[Large multicystic space-occupying liver lesion in a 19-year-old woman]. / Große multizystische Leberraumforderung bei einer 19-jährigen Frau.

A 19-year-old woman presented with liver capsule pain and a liver lesion on sonography, which contained microvesicular cystic, necrotic and solid fibrotic formations typical for alveolar echinococcosis (AE). The diagnosis was confirmed by serology and histopathology. This parasitic infection which is endemic in Germany is feared because of its malignant growth. The increasing expansion of E. multilocularis in Europe will lead to a higher incidence of AE with an occurrence of cases outside classical endemic regions.

Development of miliary tuberculosis under infliximab in a patient with spondyloarthritis and suspected Crohn's disease.

Tuberculosis (TB) infection is a major concern in patients with chronic autoimmune conditions under immunosuppressive therapy. Gastrointestinal tuberculosis can be misdiagnosed as Crohn's disease with detrimental consequences for the patient. We report on a 40-year old ethnic Turkish patient with HLA-B27 positive spondyloarthritis who developed gastrointestinal symptoms under immunosuppressive treatment with infliximab. Crohn's disease was diagnosed at a primary care hospital and immunosuppressive treatment was escalated. Initial diagnostic tests for tuberculosis were negative. When the clinical condition deteriorated, the patient was transferred to our intensive care unit for further diagnosis and treatment. Tuberculosis was suspected due to clinical presentation and radiological signs and anti-tuberculous treatment was initiated. After the onset of treatment, first microbiological results confirmed the diagnosis of miliary TB with Mycobacterium bovis. As an infection route we assume primary gastrointestinal infection with M. bovis during the patient's annual holidays in Turkey with a rapid development of miliary TB under infliximab and escalated immunosuppressive therapy. This case report demonstrates the difficulties in differentiating intestinal TB from other granulomatous conditions such as Crohn's disease. The diagnostic tools for gastrointestinal tuberculosis are discussed in detail regarding their sensitivity, specificity as well as positive and negative predictive values.

ST2859 serogroup A meningococcal meningitis outbreak in Nouna Health District, Burkina Faso: a prospective study.

We analysed cerebrospinal fluid samples from suspected meningitis cases in Nouna Health District, Burkina Faso, during the meningitis seasons of 2004-2006. Serogroup A ST2859 meningococci belonging to the ST5 clonal complex of subgroup III meningococci were the predominant causative agent. ST2859 bacteria were associated with focal outbreaks in the north of the district. While >10% of the population of an outbreak village carried ST2859, the population in the south of the district was predominantly colonised by serogroup Y ST4375 meningococci, which were associated with only sporadic cases of meningitis. Colonisation with the less virulent Y meningococci may interfere with the spread of the ST2859 to the south of the district, but there are concerns that this serogroup A clone may cause a third wave of subgroup III meningococcal disease in the African Meningitis Belt.

How to not miss alveolar echinococcosis in hepatic lesions suspicious for cholangiocellular carcinoma.

PURPOSE: Hepatic alveolar echinococcosis (AE) resembles intrahepatic cholangiocarcinoma (ICC) on radiological imaging. The purpose of this study was to identify criteria to discriminate AE from ICC with CT and MR Imaging. METHODS: One hundred and sixteen imaging studies of 94 patients (CT n = 65; MRI n = 51) diagnosed with AE (n = 55) or ICC (n = 39) were retrospectively reviewed by two blinded radiologists for lesion features including enhancement pattern and matrix composition. A consensus read was conducted in cases of disagreement. Uni- and multivariate logistic regression with bootstrapping were used for analysis. RESULTS: Using CT, no or septal enhancement and calcification yielded the highest values of sensitivity/specificity (90.9%/90.6% and 81.8%/96.9%) for AE. Using MRI, no or septal enhancement and cystic components achieved the highest sensitivity/specificity (90.9%/100.0% and 84.8%/66.7%) for AE. Multivariate logistic regression identified the following strong independent predictors for AE: for MRI, no or septal enhancement (odds ratio [OR] 322.4; p < 0.001); for CT, no or septal enhancement and calcification (OR 35.9 and 42.5; p < 0.001 and p < 0.01, respectively). No or septal enhancement and calcification demonstrated the highest interreader agreement (>90%). CONCLUSION: Enhancement characteristics and matrix calcifications offer the strongest discriminating potential between AE and ICC with a high sensitivity, specificity, and interreader agreement.

