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Illnesses Associated with Freshwater Recreation During International Travel

  • Tropical, Travel and Emerging Infections (L Chen and A Boggild, Section Editors)
  • Published:
Current Infectious Disease Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

International travel, adventure travel, and eco-tourism are increasing over the past few decades. This review aims to summarize the spectrum of infections associated with recreational freshwater activities and international travel.

Recent Findings

Recreational water activities can be associated with a wide range of infections. Acute febrile illnesses due to leptospirosis and schistosomiasis are not uncommon in travelers following extensive freshwater exposure. Aeromonas and other water-associated pathogens are important to consider in a traveler presenting with a skin and soft tissue infection. Recreational water activities are often associated with diarrheal illnesses, especially in children, and the range of enteric pathogens includes bacterial pathogens such as Escherichia coli O157:H7 and Shigella species and the protozoan parasites Cryptosporidium and Giardia duodenalis. Infections due to free-living amebas though rare can lead to fulminant central nervous system infections.

Summary

A diverse range of infections may be associated with freshwater exposure, and it is important that these entities are considered in a returning traveler presenting with an acute illness.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Haake DA, Dundoo M, Cader R, Kubak BM, Hartskeerl RA, Sejvar JJ, et al. Leptospirosis, water sports, and chemoprophylaxis. Clin Infect Dis. 2002;34:e40–3.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Bharti AR, Nally JE, Ricaldi JN, Matthias MA, Diaz MM, Lovett MA, et al. Leptospirosis: a zoonotic disease of global importance. Lancet Infect Dis. 2003;3:757–71.

    Article  PubMed  Google Scholar 

  3. Corwin A, Ryan A, Bloys W, Thomas R, Deniega B, Watts D. A waterborne outbreak of leptospirosis among United States military personnel in Okinawa, Japan. Int J Epidemiol. 1990;19:743–8.

    Article  PubMed  CAS  Google Scholar 

  4. Cacciapuoti B, Ciceroni L, Maffei C, Di Stanislao F, Strusi P, Calegari L, et al. A waterborne outbreak of leptospirosis. Am J Epidemiol. 1987;126:535–45.

    Article  PubMed  CAS  Google Scholar 

  5. Centers for Disease C, Prevention. Outbreak of leptospirosis among white-water rafters—Costa Rica, 1996. MMWR Morb Mortal Wkly Rep. 1997;46:577–9.

    Google Scholar 

  6. Sejvar J, Bancroft E, Winthrop K, Bettinger J, Bajani M, Bragg S, et al. Leptospirosis in “Eco-Challenge” athletes, Malaysian Borneo, 2000. Emerg Infect Dis. 2003;9:702–7.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Hochedez P, Escher M, Decoussy H, Pasgrimaud L, Martinez R, Rosine J, et al. Outbreak of leptospirosis among canyoning participants, Martinique, 2011. Euro Surveill. 2013;18:20472.

    PubMed  CAS  Google Scholar 

  8. Clerinx J, Van Gompel A. Schistosomiasis in travellers and migrants. Travel Med Infect Dis. 2011;9:6–24.

    Article  PubMed  Google Scholar 

  9. Chitsulo L, Engels D, Montresor A, Savioli L. The global status of schistosomiasis and its control. Acta Trop. 2000;77:41–51.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  10. Gryseels B, Polman K, Clerinx J, Kestens L. Human schistosomiasis. Lancet. 2006;368:1106–18.

    Article  PubMed  Google Scholar 

  11. •• Lingscheid T, Kurth F, Clerinx J, Marocco S, Trevino B, Schunk M, et al. Schistosomiasis in European travelers and migrants: analysis of 14 years TropNet surveillance data. Am J Trop Med Hyg. 2017;97:567–74. An important study describing the characteristics of 1465 cases of imported schistosomiasis in European travelers.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Cetron MS, Chitsulo L, Sullivan JJ, Pilcher J, Wilson M, Noh J, et al. Schistosomiasis in Lake Malawi. Lancet. 1996;348:1274–8.

    Article  PubMed  CAS  Google Scholar 

  13. Lachish T, Tandlich M, Grossman T, Schwartz E. High rate of schistosomiasis in travelers after a brief exposure to the high-altitude Nyinambuga crater lake, Uganda. Clin Infect Dis. 2013;57:1461–4.

