Neuropsychiatric side effects after the use of mefloquine.

This study describes neuropsychiatric side effects in patients after treatment with mefloquine. Reactions consisted mainly of seizures, acute psychoses, anxiety neurosis, and major disturbances of sleep-wake rhythm. Side effects occurred after both therapeutic and prophylactic intake and were graded from moderate to severe. In a risk analysis of neuropsychiatric side effects in Germany, it is estimated that one of 8,000 mefloquine users suffers from such reactions. The incidence calculation revealed that one of 215 therapeutic users had reactions, compared with one of 13,000 in the prophylaxis group, making the risk of neuropsychiatric reactions after mefloquine treatment 60 times higher than after prophylaxis. Therefore, certain limitations for malaria prophylaxis and treatment with mefloquine are recommended.

Predictors for completing an inpatient detoxification program among intravenous heroin users, methadone substituted and codeine substituted patients.

Up to 1999 more opioid dependent patients in Germany were substituted with codeine or dihydrocodeine (summarised as codeine) than with methadone. The current retrospective study compares the differences in detoxification treatment outcome for codeine-substituted patients, methadone-substituted patients and patients injecting illicit heroin. The study is based on the medical records of 1070 patients admitted consecutively for opioid and polytox detoxification between 1991 and 1997. The main hypothesis was that injecting illicit-heroin users would complete detoxification treatment less often than codeine- or methadone- substituted patients, and that methadone-substituted patients who had received more structured treatment would complete more often than codeine-substituted patients who did not receive any structured treatment beyond the prescription of codeine. We analysed a number of demographic and drug related variables as possible predictors. Our bivariate analyses confirmed our main hypothesis: 50.4% (OR: 1.8) of the methadone-substituted patients, 45.5% (OR: 1.5) of the codeine-substituted patients and 35.9% (OR: 1 comparison group) of the injecting illicit-heroin users completed the detoxification program (P=0.006). This finding remained significant even after correcting for a number of confounders. Using stepwise multiple logistic regression analyses, we found age, education, history of imprisonment, regular contact with a counsellor, currently being on probation and reported plans for participating in an abstinence treatment program to be significant predictors of completing detoxification treatment. Although the current analysis did not rule out differences in pharmacological effects as a contributing factor, the results are consistent with an interpretation of a dose-response association between psychosocial/psychotherapeutic support and detoxification outcome. More psychosocial/psychotherapeutic support leads to better detoxification treatment response.

Blockade of spontaneous posttraining performance improvement in mice by NMDA antagonists.

We investigated the effects of immediate post-training systemic administration of gamma-L-glutamyl-L-aspartate (gamma-LGLA) and 3-(2-carboxypiperazine-4-yl)-propyl-1-phosphonate (CPP), antagonists at the N-methyl-D-aspartate receptor, in a lever-press task in two inbred strains of mice. When retention performance was tested in control animals 24 h after partial acquisition of the task. BALB/c mice exhibited a spontaneous performance improvement whereas C57BL/6J mice did not gamma-LGLA at doses of 2.5 and 25 mumol/kg and CPP at doses ranging between 0.025 and 2.5 mumol/kg blocked the spontaneous performance improvement found in BALB/c mice but had no apparent effects on the retention performance of C57BL/6J mice. These data suggest that retention impairment induced by CPP and gamma-LGLA in BALB/c mice results from an interference with posttraining memory processes.

Ofloxacin causes false-positive immunoassay results for urine opiates.

Abstract Immunoassay drug screening tests are usually used as a control during methadone maintenance programmes, to check cleanliness of drugs during detoxification treatment and abstinence programmes. False-positive results can have catastrophic consequences for the patient, as shown in the case report. False-positive results were reported for opioids following ofloxacin or rifampicin and for LSD following mucolytic. Since inpatient and outpatient units usually employ an urine quick test (immunoassay), positive results should be checked with gas chromatography/mass spectroscopy (GC-MS) or high pressure liquid chromatography (HPLC) before conclusions from the positive urine screening results can be drawn.

How do patients with HIV perceive their general practitioners?