[The worm in the liver]. / Der Wurm in der Leber.

Patients with parasitic involvement of the liver are a small group of patients in European countries. In the differential diagnosis of "hepatic mass" "pain in the right upper abdomen" "biliary obstruction" or "abnormal liver function tests" parasites are, if at all, considered last. In most health care centers diagnostic and management experience is limited with respect to these diseases. They should therefore been taken care of by specialized centers. In most countries these are centers for tropical diseases. Important components of the work up of patients with parasitic diseases are: risk assessment (place of origin, travel and exposure), geographic distribution of the parasites, incubation period, prepatent period, laboratory investigations (eosinophilia, IgE, direct parasitological diagnosis) and imaging studies. Important parasites with liver involvement will be presented: schistosomiasis, echinococcosis, fascioliasis, toxocariasis.

Pitfalls in diagnosis and treatment of alveolar echinococcosis: a sentinel case series.

BACKGROUND: Alveolar echinococcosis (AE) is a neglected zoonosis presenting with focal liver lesions (FLL) with a wide range of imaging patterns resembling benign as well as malignant FLLs. Complementary serology and histopathology may be misleading. OBJECTIVE: The objective of our study is to highlight pitfalls leading to wrong diagnoses and harmful interventions in patients with AE. DESIGN: This retrospective sentinel case series analyses diagnostic and treatment data of patients with confirmed AE. RESULTS: 80 patients treated between 1999 and 2014 were included in the study. In 26/80 patients treatment decisions were based on a wrong diagnosis. AE was mistaken for cystic echinococcosis (CE) in 12/26 patients followed by cholangiocellular carcinoma (CCA) in 5/26 patients; 61/80 patients had predominantly infiltrative liver lesions and 19/80 patients had a predominantly pseudocystic radiological presentation. Serology correctly differentiated between Echinococcus multilocularis and Echinococcus granulosus in 53/80 patients. Histopathology reports attributed the right Echinococcus species in 25/58 patients but failed to differentiate E. multilocularis from E. granulosus in 25/58 patients. Although contraindicated in AE 8/25 patients treated surgically had instillation of a protoscolicidal agent intraoperatively. One of the eight patients developed toxic cholangitis and liver failure and died 1 year after liver transplantation. CONCLUSIONS: Misclassification of AE leads to a critical delay in growth inhibiting benzimidazole treatment, surgical overtreatment and bares the risk of liver failure if protoscolicidal agents are instilled in AE pseudocysts.

[Imaging methods in the diagnosis and therapy of cystic echinococcosis]. / Bildgebende Verfahren in Diagnostik und Therapie der zystischen Echinokokkose.

Imaging studies, ultrasonography, play a central role for the diagnosis and follow-up of cystic echinococcosis (hydatid disease) due to the non-specific clinical symptoms and still inadequate sensitivity and specificity of currently available serological tests. Due to the increasing number of people immigrating to central Europe from countries with a high incidence of cystic echinococcosis, cystic echinococcosis has become an important differential diagnosis of cystic lesions. The imaging modality to localize and stage the disease depends on the organs affected. Ultrasonography is the most important imaging technique to screen for abdominal lesions (more than 75 % of the cases). Therefore, an expert committee of the WHO Working Group on echinococcosis has recently suggested a standardized ultrasonographic classification of hepatic cystic echinococcosis. This classification proofs to be very useful for staging echinococcal cysts with respect to parasite activity. Ultrasonography is not only an excellent tool for the primary diagnosis and therapeutic decision but also for follow-up of patients treated for cystic echinococcosis. Indications for computed tomography or magnetic resonance tomography are restricted to extra abdominal disease, patients not suited for ultrasonography because of obesity or meteorism, complicated cysts and planning of surgery or interventional therapy. Apart from surgery three other treatment options are well established: (1) chemotherapy with albendazole or mebendazole, (2) percutaneous drainage and sterilization (PAIR) and (3) observation of inactive echinococcal stages ("watch and wait" approach).

