Taenia/Taeniasis

Taenia belong to the Cestoda class of helminths. Humans are infected with these tapeworms by eating undercooked beef (T. saginata) or pork (T. solium and T. asiatica). Taeniasis is often asymptomatic, but the ingestion of larvae can cause abdominal discomfort, nausea, and constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation or diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea. Passing proglottids in the stool is the most common sign of taeniasis. A patient who ingests T. solium eggs can develop cysticercosis, which may present with muscular and dermatologic cysts, ocular involvement, or neurologic manifestations (neurocysticercosis). The diagnosis is made by identifying proglottids or eggs in the stool. Characteristic findings on CT or MRI will help diagnose neurocysticercosis. Management generally includes anthelmintic therapy.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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General Characteristics and Epidemiology

General features of Taenia

Taenia is a genus of parasitic cestodes (tapeworms). 

Eggs: 

  • Spherical
  • Thick, striated wall
  • Contains a 6-hooked (hexacanth) embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week

Adults:

  • Size:
    • T. saginata: < 5 m in length
    • T. solium: approximately  2–7 m in length
  • Ribbon-like, segmented body:
    • Scolex: 
      • Rostellum with 2 rings of hooks in T. solium
      • 4 muscular suckers
    • Strobila with approximately 1000 proglottids:
      • Segmented
      • Contains sets of reproductive organs

Clinically relevant species

Taenia tapeworms cause the following diseases:

  • Taeniasis:
    • T. saginata (beef tapeworm)
    • T. solium (pork tapeworm)
    • T. asiatica (Asian tapeworm)
  • Cysticercosis: T. solium

Epidemiology

Geographic distribution of species:

  • T. solium and T. saginata: worldwide
  • T. asiatica: Asia

Taeniasis:

  • Affects approximately 50 million people worldwide
  • Rare in the United States
  • Highest incidence occurs in areas where:
    • There is poor access to clean water
    • Ingestion of raw or undercooked meat is common 

Cysticercosis:

  • Approximately 1000 cases diagnosed each year in the United States
  • More common in immigrants

Pathogenesis

Hosts

  • Definitive host: humans
  • Intermediate hosts:
    • T. saginata: cattle
    • T. solium and T. asiatica: pigs

Risk factors for hosts

  • Eating raw or undercooked beef or pork
  • Those living in:
    • Rural areas
    • Developing countries 
  • Poor sanitation
  • Close contact with infected animals

Transmission

  • Taeniasis: ingestion of larval stages in meat
  • Cysticercosis: ingestion of T. solium eggs through:
    • Contaminated food or water
    • Fecal–oral transmission

Life cycle and pathophysiology

Taeniasis:

  1. Pigs or cattle ingest vegetation that is contaminated with eggs or gravid proglottids.
  2. Eggs hatch in the intestine → oncospheres
  3. Invasion into the intestinal wall → bloodstream → migration to striated muscle → develop into cysticerci (larvae within a fluid-filled sac)
  4. Humans ingest raw or undercooked beef or pork → develop into an adult tapeworm in the intestine and attach to the intestinal wall with the scolex
  5. Adults produce proglottids → mature and become gravid → detach from the tapeworm
  6. Gravid proglottids and eggs are excreted in the feces → cycle continues

Cysticercosis:

  1. Humans consume food or water contaminated with T. solium eggs or gravid proglottids.
  2. Eggs hatch in the intestine → oncospheres
  3. Invasion into the intestinal wall → bloodstream → migration to tissues and organs → develop into cysticerci → cysticercosis
  4. Cysticerci can migrate to the CNS → neurocysticercosis
Life cycle t. Solium and the development of cysticercosis versus taeniasis

Life cycle of Taenia solium and the development of cysticercosis versus taeniasis.

Image: “Cysticercosis” by CDC. License: Public Domain

Clinical Presentation

Taeniasis

Most patients (particularly adults) are asymptomatic. 

