[Gastrointestinal symptoms may reflect complicated falciparum malaria]. / Gastrointestinale Symptome als Ausdruck einer komplizierten Malaria tropica.

HISTORY: A 42-year-old female presented with a two-day history of vomiting, diarrhea, fever and chills. Two weeks before she had returned to Germany from a Safari in Tanzania. She had disregarded the recommendation to take antimalarial chemoprophylaxis. CLINICAL FINDINGS AND DIAGNOSIS: The thin blood film showed Plasmodium falciparum-parasitized erythrocytes, and Plasmodium falciparum malaria was diagnosed. The full blood count showed thrombocytopenia and ultrasound imaging revealed splenomegaly. Initially the criteria for complicated malaria were not fulfilled. THERAPY AND COURSE: We started oral therapy with atovaquone/proguanil. The patient vomited the tablets twice. Therefore therapy was switched to intravenous artesunate. Subsequently, parasitemia dropped from 2.8 to 1.0 % within 22 hours. After 3 days of artesunate i. v., treatment could then be completed with oral atovaquone/proguanil, and the symptoms resolved. CONCLUSIONS: Patients with malaria and persistent vomiting should be treated intravenously and monitored closely, as severe gastrointestinal symptoms may reflect impending organ failure. We therefore propose including persistent vomiting in the list of criteria for complicated malaria.

Longitudinal detection of SARS-CoV-2-specific antibody responses with different serological methods.

Serological testing for anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies is used to detect ongoing or past SARS-CoV-2 infections. To study the kinetics of anti-SARS-CoV-2 antibodies and to assess the diagnostic performances of eight serological assays, we used 129 serum samples collected on known days post symptom onset (dpso) from 42 patients with polymerase chain reaction-confirmed coronavirus disease 2019 (COVID-19) and 54 serum samples from healthy blood donors, and children infected with seasonal coronaviruses. The sera were analyzed for the presence of immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA) antibodies using indirect immunofluorescence testing (IIFT) based on SARS-CoV-2-infected cells. They were further tested for antibodies against the S1 domain of the SARS-CoV-2 spike protein (IgG, IgA) and against the viral nucleocapsid protein (IgG, IgM) using enzyme-linked immunosorbent assays. The assay specificities were 94.4%-100%. The sensitivities varied largely between assays, reflecting their respective purposes. The sensitivities of IgA and IgM assays were the highest between 11 and 20 dpso, whereas the sensitivities of IgG assays peaked between 20 and 60 dpso. IIFT showed the highest sensitivities due to the use of the whole SARS-CoV-2 as substrate and provided information on whether or not the individual has been infected with SARS-CoV-2. Enzyme-linked immunosorbent assays provided further information about both the prevalence and concentration of specific antibodies against selected antigens of SARS-CoV-2.

Protection From COVID-19­The Efficacy of Face Masks.

BACKGROUND: Since the beginning of 2020 the SARS-CoV-2 virus has spread to nearly every country in the world. The mainly airborne pathogen has led to large numbers of deaths, principally in elderly and vulnerable segments of the population. Protective vaccines have recently become available, but it is not yet clear whether and when population-wide immunity will be achieved. The existence of evidence for the protective effect of masks covering the mouth and nose is a topic of public debate. METHODS: A selective literature search was carried out in PubMed. Data from the German Robert Koch Institute and the Centers for Disease Control and Prevention were also taken into account. RESULTS: When talking, as many as 20 000 droplets ranging in size from 20 to 500 µM are released every second. According to PCR tests, the amount of virus exhaled is highest immediately before the onset of symptoms. No randomized trials have been conducted on the effect of masks covering the mouth and nose. A metaanalysis of 29 studies on infection with SARS-CoV-2, SARS, or MERS revealed that type N-95 masks (corresponding approximately to FFP-2), surgical masks, or similar multilayer cotton masks can greatly reduce the infection risk for the wearers (RR 0.34 [0.26; 0.45], with moderate heterogeneity [I2 = 48%]). Model experiments and case reports suggest that masks covering the mouth and nose afford considerable protection against transmission of SARS-CoV-2 and other airborne diseases by reducing release of and exposure to potentially infectious droplets; in addition, infections that do occur take a milder course. A limitation of the studies analyzed is that in most cases, this effect cannot be viewed in isolation from the protective impact of other measures (distancing, hygiene precautions). CONCLUSION: It can plausibly be assumed that consistent use of masks covering the mouth and nose can play an important role in containing the spread of SARSCoV- 2.