    Article  PubMed  Google Scholar 

  14. Ross AG, Vickers D, Olds GR, Shah SM, McManus DP. Katayama syndrome. Lancet Infect Dis. 2007;7:218–24.

    Article  PubMed  Google Scholar 

  15. Doherty JF, Moody AH, Wright SG. Katayama fever: an acute manifestation of schistosomiasis. BMJ. 1996;313:1071–2.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  16. Visser LG, Polderman AM, Stuiver PC. Outbreak of schistosomiasis among travelers returning from Mali, West Africa. Clin Infect Dis. 1995;20:280–5.

    Article  PubMed  CAS  Google Scholar 

  17. Gray DM 2nd, Nakashima M, Davidson NO. Education and imaging. Gastrointestinal: schistosomiasis-diagnosis by colonoscopy. J Gastroenterol Hepatol. 2013;28:763.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Lang R, Minion J, Wong A. Hematospermia in a returned traveler. Can Urol Assoc J. 2017;11:E41–3.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Szekeres C, Galletout P, Jaureguiberry S, Crickx E, Monsel G, Chabriat H, et al. Neurological presentation of schistosomiasis. Lancet. 2013;381:1788.

    Article  PubMed  Google Scholar 

  20. Houdon L, Flodrops H, Rocaboy M, Bintner M, Feriot JP, Tournebize P, et al. Two patients with imported acute neuroschistosomiasis due to Schistosoma mansoni. J Travel Med. 2010;17:274–7.

    Article  PubMed  Google Scholar 

  21. Anita S, Amir KM, Fadzilah K, Ahamad J, Noorhaida U, Marina K, et al. Risk factors for typhoid outbreak in Sungai Congkak Recreational Park, Selangor 2009. Med J Malaysia. 2012;67:12–6.

    PubMed  CAS  Google Scholar 

  22. Pham Thanh D, Thompson CN, Rabaa MA, Sona S, Sopheary S, Kumar V, et al. The molecular and spatial epidemiology of typhoid fever in rural Cambodia. PLoS Negl Trop Dis. 2016;10:e0004785.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Mahoney FJ, Farley TA, Kelso KY, Wilson SA, Horan JM, McFarland LM. An outbreak of hepatitis A associated with swimming in a public pool. J Infect Dis. 1992;165:613–8.

    Article  PubMed  CAS  Google Scholar 

  24. Garin D, Fuchs F, Crance JM, Rouby Y, Chapalain JC, Lamarque D, et al. Exposure to enteroviruses and hepatitis A virus among divers in environmental waters in France, first biological and serological survey of a controlled cohort. Epidemiol Infect. 1994;113:541–9.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  25. Bryan JA, Lehmann JD, Setiady IF, Hatch MH. An outbreak of hepatitis-A associated with recreational lake water. Am J Epidemiol. 1974;99:145–54.

    Article  PubMed  CAS  Google Scholar 

  26. Currie BJ, Dance DA, Cheng AC. The global distribution of Burkholderia pseudomallei and melioidosis: an update. Trans R Soc Trop Med Hyg. 2008;102(Suppl 1):S1–4.

    Article  PubMed  Google Scholar 

  27. Dan M. Melioidosis in travelers: review of the literature. J Travel Med. 2015;22:410–4.

    Article  PubMed  Google Scholar 

  28. Saidani N, Griffiths K, Million M, Gautret P, Dubourg G, Parola P, et al. Melioidosis as a travel-associated infection: case report and review of the literature. Travel Med Infect Dis. 2015;13:367–81.

    Article  PubMed  Google Scholar 

  29. • Hagmann SH, Han PV, Stauffer WM, Miller AO, Connor BA, Hale DC, et al. Travel-associated disease among US residents visiting US GeoSentinel clinics after return from international travel. Fam Pract. 2014;31:678–87. An important study describing the range of illness in returning US international travelers over a 13-year period.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Vally H, Whittle A, Cameron S, Dowse GK, Watson T. Outbreak of Aeromonas hydrophila wound infections associated with mud football. Clin Infect Dis. 2004;38:1084–9.