Prospective molecular epidemiological study on transmission of pulmonary Tuberculosis and Migration (MuT study) -- an interim report.

INTRODUCTION: In Western Europe prevalence and incidence of tuberculosis in the indigenous population is declining and TB in migrants from high prevalence countries is becoming a major issue of TB control. Resulting changes in transmission patterns need to be investigated to adapt control strategies. The MuT (Migration and Tuberculosis) study a co-operation among federal and local public health services (ODG), the National Surveillance Center (RKI) and the University has been established in Baden-Wuerttemberg to address these issues. OBJECTIVES: The goal of this ongoing study is to determine the transmission dynamics of TB in Baden-Wuerttemberg. Here, we present the first set of data on TB cases and their contacts and discuss strategies to overcome arising difficulties. METHODS: Prospective data collection of culture positive pulmonary tuberculosis cases and their contacts. Analysis of (1) routine data, (2) spatial data, (3) social interaction data, (4) molecular typing data, and (5) observational data of the implementation phase. RESULTS: The study demonstrates the capability of the study consortium to identify clusters. It provides valuable insights into current case detection and case management procedures and shows ways to improve. A set of factors has been identified that (a) facilitate and (b) discourage study participation. CONCLUSION: Collaboration among federal and local public health services (OGD), National Surveillance Center (RKI) and the University is a promising approach to investigate and improve TB control. This model has potentials for other infectious disease control.

[Asylum seekers and refugees in the emergency department]. / Asylsuchende und Flüchtlinge in der Notfallstation.

This cross-sectional study describes the health problems and the health care of asylum seekers and refugees from the point of view of accident & emergency (A & E) physicians at the major hospital in St. Gallen, Switzerland. The physicians filled in a detailed questionnaire and documented all consultations of asylum seekers/refugees and of a control group of patients during eleven weeks (2 x 98 consultations). 76% of these asylum seekers/refugees originated from former Yugoslavia. The distribution of the main ICD-coded diagnoses did not differ between asylum seekers/refugees and the control group after correction for age. In comparison with the asylum seekers and refugees attending GPs, injuries were much more common in the A & E department attenders (37% vs. 8%). Asylum seekers/refugees and the patients in the control group did not differ in respect to being classified as an emergency case (58% vs. 65%). There were also no differences in hospitalisation rates (29% vs. 36%). Asylum seekers/refugees who were registered with a GP attended the A & E department more often during the night than during the day compared to patients who were not registered with a GP. Consultations which have been classified as emergencies occurred more frequently during the day than at night time. The time of residence in Switzerland was negatively associated with the registration with a GP and with being classified as an emergency case. A lack of experience in caring for asylum seekers and refugees and of specific training in this field has been the major complaint by the A & E physicians. Asylum seekers should be introduced to the tasks and functions of the various sectors of the national health care system as early as possible. Registration with a GP in the community should be promoted.

[Asylum seekers and refugees in general practice: problems and possible developments]. / Asylsuchende und Flüchtlinge in der hausärztlichen Praxis: Probleme und Entwicklungsmöglichkeiten.

Health and health services provided to asylum seekers and refugees by the Swiss National Health System have so far not been systematically investigated. The aim of this cross-sectional study was to describe the attending asylum seekers and refugees demographically and clinically, to identify main problem areas as perceived by general practitioners and to highlight options and venues for improvements. 272 questionnaires have been filled in by GPs of eight "federal districts" (Kantone) and the consultations of 1477 asylum seekers and refugees have been documented during one month in 193 surgeries. The documented asylum seekers and refugees reflected the distribution of this population in Switzerland. Low consultation rates of asylum seekers and refugees in the majority of surgeries and high diversity of this population in respect to places of origin, education and proficiency in languages appear to be the major determinants of the difficulties in providing adequate health services to them. Readily available information on the past medical history and on the ethnic background of these patients and continuing education on specific topics concerning health care for asylum seekers and refugees were thought to be particularly useful. This needs to be considered in the planning of services for this group. General practitioners specialized in health care for asylum seekers and refugees is an option for providing improved specific services (interpreters, institutional links, culturally adapted medical care).