[Mosquitoes and Ticks: The Influence of Global Warming in the Transmission of Infectious Diseases in Germany]. / Mücken und Zecken als Krankheitsvektoren: der Einfluss der Klimaerwärmung.

During the last 135 years, the average temperature in Germany has increased by 1.4 °C. By 2050, a further rise by 1.5 °C is expected. This is associated with an increase of precipitation during the winter months. This climate change probably will improve both the growth conditions for mosquitoes and ticks, as well as their ability to transmit infectious diseases. Today, vectors that have not yet been present are invading into Germany. Among them is Aedes albopictus, which transmits Chikungunya, Zika, and Dengue Fever. Also, spreading of autochthonous malaria and West Nile Fever appear possible in Germany. Because of the increased presence of Phlebotomus species, leishmaniasis should be considered as a potential differential diagnosis in unclear hematologic diseases. Among the tick-borne diseases, climate change has already led to increased case numbers of Borreliosis and Tick Borne Encephalitis (TBE), and Crimean Congo Virus is spreading from the Balkan region towards Central Europe. This requires physicians to consider additional differential diagnoses in febrile illnesses.

Stronger host response per parasitized erythrocyte in Plasmodium vivax or ovale than in Plasmodium falciparum malaria.

OBJECTIVE AND METHODS: Fever tends to start at a lower level of parasitemia in Plasmodium vivax or ovale than in P. falciparum malaria, but hyperparasitemia and complications are more likely to occur in P. falciparum malaria. Therefore, we compared the relationship between parasitemia and host response parameters before therapy in 97 patients with P. faciparum malaria (18 with complications), and 28 with P. vivax or ovale malaria. RESULTS: In both types of malaria, parasitemia correlated with blood levels of tumour necrosis factor alpha (TNF-alpha), lactate dehydrogenase (LDH), Thrombin-antithrombin III (TAT) and elastase, and these parameters were higher in P. falciparum malaria than in P. vivax or ovale malaria. In contrast, the ratios of TNF-alpha, TAT, elastase, and LDH per parasitized erythrocyte were higher in P. vivax or ovale malaria than in uncomplicated P. falciparum malaria. They were lowest in complicated disease. Multivariate regression analysis confirmed that parasitemia did not affect these differences. CONCLUSION: The host response may reach full strength at lower parasitemia in Plasmodium vivax or ovale, than in P. falciparum malaria. With hyperparasitemia in P. falciparum malaria, the host response seems to be unable to control parasite multiplication.

Plasmodium falciparum Malaria: reduction of endothelial cell apoptosis in vitro.

Organ failure in Plasmodium falciparum malaria is associated with neutrophil activation and endothelial damage. This study investigates whether neutrophil-induced endothelial damage involves apoptosis and whether it can be prevented by neutralization of neutrophil secretory products. Endothelial cells from human umbilical veins were coincubated with neutrophils from healthy donors and with sera from eight patients with P. falciparum malaria, three patients with P. vivax malaria, and three healthy controls. Endothelial apoptosis was demonstrated by terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling (TUNEL) and annexin V staining. The rate of apoptosis of cells was markedly increased after incubation with patient serum compared to that with control serum. Apoptosis was most pronounced after incubation with sera from two patients with fatal cases of P. falciparum malaria, followed by sera of survivors with severe P. falciparum malaria and, finally, by sera of patients with mild P. falciparum and P. vivax malaria. Ascorbic acid, tocopherol, and ulinastatin reduced the apoptosis rate, but gabexate mesilate and pentoxifylline did not. Furthermore, in fatal P. falciparum malaria, apoptotic endothelial cells were identified in renal and pulmonary tissue by TUNEL staining. These findings show that apoptosis caused by neutrophil secretory products plays a major role in endothelial cell damage in malaria. The antioxidants ascorbic acid and tocopherol and the protease inhibitor ulinastatin can reduce malaria-associated endothelial apoptosis in vitro.