OBJECTIVE: To study the perceptions of patients with HIV of their general practitioners in terms of knowledge, abilities, confidence, and satisfaction. DESIGN: Questionnaire survey of inpatients, outpatients, and members of a self help group. SETTING: Two city hospitals, three outpatient clinics, and one AIDS self help group in Munich and Berlin, Germany. SUBJECTS: All 402 patients available between 1 September 1988 and 31 May 1989. MAIN OUTCOME MEASURES: General practitioners' attitudes towards the patients' HIV status; patients' experience of treatment rejection; reception in the general practitioner's office; the doctor's perceived knowledge about HIV and AIDS. RESULTS: 394 of 402 patients consented to interview; 87% were registered with a general practitioner and 91% of those indicated that the doctor was aware of their HIV diagnosis. The overwhelming majority of patients (94%) had a friendly or at least neutral reception in the general practitioner's surgery and only six patients' general practitioner changed his or her behaviour for the worse because of the HIV diagnosis. Two thirds of patients said they would consult first with their primary care doctor for a physical problem, but only 13% would do so for psychological problems. Over a third of the patients did not routinely inform other doctors or medical staff about their HIV status, but there was no significant correlation between this concealment and ever having been rejected by a doctor (7%) or a dentist (12%). CONCLUSION: Most patients expressed a high degree of satisfaction with their general practitioners in terms of confidential issues, attitudes, knowledge, and management.

[Boutonneuse fever in tourists as a model for clinical diagnosis of rickettsioses (author's transl)]. / Fièvre boutonneuse bei Touristen als Modell zur klinischen Diagnose der Rickettsiosen.

Case histories of boutonneuse fever are described in order to exemplify major characteristics of most rickettsioses: recent travel history, feverish illness with severe headache, skin eruptions and histological findings. Up-to-date informations concerning the epidemiologic situation of typhus, scrub typhus and Rocky Mountain spotted fever are given. The characteristics of Q fever and the possibility of rickettsial laboratory infections are pointed out.

[Parasite detection and symptoms of parasitic diseases. 1: Blood parasites]. / Parasitennachweis und Symptomatik parasitärer Erkrankungen. Teil 1: Blutparasiten.

Blood parasites are malaria plasmodia, microfilaria species, trypanosomes (the causative agents of African sleeping sickness and South American Changas disease) and the causative agents of schistosomiasis of the bladder and the intestine. Their geographical distribution, incubation periods, signs and symptoms, microscopic and serological methods are described. In Germany around 1,000 tourists contract malaria every year, mostly travellers to Africa. Over 70% suffer from the life-threatening P. falciparum infection. Only a few days after the onset of this flu-like disease, complications may evolve. The best diagnostic method is the thin blood film. In case of a negative result this procedure must be repeated twice daily. The thick film requires experience. Rapid diagnostic tests can be helpful but are hampered by false negative results. Filaria loa loa may cause skin swellings, involvement of the eye and even the CNS; Wuchereria bancrofti can cause severe lymphedema. West African sleeping sickness (Trypanosoma gambiense) ends up in encephalitis, the East African form (T. rhodesiense) in a polyserositis. Schistosomiasis of the urinary bladder and the large intestine may cause severe diseases of the urinary tract or the liver.

[Detection of parasites and symptoms of parasitic diseases. 2: Parasites of the gastrointestinal tract, tissue and organ parasites, ecto- and skin parasites]. / Parasitennachweis und Symptomatik parasitärer Erkrankungen. Teil 2: Parasiten des Gastrointestinaltraktes, Gewebe- und Organparasiten, Ekto- und Hautparasiten.

Intestinal parasites are Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica, hookworms, ascaris, tape worms and others. As to organ parasites, their life-threatening courses are pointed out: amebiasis in the intestine, liver, lung and brain, toxoplasmosis in the brain, lung and heart muscle, including the danger for the child of a pregnant woman with an acute infection, West African sleeping sickness with encephalitis, the East African form with polyserositis, South American Chagas' disease with intestinal and myocardial involvement, visceral leishmaniasis Kala Azar, the filariasis Onchocerca volvulus with threatening blindness, the dog tapeworm with cysts and Echinococcus multilocularis with carcinoma-like infiltration of the liver and other organs, cysticercosis of the brain, eye and muscle tissue; partly generalizing parasitoses in immuno-suppressed including AIDS patients, finally skin parasites as causes of disease (e.g. scabies), and as potential carriers of pathogens.