  • Common symptoms include:
    • Passing proglottids in the stool (most common)
    • Nausea
    • Anorexia 
    • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Pruritus ani
  • Less common:
    • Constipation or diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
    • Headache
    • Dizziness
    • Anxiety
  • Complications due to obstruction from tapeworm segments:
    • Biliary obstruction: 
      • Cholecystitis Cholecystitis Cholecystitis is the inflammation of the gallbladder (GB) usually caused by the obstruction of the cystic duct (acute cholecystitis). Mechanical irritation by gallstones can also produce chronic GB inflammation. Cholecystitis is one of the most common complications of cholelithiasis but inflammation without gallstones can occur in a minority of patients. Cholecystitis
      • Pancreatitis
    • Intestinal obstruction
    • Appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis

Cysticercosis

Signs and symptoms depend on the tissues involved.

Muscular and dermatologic cysticercosis:

  • Most are asymptomatic
  • Cysts may be palpated under the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
  • Myalgia
  • Myositis

Ocular cysticercosis:

  • Foreign body sensation
  • Ocular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Floaters
  • Impaired vision
  • Sensation of movement in the eye
  • Redness
  • Photophobia

Neurocysticercosis:

  • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
  • Focal neurologic deficits
  • Intracranial hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension:
    • Headache
    • Nausea
    • Vertigo Vertigo Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo
    • Papilledema
  • Psychiatric disturbances:
    • Altered mental status
    • Changes in personality
    • Learning disabilities
Cysticercosis eye

A cysticercus of the Taenia solium pork tapeworm in the pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil of a patient’s eye:
Although rare, cysticerci may float in the eye, causing vision changes.

Image: “14629” by CDC/Dr. H. Zaiman, Dr. Myron G. Schultz. License: Public Domain

Diagnosis and Management

Diagnosis

  • Nonspecific laboratory findings:
    • Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview
    • Eosinophilia
  • Stool studies:
    • Identifying eggs or proglottids will establish the diagnosis of taeniasis.
    • ELISA for Taenia antigens
    • PCR PCR Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. Polymerase Chain Reaction (PCR) to identify DNA DNA The molecule DNA is the repository of heritable genetic information. In humans, DNA is contained in 23 chromosome pairs within the nucleus. The molecule provides the basic template for replication of genetic information, RNA transcription, and protein biosynthesis to promote cellular function and survival. DNA Types and Structure
  • Serology for cysticercosis: enzyme-linked immunoelectrotransfer blot
  • CT or MRI may be used in patients with suspected neurocysticercosis.
    • “Swiss cheese” appearance
    • Lesions can be:
      • Cystic
      • Calcified
      • Ring-enhancing
    • Other potential findings:
      • Hydrocephalus with ventricular enlargement
      • Leptomeningeal enhancement
Neurocysticercosis

MRI from a patient with neurocysticercosis:
Note the “Swiss cheese” cystic lesions present throughout the brain.

Image: “ Neurocysticercosis” by Shushruth. License: Public Domain

Taeniasis management

Taeniasis can be treated with anthelmintic therapy:

  • Praziquantel (preferred)
  • Niclosamide

Cysticercosis management

  • General: Asymptomatic disease does not require treatment.
  • Ocular cysticercosis: ophthalmologic evaluation
  • Neurocysticercosis:
    • Anthelmintic therapy
      • Albendazole
      • Praziquantel may be added.
    • Corticosteroids
      • Prednisone or dexamethasone
      • Given prior to and during anthelmintic therapy
      • Reduce inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation caused by dying cysts
    • Antiepileptic medications
    • Neurosurgical consultation for: 
      • ↑ Intracranial pressure 
      • Intraventricular cysticerci

Prevention

  • Properly cook meat.
  • Identify and treat infected patients.
  • Perform proper hygiene.
  • Avoid potentially contaminated food and water.