    Article  PubMed  Google Scholar 

  31. Kimbrough RC, Winn RE, Jeter RM, Warren WJ, Huddleston JR, Zak JC. Aeromonas infection from river and playa lake waters in West Texas and southeastern New Mexico. Southwest Respir Crit Care Chron. 2016;4:19–25.

    Article  Google Scholar 

  32. Hanson PG, Standridge J, Jarrett F, Maki DG. Freshwater wound infection due to Aeromonas hydrophila. JAMA. 1977;238:1053–4.

    Article  PubMed  CAS  Google Scholar 

  33. Gold WL, Salit IE. Aeromonas hydrophila infections of skin and soft tissue: report of 11 cases and review. Clin Infect Dis. 1993;16:69–74.

    Article  PubMed  CAS  Google Scholar 

  34. Janda JM, Abbott SL. The genus Aeromonas: taxonomy, pathogenicity, and infection. Clin Microbiol Rev. 2010;23:35–73.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  35. Hiransuthikul N, Tantisiriwat W, Lertutsahakul K, Vibhagool A, Boonma P. Skin and soft-tissue infections among tsunami survivors in southern Thailand. Clin Infect Dis. 2005;41:e93–6.

    Article  PubMed  Google Scholar 

  36. Tsai YH, Hsu RW, Huang TJ, Hsu WH, Huang KC, Li YY, et al. Necrotizing soft-tissue infections and sepsis caused by Vibrio vulnificus compared with those caused by Aeromonas species. J Bone Joint Surg Am. 2007;89:631–6.

    Article  PubMed  Google Scholar 

  37. Slaven EM, Lopez FA, Hart SM, Sanders CV. Myonecrosis caused by Edwardsiella tarda: a case report and case series of extraintestinal E. tarda infections. Clin Infect Dis. 2001;32:1430–3.

    Article  PubMed  CAS  Google Scholar 

  38. Pence MA. The brief case: wound infection with Plesiomonas shigelloides following a freshwater injury. J Clin Microbiol. 2016;54:1180–2.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  39. Herve V, Bigaillon C, Duhamel P, Petit MP, Soler C. Cutaneous abscess due to Plesiomonas shigelloides consecutive to a trauma in fresh water. Med Mal Infect. 2007;37:840.

    Article  PubMed  CAS  Google Scholar 

  40. Harth M, Ralph ED, Faraawi R. Septic arthritis due to Mycobacterium marinum. J Rheumatol. 1994;21:957–60.

    PubMed  CAS  Google Scholar 

  41. Iredell J, Whitby M, Blacklock Z. Mycobacterium marinum infection: epidemiology and presentation in Queensland 1971–1990. Med J Aust. 1992;157:596–8.

    PubMed  CAS  Google Scholar 

  42. Tsai HC, Kunin CM, Lee SS, Chen YS, Wann SR, Liu YW, et al. Fish gambler’s tenosynovitis caused by Mycobacterium marinum: environmental investigation of a fishing pond in Southern Taiwan. Diagn Microbiol Infect Dis. 2007;59:227–30.

    Article  PubMed  Google Scholar 

  43. Tebruegge M, Connell T, Ritz N, Orchard D, Curtis N. Mycobacterium marinum infection following kayaking injury. Int J Infect Dis. 2010;14(Suppl 3):e305–6.

    Article  PubMed  Google Scholar 

  44. WHO UNICEF. Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF and WHO, UNICEF; 2015.

    Google Scholar 

  45. Soller JA, Bartrand T, Ashbolt NJ, Ravenscroft J, Wade TJ. Estimating the primary etiologic agents in recreational freshwaters impacted by human sources of faecal contamination. Water Res. 2010;44:4736–47.

    Article  PubMed  CAS  Google Scholar 

  46. Fayer R, Morgan U, Upton SJ. Epidemiology of Cryptosporidium: transmission, detection and identification. Int J Parasitol. 2000;30:1305–22.

    Article  PubMed  CAS  Google Scholar 

  47. Kramer MH, Sorhage FE, Goldstein ST, Dalley E, Wahlquist SP, Herwaldt BL. First reported outbreak in the United States of cryptosporidiosis associated with a recreational lake. Clin Infect Dis. 1998;26:27–33.

