Schistosoma and Strongyloides screening in migrants initiating HIV Care in Canada: a cross sectional study.

BACKGROUND: Following migration from Schistosoma and Strongyloides endemic to non-endemic regions, people remain at high risk for adverse sequelae from these chronic infections. HIV co-infected persons are particularly vulnerable to the serious and potentially fatal consequences of untreated helminth infection. While general screening guidelines exist for parasitic infection screening in immigrant populations, they remain silent on HIV positive populations. This study assessed the seroprevalence, epidemiology and laboratory characteristics of these two parasitic infections in a non-endemic setting in an immigrant/refugee HIV positive community. METHODS: Between February 2015 and 2018 individuals born outside of Canada receiving care at the centralized HIV clinic serving southern Alberta, Canada were screened by serology and direct stool analysis for schistosomiasis and strongyloidiasis. Canadian born persons with travel-based exposure risk factors were also screened. Epidemiologic and laboratory values were analyzed using bivariate logistic regression. We assessed the screening utility of serology, direct stool analysis, eosinophilia and hematuria. RESULTS: 253 HIV positive participants were screened. The prevalence of positive serology for Schistosoma and Strongyloides was 19.9 and 4.4%, respectively. Age between 40 and 50 years (OR 2.50, 95% CI 1.13-5.50), refugee status (3.55, 1.72-7.33), country of origin within Africa (6.15, 2.44-18.60), eosinophilia (3.56, 1.25-10.16) and CD4 count < 200 cells/mm3 (2.46, 1.02-5.92) were associated with positive Schistosoma serology. Eosinophilia (11.31, 2.03-58.94) was associated with positive Strongyloides serology. No Schistosoma or Strongyloides parasites were identified by direct stool microscopy. Eosinophilia had poor sensitivity for identification of positive serology. Hematuria was not associated with positive Schistosoma serology. CONCLUSION: Positive Schistosoma and Strongyloides serology was common in this migrant HIV positive population receiving HIV care in Southern Alberta. This supports the value of routine parasitic screening as part of standard HIV care in non-endemic areas. Given the high morbidity and mortality in this relatively immunosuppressed population, especially for Strongyloides infection, screening should include both serologic and direct parasitological tests. Eosinophilia and hematuria should not be used for Schistosoma and Strongyloides serologic screening in HIV positive migrants in non-endemic settings.

Severe facial necrosis in a type 1 diabetic patient secondary to mucormycosis masquerading as an internal maxillary artery occlusion: a case report.

BACKGROUND: Mucormycosis is a group of rare but life threatening angioinvasive infections caused by fungi of the order Mucorales that often occurs in immunocompromised patients and individuals with poorly controlled diabetes. Rhinocerebral mucormycosis can mimic sinusitis but can rapidly progress to deeper disease and cause facial necrosis. Facial vascular thrombosis is a rare complication of mucormycosis and can confound diagnosis of the disease. CASE PRESENTATION: We report the case of a 25-year-old female with poorly controlled type 1 diabetes mellitus who initially presented with symptoms of sinusitis but rapidly progressed with signs of left-sided facial necrosis due to occlusion of the left internal maxillary artery. Early surgical debridement did not yield a microbiological diagnosis. Deeper surgical debridements ultimately revealed angioinvasive fungal disease consistent with mucormycosis. The patient recovered after repeated surgical intervention and aggressive parenteral antifungal therapy. CONCLUSION: This case illustrates an atypical complication of mucormycosis, and emphasizes that a high index of suspicion in vulnerable patient populations aids in the diagnosis of this life-threatening infection.

False positive malaria rapid diagnostic test in returning traveler with typhoid fever.

