results from abscesses or eosinophilic granulomas caused by parasite invasion. This later form can mimic appendicitis, duodenal ulcer, inflammatory bowel diseases and intestinal obstruction. An early gastroduodenoscopy can confirm the diagnosis and prevent the complications. Serodiagnosis of anisakiasis is difficult since many Anisakis antigens show cross-reativity complications. In fact many people have high IgE titles in the absence of obvious allergic reactions to seafoods. As preventive measures heating for 10 min over 65 degrees C or freezing (minus 20 degrees for 24 h) destroys the infectivity of the larval stage but not always prevent allergic reactions.

Anisakis spp. as etiological agent of zoonotic disease and allergy in European region – an overview

Nematodes of the genus Anisakis are worldwide distributed marine species parasitized many fish and cephalopod species as larvae and sea mammals as adult form. Anisakiosis as food-borne disease is an important public health problem worldwide. Human become infected by eating raw or undercooked fish or squids. Well documented are gastrointestinal response to infection but increasingly allergic symptoms were observed also after eating well cooked fish. This is because some of allergens of Anisakis are thermostable and resistant to pepsin treatment. Due to a significant increase in human mobility and global transport of fresh products like fish on ice, food-borne diseases require educational campaigns that pay attention to threats in various parts of the world.

Changes over Time in IgE Sensitization to Allergens of the Fish Parasite Anisakis spp.

Sensitization to Anisakis spp. can produce allergic reactions after eating raw or undercooked parasitized fish. Specific IgE is detected long after the onset of symptoms, but the changes in specific IgE levels over a long follow-up period are unknown; furthermore, the influence of Anisakis spp. allergen exposure through consumption of fishery products is also unknown. To analyse the changes in IgE sensitization to Anisakis spp. allergens over several years of follow-up and the influence of the consumption of fishery products in IgE sensitization. Total IgE, Anisakis spp.-specific IgE, anti-Ani s 1 and anti-Ani s 4 IgE were repeatedly measured over a median follow-up duration of 49 months in 17 sensitized patients. Anisakis spp.-specific IgE was detected in 16/17 patients throughout the follow-up period. The comparison between baseline and last visit measurements showed significant decreases in both total IgE and specific IgE. The specific IgE values had an exponential or polynomial decay trend in 13/17 patients. In 4/17 patients, an increase in specific IgE level with the introduction of fish to the diet was observed. Three patients reported symptoms after eating aquaculture or previously frozen fish, and in two of those patients, symptom presentation was coincident with an increase in specific IgE level. IgE sensitization to Anisakis spp. allergens lasts for many years since specific IgE was detectable in some patients after more than 8 years from the allergic episode. Specific IgE monitoring showed that specific IgE titres increase in some allergic patients and that allergen contamination of fishery products can account for the observed increase in Anisakis spp.-specific IgE level. Following sensitization to Anisakis spp. allergens, the absence of additional exposure to those allergens does not result in the loss of IgE sensitization. Exposure to Anisakis spp. allergens in fishery products can increase the specific IgE level in some sensitized patients.

Sensitization to the fish parasite Anisakis simplex: clinical and laboratory aspects.

Hypersensitivity to Anisakis simplex is a worldwide medical problem. The parasite larvae die after freezing or cooking, but the tolerance of sensitized subjects to eating frozen fish remains a matter of controversy with contradictory findings. The aim of this study was to test if intolerance to properly cooked/frozen fish was due to the recognition of a particular allergen. Sixty-four patients with Anisakis simplex sensitization were studied by an IgE multiblot using simultaneously five different antigenic extracts. The antigens tested were a crude extract, excretory/secretory allergens, a heated extract, and two gradient ethanol precipitates of the crude extract. Intolerance was reported by 20% of the patients and was not related to the detection of any special allergen, nor to total or specific IgE levels. Intolerant patients only reported a higher frequency of digestive symptoms than the patients who tolerated fish ingestion. The most sensitive immunoblot antigen source was the 50-66% ethanol fraction of a crude extract (10x concentrated) that was found to be positive in 100% of the samples. Interestingly, 95% sensitivity in the IgE-immunoblot assay could be achieved using only two allergens, Ani s 1 and Ani s 4. Allergens from the dead larvae remain a problem for 20% of the sensitized subjects. The use of a fractionated and concentrated crude extract improved the sensitivity of the immunoblot assay.

Anisakiasis of the colon presenting as bowel obstruction.