Comparison of Tapeworm Species

Table: Characteristics and diseases of different tapeworm species
Organism Diphyllobothrium Diphyllobothrium Diphyllobothriasis represents an intestinal parasitic infection caused by the cestode Diphyllobothrium. Diphyllobothriasis is acquired by ingestion of late larvae in undercooked or raw fish. The clinical presentation of diphyllobothriasis varies from asymptomatic, nonspecific symptoms to intestinal obstruction, and/or vitamin B12 deficiency. Diphyllobothrium/Diphyllobothriasis latum Taenia saginata Echinococcus Echinococcus Echinococcosis is a parasitic disease caused by Echinococcus tapeworms. Infection most often occurs from the ingestion of Echinococcus eggs in food or water contaminated with dog feces. Signs and symptoms are caused by hydatid cyst development in visceral organs and depend on the species. Echinococcus/Echinococcosis granulosus
Characteristics
  • Approximately 10 m long
  • No hooks
  • Bothria present
  • > 3000 proglottids
  • < 5 m long
  • No hooks
  • No neck
  • Approximately 1000 proglottids
  • 2–7 mm long
  • Hooks present
  • 3–6 proglottids
Transmission Eating raw infected fish Eating raw infected beef Fecal–oral (ingestion of contaminated food or water)
Disease Diphyllobothriasis Diphyllobothriasis Diphyllobothriasis represents an intestinal parasitic infection caused by the cestode Diphyllobothrium. Diphyllobothriasis is acquired by ingestion of late larvae in undercooked or raw fish. The clinical presentation of diphyllobothriasis varies from asymptomatic, nonspecific symptoms to intestinal obstruction, and/or vitamin B12 deficiency. Diphyllobothrium/Diphyllobothriasis Taeniasis Cystic echinococcosis Echinococcosis Echinococcosis is a parasitic disease caused by Echinococcus tapeworms. Infection most often occurs from the ingestion of Echinococcus eggs in food or water contaminated with dog feces. Signs and symptoms are caused by hydatid cyst development in visceral organs and depend on the species. Echinococcus/Echinococcosis
Clinical
  • Abdominal discomfort
  • Weight loss
  • Vitamin B12 deficiency
  • Bowel obstruction
  • Usually asymptomatic
  • Mild GI symptoms
Depends on location and size of hydatid cysts
Diagnosis Eggs or proglottids in stool Eggs or proglottids in stool
  • Imaging
  • Serology
Management
  • Praziquantel
  • Niclosamide
  • Praziquantel
  • Niclosamide
  • Albendazole
  • Percutaneous drainage
  • Surgical excision
Prevention
  • Freeze fish.
  • Thoroughly cook fish.
  • Water sanitation measures
Beef should be cooked thoroughly.
  • Personal hygiene
  • Avoid contact with stray dogs.
  • Avoid potentially contaminated food.
  • Improve water sanitation.