BACKGROUND: Rapid diagnostic tests play a pivotal role in the early diagnosis of malaria where microscopy or polymerase chain reaction are not immediately available. CASE PRESENTATION: We report the case of a 39 year old traveler to Canada who presented with fever, headache, and abdominal pain after visiting friends and relatives in India. While in India, the individual was not ill and had no signs or symptoms of malaria. Laboratory testing upon his return to Canada identified a false positive malaria rapid diagnostic (BinaxNOW® malaria) result for P. falciparum with coincident Salmonella Typhi bacteraemia without rheumatoid or autoimmune factors. Rapid diagnostic test false positivity for malaria coincided with the presence or absence of Salmonella Typhi in the blood. CONCLUSIONS: Clinicians should be aware that Salmonella Typhi infection may result in a false positive malaria rapid diagnostic test. The mechanism of this cross-reactivity is not clear.

A case report of Capnocytophaga canimorsus meningitis with failure of ceftriaxone therapy.

Background: Capnocytophaga canimorsus is a gram-negative zoonotic organism that has the potential to cause devastating human infection. Historically, treatment with beta-lactams including penicillin and ceftriaxone has been effective. Methods: We describe a complicated case of C. canimorsus meningitis in a 70-year-old female following a superficial puncture wound from her dog's teeth. Results: The case described here was complicated by seizures following treatment with ceftriaxone therapy. This case is also the first reported case of C. canimorsus meningitis associated with moyamoya disease and fibromuscular dysplasia. Conclusions: Physicians should be aware of the possibility of ceftriaxone-resistant C. canimorsus and have a low threshold to broaden antimicrobial coverage in the absence of clinical improvement. We also raise the possibility of an association between vasculopathies and unusual infections like C. canimorsus.

Historique: Le Capnocytophaga canimorsus est un organisme zoonotique à Gram négatif qui a le potentiel de causer une infection humaine dévastatrice. Par le passé, le traitement aux bêta-lactamines, y compris la pénicilline et la ceftriaxone, était efficace. Méthodologie: L'autrice décrit un cas compliqué de méningite à C. canimorsus chez une femme de 70 ans après une plaie punctiforme superficielle causée par la morsure de son chien. Résultats: Ce cas a été compliqué par des convulsions après un traitement à la ceftriaxone. C'est également le premier cas déclaré de méningite à C. canimorsus associée à une maladie de moyamoya et une dysplasie fibromusculaire. Conclusions: Les médecins devraient être au courant du risque de C. canimorsus résistant à la ceftriaxone et du faible seuil pour élargir la couverture antimicrobienne en l'absence d'amélioration clinique. Les auteurs soulèvent également la possibilité d'association entre les vasculopathies et des infections inhabituelles comme le C. canimorsus.

Population-based surveillance for hypermucoviscosity Klebsiella pneumoniae causing community-acquired bacteremia in Calgary, Alberta.

The characteristics of hypermucoviscosity isolates among Klebsiella pneumoniae causing community-acquired bacteremia were investigated. The hypermucoviscous phenotype was present in 8.2% of K pneumoniae isolates, and was associated with rmpA and the K2 serotype; liver abscesses were the most common clinical presentation. The present analysis represents the first population-based surveillance study of hypermucoviscosity among K pneumoniae causing bacteremia.

Les chercheurs ont examiné les caractéristiques des isolats d'hypermucoviscosité en cas de Klebsiella pneumoniae responsable de bactériémie d'origine non nosocomiale. Ils ont constaté la présence du phénotype hypermucovisqueuxdans 8,2 % des isolats de K pneumoniae, qui s'associait au rmpA et au sérotype K2. Les abcès hépatiques en étaient la présentation clinique la plus courante. La présente analyse est la première étude de surveillance en population de l'hypermucoviscosité en cas de K pneumoniae responsable d'une bactériémie.

A case series of infectious complications in medical tourists requiring hospital admission or outpatient home parenteral therapy.

