A Difficult Diagnosis of Plasmodium ovale Malaria.

Malaria is a major cause of suffering, disease, and death worldwide and is considered the most important of all human parasitic diseases. Malaria is still endemic in most tropical and sub-tropical areas and globalization has contributed to an increase of imported cases around the world. We report a Plasmodium ovale infection in a traveler with recent return from a long land trip across West Africa. He declared adherence to mefloquine chemoprophylaxis only at the start of the trip. Initially, he was seen at two different hospitals and in both he was screened for malaria by microscopy and rapid diagnostic test, but his diagnosis was not confirmed. The traveler was then diagnosed at our hospital with a malaria infection by Plasmodium ovale. Complete blood count showed mild anemia, but leukocytes and platelets were already normal. Symptoms resolved in 24 hours after treatment started. Microscopy of stained blood films remains the gold standard for malaria diagnosis, which is critically dependent on trained eyes. In non-endemic regions with few cases during the year, training programs in malaria microscopy are crucial. The aim is to prevent the reintroduction of malaria in Europe, reduce individual morbidity and suffering, and thus contribute towards reduction in deaths caused by this disease.

A malária é uma das principais causas de sofrimento, doença e morte no mundo e é considerada a mais importante doença parasitária em humanos. A malária ainda é endémica na maioria das áreas tropicais e sub-tropicais e a globalização tem contribuído para o aumento de casos em todo o mundo. Relatamos um caso de infeção por Plasmodium ovale num viajante com regresso recente de uma viagem por terra por vários países de África Ocidental. O viajante aderiu à profilaxia com mefloquina apenas no início da viagem. Já em Portugal, sentindo-se doente, febril, dirigiu-se a dois hospitais, onde realizou despiste para malária por microscopia e teste rápido, que foram descritos como negativos. Posteriormente, o viajante dirigiu-se ao nosso serviço onde foi diagnosticada uma infeção de malária por Plasmodium ovale. Os achados analíticos revelaram uma contagem de leucócitos normal, anemia moderada e, uma contagem de plaquetas já normal. Os sintomas terminaram com apenas 24 horas de tratamento. O método de referência do diagnóstico de malária continua a ser a microscopia, que é altamente dependente da experiência do pessoal do laboratório. Em regiões não endémicas com poucos casos durante o ano, é essencial promover e manter programas de capacitação em microscopia para prevenir a reintrodução da malária na Europa, diminuir a morbilidade e o sofrimento, e contribuir assim, para a redução do número de mortes pela doença.

Risk of liver decompensation assessed in HIV/HCV co-infected individuals with advanced liver fibrosis: a faster countdown experience.

INTRODUCTION: Cirrhosis secondary to HCV infection is expected to peak in the next decade, particularly in the HIV co-infected subgroup and has become a leading cause of morbidity among these individuals. Efforts must be done to estimate the risk of liver decompensation (LD) in the short term, in order to define the appropriate time for HCV treatment. MATERIALS AND METHODS: Retrospective observational cohort study aimed to assess the risk of LD among a group of HIV/HCV co-infected patients diagnosed in the past 23 years in a central hospital of Lisbon. INCLUSION CRITERIA: (1) advanced liver fibrosis ≥F3; (2) HCV treatment naïve or without sustained virologic response (SVR). Patients had a one to five years period of follow-up. Multiple linear regression, Mann-Whitney and Kendall were the statistical tests performed. RESULTS: From 444 HIV/HCV co-infections, 66 met the inclusion criteria, with preponderance of male gender (82%), 35-45 years of age (55%), genotype 1a (52%), a mean of 13 years of co-infection and an AIDS stage documented in 65%, though the majority is under antiretroviral therapy (86%) and have TCD4+>500 µ/L (59%). Half (52%) showed evidence of steatosis, many of these (41%) presenting a history of alcoholism or overweight (BMI ≥25 Kg/m(2)). Pre-cirrhotic (F3 or F3/4) or cirrhotic (F4) stage was documented in 36 and 30 patients respectively. After staging, 28 (42%) initiated HCV treatment and SVR was achieved in 8 (29%) of those. Five (14%) pre-cirrhotic and twelve (40%) cirrhotic patients experienced at least one LD episode: 8 vs 28 cumulative events at five years and 2.8 vs 1.8 average years up to the first LD episode for pre-cirrhotic vs cirrhotic. The probability of remaining free of LD for pre-cirrhotic vs cirrhotic patients was 97% vs 78% (p≤0.01) at one year; 88% vs 65% (p≤0.001) at three years and 71% vs 44% (p≤0.001) at five years. Positive correlation was found between LD and the cirrhotic stage (vs pre-cirrhosis, p≤0.001), baseline AST ≥100 µ/L (vs <100 µ/L, p≤0.01) and platelet count <120 x 109/L (vs >120 x 109/L, p≤0.05). CONCLUSIONS: Cirrhosis accounts for a significant superior risk of LD. The time up to the first LD event differed in only one year between pre-cirrhotic and cirrhotic, standing for the importance of a rapid treatment referral in both subgroups. Modifiable risk factors that accelerate fibrosis are prevalent in HIV/HCV co-infected patients. Low platelet count, elevated AST and F4 stage predict the rapid progression to LD and the need for early HCV treatment. Large studies are required for further support of these results.

