Cutaneous Strongyloides Infection Postchemotherapy.

BACKGROUND AND OBJECTIVE: While clinical symptoms of strongyloidiasis are often nonspecific, larva currens (with erythematous, serpiginous, and pruritic papules and plaques) should prompt investigation including stool microscopy, serology, and skin biopsy of the lesion. Appropriate diagnosis and treatment with ivermectin is necessary, especially in the immunocompromised patient who is at increased risk for hyperinfection syndrome and disseminated disease. CONCLUSION: We present a 61-year-old immunocompromised man with presentation of larva currens of cutaneous strongyloides infection without symptoms of hyperinfection or disseminated disease.

Illness in travelers returned from Brazil: the GeoSentinel experience and implications for the 2014 FIFA World Cup and the 2016 Summer Olympics.

BACKGROUND: Brazil will host the 2014 FIFA World Cup and the 2016 Olympic and Paralympic Games, events that are expected to attract hundreds of thousands of international travelers. Travelers to Brazil will encounter locally endemic infections as well as mass event-specific risks. METHODS: We describe 1586 ill returned travelers who had visited Brazil and were seen at a GeoSentinel Clinic from July 1997 through May 2013. RESULTS: The most common travel-related illnesses were dermatologic conditions (40%), diarrheal syndromes (25%), and febrile systemic illness (19%). The most common specific dermatologic diagnoses were cutaneous larva migrans, myiasis, and tungiasis. Dengue and malaria, predominantly Plasmodium vivax, were the most frequently identified specific causes of fever and the most common reasons for hospitalization after travel. Dengue fever diagnoses displayed marked seasonality, although cases were seen throughout the year. Among the 28 ill returned travelers with human immunodeficiency virus (HIV) infection, 11 had newly diagnosed asymptomatic infection and 9 had acute symptomatic HIV. CONCLUSIONS: Our analysis primarily identified infectious diseases among travelers to Brazil. Knowledge of illness in travelers returning from Brazil can assist clinicians to advise prospective travelers and guide pretravel preparation, including itinerary-tailored advice, vaccines, and chemoprophylaxis; it can also help to focus posttravel evaluation of ill returned travelers. Travelers planning to attend mass events will encounter other risks that are not captured in our surveillance network.

GeoSentinel surveillance of illness in returned travelers, 2007-2011.

BACKGROUND: International travel continues to increase, particularly to Asia and Africa. Clinicians are increasingly likely to be consulted for advice before travel or by ill returned travelers. OBJECTIVE: To describe typical diseases in returned travelers according to region, travel reason, and patient demographic characteristics; describe the pattern of low-frequency travel-associated diseases; and refine key messages for care before and after travel. DESIGN: Descriptive, using GeoSentinel records. SETTING: 53 tropical or travel disease units in 24 countries. PATIENTS: 42 173 ill returned travelers seen between 2007 and 2011. MEASUREMENTS: Frequencies of demographic characteristics, regions visited, and illnesses reported. RESULTS: Asia (32.6%) and sub-Saharan Africa (26.7%) were the most common regions where illnesses were acquired. Three quarters of travel-related illness was due to gastrointestinal (34.0%), febrile (23.3%), and dermatologic (19.5%) diseases. Only 40.5% of all ill travelers reported pretravel medical visits. The relative frequency of many diseases varied with both travel destination and reason for travel, with travelers visiting friends and relatives in their country of origin having both a disproportionately high burden of serious febrile illness and very low rates of advice before travel (18.3%). Life-threatening diseases, such as Plasmodium falciparum malaria, melioidosis, and African trypanosomiasis, were reported. LIMITATIONS: Sentinel surveillance data collected by specialist clinics do not reflect healthy returning travelers or those with mild or self-limited illness. Data cannot be used to infer quantitative risk for illness. CONCLUSION: Many illnesses may have been preventable with appropriate advice, chemoprophylaxis, or vaccination. Clinicians can use these 5-year GeoSentinel data to help tailor more efficient pretravel preparation strategies and evaluate possible differential diagnoses of ill returned travelers according to destination and reason for travel. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

Travel-associated illness trends and clusters, 2000-2010.

Longitudinal data examining travel-associated illness patterns are lacking. To address this need and determine trends and clusters in travel-related illness, we examined data for 2000-2010, prospectively collected for 42,223 ill travelers by 18 GeoSentinel sites. The most common destinations from which ill travelers returned were sub-Saharan Africa (26%), Southeast Asia (17%), south-central Asia (15%), and South America (10%). The proportion who traveled for tourism decreased significantly, and the proportion who traveled to visit friends and relatives increased. Among travelers returning from malaria-endemic regions, the proportionate morbidity (PM) for malaria decreased; in contrast, the PM trends for enteric fever and dengue (excluding a 2002 peak) increased. Case clustering was detected for malaria (Africa 2000, 2007), dengue (Thailand 2002, India 2003), and enteric fever (Nepal 2009). This multisite longitudinal analysis highlights the utility of sentinel surveillance of travelers for contributing information on disease activity trends and an evidence base for travel medicine recommendations.

A review of amoebic liver abscess for clinicians in a nonendemic setting.

Amoebic liver abscess (ALA) is an uncommon but potentially life-threatening complication of infection with the protozoan parasite Entamoeba histolytica. E histolytica is widely distributed throughout the tropics and subtropics, causing up to 40 million infections annually. The parasite is transmitted via the fecal-oral route, and once it establishes itself in the colon, it has the propensity to invade the mucosa, leading to ulceration and colitis, and to disseminate to distant extraintestinal sites, the most common of which is the liver. The authors provide a topical review of ALA and summarize clinical data from a series of 29 patients with ALA presenting to seven hospitals in Toronto, Ontario, a nonendemic setting, over 30 years.