[Epidemiologic studies of various forms of meningitis based on public health reports in West Berlin from 1981 to 1985]. / Epidemiologische Untersuchungen zu den verschiedenen Meningitisformen anhand der amtlichen Meldebögen in Berlin (West) 1981 bis 1985.

In the Federal Republic of Germany, four types of meningitis must be reported since 1980 instead of the previous two categories (i.e. meningococcal disease and other forms of meningitis). Consequently, various forms of purulent meningitis can be differentiated from viral meningitis. A retrospective study, considering the population of West Berlin, carried out between the years 1981 and 1985, shows the influence of age, nationality and living areas on morbidity and mortality rate. A critical evaluation was undertaken, considering possible changes in management efficiency of public health authorities since the introduction of the new reporting system. Population at high risk, predisposed to develop meningococcal meningitis, are mainly Turkish children living in areas of high population density and poor social structure. The activities of the public health administration seem inadequate. The reported meningitis cases were partly filed wrongly and thus were transmitted wrongly to the Federal Office of Statistics (Statistisches Bundesamt). No substantial scientific epidemiological analysis was performed. The most frequent reaction of public health authorities was disinfection of apartments, day-care centres and schools, as done for example in 67% of the reported meningococcal meningitis cases, although it is well known that there is no reason for room disinfection in droplet-transmitted infection of the nasopharyngeal mucosa. As shown by our results, the differentiation of the reporting system in use since 1980 did not prove advantageous considering the health policy and epidemiological research of prevention in our study area. Disinfection measures are obsolete.

[Tertian malaria in children and adults from an epidemic region in southern Turkey (author's transl)]. / Malaria tertiana bei Kindern und Erwachsenen aus dem Epidemiegebiet der südlichen Türkei.

Since 1974 an epidemic of tertian malaria has been spreading around the Adana and Tarsus townships in southern Turkey, with a peak incidence of 115 500 cases in 1977. A further increase is to be expected because the insect vectors have become resistant to insecticides. Since 1975 eleven children and three adults have been treated for P. vivax malaria. They had all stayed in the epidemic area during the transmission season which lasts from July to October. Because of a long primary latent period seven patients only developed first manifestations of the disease six to nine months after leaving Turkey. The classical malarial paroxysms were missing during the first weeks of the primary attack. Several children had a febrile illness over weeks with headache, vomiting, abdominal pain, hepatosplenomegaly, high blood-sedimentation rate and severe haemolytic anaemia, so that appendicitis or septicaemia had been suspected. Tetracyclines and trimethroprimsulphamethoxazole were able to suppress the disease without preventing relapses.

[A case of chloroquine-resistant (R1) falciparum malaria from the East African Comoros Islands (author's transl)]. / Ein Fall von Falciparum-Malaria mit Chloroquin-Resistenz (R1) von den ostafrikanischen Komoren-Inseln.

An African from the Comoros Islands, who has been living in Berlin for eleven years and who had made his last journey to Africa two years before, fell ill with high fever upon returning from a visit to Mayotte and Grande Comore. His blood smear revealed trophozoites of Plasmodium falciparum. After intake of 25 mg of chloroquine base per kg body weight within 66 hours, defervescence and clearance of blood ensued and by the fourth day after start of treatment the parasites could no longer be detected in the blood. On the 25th day high fever occurred and P. falciparum was found again. After chloroquine treatment had been repeated with an additional single dose of 75 mg pyrimethamine and 1.5 g sulphadoxine the patient remained healthy. During observation over a period of eight months plasmodia could no longer be detected in thick films.

[The "Qualified Detoxification Treatment of Drug Dependent Patients" Federal Model Project in a general hospital: concept, investments and clinical results]. / Das Bundesmodellprojekt "Qualifizierte Entzugsbehandlung Drogenabhängiger" an einem Krankenhaus der Maximalversorgung: Konzept, Inanspruchnahme und klinische Ergebnisse.

