[Importation of rare but life-threatening and highly contagious diseases. Current situation and outlook]. / Import seltener, aber lebensbedrohlicher und hochansteckender Erreger : Heutige Situation und Ausblick.

Internists should expect to be the first contact for patients with rare, but highly contagious, life-threatening illnesses. Although certainly not encountered often, it is associated with significant consequences. Thus, physicians should be familiar with viral hemorrhagic fevers: filoviruses cause Ebola and Marburg fever, arenaviruses cause Lassa fever and South American hemorrhagic fevers, and the bunyaviruses cause among others Crimean-Congo hemorrhagic fever. Furthermore, physicians should be familiar with highly contagious respiratory infections, such as hantavirus pulmonary syndrome, pneumonic plague, and Middle East respiratory syndrome (MERS).

Virological failure after 1 year of first-line ART is not associated with HIV minority drug resistance in rural Cameroon .

OBJECTIVES: The aim of this study was to describe clinical and virological outcomes in therapy-naive HIV-1-positive patients treated in a routine ART programme in rural Cameroon. METHODS: In a prospective cohort, 300 consecutive patients starting first-line ART were enrolled and followed for 12 months. Among 238 patients with available viral load data at Month 12, logistic regression was used to analyse risk factors for virological failure (≥1000 HIV RNA copies/mL) including clinical, immunological and virological parameters, as well as data on drug adherence. Population sequencing was performed to detect the presence of drug-resistance mutations in patients with virological failure at Month 12; minority drug-resistance mutations at baseline were analysed using next-generation sequencing in these patients and matched controls. RESULTS: At Month 12, 38/238 (16%) patients experienced virological failure (≥1000 HIV RNA copies/mL). Patients with virological failure were younger, had lower CD4 cell counts and were more often WHO stage 3 or 4 at baseline. Sixty-three percent of patients with virological failure developed at least one drug-resistance mutation. The M184V (n = 18) and K103N (n = 10) mutations were most common. At baseline, 6/30 patients (20%) experiencing virological failure and 6/35 (17%) matched controls had evidence of minority drug-resistance mutations using next-generation sequencing (P = 0.77). Lower CD4 count at baseline (OR per 100 cells/mm(3) lower 1.41, 95% CI 1.02-1.96, P = 0.04) and poorer adherence (OR per 1% lower 1.05, 95% CI 1.02-1.08, P < 0.001) were associated with a higher risk of virological failure. Unavailability of ART at the treatment centre was the single most common cause for incomplete adherence. CONCLUSIONS: Virological failure after 1 year of ART was not associated with minority drug resistance at baseline but with incomplete adherence. Strategies to assure adherence and uninterrupted drug supplies are pivotal factors for therapy success.

[Treatment of diseases acquired abroad]. / Behandlung von auf Fernreisen erworbenen Erkrankungen.

Most imported diseases can be well treated-provided the diagnosis is made in due time. For example, only the rapid and correctly performed treatment of falciparum malaria can impede severe complications and save the patient's life. Effective treatments for amebiasis, giardiasis, leishmaniasis and worm diseases are available. However, it has to be mentioned that evidence from clinical trials is often insufficient. Accordingly only few international guidelines for imported diseases exist.

[Fever in returning travelers]. / Fieber bei Reiserückkehrern.

Travel-related illness is most often due to gastrointestinal, febrile, and dermatologic diseases. Fever in a returned traveler demands prompt attention because it may be a manifestation of an infection that could be rapidly progressive and lethal. The approach to the febrile patient should be stepwise and consider travel and exposure history. Malaria is the most common cause of fever in patients returning from Sub-Saharan Africa, whereas dengue is more frequent in travelers from other tropical and subtropical areas. Other serious diseases are typhoid and paratyphoid fever, amebic liver abscess, visceral leishmaniasis, leptospirosis and-rarely-viral hemorrhagic fevers.

High HIV prevalence among children presenting for general consultation in rural Cameroon.

Data on the HIV-prevalence children presenting to health care facilities in sub-Saharan Africa are scant in general, and the debate about opportunities for paediatric HIV screening is ongoing. Nine hundred and eighty-one children with unknown HIV-status presenting to a large general paediatric outpatient department in rural Cameroon were tested using the Determine HIV-1/2 rapid test (Abbott), and positive results were confirmed with the Hexagon HIV rapid test (Human Diagnostics). In children younger than 18 months, HIV infection was confirmed by PCR testing. Median age was 1.3 years and 52.8% were of male gender. In 514 children below 18 months of age, 16 (3.1%) tested positive. Of those, HIV-1 PCR was available for 11 children, of whom 6 had a positive PCR result. HIV prevalence was highest in the age group 5-9 years, being 8.8%. Malnutrition (33.3 vs 5.2%, p < 0.001) was associated with HIV infection. Our study results indicate that HIV testing should be offered to all children at possible entry points to medical care, irrespective of symptoms, in order to reduce HIV-associated mortality through timely initiation of antiretroviral therapy.

