Longitudinal associations of plasma amino acid levels with recovery from malarial coma.

BACKGROUND: Disordered amino acid metabolism is observed in cerebral malaria (CM). This study sought to determine whether abnormal amino acid concentrations were associated with level of consciousness in children recovering from coma. Twenty-one amino acids and coma scores were quantified longitudinally and the data were analysed for associations. METHODS: In a prospective observational study, 42 children with CM were enrolled. Amino acid levels were measured at entry and at frequent intervals thereafter and consciousness was assessed by Blantyre Coma Scores (BCS). Thirty-six healthy children served as controls for in-country normal amino acid ranges. Logistic regression was employed using a generalized linear mixed-effects model to assess associations between out-of-range amino acid levels and BCS. RESULTS: At entry 16/21 amino acid levels were out-of-range. Longitudinal analysis revealed 10/21 out-of-range amino acids were significantly associated with BCS. Elevated phenylalanine levels showed the highest association with low BCS. This finding held when out-of-normal-range data were analysed at each sampling time. CONCLUSION: Longitudinal data is provided for associations between abnormal amino acid levels and recovery from CM. Of 10 amino acids significantly associated with BCS, elevated phenylalanine may be a surrogate for impaired clearance of ether lipid mediators of inflammation and may contribute to CM pathogenesis.

Travel-associated disease among US residents visiting US GeoSentinel clinics after return from international travel.

BACKGROUND: US residents make 60 million international trips annually. Family practice providers need to be aware of travel-associated diseases affecting this growing mobile population. OBJECTIVE: To describe demographics, travel characteristics and clinical diagnoses of US residents who present ill after international travel. METHODS: Descriptive analysis of travel-associated morbidity and mortality among US travellers seeking care at 1 of the 22 US practices and clinics participating in the GeoSentinel Global Surveillance Network from January 2000 to December 2012. RESULTS: Of the 9624 ill US travellers included in the analysis, 3656 (38%) were tourist travellers, 2379 (25%) missionary/volunteer/research/aid workers (MVRA), 1580 (16%) travellers visiting friends and relatives (VFRs), 1394 (15%) business travellers and 593 (6%) student travellers. Median (interquartile range) travel duration was 20 days (10-60 days). Pre-travel advice was sought by 45%. Hospitalization was required by 7%. Compared with other groups of travellers, ill MVRA travellers returned from longer trips (median duration 61 days), while VFR travellers disproportionately required higher rates of inpatient care (24%) and less frequently had received pre-travel medical advice (20%). Illnesses of the gastrointestinal tract were the most common (58%), followed by systemic febrile illnesses (18%) and dermatologic disorders (17%). Three deaths were reported. Diagnoses varied according to the purpose of travel and region of exposure. CONCLUSIONS: Returning ill US international travellers present with a broad spectrum of travel-associated diseases. Destination and reason for travel may help primary health care providers to generate an accurate differential diagnosis for the most common disorders and for those that may be life-threatening.

Longitudinal associations of plasma amino acid levels with recovery from malarial coma.

Background: Disordered amino acid metabolism is observed in cerebral malaria (CM). We sought to determine whether abnormal amino acid concentrations were associated with level of consciousness in children recovering from coma. We quantified 21 amino acids and coma scores longitudinally and analyzed data for associations. Methods: In a prospective observational study, we enrolled 42 children with CM. We measured amino acid levels at entry and at frequent intervals thereafter and assessed consciousness by Blantyre Coma Scores (BCS). Thirty-six healthy children served as controls for in-country normal amino acid ranges. We employed logistic regression using a generalized linear mixed-effects model to assess associations between out-of-range amino acid levels and BCS. Results: At entry 16/21 amino acid levels were out-of-range. Longitudinal analysis revealed 10/21 out-of-range amino acids were significantly associated with BCS. Elevated phenylalanine levels showed the highest association with low BCS. This finding held when out-of-normal-range data were analyzed at each sampling time. Discussion: We provide longitudinal data for associations between abnormal amino acid levels and recovery from CM. Of 10 amino acids significantly associated with BCS, we propose that elevated phenylalanine may be a surrogate for impaired clearance of ether lipid mediators of inflammation contributing to CM pathogenesis.

Association of Campylobacter upsaliensis with persistent bloody diarrhea.

Campylobacter upsaliensis is a zoonotic, emerging pathogen that is not readily recovered in traditional stool culture. This case represents the first report of persistent bloody diarrhea with C. upsaliensis that was confirmed by filtration culture, PCR, and sequencing.

Double-blind placebo-controlled study of mesalamine in post-infective irritable bowel syndrome--a pilot study.