    Article  PubMed  CAS  Google Scholar 

  48. Huang DB, White AC. An updated review on Cryptosporidium and Giardia. Gastroenterol Clin N Am. 2006;35:291–314. viii

    Article  Google Scholar 

  49. Nash TE, Herrington DA, Losonsky GA, Levine MM. Experimental human infections with Giardia lamblia. J Infect Dis. 1987;156:974–84.

    Article  PubMed  CAS  Google Scholar 

  50. Stuart JM, Orr HJ, Warburton FG, Jeyakanth S, Pugh C, Morris I, et al. Risk factors for sporadic giardiasis: a case-control study in southwestern England. Emerg Infect Dis. 2003;9:229–33.

    Article  PubMed  Google Scholar 

  51. Gray SF, Gunnell DJ, Peters TJ. Risk factors for giardiasis: a case-control study in Avon and Somerset. Epidemiol Infect. 1994;113:95–102.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  52. Wang G, Doyle MP. Survival of enterohemorrhagic Escherichia coli O157:H7 in water. J Food Prot. 1998;61:662–7.

    Article  PubMed  CAS  Google Scholar 

  53. Keene WE, McAnulty JM, Hoesly FC, Williams LP Jr, Hedberg K, Oxman GL, et al. A swimming-associated outbreak of hemorrhagic colitis caused by Escherichia coli O157:H7 and Shigella sonnei. N Engl J Med. 1994;331:579–84.

    Article  PubMed  CAS  Google Scholar 

  54. Probert WS, Miller GM, Ledin KE. Contaminated stream water as source for Escherichia coli O157 illness in children. Emerg Infect Dis. 2017;23:1216–8.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Blostein J. Shigellosis from swimming in a park pond in Michigan. Public Health Rep. 1991;106:317–22.

    PubMed  PubMed Central  CAS  Google Scholar 

  56. Kramer MH, Herwaldt BL, Craun GF, Calderon RL, Juranek DD. Surveillance for waterborne-disease outbreaks—United States, 1993–1994. MMWR CDC Surveill Summ. 1996;45:1–33.

    PubMed  CAS  Google Scholar 

  57. Carter AM, Pacha RE, Clark GW, Williams EA. Seasonal occurrence of Campylobacter spp. in surface waters and their correlation with standard indicator bacteria. Appl Environ Microbiol. 1987;53:523–6.

    PubMed  PubMed Central  CAS  Google Scholar 

  58. Arvanitidou M, Stathopoulos GA, Constantinidis TC, Katsouyannopoulos V. The occurrence of Salmonella, Campylobacter and Yersinia spp. in river and lake waters. Microbiol Res. 1995;150:153–8.

    Article  PubMed  CAS  Google Scholar 

  59. Polo F, Figueras MJ, Inza I, Sala J, Fleisher JM, Guarro J. Prevalence of Salmonella serotypes in environmental waters and their relationships with indicator organisms. Antonie Van Leeuwenhoek. 1999;75:285–92.

    Article  PubMed  CAS  Google Scholar 

  60. • Martinez-Castillo M, Cardenas-Zuniga R, Coronado-Velazquez D, Debnath A, Serrano-Luna J, Shibayama M. Naegleria fowleri after 50 years: is it a neglected pathogen? J Med Microbiol. 2016;65:885–96. https://doi.org/10.1099/jmm.0.000303. A comprehensive review of the epidemiology, microbiology, pathogenesis, and clinical manifestions of Naegleria fowleri infection in humans.

    Article  PubMed  Google Scholar 

  61. Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epidemiology of primary amoebic meningoencephalitis in the USA, 1962–2008. Epidemiol Infect. 2010;138:968–75.

    Article  PubMed  CAS  Google Scholar 

  62. Schuster FL, Visvesvara GS. Free-living amoebae as opportunistic and non-opportunistic pathogens of humans and animals. Int J Parasitol. 2004;34:1001–27.