BACKGROUND: Travelling for medical care is increasing, and this medical tourism (MT) may have complications, notably infectious diseases (ID). We sought to identify MT-related infections (MTRIs) in a large Canadian health region and estimate resulting costs. METHODS: Retrospective and prospective capture of post-MT cases requiring hospital admission or outpatient parenteral antimicrobial therapy was completed by canvassing ID physicians practising in Calgary, Alberta, from January 2017 to July 2019. Cost estimates for management were made with the Canadian Institute for Health Information's (CIHI's) patient cost estimator database tool applied to estimated rates of Canadians engaging in MT from a 2017 Fraser Institute report. RESULTS: We identified 12 cases of MT-related infectious syndromes. Eight had microbial etiologies identified. MTs were young (mean 40.3 [SD 12.2] y) and female (n = 11) and pursued surgical treatment (n = 11). Destination countries and surgical procedures varied but were largely cosmetic (n = 5) and orthopaedic (n = 3). Duration to organism identification (mean 5.3 wk) and treatment courses (mean 19 wk) appeared lengthy. CIHI cost estimates for management of relevant infectious complications of our cases ranged from $6,288 to $20,741, with total cost for cases with matching codes (n = 8) totalling $94,290. CONCLUSIONS: In our series of MTRIs, etiologic organisms often found in Canadian-performed post-procedural infections were identified, and prolonged treatment durations were noted. Young women pursuing cosmetic surgery may be a population to target with public health measures to reduce the incidence of MTRIs and burden of disease.

HISTORIQUE: Le nombre de voyages pour obtenir des soins médicaux augmente, et ce tourisme médical (TM) peut être la source de complications, notamment de maladies infectieuses (MI). Les chercheurs ont entrepris de colliger les infections liées au TM (ILTM) dans une grande région sociosanitaire canadienne et d'en estimer les coûts. MÉTHODOLOGIE: Pour procéder à la saisie rétrospective et prospective des cas exigeant une hospitalisation ou un traitement antimicrobien parentéral ambulatoire après le TM, les chercheurs ont sondé les infectiologues d'une grande région sociosanitaire canadienne entre janvier 2017 et juillet 2019. Ils ont évalué les coûts du traitement de ces cas à l'aide de l'outil de la base de données d'évaluation des coûts des patients de l'Institut canadien d'information sur la santé (ICIS), qu'ils ont appliqué aux taux estimatifs de Canadiens qui avaient fait du TM d'après le rapport de l'Institut Fraser de 2017. RÉSULTATS: Les chercheurs ont détecté 12 cas de syndromes infectieux liés au TM, dont huit étaient rattachés à une étiologie microbienne connue. Les touristes médicaux étaient de jeunes (moyenne de 40,3 [ÉT = 12,2] ans) femmes (n = 11) qui voulaient subir une intervention chirurgicale (n = 11). Les destinations et les interventions chirurgicales variaient, mais elles étaient surtout esthétiques (n = 5) et orthopédiques (n = 3). La période avant d'identifier l'organisme (moyenne de 5,3 semaines) et la durée du traitement (moyenne de 19 semaines) semblaient longues. L'ICIS a estimé que les coûts de prise en charge des complications infectieuses pertinentes des cas se situent entre 6 288 $ à 20 741 $, le coût de tous les cas correspondant à un code (n = 8) totalisant 94 290 $. CONCLUSIONS: Dans la série d'ILTM, les chercheurs ont détecté des organismes étiologiques souvent constatés après une intervention réalisée au Canada et ont remarqué que le traitement était plus long. Les jeunes femmes qui veulent subir des interventions de chirurgie esthétique pourraient être une population ciblée pour transmettre des mesures sanitaires, afin de réduire l'incidence d'ILTM et le fardeau de la maladie.

Herpes simplex virus hepatitis in a renal transplant recipient seronegative pre-transplant.