[Malaria]. / Malaria.

Malaria is the most important infectious disease imported by travelers and migrants from tropical and subtropical areas. It is imported quite frequently. It is a life-threatening disease. Symptoms are nonspecific and cannot easily be distinguished from a wide range of other febrile conditions. Therefore, travel history must be taken in all patients with fever of unknown origin and malaria diagnostics must be performed immediately on suspicion of malaria. Uncomplicated falciparum malaria should be treated in the hospital with either atovaquone-proguanil or with an artemisinin-based combination preparation. If there is evidence of severe malaria, the patient must be moved to an intensive care unit. The antiparasitic agent of choice is then artesunate.

[Travelers' diarrhea]. / Reisediarrhoe.

Travelers diarrhea affects millions of tourists each year. Most cases are caused by a variety of bacterial enteropathogens: toxigenic Escherichia coli, Campylobacter, Shigella, Salmonella, Aeromonas, Plesiomonas and non-cholera vibrios. Treatment may include antibacterial therapy with either ciprofloxacin, or azitrhomycin, or rifaximin. Viral pathogens such as norovirus usually cause short-term illness that typically resolves before travelers seek medical attention. Chronic gastrointestinal disease in returning travelers often is caused by parasitic pathogens like Giardia lamblia. The impact of prevention of travelers diarrhea is limited, therefore travelers should be informed about early self-treatment.

Travel-related imported infections in Europe, EuroTravNet 2009.

The aim of this study was to investigate travel-associated morbidity in European travellers in 2009 in comparison with 2008, with a particular emphasis on emerging infectious diseases with the potential for introduction into Europe. Diagnoses with demographic, clinical and travel-related predictors of disease from ill returning travelers presenting to 12 core EuroTravNet sites from January to December 2009 were analysed. A total of 6392 patients were seen at EuroTravNet core sites in 2009, as compared with 6957 in 2008. As compared with 2008, there was a marked increase in the number of travellers exposed in North America and western Europe. Respiratory illnesses, in particular pandemic A(H1N1) influenza, influenza-like syndromes, and tuberculosis, were also observed more frequently. A significant increase in reported dengue cases in 2009 as compared with 2008 was observed (n = 172, 2.7% vs. n = 131, 1.90%) (p 0.002). The numbers of malaria and chikungunya cases were also increasing, although not significantly. Two deaths were recorded: visceral leishmaniasis and sepsis in a Sudanese migrant, and Acinetobacter sp. pneumonia in a patient who had visited Spain. This is the most comprehensive study of travel-related illness in Europe in 2009 as compared with 2008. A significant increase in travel-related respiratory and vector-borne infections was observed, highlighting the potential risk for introduction of these diseases into Europe, where competent vectors are present. The number of traveller deaths is probably underestimated. The possible role of the travellers in the emergence of infectious diseases of public health concern is highlighted.

[Therapeutic management of malaria]. / Therapiemanagement bei Malaria.

Plasmodium falciparum and to some extent malaria caused by other species of Plasmodia can quickly lead to cerebral malaria, acute renal failure, or acute respiratory distress syndrome. The mortality rate for patients with severe malaria lies around 10%. Malaria must be given priority in the differential diagnosis of travelers returning febrile from endemic areas. Treatment requires prompt administration of safe and fast-acting antimalarials, which in severe malaria is treatment with quinine or artesunate. Hospitals must be prepared to diagnose and treat malaria patients-or have a standard operating procedure for transferring the patient to a specialized center.

Of guinea pigs and men--an unusual case of jaundice.

A 21-year-old male presented at the emergency room with jaundice, itching, dry cough, malaise and weight loss of 10 kg during the preceding four weeks. Eighteen months earlier, the patient had suffered an automobile accident leading to polytrauma. Serological markers for viral or other causes of hepatitis were absent. For suspected secondary sclerosing cholangitis, ultrasound and ERCP were performed but failed to reveal pathological findings. A liver biopsy showed cholestatic liver disease without signs of portal field-associated hepatitis. Hepato-biliary scintigraphy demonstrated hepatocellular dysfunction. The patient finally mentioned his guinea pig farm with around 50 animals, 20 of which had recently died for unknown reasons. The patient and three of his guinea pigs were subsequently tested for serological evidence of leptospirosis. IgG and IgM antibodies reacting with Leptospira interrogans were detected in the patient's serum, and all 3 guinea pigs were serologically positive for serovar Bratislava. Bacterial culture was not successful, and also PCR tests remained negative. The clinical symptoms quickly resolved after the initiation of antibiotic therapy with amoxicillin.