    Article  PubMed  Google Scholar 

  63. Siddiqui R, Khan NA. Primary amoebic meningoencephalitis caused by Naegleria fowleri: an old enemy presenting new challenges. PLoS Negl Trop Dis. 2014;8:e3017.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Cope JR, Ratard RC, Hill VR, Sokol T, Causey JJ, Yoder JS, et al. The first association of a primary amebic meningoencephalitis death with culturable Naegleria fowleri in tap water from a US treated public drinking water system. Clin Infect Dis. 2015;60:e36–42.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Yoder JS, Straif-Bourgeois S, Roy SL, Moore TA, Visvesvara GS, Ratard RC, et al. Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clin Infect Dis. 2012;55:e79–85.

    Article  PubMed  Google Scholar 

  66. Centers for Disease C, Prevention. Notes from the field: primary amebic meningoencephalitis associated with ritual nasal rinsing—St. Thomas, U.S. Virgin Islands, 2012. MMWR Morb Mortal Wkly Rep. 2013;62:903.

    Google Scholar 

  67. Stubhaug TT, Reiakvam OM, Stensvold CR, Hermansen NO, Holberg-Petersen M, Antal EA, et al. Fatal primary amoebic meningoencephalitis in a Norwegian tourist returning from Thailand. JMM Case Rep. 2016;3:e005042.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Marciano-Cabral F, MacLean R, Mensah A, LaPat-Polasko L. Identification of Naegleria fowleri in domestic water sources by nested PCR. Appl Environ Microbiol. 2003;69:5864–9.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  69. Marciano-Cabral F, Cabral G. Acanthamoeba spp. as agents of disease in humans. Clin Microbiol Rev. 2003;16:273–307.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Diaz JH. The public health threat from Balamuthia mandrillaris in the southern United States. J La State Med Soc. 2011;163:197–204.

    PubMed  Google Scholar 

  71. Diaz JH. Behavioral and recreational risk factors for free-living amebic infections. J Travel Med. 2011;18:130–7.

    Article  PubMed  Google Scholar 

  72. Kaji Y, Hu B, Kawana K, Oshika T. Swimming with soft contact lenses: danger of Acanthamoeba keratitis. Lancet Infect Dis. 2005;5:392.

    Article  PubMed  Google Scholar 

  73. Mannocci A, La Torre G, Spagnoli A, Solimini AG, Palazzo C, De Giusti M. Is swimming in recreational water associated with the occurrence of respiratory illness? A systematic review and meta-analysis. J Water Health. 2016;14:590–9.

    Article  PubMed  Google Scholar 

  74. Den Boer JW, Yzerman EP, Schellekens J, Lettinga KD, Boshuizen HC, Van Steenbergen JE, et al. A large outbreak of Legionnaires’ disease at a flower show, the Netherlands, 1999. Emerg Infect Dis. 2002;8:37–43.

    Article  Google Scholar 

  75. Fields BS, Benson RF, Besser RE. Legionella and Legionnaires’ disease: 25 years of investigation. Clin Microbiol Rev. 2002;15:506–26.

    Article  PubMed  PubMed Central  Google Scholar 

  76. Ortiz-Roque CM, Hazen TC. Abundance and distribution of Legionellaceae in Puerto Rican waters. Appl Environ Microbiol. 1987;53:2231–6.

    PubMed  PubMed Central  CAS  Google Scholar 

  77. Everett ED, Nelson RA. Pulmonary melioidosis. Observations in thirty-nine cases. Am Rev Respir Dis. 1975;112:331–40.

    PubMed  CAS  Google Scholar 

  78. Covert TC, Rodgers MR, Reyes AL, Stelma GN Jr. Occurrence of nontuberculous mycobacteria in environmental samples. Appl Environ Microbiol. 1999;65:2492–6.

    PubMed  PubMed Central  CAS  Google Scholar 

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Authors and Affiliations

  1. Division of Infectious Diseases and Travel Medicine, Department of Medicine, Mount Auburn Hospital, Cambridge, MA, USA

    Daniel L. Bourque

  2. Harvard Medical School, Boston, MA, USA

    Daniel L. Bourque

  3. Division of Infectious Diseases, Department of Medicine, University of California, San Diego, La Jolla, CA, USA

    Joseph M. Vinetz

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Bourque, D.L., Vinetz, J.M. Illnesses Associated with Freshwater Recreation During International Travel. Curr Infect Dis Rep 20, 19 (2018). https://doi.org/10.1007/s11908-018-0623-z

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