[Asylum seekers and refugees in the medical polyclinic: a comparison between the Basel, Bern and Geneva polyclinics]. / Asylsuchende und Flüchtlinge in der medizinischen Poliklinik: Ein Vergleich zwischen den Polikliniken Basel, Bern und Genf.

This cross-sectional study describes the state of health of asylum seekers and refugees and the health services provided to them by the medical outpatient departments of three major Swiss university hospitals, Basel, Berne and Geneva. The comparison of outpatient departments differing in organisational structure facilitated the identification of positive and negative determinants of health service provision. Questionnaires have been filled in by all physicians of the three medical outpatient departments (Basel: 10, Berne: 1, Geneva: 36). All consultations of asylum seekers and refugees have been recorded during the study period (Basel: 42, Berne: 93, Geneva: 187). Interviews have been done with the physicians who coordinated the study. During the study period the majority of the patients originated from former Yugoslavia, Turkey, Sri Lanka, Somalia, Angola and Zaire. One of the most prominent features of the population investigated has been its diversity in respect to countries of origin, languages, ability to communicate and education. Diversity and low consultation rates per physician could explain many of the problems which have been observed, e.g. the lack of experience in specific approaches to these patients or difficulties to provide interpreters. To improve the health care for this group of patients in medical outpatient departments small teams of physicians should be selected. By these means adequate levels of experience could be achieved and organizational problems could be dealt with more effectively. In addition, the relationship between specific problems of asylum seekers and refugees and more general issues of the interaction between physicians and patients are discussed in view of tasks in research and training.

[Imported viral infections in international travel; from the virtual to real epidemiology of pandemics]. / Importierte Virusinfektionen im internationalen Reiseverkehr. Von der virtuellen zur realen Epidemiologie von Seuchen.

Viruses have become more mobile alongside with increasing human mobility and speed of travel. At the same time we get access to information on viral outbreaks and epidemics from large parts of the world faster than ever before. Two recent epidemics will be presented to explore the value and the consequences of communicating epidemiological information through the Internet. The epidemiology, clinical features, diagnostic procedures and prophylaxis of imported viral infections are presented. Risk factors for the emergence and resurgence of viral diseases are being discussed.

[Poisonous snake bites: prevention--first aid--clinical management]. / Giftschlangenbisse: Prävention--Erste Hilfe--ärztliche Versorgung.

Envenomation due to terrestrial snakes is a rarity in travellers and tourists and can be readily controlled by preventive measures. It is a widely underestimated health problem of the rural population in tropical and subtropical countries, however. Prevention, First Aid, diagnostic procedures, symptomatic and specific (antivenom) treatment regimens of envenomation due to terrestrial snakes are presented.

[Principles and practice of malaria chemoprophylaxis and of malaria emergency medication for travelers]. / Prinzipien und Praxis der Malaria-Chemoprophylaxe und der Malaria-Notfallmedikation für Reisende.

Malaria chemoprophylaxis and stand-by medication, avoidance of being bitten by mosquitoes, and instruction on the mode of infection, symptoms of disease and appropriate steps if malaria is suspected, are all crucial for malaria prevention in travellers. Drugs used for chemoprophylaxis do not prevent infection but help to avoid multiplication of parasites and disease. If a traveller is on stand-by medication, he decides himself according to symptoms when to take it; nevertheless, he is advised to see a doctor afterwards. Length of stay in an endemic area, health status of the traveller, malaria transmission rate and drug resistance determine the strategy of malaria prevention to be chosen. Risk-benefit analysis of a chemoprophylactic regimen compares the risk of severe side effects of the drug with that of a life-threatening malaria attack. Stand-by medication presents an alternative, if the former outweighs the latter. The Swiss Working Group on Medical Counselling for Travellers updates guidelines for malaria prophylaxis. Recommendations for individual countries are regularly published by the Swiss Health Authorities (BAG). If chemoprophylaxis fails or if a malaria attack is not fully covered by stand-by medication, diagnosis and treatment can cause problems.

