Ofloxacin-Containing Multidrug Therapy in Ambulatory Leprosy Patients: A Case Series.

BACKGROUND: Standard dapsone and clofazimine-containing multidrug therapy (MDT) for leprosy is limited by drug tolerability, which poses treatment adherence barriers. Although ofloxacin-based regimens are promising alternatives, current efficacy and safety data are limited, particularly outside of endemic areas. We evaluated treatment outcomes in patients with leprosy receiving ofloxacin-containing MDT (OMDT) at our center. METHODS: We performed a retrospective chart review of patients treated for leprosy at our center over an 8-year period (2011-2019). Primary outcomes evaluated were clinical cure rate, occurrence of leprosy reactions, antibiotic-related adverse events, and treatment adherence. Analyses were descriptive; however, data were stratified by age, sex, spectrum of disease, region of origin, and treatment regimen, and odds ratios were reported to assess associations with adverse outcomes. RESULTS: Over the enrolment period, 26 patients were treated with OMDT (n = 19 multibacillary, n = 7 paucibacillary), and none were treated with clofazimine-based standard MDT. At the time of analysis, 23 patients (88%) had completed their course of treatment, and all were clinically cured, while 3 (12%) were still on treatment. Eighteen patients (69%) experienced either ENL (n = 7, 27%), type 1 reactions (n = 7, 27%), or both (n = 4, 15%). No patients stopped ofloxacin due to adverse drug effects, and there were no cases of allergic hypersensitivity, tendinopathy or rupture, or C. difficile colitis. CONCLUSIONS: We demonstrate a high cure rate and tolerability of OMDT in this small case series over an 8-year period, suggesting its viability as an alternative to standard clofazimine-containing MDT.

Cutaneous and mucocutaneous leishmaniasis in travellers and migrants: a 20-year GeoSentinel Surveillance Network analysis.

BACKGROUND: Cutaneous leishmaniasis (CL) may be emerging among international travellers and migrants. Limited data exist on mucocutaneous leishmaniasis (MCL) in travellers. We describe the epidemiology of travel-associated CL and MCL among international travellers and immigrants over a 20-year period through descriptive analysis of GeoSentinel data. METHODS: Demographic and travel-related data on returned international travellers diagnosed with CL or MCL at a GeoSentinel Surveillance Network site between 1 September 1997 and 31 August 2017 were analysed. RESULTS: A total of 955 returned travellers or migrants were diagnosed with travel-acquired CL (n = 916) or MCL during the study period, of whom 10% (n = 97) were migrants. For the 858 non-migrant travellers, common source countries were Bolivia (n = 156, 18.2%) and Costa Rica (n = 97, 11.3%), while for migrants, they were Syria (n = 34, 35%) and Afghanistan (n = 22, 22.7%). A total of 99 travellers (10%) acquired their disease on trips of ≤ 2 weeks. Of 274 cases for which species identification was available, Leishmania Viannia braziliensis was the most well-represented strain (n = 117, 42.7%), followed by L. major (n = 40, 14.6%) and L. V. panamensis (n = 38, 13.9%). Forty cases of MCL occurred, most commonly in tourists (n = 29, 72.5%) and from Bolivia (n = 18, 45%). A total of 10% of MCL cases were acquired in the Old World. CONCLUSIONS: Among GeoSentinel reporting sites, CL is predominantly a disease of tourists travelling mostly to countries in Central and South America such as Bolivia where risk of acquiring L. V. braziliensis and subsequent MCL is high. The finding that some travellers acquired leishmaniasis on trips of short duration challenges the common notion that CL is a disease of prolonged travel. Migrants from areas of conflict and political instability, such as Afghanistan and Syria, were well represented, suggesting that as mass migration of refugees continues, CL will be increasingly encountered in intake countries.

Implementation and evaluation of a quality and safety tool for ambulatory strongyloidiasis patients at high risk of adverse outcome.

BACKGROUND: Strongyloidiasis is a common infection in Canadian migrants that can cause life-threatening hyperinfection in immunosuppressed hosts. We designed and implemented a safety tool to guide management of patients with Strongyloides in order to prevent adverse outcomes. Methods: Patients treated at our centre for strongyloidiasis from January 1, 2013 to December 31, 2015 were identified through our ivermectin access log. Patients were categorized into pre-implementation and post-implementation groups. A retrospective chart review for predefined variables was conducted. RESULTS: Of 37 patients with strongyloidiasis, 26 were in the pre-implementation group and 11 were in the post-implementation group. Documented seroreversion (positive to negative) occurred in 42.1% of patients pre-implementation and 62.5% of patients post-implementation (p = 0.420). Documented stool clearance occurred in 80.0% of patients pre-implementation and 100.0% of patients post-implementation (p = 1.000). More patients were screened for HTLV-1 coinfection post-implementation (80.0%) versus pre-implementation (30.8%) (p = 0.011). Loss to follow-up after treatment occurred in 23.1% of patients pre-implementation and 20.0% of patients post-implementation (p = 1.000). CONCLUSIONS: The safety tool may be useful in the treatment of patients with strongyloidiasis to improve documentation of patient outcomes and standardize care. Future research should include a powered prospective study.