BACKGROUND: Herpes simplex virus (HSV) is a rare cause of acute viral hepatitis but has high mortality rates and primarily affects immunocompromised hosts. We report a case of HSV hepatitis in a 20-year-old female kidney transplant recipient who had 1000-fold elevations in transaminases on post-transplant day 14, and the strategies employed for diagnoses and treatment. METHODS: Routine laboratory, serological, and molecular viral testing was completed, and she underwent a bone marrow biopsy given initial suspicion of hemophagocytic lymphohistiocytosis (HLH). HSV serologic results and high transaminases triggered a liver biopsy. RESULTS: The patient presented with elevated transaminases (ALT 1731 U/L and AST 1400) and ferritin (1431 µg/L). Transaminases and ferritin peaked with an ALT of 6609 U/L, AST of 6525 U/L, and ferritin >50000 µg/L. Bone marrow biopsy revealed no definitive HLH. HSV-DNA PCR of blood was positive, and she was empirically started on intravenous acyclovir 10 mg/kg 3 times per day. Liver biopsy confirmed the histological diagnosis of HSV hepatitis. CONCLUSIONS: Given the high mortality rates associated with HSV hepatitis, it is crucial to determine pre-transplant HSV status, initiate appropriate antiviral prophylaxis, and to have a low threshold for investigating for HSV hepatitis and initiating treatment in patients with a suspected diagnosis.

COVID-19 outbreak among physicians at a Canadian curling bonspiel: a descriptive observational study.

BACKGROUND: Transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is known to occur among individuals who congregate in large groups, especially during indoor activities. Our objective was to provide a detailed clinical description of an outbreak of coronavirus disease 2019 (COVID-19) that occurred after a sporting and social event during the early days of the pandemic. METHODS: We conducted a descriptive study of a curling bonspiel in Edmonton held on Mar. 11-14, 2020. We used standardized interviews between Apr. 17 and May 5, 2020, to collect demographic data, travel history, symptoms (type, onset and duration), self-reported testing results for SARS-CoV-2 ribonucleic acid (RNA) using reverse transcription polymerase chain reaction (RT-PCR), and clinical outcomes. We also obtained results of convalescent SARS-CoV-2 immunoglobulin G serology. RESULTS: All 73 curlers (55 active health care workers) who participated in the bonspiel were interviewed for the study. Convalescent SARS-CoV-2 immunoglobulin G serology was completed in 62 (85%) participants. Of the 73 participants (55 [75%] male, median age 51 [range 26-79] yr, 58 [79%] physicians), 40 curlers (55%) tested positive for SARS-CoV-2 RNA by RT-PCR; an additional 16 participants developed symptoms but had negative swabs or were not tested (14 were probable cases), for a 74% attack rate (confirmed or probable cases). Anosmia with ageusia or dysgeusia occurred in 39 of 54 (72%) confirmed or probable cases. The clinical course was mild in most participants (1 emergency visit, no hospital admissions). Transmission likely occurred from multiple individuals with minor nonspecific symptoms during the event, possibly during shared meals. INTERPRETATION: The 74% attack rate (confirmed or probable cases) highlights the infectivity of SARS-CoV-2 during sporting and social events. This reinforces the need for public health measures (masking, physical distancing and limiting the size of social gatherings) during future waves of COVID-19 in Canada.

Risk of malaria associated with travel to malaria-endemic areas to visit friends and relatives: a population-based case-control study.