For 150,000 drug addicts 5,200 therapy slots are available in Germany. Until the late 80's detoxification treatment was only given a subordinate role in treating drug addicts. Due to the threat of the infectious disease AIDS and the increasing number of drug deaths new concepts were explored: In 1991 the first qualified detoxification ward for drug addicts was opened in a general hospital under the auspices of the Federal German model project "compact therapy for comprehensive drug treatment". Subsequently more than ten detoxification wards specifically for drug addicts were established in Bavaria alone, primarily in psychiatric county hospitals. Drug addicts are accepted into these qualified detoxification wards without preparation and precondition. Data of 1656 drug addicts were analysed who were treated between 1991 and 1996 at the ward described below: More than 70% come directly from the scene and 33% were accepted for the first time to inpatient detoxification treatment. Most of them are diagnosed with addictions to at least two substances (three substances 44%, two substances 24%). Many suffer from additional diseases: In 1079 out of 1656 a positive hepatitis-C serology was found, 22% had previously tried to commit suicide, 37% had to be treated in intensive-care because of life-threatening intoxication. Nevertheless, 58% of the drug addicts are transferred into continuing therapy after detoxification treatment or they continue to work in permanent employment. During detoxification treatment no patient died. Acceptance, additional diseases which can be diagnosed and treated best in a general hospital, and the high prevalence of addicted persons (at least 17-24%) in internal medical or surgical wards suggest that establishing qualified wards with special settings for addicts in general hospital is useful.

[Prognostic factors in malaria tropica--results of a 1963-1988 evaluation study in Germany]. / Prognostische Faktoren der Malaria tropica--Ergebnisse einer Evaluationsstudie in der Bundesrepublik Deutschland 1963-1988.

A retrospective study was performed on all cases of malaria recorded in the Federal Republic of Germany between 1963 and 1988. The questionnaires evaluated by the Federal Bureau of Public Health showed a total of 8049 cases, of which 3991 concerned malaria tropica, and 173 deaths. During this 26-year period, 90% of the patients suffering from malaria tropica had contracted the disease in Africa. Deaths from malaria had shown a constant figure of almost 10% between 1963 and 1978, but after that there was a distinct drop. Differentiated analysis revealed that between 1979 and 1988 the death rate for malaria tropica acquired in Africa had been 3.3%. This was clearly dependent on chemoprophylaxis behaviour, on the time of initiation of treatment and on the age of the patients; if tablets were taken regularly, the death rate was 2.3%, rising to 3.1% on irregular intake and to 5.4% without chemoprophylaxis. If therapeutic measures were initiated on the 1st to 5th day of onset, the death rate was 0.6%, on the 6th to 10th day 2.4%, on the 11th to 15th day 2.5% and on the 16th to 20th day 16.7%. In the age group between 60 and over 60 years the lethality was 15.9%. In the course of this study the authors worked out a new malaria questionnaire for the Federal Bureau of Public Health.

[A small outbreak of trichinosis caused by imported smoked ham]. / Trichinose-Kleinepidemie durch importierten Schweineschinken.

Three patients fell ill with diarrhoea 14 to 15 days after eating smoked ham. All had an increased white cell count (up to 16,200 microliters), eosinophilia (14 to 38%) and increased creatinkinase activity (357 up to 1905 U/l). Patient 1 (a 21-year-old woman) also had fever of around 40 degrees C; patient 2 (32-year-old woman) had a fever up to 39 degrees C, with muscle pains and swellings in the face. Patient 3 (38-year-old man) had no other symptoms. Because of eosinophilia and as five other family members in former Yugoslavia whence the ham had been imported, also had had fevers, trichinosis was soon considered as the cause. Serology in patients 1 and 2 was positive on admission, in patient 3 after one week. Mebendazole was administered, initially 50 mg/kg in three doses for 2 days. Drug blood levels were determined 1 and 4 hours after start of treatment and the dosage was then increased to 80-100 mg/kg daily. Duration of treatment ranged from 11 to 14 days. All patients were discharged symptom-free and there have been no sequelae. In Germany trichinosis typically occurs in small outbreaks. It is assuming increasing importance as an imported disease.