OBJECTIVE: Post-infective irritable bowel syndrome (PI-IBS) is characterized by continuing symptoms of irritable bowel syndrome, typically diarrhea-predominant, following an episode of acute gastroenteritis. There is often an increase in sub-epithelial inflammatory and neuroendocrine cells on colonic mucosal biopsy. Mesalamine is an anti-inflammatory agent, effective in the treatment of inflammatory bowel disease. The goal of this study was to compare mesalamine to placebo on symptoms and quality-of-life (QOL) in PI-IBS. MATERIAL AND METHODS: Twenty patients who developed diarrhea-predominant IBS after gastroenteritis were randomized to receive mesalamine (Asacol®) 1.6 gm b.i.d. or placebo for 12 weeks in a double-blind placebo-controlled study. QOL was assessed using the IBS-QOL questionnaire. Stool frequency, stool consistency, urgency, severity of abdominal pain, severity of bloating, and global-improvement scale were recorded in daily diaries for 7 days at baseline and every 4 weeks. Data were analyzed by comparing the change from baseline to last follow-up. RESULTS: One patient withdrew after randomization; data were incomplete in two patients. Thus, data were analyzed from 17 patients (11 men and 6 women, median age: 27 years, range 22-45 years). Mesalamine was not associated with significant improvement in global symptoms, abdominal pain, bloating, stool urgency, frequency, or consistency (all p ≥ 0.11) or QOL (p ≥ 0.16). CONCLUSIONS: There was no significant improvement in global symptoms or overall QOL with mesalamine in patients with PI-IBS.

Patterns of illness in travelers visiting Mexico and Central America: the GeoSentinel experience.

BACKGROUND: Mexico and Central America are important travel destinations for North American and European travelers. There is limited information on regional differences in travel related morbidity. METHODS: We describe the morbidity among 4779 ill travelers returned from Mexico and Central America who were evaluated at GeoSentinel network clinics during December 1996 to February 2010. RESULTS: The most frequent presenting syndromes included acute and chronic diarrhea, dermatologic diseases, febrile systemic illness, and respiratory disease. A higher proportion of ill travelers from the United States had acute diarrhea, compared with their Canadian and European counterparts (odds ratio, 1.9; P < .0001). During the 2009 H1N1 influenza outbreak from March 2009 through February 2010, the proportionate morbidity (PM) associated with respiratory illnesses in ill travelers increased among those returned from Mexico, compared with prior years (196.0 cases per 1000 ill returned travelers vs 53.7 cases per 1000 ill returned travelers; P < .0001); the PM remained constant in the rest of Central America (57.3 cases per 1000 ill returned travelers). We identified 50 travelers returned from Mexico and Central America who developed influenza, including infection due to 2009 H1N1 strains and influenza-like illness. The overall risk of malaria was low; only 4 cases of malaria were acquired in Mexico (PM, 2.2 cases per 1000 ill returned travelers) in 13 years, compared with 18 from Honduras (PM, 79.6 cases per 1000 ill returned travelers) and 14 from Guatemala (PM, 34.4 cases per 1000 ill returned travelers) during the same period. Plasmodium vivax malaria was the most frequent malaria diagnosis. CONCLUSIONS: Travel medicine practitioners advising and treating travelers visiting these regions should dedicate special attention to vaccine-preventable illnesses and should consider the uncommon occurrence of acute hepatitis A, leptospirosis, neurocysticercosis, acute Chagas disease, onchocerciasis, mucocutaneous leishmaniasis, neurocysticercosis, HIV, malaria, and brucellosis.

Exploring the relationship between chronic undernutrition and asymptomatic malaria in Ghanaian children.

BACKGROUND: A moderate association has been found between asymptomatic parasitaemia and undernutrition. However, additional investigation using the gold standard for asymptomatic parasitaemia confirmation, polymerase chain reaction (PCR), is needed to validate this association. Anthropometric measurements and blood samples from children less than five years of age in a rural Ghanaian community were used to determine if an association exists between chronic undernutrition and PCR-confirmed cases of asymptomatic malaria. METHODS: This was a descriptive cross-sectional study of 214 children less than five years of age from a community near Kumasi, Ghana. Blood samples and anthropometric measurements from these children were collected during physical examinations conducted in January 2007 by partners of the Barekuma Collaborative Community Development Programme. RESULTS: Findings from the logistic model predicting the odds of asymptomatic malaria indicate that children who experienced mild, moderate or severe stunting were not more likely to have asymptomatic malaria than children who were not stunted. Children experiencing anaemia had an increased likelihood (OR = 4.15; 95% CI: 1.92, 8.98) of asymptomatic malaria. Similarly, increased spleen size, which was measured by ultrasound, was also associated with asymptomatic malaria (OR = 2.17; 95% CI: 1.44, 3.28). Fast breathing, sex of the child, and age of the child were not significantly associated with the asymptomatic malaria. CONCLUSIONS: No significant association between chronic undernutrition and presence of asymptomatic malaria was found. Children who experience anaemia and children who have splenomegaly are more likely to present asymptomatic malaria. Programmes aimed at addressing malaria should continue to include nutritional components, especially components that address anaemia.