Differences in the Clinical and Laboratory Features of Imported Onchocerciasis in Endemic Individuals and Temporary Residents.

Many parasitic infections have different presenting features in endemic individuals (ENDs) and immunologically naive temporary residents (TRs). Temporary residents with loiasis often display acute symptoms and hypereosinophilia, in contrast to a parasite-induced subclinical state in chronically infected ENDs. Few studies have examined differences in ENDs and TRs infected with the related filarial parasite Onchocerca volvulus. We identified 40 TRs and 36 ENDs with imported onchocerciasis at the National Institutes of Health between 1976 and 2016. All study subjects received an extensive pretreatment medical history, physical examination, and laboratory investigations. We performed additional parasite-specific serologic testing on stored patient sera. Asymptomatic infection occurred in 12.5% of TRs and no ENDs (P = 0.06). Papular dermatitis was more common in TRs (47.5% versus 2.7%, P < 0.001), whereas more pigmentation changes occurred in ENDs (41.7% versus 15%, P = 0.01). Only endemic patients reported visual disturbance (13% versus 0%, P = 0.03). One TR (3.3%) had onchocercal eye disease, compared with 22.6% of ENDs (P = 0.053). Absolute eosinophil counts (AECs) were similar in ENDs and TRs (P = 0.5), and one-third of subjects had a normal AEC. Endemic individuals had higher filarial-specific IgG4 and were more likely to be positive for IgG4 antibodies to Ov-16. Temporary residents and ENDs with imported O. volvulus infection presented with different dermatologic manifestations; ocular involvement occurred almost exclusively in ENDs. Unlike Loa loa, clinical differences appear not to be eosinophil-mediated and may reflect chronicity, intensity of infection, or the presence of Wolbachia in O. volvulus.

Imported onchocerciasis in migrants and travelers.

PURPOSE OF REVIEW: With increasing international travel and mass global population migration, clinicians in nonendemic countries must be familiar with imported neglected tropical diseases including onchocerciasis, which is commonly known as 'river blindness'. RECENT FINDINGS: Imported onchocerciasis manifests differently in travelers compared with migrants from endemic areas and is likely underdiagnosed in both groups. Recent clinical studies confirm that eosinophilia is not a sensitive marker for Onchocerca volvulus, with one-third of patients having a normal eosinophil count. Novel diagnostics measuring antibodies to multiple recombinant O. volvulus antigens maintain a high sensitivity while improving specificity compared with conventional pan-filarial serologic testing. A 6-week course of doxycycline has macrofilaricidal activity through Wolbachia depletion and may be useful in nonendemic areas in addition to standard serial ivermectin. SUMMARY: Recent studies characterizing distinct clinical presentations in travelers and migrants may enable clinicians to better recognize imported onchocerciasis. Although novel diagnostics have improved specificity, most remain restricted to tropical disease reference laboratories and to date there is no marker of cure. Prolonged doxycycline treatment may reduce the need for serial ivermectin, though more potent short-course macrofilaricidal drugs are being developed.

Cutaneous leishmaniasis in travellers: a focus on epidemiology and treatment in 2015.

Imported cutaneous leishmaniasis (CL) is a growing problem with increasing global travel to endemic areas. Returned travellers seeking care encounter significant barriers to treatment, including diagnostic delays and difficult access to anti-leishmanial drugs. Treatment recommendations in non-endemic settings are a moving target, reflecting recent developments in Leishmania diagnostics and therapeutics. Accumulating experience with molecular-based species identification has enabled species-directed therapy. Clinicians are reevaluating more toxic traditional regimens in light of newly approved therapeutic agents and emerging data on local cutaneous treatments. Referral centers are implementing treatment decision algorithms designed to maximize efficacy while minimizing adverse events. Although management strategies continue to evolve, treatment of CL in non-endemic settings remains controversial. Persistent reliance on expert opinion reflects lack of research focused on travellers and limited randomized controlled trial evidence. We herein review the current epidemiology of cutaneous leishmaniasis in travellers and species-specific evidence for available therapies.

Hospital-associated transmission of Brucella melitensis outside the laboratory.

Brucella melitensis was identified in an aspirate obtained from a patient's hip joint during a procedure at a hospital in Canada. We conducted an investigation into possible exposures among hospital workers; 1 worker who assisted with the procedure tested positive for B. melitensis. Aerosol-generating procedures performed outside the laboratory may facilitate transmission of this bacterium.

Parasitic diseases in travelers: a focus on therapy.

Parasitic infections are an important cause of illness among returned travelers, and can lead to considerable morbidity and, in some cases, mortality. The complexity of parasitic life cycles and geographic specificities can present diagnostic challenges, particularly in non-endemic settings to which most travelers return for care. Clinical manifestations reflect the diverse taxonomy and pathogenesis of parasites, and appropriate diagnosis and management therefore necessitate a high index of suspicion of parasitic illnesses. Much of our knowledge surrounding management of parasitic infections in travelers is extrapolated from evidence derived in endemic populations, or is based on expert opinion and case series. We herein provide an overview of parasitic diseases of short-term travelers, and summarize current therapeutic strategies for each illness.