Anisakiasis is a disease caused by human infection by the Anisakis larvae, a marine nematode found in raw or undercooked fish. With the increased popularity of eating sushi and raw fish (sashimi) in the United States infection with anisakis is expected to rise. We present the first reported case in the United States of intestinal anisakiasis presenting as a bowel obstruction. A 25-year-old healthy woman with no prior history of surgery presented to the emergency room with bowel obstruction by history and CT. CT also showed a mass in the right lower quadrant. She had eaten seviche, a raw fish appetizer, 2 days earlier and sashimi 3 weeks before admission. She was taken to the operating room for an exploratory laparotomy and was found to have an obstruction, the 2-cm mass in the mesentery, and diffuse mesenteric adenopathy. She had an ileocolectomy. Pathology showed a degenerating fish worm, anisakiasis. She also had a serologic test for immunoglobulin E specific to anisakiasis and it was highly positive. Human infections, as mentioned before, are principally the result of ingestion of the Anisakis larvae. These larvae are usually found in herring, mackerel, salmon, cod, halibut, rockfish, sardine, and squid. Most human infections have been reported from Japan and The Netherlands and involve the stomach. Invasion of the gastric or intestinal wall one to 5 days after eating raw fish may be characterized by the abrupt onset of abdominal pain, nausea and/or vomiting, diarrhea, or an ileus. For transient anisakiasis, supportive measures and reassurance are all that is needed. If the larvae have invaded the intestine or the stomach wall diagnosis and cure occur with endoscopic or surgical removal if evidence of obstruction or perforation is found. The incidence of anisakiasis in the United States is unknown but will likely continue to increase with the popularity of eating sashimi. This case is meant to demonstrate another possible cause for bowel obstruction in the patient who has just eaten raw or undercooked fish.

[A case of an allergic reaction due to Anisakis simplex after the ingestion of salted fish guts made of Sagittated calamari: allergen analysis with recombinant and purified Anisakis simplex allergens].

A 75-year-old man ingested salted fish guts made of Sagittated calamari which he caught in the daytime, with alcohol and then dozed. Five hours later, he woke up due to itching over his entire body and noticed generalized urticaria and a swollen tongue, which was too large for him to close his mouth. Serum total IgE was 456 IU/ml and ImmunoCAP was positive for anisakis, but negative for squid, shrimp, and ascaris. A skin prick test (SPT) was positive for anisakis extract (10 mg/ml) and house dust mites, but negative for squid and shrimp. He was diagnosed with IgE-mediated allergy due to Anisakis simplex after the ingestion of salted fish guts made of Sagittated calamari, which had been parasitized by Anisakis simplex. Furthermore, we performed SPT with six extracts of purified or recombinant allergens (Ani s 1, 3, 4, 5, 6, and 8) to identify the causative allergens in this case. Only Ani s 3 (tropomyosin) was positive, indicating that Ani s 3 was the causative allergen in this case. Third stage larvae of the nematode Anisakis simplex often parasitize not only marine fish but also invertebrates, including squid. It is necessary to consider Anisakis simplex allergy for urticarial reactions that develop after the ingestion of squid.

Gingivostomatitis after eating fish parasitized by Anisakis simplex: a case report.

Anisakis simplex (AS) is a nematode that may be encountered as a parasite in various kinds of seafood. Human beings may accidentally acquire AS larvae by eating raw or undercooked seafood. In addition to human parasitization (anisakiasis), this nematode can induce allergic reactions. AS-related diseases are frequent, especially in those countries with a high level of fish consumption and with traditions of eating raw or undercooked seafood. To our knowledge, this is the first report of gingivostomatitis secondary to the ingestion of fish with AS parasites.

[Anisakis and anisakiosis].

The nematode Anisakis simplex (AS) is a world wide distributed parasite that infects consumers of raw or undercoocked parasitized fish. The clinical manifestation of Anisakiosis depend on the site in the digestive tract in which larva lodges. The symptoms develops as a result of the inflammation when the larvae penetrates the gastric mucous. Most of asymptomatic subjects show high levels of specific IgE to AS. Diagnosis of AS allergy is not simple, due to cross-reactivity with other allergens. In childhood is more difficult to make a right diagnosis than in adult population. Most of positive prick test to AS correspond to children with positive prick tests to other allergens. Cross-reactivity between this parasite and other parasites with a higher prevalence in childhood, is the cause of a false diagnosis. The secretor-excretory antigen shows a better specificity, recognizing the true parasitized patients. This antigen could be used as indicator of parasitization. To follow prevention rules AS, avoid consumption of raw fish unless frozen for 48 hours or ingestion of fresh fish always cooked for more than 20 minutes at least at 60 C.

First case of human anisakiasis in Poland.

Consumption of raw or inadequately processed marine fish may result in anisakidosis - a zoonotic disease caused by larvae of the parasitic nematodes of the family Anisakidae (anisakiasis when caused by members of the genus Anisakis (Nematoda: Anisakidae)), commonly found in a variety of marine fish species all over the world. Most cases of anisakidosis have been detected in the residents of Japan and South Korea, which results from the tradition of eating raw and semi-raw fish dishes. However, the disease is now increasingly often diagnosed in other parts of the world, including Europe (mainly in Spain and Italy). In Poland, no cases of human infection with anisakid nematodes have been detected so far. In this study, we report the first case of gastric anisakiasis in Poland, in a 59-year-old female patient, after eating raw Atlantic salmon (Salmo salar). The parasite was identified as the third-stage larva of Anisakis simplex sensu stricto on the basis of morphology and molecular analysis. The larva was still alive and causing pain until it was removed, which occurred more than 5 weeks after infection. The described case prove that anisakiasis should be considered as a potential cause of gastrointestinal tract ailments following the consumption of seafood in countries where no cases of this zoonosis have been reported to date.