Prevalence of Strongyloides stercoralis infection and other soil-transmitted helminths by cross-sectional survey in a rural community in Gisagara District, Southern Province, Rwanda.

Background: Strongyloides stercoralis is one of the most neglected tropical diseases. Sparse, dated central African and Rwandan data on seroprevalence are available to guide public health efforts and clinical care. Methods: In February 2016 we conducted a community-based cross-sectional study among 539 asymptomatic participants in a rural area in the Gisagara District, Southern Province, Rwanda. Direct faecal smear (DFS) and modified Koga agar plate culture (APC) were used to detect S. stercoralis infection in a single stool sample. Data on other soil-transmitted helminths diagnosed by DFS were also recorded. Results: Four intestinal helminth infections were diagnosed, with S. stercoralis (17.4%) and hookworms (8.2%) seen most often. APC, compared with DFS, increased the diagnosis rate for S. stercoralis from 1.9% to 17.4% (p<0.01). The prevalence was higher in farmers and those with lower socio-economic status. Females were less often infected than males (odds ratio 0.6 [95% confidence interval 0.3 to 0.9], p=0.02). Conclusions: S. stercoralis is highly prevalent among the general population in a rural area of Gisagara District, Southern Province, Rwanda. Access to effective diagnosis and treatment is needed for this neglected disease.

Case report: gnathostomiasis in two travelers to Zambia.

Gnathostomiasis is a systemic infection caused by migrating nematode larvae of the genus Gnathostoma. It is a zoonosis involving a wide variety of animals as intermediate and definitive hosts, and consumption of raw fish is the main risk factor. The condition is most commonly seen in southeastern Asia, but has been described in a number of other countries, all outside Africa. We report the infection in two travelers returning from southcentral Africa, who presented with non-specific symptoms and marked eosinophilia, and in whom schistosomiasis was initially suspected. The typical migratory skin lesions of gnathostomiasis appeared later. The infections responded well to albendazole. The patients acquired the infection in western Zambia; this region of Africa appears to be a newly identified risk area for gnathostomiasis in tourists who indulge in eating raw freshwater fish.

A prospective, randomized controlled study of computer-assisted learning in parasitology.

PURPOSE: To compare, using a prospective, randomized controlled study, three methods of teaching a medical school parasitology course: computer-based instruction, traditional lecture-based instruction, and a combination of computer-based and lecture-based instruction. METHOD: A single class of the University of Utah School of Medicine was randomized into three study groups for the second-year parasitology course. The computer group (n = 29) used a locally developed interactive parasitology computer program; the lecture group (n = 32) had traditional lectures, and the combined group (n = 33) used both the computer program and lectures. Students' knowledge was assessed using a pretest, a final examination, and a posttest administered four months after the course. Students also used logs to track the amounts of time they spent studying. Their impressions and course evaluations were collected using a standardized course-evaluation form. RESULTS: The groups' scores on the pretest, final examination, and posttest were not statistically significantly different. Students in the computer group averaged 26.8 hours of studying over the two-week course compared with 32.1 hours in the lecture group and 32.7 hours in the combined group. The difference in study times between the computer and combined groups yielded a significant p value of 0.036. Students were generally positive about the course and the computer program. CONCLUSION: Students can learn parasitology from computer-based instruction as effectively as from traditional lecture-based instruction, and they can do so in less time.

The visiting internet Fiancé/ée (VIF): an emerging group of international travelers.

Here we describe an emerging category of travelers called the Visiting Internet Fiancé/ée (VIF), characterized by their travel to pursue a romantic relationship with an individual they have only encountered online. The VIF is not well identified in travel medicine literature despite having a higher risk for several travel-related issues including sexually transmitted infections, monetary fraud, and international scams. We also propose specific counseling interventions designed to minimize the adverse outcomes faced by the VIF traveler.

Acute primary toxoplasmosis in travelers returning from endemic countries.

Fourteen cases of toxoplasmosis in immunocompetent travelers who visited high prevalence countries are described. This represents the first series of toxoplasmosis in returned travelers from North America, substantiating the need to consider toxoplasmosis in returned travelers who present with non-specific symptoms, especially fever, lymphadenopathy, and fatigue.

Standardized training in nurse model travel clinics.