BACKGROUND: Reports relying on population-based data and using epidemiologic methodologies such as case-control study designs for malaria in travellers and multivariable regression analysis of risk factors are rare. The aim of this study was to investigate the epidemiologic characteristics of travellers who tested positive for malaria after visiting friends and relatives in malaria-endemic areas to determine the risk of malaria associated with such travel. METHODS: Using routinely collected data from a population-based laboratory database, we conducted a case-control study of symptomatic people returning from travel to malaria-endemic areas who presented for malaria testing in Calgary from 2013 to 2017. We used a multivariable logistic regression to analyze the association between the presence of malaria and other risk factors. RESULTS: There were 251 confirmed malaria cases during the study period, of which 219 were matched to 1129 returning travellers without malaria. Based on the multivariable regression, the odds of a traveller who visited friends and relatives in malariaendemic areas being diagnosed with malaria was 2.82 (95% confidence interval [CI] 1.42-5.92) times greater than that of other travellers to these regions. Adults (odds ratio [OR] 3.62, 95% CI 1.66-8.84), males (OR 2.70, 95% CI 1.56-4.80), travellers to Africa (OR 11.52, 95% CI 6.33-22.05) and those who did not seek pretravel advice (OR 0.38, 95% CI 0.20-0.70) were more likely to be diagnosed with malaria. Although those travelling to visit friends and relatives tended to stay longer in endemic areas than other travellers, visit duration was not associated with an increased likelihood of malaria in the model. The annual incidence of malaria was highest (13.34 per 100 000) in metropolitan wards associated with lower socioeconomic status and immigrant communities. INTERPRETATION: Travellers who visited friends and relatives in malaria-endemic areas were less likely than other travellers to these regions to seek pretravel advice, take prophylaxis and have a visit duration less than 2 weeks; travelling to Africa and being male increased the odds of being diagnosed with malaria, independent of other factors. These data suggest that targeted strategies to provide pretravel care to travellers who visit friends and relatives in malaria-endemic areas may aid in reducing the burden of malaria in this population.

Case Report: Bartonella quintana Endocarditis Outside of the Europe-African Gradient: Comprehensive Review of Cases within North America.

Clinical syndromes associated with Bartonella quintana infection can be insidious and difficult to diagnose for multiple reasons. Clinically, B. quintana can manifest as asymptomatic bacteremia or with subtle subacute constitutional symptoms. Second, it is a fastidious organism that is difficult to identify using traditional culture methods. Last, the body lice vector of B. quintana transmission is likely not uncommon in most patients affected, who are homeless and of low socioeconomic status. Therefore, barriers in seeking medical care and financial constraints for medications are important considerations. The mainstay of literature surrounding B. quintana endocarditis is from Europe and the developing nations. Herein, we describe a case of native valve endocarditis secondary to B. quintana in a homeless male with preexisting valvular disease and undertake a comprehensive literature review of documented B. quintana endocarditis in North America.

NINA-LAMP compared to microscopy, RDT, and nested PCR for the detection of imported malaria.

Microscopy and field adaptable rapid diagnostic tests (RDTs) are not sensitive and specific in certain conditions such as poor training of microscopists, lack of electricity, or lower sensitivity in the detection of non-falciparum malaria. More sensitive point-of-care testing (POCT) would reduce delays in diagnosis and initiation of therapy. In the current study, we have evaluated the efficacy of noninstrumented nucleic acid amplification (NINA) coupled with loop-mediated isothermal amplification (LAMP) for detection of traveler's malaria (n=140) in comparison with microscopy, nested PCR, and the only Food and Drug Administration-approved rapid diagnostic test. NINA-LAMP was 100% sensitive and 98.6% specific when compared to nested PCR. For non-falciparum detection, NINA-LAMP sensitivity was 100% sensitive compared to nested PCR, whereas RDT sensitivity was 71%. LAMP is highly sensitive and specific for symptomatic malaria diagnosis regardless of species.

Subacute sclerosing panencephalitis in pregnancy.

We present a case of subacute sclerosing panencephalitis that developed in a previously healthy 29-year-old pregnant woman who had returned from a trip to rural India shortly before the onset of symptoms. She was admitted to hospital at 27 weeks' gestation with a history of cognitive decline and difficulty completing simple tasks. She had no clinical signs of infection. The working diagnosis was autoimmune encephalitis, although extensive investigations did not lead to a final classifying diagnosis. The patient became comatose and developed hypertension, and an emergency caesarean section was done at 31 weeks to deliver the child, who seemed healthy. The patient died about 6 weeks after the onset of symptoms. The patient was found to have had subacute sclerosing panencephalitis at autopsy. In this Grand Round, we review the clinical features and treatment of subacute sclerosing panencephalitis, and the epidemiological and public health aspects of the case.

First case of Zika virus infection in a returning Canadian traveler.