[Erroneous tracks in the diagnosis of cutaneous and mucocutaneous leishmaniasis]. / Irrwege in der Diagnostik kutaner und mukokutaner Leishmaniosen.

Cutaneous leishmaniasis is an uncommon finding among patients seen in Central Europe. We report on three patients with cutaneous leishmaniasis who were initially misdiagnosed. Case 1, a woman who had returned from South America, was first thought to have an ulcer due to immunosuppression. Spread of the lesions to the nasal mucosa and a cosmetically disturbing scar were partly caused by delayed diagnosis and treatment. Case 2 shows a patient who has developed red papules on both legs after a trip to Spain. The lesions were misinterpreted as a residual reaction to insect bites. In case 3, a patient who had travelled in Nicaragua, the diagnosis of leishmaniasis was delayed because of coexisting acne vulgaris. In all three patients the final diagnosis of cutaneous leishmaniasis was confirmed by culture of the parasite. The only case with positive serology was the patient with mucocutaneous involvement. Two patients were radically cured, and one patient showed a substantial improvement of the lesions. The importance of a broad history including previous travel is emphasized to avoid the fallacies of missing a rare, but important disease among people travelling to countries with endemic leishmaniasis.

[Malaria study]. / Malariastudie.

Compliance with malaria prophylaxis or reserve drugs was investigated in 477 individuals travelling to regions with endemic malaria. Correct intake of prophylactic medication was confirmed in 225 out of 285 (= 78%). Compliance was independent of type of drug (Mefloquine, Sulfadoxine-Pyrimethamine, Chloroquine). Two tourists missed to start prophylaxis one week before the onset of their travel. 14 travellers stopped prophylactic medication too early after their return, 31 tourists took too high doses of mefloquine. None of the tourists travelling to countries with a therapeutic reserve only became sick, whereas two travelling to Africa contracted malaria.

[Poisonous animals at bathing beaches]. / Giftgetier am Badestrand.

Tourists and native inhabitants of tropical and subtropical regions differ significantly with regard to the risk and nature of incidents involving venomous and poisonous animals. While the indigenous population encounters such risks daily during work and other activities, tourists are usually endangered while swimming or diving, or by ingesting toxin-containing fish and/or other seafood. Whether abroad or at home, allergic reactions to the stings of bees, wasps and hornets are probably the most common manifestations of an encounter with a "poisonous animal". Travellers should be well acquainted with the dangers entailed in encountering or ingesting a venomous or poisonous animal--prevention is the most important measure.

[Extrapulmonary tuberculosis: radiological imaging of an almost forgotten transformation artist]. / Extrapulmonale Tuberkulose: Die radiologische Bildgebung eines fast vergessenen Verwandlungskünstlers.

Tuberculosis (TB) continues to be one of the infectious diseases with the world's highest rates of avoidable morbidity and mortality. A continuing downward trend has only been observed in highly industrialized countries, including Germany with 4,400 cases in the year 2009 representing an incidence of 5.5 per 100,000 persons. At the same time, the exposure to this patient group and the clinical experience are decreasing. Tuberculosis may affect any organ. The lung was the manifestation site in 80% of cases, and extrapulmonary manifestations were recorded in 20% of cases in Germany in the year 2008. Lymph node involvement is most common with a rate of approximately 50% of all extrapulmonary cases followed by the pleura in 18% of cases, genitourinary tract in 13% of cases, bones and joints in 6% of cases, gastrointestinal tract in 6% of cases, the central nervous system in 3% of cases and the spine in 3% of cases. Symptoms like fever, night sweats and weight loss are non-specific and may be absent. The aim of the review is to raise awareness of this disease, which is increasingly falling into oblivion, with its various radiological manifestations and to point out clinical-epidemiological and demographic factors that raise suspicion of tuberculosis.