Quinine resistant falciparum malaria acquired in east Africa.

A 43 year old man with falciparum malaria acquired in East Africa was treated with quinine intravenously at a loading dose of 500 mg and subsequently 500 mg tid. Within 42 hours after initiation of treatment the parasitaemia increased from 2% to 16%. A RIII-resistance against quinine was suspected and therapy was switched to oral administration of halofantrine (500 mg at 6 hourly intervals) which led to complete recovery. Blood samples were cultured for malaria parasites 42 hours after start of therapy with quinine but before initiation of therapy with halofantrine. In vitro resistance testing was performed with samples directly derived from the patient and after 24 and 48 hours of culturing. In repeated tests an in vitro resistance to quinine could be confirmed (IC50: 25.6 x 10(-6) mol/l, IC99: > 51.2 x 10(-6) mol/l) while the strain was fully susceptible to chloroquine (IC50: < 0.4 x 10(-6) mol/l, IC99: 1.6 x 10(-6) mol/l), mefloquine (IC50: < 0.4 x 10(-6) mol/l, IC99: 3.2 x 10(-6) mol/l), tetracycline (IC50: 0.16 x 10(-6) mol/l, IC99: 0.32 x 10(-6) mol/l) and halofantrine (IC50: 0.02 x 10(-6) mol/l, IC99: 0.04 x 10(-6) mol/l). Increased susceptibility to quinine after addition of verapamil was noted. The presence of a specific mutation, on the pfmdr1-gene on chromosome 5, previously associated with chloroquine drug resistance, could be confirmed by polymerase chain reaction. To our knowledge a R III-in vivo and in vitro resistance of Plasmodium falciparum to quinine has not been described yet in East Africa.(ABSTRACT TRUNCATED AT 250 WORDS)

[Subacute progressive polyneuropathy syndrome in HIV infection. The efficacy of immunosuppressive treatment?]. / Subakut progredientes Polyneuropathiesyndrom bei HIV-Infektion. Wirksamkeit der immunsuppressiven Behandlung?

A subacute advanced severe sensorimotor polyneuropathy developed over 6 months in a 47-year-old patient in stage 5 of an HIV infection (Walter Reed Hospital classification). Clinical examination, cranial computed tomography and spinal nuclear magnetic imaging failed to demonstrate any central nervous system complication. Cerebrospinal fluid showed a lymphocytic pleocytosis of 57/3 cells and total protein raised to 132 mg/dl as sign of an abnormal blood-brain barrier. Circulating immune complex in blood was raised to 30%. Assuming an immune-complex mediated neuropathy treatment with oral steroids was started, initially 150 mg daily. The signs of polyneuropathy regressed almost completely, even after prednisolone was discontinued. The proportion of circulating immune complexes in blood fell within 7 weeks to 10% during this treatment. It is suggested that in HIV-infected patients severe polyneuropathies may develop as part of a humoral immune reaction in which immunosuppressive treatment can be effective. Even in advanced HIV infection high-dosage and prolonged steroid treatment can be undertaken, under strictest indications, and may have impressive results.

Treatment of hepatitis C infection in injection drug users.

Chronic hepatitis C is the most common infectious disease among injection drug users (IDUs). Because of the allegedly poor compliance of IDUs with treatment requirements and conditions, hepatologists recommend treatment only if former IDUs have spent 6 to 12 months drug free. The aim of this prospective study was to investigate whether opiate-dependent IDUs with chronic hepatitis C virus (HCV) infection can be treated successfully with interferon. Eligibility for the study meant IDUs had to be HCV-RNA positive by polymerase chain reaction. Subsequently 50 inpatients were enrolled during detoxification treatment. HCV treatment was started with interferon alfa-2a (through 1998) or a combined regimen consisting of interferon alfa-2a and ribavirin (begun in 1998). All patients were treated and supervised by specialized physicians in both hepatology and addiction medicine. The end point for this study was defined as a loss of detectable serum HCV RNA at week 24 after treatment. The rate of sustained virologic response was 36%. Sustained response rates were not significantly different for patients who relapsed and returned to treatment (53%), relapsed and did not return to treatment (24%), or did not relapse (40%; P >.05). During the 24 weeks after treatment, we were unable to detect any reinfection, even among patients who injected heroin during this period. This surprising result should be examined in further studies. In conclusion, HCV-infected drug addicts with chronic HCV infection can be treated successfully with interferon alfa-2a and ribavirin if they are closely supervised by physicians specialized in both hepatology and addiction medicine.