A woman who recently traveled to Thailand came to a local emergency department with a fever and papular rash. She was tested for measles, malaria, and dengue. Positive finding for IgM antibody against dengue and a failure to seroconvert for IgG against dengue for multiple blood samples suggested an alternate flavivirus etiology. Amplification of a conserved region of the non-structural protein 5 gene of the genus Flavivirus yielded a polymerase chain reaction product with a matching sequence of 99% identity with Zika virus. A urine sample and a nasopharygeal swab specimen obtained for the measles investigation were also positive for this virus by reverse transcription polymerase chain reaction. Subsequently, the urine sample yielded a Zika virus isolate in cell culture. This case report describes a number of novel clinical and laboratory findings, the first documentation of this virus in Canada, and the second documentation from this region in Thailand.

Incidence, risk factors, and outcomes of Klebsiella pneumoniae bacteremia.

BACKGROUND: Although Klebsiella pneumoniae is the second most common cause of Gram-negative bloodstream infections, its epidemiology has not been defined in a nonselected population. We sought to describe the incidence of, risk factors for, and outcomes associated with K. pneumoniae bacteremia. METHODS: Population-based surveillance for K. pneumoniae bacteremia was conducted in the Calgary Health Region (population 1.2 million) from 2000 to 2007. RESULTS: A total of 640 episodes of K. pneumoniae bacteremia were identified for an overall annual population incidence of 7.1 per 100,000; 174 (27%) were nosocomial, 276 (43%) were healthcare-associated community onset, and 190 (30%) were community acquired. Elderly patients and men were at highest risk for K. pneumoniae bacteremia. Dialysis, solid-organ transplantation, chronic liver disease, and cancer were the most important risk factors for acquiring K. pneumoniae bacteremia. Rates of resistance to trimethoprim/sulfamethoxazole increased significantly during 2000 to 2007. The case fatality rate was 20%, and the annual population mortality rate was 1.3 per 100,000. Increasing age, nosocomial acquisition, non-urinary and non-biliary focus of infection, and several comorbid illnesses were independently associated with an increased risk of death. CONCLUSION: This is the first population-based study to document the major burden of illness associated with K. pneumoniae bacteremia and identifies groups at increased risk of acquiring and dying of these infections.

Disability and quality of life in Canadian aboriginal and non-aboriginal diabetic lower-extremity amputees.

OBJECTIVE: To compare and contrast disability and quality of life (QOL) in Aboriginal and non-Aboriginal subjects with diabetes who had lower-extremity amputation (LEA) and were living in urban and rural communities in Canada. DESIGN: Descriptive study using an interviewer-administered questionnaire and hospital medical record review. SETTING: Tertiary care center. PARTICIPANTS: Forty-four diabetic subjects (minimum age, 18 y) not receiving dialysis, including 21 Aboriginal (8 urban, 13 rural) and 23 non-Aboriginal (16 urban, 7 rural) subjects. Subjects were living in their current residence and had undergone LEA above the level of the ankle 6 months or more before interview. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Qualitative and quantitative data about symptoms, impairment, and QOL. RESULTS: Aboriginal subjects were younger than non-Aboriginal subjects at the time of diabetes diagnosis (Aboriginal, 42+/-10 y; non-Aboriginal, 52+/-14 y; P<.005) and first major LEA (Aboriginal, 57+/-7 y; non-Aboriginal, 64+/-11 y; P<.015). All subjects received rehabilitation after amputation. More rural non-Aboriginal subjects (83%) used their prosthesis both in and outside the home for all movements than other subjects (P<.048). Rural non-Aboriginal subjects had the lowest and urban non-Aboriginal subjects had the highest frequency of walking-aid use outside the home. Assistance with personal care was required by a minority of subjects, but assistance with daily housework was required by the majority of subjects. Qualitative analysis revealed that participants were, in most cases, comfortable with their postamputation life. CONCLUSIONS: Although the majority of participants in this study generally felt satisfied with their current status, major functional changes were noted after LEA that had a large negative impact on QOL.