Differential Diagnosis

  • Ascariasis Ascariasis Ascariasis is most often caused by A. lumbricoides. If symptomatic, characteristics typically follow 2 phases, which correlate with the migration of the parasite through the body. The early phase may include cough, dyspnea, and wheezing. The late phase typically includes abdominal discomfort, bloating, nausea, and intermittent diarrhea. Ascaris/Ascariasis: infection caused by the parasitic roundworm, Ascaris Ascaris Ascaris is a genus of parasitic nematodes. The infection, ascariasis, is most often caused by A. lumbricoides. Transmission occurs primarily via ingestion of water or food contaminated with Ascaris eggs. Most patients with ascariasis are asymptomatic. Ascaris/Ascariasis lumbricoides: Transmission of the worm occurs from ingestion of water or food that is contaminated with Ascaris Ascaris Ascaris is a genus of parasitic nematodes. The infection, ascariasis, is most often caused by A. lumbricoides. Transmission occurs primarily via ingestion of water or food contaminated with Ascaris eggs. Most patients with ascariasis are asymptomatic. Ascaris/Ascariasis eggs. Patients may be asymptomatic or experience cough and hemoptysis Hemoptysis Hemoptysis is defined as the expectoration of blood originating in the lower respiratory tract. Hemoptysis is a consequence of another disease process and can be classified as either life threatening or non-life threatening. Hemoptysis can result in significant morbidity and mortality due to both drowning (reduced gas exchange as the lungs fill with blood) and hemorrhagic shock. Hemoptysis. A large worm burden can cause intestinal obstruction and impair growth in children. Examination of the stool may show the presence of worms or eggs. Management is with anthelmintic therapy.
  • Gastroenteritis Gastroenteritis Gastroenteritis is inflammation of the stomach and intestines, commonly caused by infections from bacteria, viruses, or parasites. Transmission may be foodborne, fecal-oral, or through animal contact. Common clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Gastroenteritis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach and intestines, commonly caused by infections from bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview, viruses, or parasites: Common clinical features include abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, vomiting, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, and dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration. Diagnostic testing with stool analysis or culture is not always required but can help determine the etiology in certain circumstances. Most cases are self-limited; therefore, the only required treatment is supportive therapy (fluids). 
  • Inflammatory bowel disease (IBD): includes Crohn’s disease and ulcerative colitis Ulcerative colitis Ulcerative colitis (UC) is an idiopathic inflammatory condition that involves the mucosal surface of the colon. It is a type of inflammatory bowel disease (IBD), along with Crohn's disease (CD). The rectum is always involved, and inflammation may extend proximally through the colon. Ulcerative Colitis and is characterized by chronic inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the GI tract owing to a cell-mediated immune response to the GI mucosa. Symptoms include diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, weight loss, and extraintestinal manifestations. Diagnosis includes imaging, endoscopy, and biopsy. Management involves steroids, aminosalicylates, immunomodulators, and biologic agents.
  • Pernicious anemia: causes vitamin B12 deficiency and megaloblastic anemia Megaloblastic anemia Megaloblastic anemia is a subset of macrocytic anemias that arises because of impaired nucleic acid synthesis in erythroid precursors. This impairment leads to ineffective RBC production and intramedullary hemolysis that is characterized by large cells with arrested nuclear maturation. The most common causes are vitamin B12 and folic acid deficiencies. Megaloblastic Anemia due to a deficiency of intrinsic factor, which is required for vitamin B12 absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption: Patients may have fatigue, cognitive decline, neuropathy, ataxia, and glossitis. Low vitamin B12 levels, anti-intrinsic factor antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins, and the Schilling test can be used for diagnosis. Management includes vitamin B12 replacement.
  • Bacterial meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis: life-threatening bacterial infection of the meninges Meninges The brain and the spinal cord are enveloped by 3 overlapping layers of connective tissue called the meninges. The layers are, from the most external layer to the most internal layer, the dura mater, arachnoid mater, and pia mater. Between these layers are 3 potential spaces called the epidural, subdural, and subarachnoid spaces. Meninges: Bacterial meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis can present with fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, headache, meningeal signs, and seizures.  The diagnosis is made by clinical examination and confirmed by finding bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview in the CSF, which is obtained by lumbar puncture. Management involves corticosteroids and IV antibiotics directed against the identified bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview.
  • Intracranial tumors: benign or malignant growth of cells in the brain: Intracranial tumors present as headache, unexplained nausea or vomiting, blurred vision, and difficulty in speech or hearing. The diagnosis is made with a neurologic examination, imaging (MRI or CT), and sometimes biopsy. Management includes radiation, chemotherapy, and/or surgery.
  • Brain abscess Brain abscess Brain abscess is a life-threatening condition that involves the collection of pus in the brain parenchyma caused by infection from bacteria, fungi, parasites, or protozoa. The most common presentation is headache, fever with chills, seizures, and neurological deficits. Brain Abscess: a collection of pus in the brain parenchyma due to an infection: Brain abscess Brain abscess Brain abscess is a life-threatening condition that involves the collection of pus in the brain parenchyma caused by infection from bacteria, fungi, parasites, or protozoa. The most common presentation is headache, fever with chills, seizures, and neurological deficits. Brain Abscess presents with fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, headache, seizures, nausea, and vomiting. The diagnosis is based mainly on imaging, as it is difficult to arrive at a definitive diagnosis on the basis of clinical presentation alone. Management includes antibiotic therapy and surgery to drain the abscess. 

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