[Disseminated cryptococcosis in 2 AIDS patients. A contribution to cryptococcosis diagnosis in AIDS]. / Disseminierte Kryptokokkose bei zwei AIDS-Patienten. Ein Beitrag zur Kryptokokkose-Diagnostik bei AIDS.

In two AIDS patients (homosexual men) microscopical demonstration of Cryptococcus neoformans in samples obtained by puncture of the liver (n = 1) and additionally of the spleen (n = 1) led to the diagnosis of systemic cryptococcosis. Using the India ink method capsulated Cryptococcus neoformans cells could also be detected in cerebrospinal fluid (CSF) and urine. Concomitant culture of the fungus from tracheal secretion, CSF, urine and faeces confirmed the diagnosis of a disseminated infection; the identification and germ count of C. neoformans was achieved by means of the differential-selective medium Guizotia-abyssinica-creatinine agar. The C. neoformans antigen titres in serum and CSF corresponded to the stage of the mycosis as detected by microscopy and culture. After a six-week course of treatment with amphotericin B and flucytosine (Ancotil), the fungus could no longer be isolated from the materials examined in one patient. Mycological monitoring aiming at the detection of C. neoformans in the tracheal secretions by means of the mentioned differential-selective medium is therefore recommended as a prophylactic measure in AIDS patients and persons at risk.

HIV-related malignant lymphomas. A clinical and pathological study of 13 cases.

The clinical and laboratory records of 13 patients with HIV-related lymphomas diagnosed between 1983 and 1987 are reviewed. 8 cases were classified as high-grade Non-Hodgkin-lymphomas (NHL), 4 as low-grade NHL (including 2 plasmocytomas), and one as Hodgkin's disease (HD). 11 of the 12 NHL were of the B-cell lineage. The mean patient's age was 39 years. At initial staging evaluation extranodal disease was present in 10 patients, in one of them as primary central nervous system (CNS) lymphoma; 9 patients presented with stage III or stage IV involvement. 9 patients were eligible for multidrug chemotherapy. In 5 cases an initial complete remission (CR) was observed, followed, however, by CNS relapse within a few months in 3 patients. 3 patients did not respond to chemotherapy and died within 4 to 6 weeks. Of the 9 patients treated chemotherapeutically, 5 died within 1 to 5 months, 1 is still alive in CR and 3 are still alive in partial remission (PR).

[Falciparum malaria in East African tourists in spite of fansidar prevention. A contribution on increased chloroquine and pyrimethamine-sulfadoxine resistance in areas of East Africa]. / Falciparum-Malaria bei Ostafrika-Touristen trotz Fansidar-Prophylaxe. Ein Beitrag zur wachsenden Chloroquin- und Pyrimethamin-Sulfadoxin-Resistenz in Gebieten Ostafrikas.

A decreased chloroquine (Resochin) sensitivity of strains of Plasmodium falciparum in certain areas of East Africa has given rise to an inappropriate change of chemoprophylaxis to pyrimethamine-sulfadoxine (Fansidar). Falciparum malaria occurred in five tourists during or after Fansidar prophylaxis. A therapeutic chloroquine-R2-resistance was observed in one seriously ill patient. In some patients the course of disease was prolonged to such an extent that the diagnosis could be established only after as much as 4 months after the end of the journey. This was in part surely caused by intake of anti-plasmodial drugs such as sulfonamides, tetracyclines and co-trimoxazol. The high mortality of falciparum malaria of nearly 10% in this country does not depend on the choice of drug prophylaxis or on problems of resistance, but still on a missed or delayed diagnosis.