Genomic tandem repeat analysis proves laboratory-acquired brucellosis in veterinary (camel) diagnostic laboratory in the United Arab Emirates.

We report a case of a 64-year-old veterinarian working in a state camel veterinary laboratory who was diagnosed with and treated for acute brucellosis with complicating epididymo-orchitis. Genomic tandem repeat analysis (MLVA-16) revealed identical Brucella strains in patient cultures and from different dromedary milk samples positive for Brucella melitensis, thereby confirming the diagnosis of a laboratory acquired infection. The case illustrates the high (airborne) infectivity of brucellosis in laboratory settings and the need to implement vigorous bio-safety measures in veterinary laboratories handling camel specimen diagnostic veterinary laboratory.

Necrotizing lymphadenitis: Kikuchi--Fujimoto disease alias lupus lymphadenitis?

Differentiation between lymphadenopathy in potentially life-threatening systemic lupus erythematosus (SLE) and self-limiting necrotizing lymphadenitis, also called Kikuchi- Fujimoto disease (KFD), is difficult. In the past, co-occurrence of SLE and KFD has been described repeatedly in case reports. Here, we report a case of necrotizing lymphadenitis, describe the clinical and histopathologic features in detail and discuss the current literature. KFD may in fact be a histopathologic characteristic of SLE supporting the hypothesis that KFD is a rare manifestation of SLE. To clarify whether KFD is the same entity as lupus lymphadenitis, more cases with SLE and lymphadenopathy should be examined in detail.

Prophylactic immunisation against traveller's diarrhoea caused by enterotoxin-forming strains of Escherichia coli and against cholera: does it make sense and for whom?

Traveller's diarrhoea (TD) constitutes the most common disease relevant to travel medicine with ETEC as the leading causative pathogen. Cholera is the most serious, but very rare form of TD. ETEC and cholera share pathogenic mechanisms by producing a toxin that has an 80% amino acid homology. A consensus of German-speaking experts sees the indication to use the whole cell/B subunit oral cholera vaccine (WC--BS) if cholera is a risk for aid workers or travellers with an anticipated threat of cholera who stay under poor hygienic conditions. The use of the vaccine should be considered in the indication to avoid ETEC TD for travellers with predisposing illness or medication or for travellers at risk to develop a serious course.

[Severe ileocolitis refractory to standard medical treatment. A diagnostic dilemma]. / Therapierefraktäre schwere Ileokolitis. Ein diagnostisches Dilemma.

The differential diagnosis of granulomatous intestinal diseases leads to recurrent false diagnoses. Our patient who was presenting with gastrointestinal complaints was first diagnosed as having Crohn's disease. Put on an immunosuppressive treatment, the symptoms deteriorated. Examination of sputum revealed acid-fast bacilli, later confirmed as M. tuberculosis in culture, and colonoscopy showed necrotizing granulomas, which lead us to the final diagnosis of abdominal tuberculosis. Our patient improved under an adequate tuberculostatic regime.

Pulmonary infection with rapidly growing mycobacteria in a singer with achalasia: a case report.

We report the case of a 37-year-old male patient with prolonged pneumonia and achalasia. Culture and molecular genetic typing identified Mycobacterium abscessus as causative agent. Treatment with clarithromycin and minocycline over 8 months gradually resolved the infection. Rapidly growing, non-obligate pathogenic mycobacteria are widespread in the environment. Several cases of pulmonary infections with these mycobacteria in patients with achalasia have been reported, suggesting a causative association. This is the first report of a case with isolation of M. abscessus in this context.

[Chronic lupoid leishmaniasis. A rare differential diagnosis in Germany for erythematous infiltrative facial plaques]. / Chronische lupoide Leishmaniose: In Deutschland eine seltene Differenzialdiagnose erythematös-infiltrativer Plaques im Gesicht.

Lupoid leishmaniasis is a unique form of cutaneous leishmaniasis characterized by unusual clinical features and a chronic relapsing course. Clinically and histologically it is similar to lupus vulgaris, which is thus the most important differential diagnostic consideration. All patients with granulomatous facial lesions coming from endemic areas or with a positive travel history should be suspected of having leishmaniasis. We describe a 59-year-old woman with facial lupoid leishmaniasis.