BACKGROUND: International travel plays a significant role in the emergence and redistribution of major human diseases. The importance of travel medicine clinics for preventing morbidity and mortality has been increasingly appreciated, although few studies have thus far examined the management and staff training strategies that result in successful travel-clinic operations. Here, we describe an example of travel-clinic operation and management coordinated through the University of Utah School of Medicine, Division of Infectious Diseases. This program, which involves eight separate clinics distributed statewide, functions both to provide patient consult and care services, as well as medical provider training and continuing medical education (CME). METHODS: Initial training, the use of standardized forms and protocols, routine chart reviews and monthly continuing education meetings are the distinguishing attributes of this program. An Infectious Disease team consisting of one medical doctor (MD) and a physician assistant (PA) act as consultants to travel nurses who comprise the majority of clinic staff. RESULTS: Eight clinics distributed throughout the state of Utah serve approximately 6,000 travelers a year. Pre-travel medical services are provided by 11 nurses, including 10 registered nurses (RNs) and 1 licensed practical nurse (LPN). This trained nursing staff receives continuing travel medical education and participate in the training of new providers. All nurses have completed a full training program and 7 of the 11 (64%) of clinic nursing staff serve more than 10 patients a week. Quality assurance measures show that approximately 0.5% of charts reviewed contain a vaccine or prescription error which require patient notification for correction. CONCLUSION: Using an initial training program, standardized patient intake forms, vaccine and prescription protocols, preprinted prescriptions, and regular CME, highly trained nurses at travel clinics are able to provide standardized pre-travel care to international travelers originating from Utah.

Health risks in travelers to South Africa: the GeoSentinel experience and implications for the 2010 FIFA World Cup.

Using the GeoSentinel database, an analysis of ill patients returning from throughout sub-Saharan Africa over a 13-year period was performed. Systemic febrile illness, dermatologic, and acute diarrheal illness were the most common syndromic groupings, whereas spotted fever group rickettsiosis was the most common individual diagnosis for travelers to South Africa. In contrast to the rest of sub-Saharan Africa, only six cases of malaria were documented in South Africa travelers. Vaccine-preventable diseases, typhoid, hepatitis A, and potential rabies exposures were uncommon in South Africa travelers. Pre-travel advice for the travelers to the 2010 World Cup should be individualized according to these findings.

Development of functional diarrhea, constipation, irritable bowel syndrome, and dyspepsia during and after traveling outside the USA.

BACKGROUND: Persistent gastrointestinal (GI) symptoms after travel abroad may be common. It remains unclear how often subjects who developed new GI symptoms while abroad have persistent symptoms on return. The objective of this retrospective study was to evaluate the prevalence of persistent GI symptoms in a healthy cohort of travelers. METHODS: One hundred and eight consecutive patients, mostly returned missionaries, attending the University of Utah International Travel Clinic for any reason (but mostly GI symptoms) had data recorded about their bowel habits before, during, and after travel abroad. All subjects had standard hematological, biochemical, and microbiological tests to exclude known causes of their symptoms. Endoscopic procedures were performed when considered necessary by the treating physician. Diarrhea, constipation, irritable bowel syndrome (IBS), bloating, and dyspepsia were defined according to the Rome II Criteria. RESULTS: Eighty three (82% men and 18% women, median age 21 years) completed the survey with 68 subjects completing the questionnaire about bowel habits before and during travel. Among the respondents, 55 (82.1%) did not have any symptoms before travel. During travel, 41 (63%) developed new onset diarrhea; 6 (9%) developed constipation; 16 (24%) IBS, 29 (45%) bloating; and 11 (16%) dyspepsia. Of those who developed symptoms during travel, 27 (68%) had persistent diarrhea, 3 (50%) had persistent constipation, 10 (63%) had persistent IBS, 12 (43%) had persistent bloating and 8 (73%) had persistent dyspepsia. The presence of bowel symptoms during and after travel was not associated with age, gender, travel destination, or duration of travel. CONCLUSIONS: This study suggests that new onset of diarrhea, IBS, constipation, and dyspepsia are common among subjects traveling abroad. Gastrointestinal symptoms that develop during travel abroad usually persist on return.

Fatal granulomatous Acanthamoeba encephalitis mimicking a stroke, diagnosed by correlation of results of sequential magnetic resonance imaging, biopsy, in vitro culture, immunofluorescence analysis, and molecular analysis.

Amebic infections involving the central nervous system are rare and difficult to diagnose. Magnetic resonance imaging (MRI) at timed intervals may be helpful, where scans reveal enhancing lesions and increased signal. We report a unique case of granulomatous amebic encephalitis that was proven pathologically with progressive radiological findings on MRI.