Severe refractory erythema nodosum leprosum successfully treated with the tumor necrosis factor inhibitor etanercept.

Erythema nodosum leprosum (ENL), or type II reaction, is a common complication of lepromatous leprosy that can cause significant patient debility. First-line therapy includes prednisone and thalidomide, with clofazimine reserved for patients who do not respond to first-line treatment. We present the case of a 33-year-old woman with ENL that failed to respond adequately to conventional therapy over a 6-year period. Because of the severe nature of her disease and the adverse effects of therapy that she experienced, a trial of etanercept was undertaken, which led to full resolution of her ENL. The rationale behind our choice of therapy and its future implications are discussed.

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.

Multicenter GeoSentinel analysis of rickettsial diseases in international travelers, 1996-2008.

We investigated epidemiologic and clinical aspects of rickettsial diseases in 280 international travelers reported to the GeoSentinel surveillance Network during 1996-2008. Of these 280 travelers, 231 (82.5%) had spotted fever (SFG) rickettsiosis, 16 (5.7%) scrub typhus, 11 (3.9%) Q fever, 10 (3.6%) typhus group (TG) rickettsiosis, 7 (2.5%) bartonellosis, 4 (1.4%) indeterminable SFG/TG rickettsiosis, and 1 (0.4%) human granulocytic anaplasmosis. One hundred ninety-seven (87.6%) SFG rickettsiosis cases were acquired in sub-Saharan Africa and were associated with higher age, male gender, travel to southern Africa, late summer season travel, and travel for tourism. More than 90% of patients with rickettsial disease were treated with doxycycline, 43 (15.4%) were hospitalized, and 4 had a complicated course, including 1 fatal case of scrub typhus encephalitis acquired in Thailand.

Spectrum of disease and relation to place of exposure among ill returned travelers.

BACKGROUND: Approximately 8 percent of travelers to the developing world require medical care during or after travel. Current understanding of morbidity profiles among ill returned travelers is based on limited data from the 1980s. METHODS: Thirty GeoSentinel sites, which are specialized travel or tropical-medicine clinics on six continents, contributed clinician-based sentinel surveillance data for 17,353 ill returned travelers. We compared the frequency of occurrence of each diagnosis among travelers returning from six developing regions of the world. RESULTS: Significant regional differences in proportionate morbidity were detected in 16 of 21 broad syndromic categories. Among travelers presenting to GeoSentinel sites, systemic febrile illness without localizing findings occurred disproportionately among those returning from sub-Saharan Africa or Southeast Asia, acute diarrhea among those returning from south central Asia, and dermatologic problems among those returning from the Caribbean or Central or South America. With respect to specific diagnoses, malaria was one of the three most frequent causes of systemic febrile illness among travelers from every region, although travelers from every region except sub-Saharan Africa and Central America had confirmed or probable dengue more frequently than malaria. Among travelers returning from sub-Saharan Africa, rickettsial infection, primarily tick-borne spotted fever, occurred more frequently than typhoid or dengue. Travelers from all regions except Southeast Asia presented with parasite-induced diarrhea more often than with bacterial diarrhea. CONCLUSIONS: When patients present to specialized clinics after travel to the developing world, travel destinations are associated with the probability of the diagnosis of certain diseases. Diagnostic approaches and empiric therapies can be guided by these destination-specific differences.

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.

Seasonality, annual trends, and characteristics of dengue among ill returned travelers, 1997-2006.

We examined seasonality and annual trends for dengue cases among 522 returned travelers reported to the international GeoSentinel Surveillance Network. Dengue cases showed region-specific peaks for Southeast Asia (June, September), South Central Asia (October), South America (March), and the Caribbean (August, October). Travel-related dengue exhibited annual oscillations with several epidemics occurring during the study period. In Southeast Asia, annual proportionate morbidity increased from 50 dengue cases per 1,000 ill returned travelers in nonepidemic years to an average of 159 cases per 1,000 travelers during epidemic years. Dengue can thus be added to the list of diseases for which pretravel advice should include information on relative risk according to season. Also, dengue cases detected at atypical times in sentinel travelers may inform the international community of the onset of epidemic activity in specific areas.

The underestimated risk of hepatitis A and hepatitis B: benefits of an accelerated vaccination schedule.

Hepatitis A virus (HAV) and hepatitis B virus (HBV) are vaccine-preventable. Current recommendations advocate vaccination of non-immune adults at risk of exposure, including travelers to HAV or HBV endemic areas, individuals with high risk of contracting a sexually transmitted infection, and some correctional facility inmates. We review the use of an accelerated schedule to administer the combination hepatitis A and hepatitis B vaccine (Twinrix). Administering three doses over three weeks and a fourth at 12 months provides rapid initial protection of most individuals for whom the standard 6-month vaccination schedule would not be suitable, including last-minute travelers and short-term correctional facility inmates. Furthermore, we consider the role of a universal vaccination strategy in preventing the spread of HAV and HBV.

Unsuccessful treatment of a horse with mandibular granulomatous osteomyelitis due to Halicephalobus gingivalis.

An 8-year-old horse was presented with a submandibular swelling. Biopsy of the lesion indicated granulomatous osteomyelitis due to Halicephalobus gingivalis. In the absence of evidence of involvement of the central nervous system at the time of diagnosis, the horse was treated with ivermectin. Unfortunately, the horse did not survive.