Durability of first antiretroviral treatment in HIV chronically infected patients: why change and what are the outcomes?

INTRODUCTION: First antiretroviral therapy (ART) is often switched to simpler, more potent or better tolerated regimens (1, 2). Although discontinuation rates are frequently studied, the durability of regimens is rarely approached. MATERIALS AND METHODS: Retrospective study with the following objectives: analyze first ART schemes and their durability in naive patients with chronic HIV-1 and 2 infections, evaluate factors influencing ART change, second-line ART and consequent virologic and immunologic responses. Patients had follow-ups in a Central University Hospital, started ART between January 2007 and December 2012 and changed first regimens. Clinical data was obtained from medical records and analyzed using the Statistical Package for the Social Sciences (version 20). RESULTS: Of the 652 naive patients who started ART, 164 changed regimens. The majority had HIV-1 infection (n=158). The mean age was 43.9 years (standard deviation±14.3), with a male predominance of 57.9%. Regimens with efavirenz were the most common amongst HIV-1 patients (50%) followed by lopinavir/r (22%). In HIV-2 patients, lopinavir/r (n=3) regimens were most prevalent. First ART regimens had a mean duration of 12.1 months. There was no difference between NNRTI (59.8%) and protease inhibitor (40.2%) schemes regarding durability. Adverse reactions were the major cause of ART switching (55.5%) followed by therapy resistance (12.1%). Age was inversely related to durability (p=0.007 Mann-Whitney, Phi coefficient -0.161) and associated with the appearance of adverse reactions (p=0.04, Chi-square). Younger patients had a reduced risk of adverse reactions by 27%. Adverse reactions increased the risk of inferior durability by 40%. Psychiatric symptoms (28.4%) were the most prevalent, all attributed to efavirenz. The year of ART initiation was associated with different durability rates (p=0.005, Mann-Whitney). Patients started on ART before the year 2010 reduced the probability of inferior ART duration by 25.8%. After second-line ART regimens, TCD4+ counts>500 cell/µL were increased by 38% and favourable virologic outcome achieved in 84%. CONCLUSIONS: Adverse reactions were the main cause for ART switching, supporting a cautious approach when initiating regimens, particularly in older patients. All ART naive patients who changed initial therapy had favourable immunological and virologic responses.

Ebolavirosis: a 2014 review for clinicians.

Ebolavirosis, like Marburgvirosis, are African zoonosis, and for both the primary animal reservoir are bats. It is a typical acute haemorrhagic fever, characterized by a high lethality rate. In an outbreak, the human index case became infected after contact with an infected animal or its blood, in most cases during hunting. Secondary human cases became infected after close contact with another human case, with infected human fluids or with a recent dead corps of a human case. These viruses are easily transmitted by direct contact or by contact with patient body fluids, mainly blood. As such, health professionals working under suboptimal conditions usually constitute a large share of Ebola victims. At the moment, the treatment is only supportive, but several drugs are almost ready to be tried in human trials. There is no vaccine approved, but again there are several very promising in the pipeline.

A Ebolavirose, tal como a Marburgvirose, são zoonoses africanas, e para ambas o reservatório animal primário são morcegos. São febres hemorrágicas agudas típicas, caracterizadas por uma elevada taxa de letalidade. Num surto, o caso index humano infecta-se por contacto com um animal infectado, na maioria dos casos numa caçada. Os casos humanos secundários infectam-se por contacto próximo com um caso humano, com os seus fluidos corporais ou com um cadáver recente de um caso humano. São vírus que se transmitem facilmente por contacto directo com um caso infectado, ou por contacto com os seus fluidos corporais, basicamente com o sangue. Por isso, profissionais de saúde a trabalhar em condições subóptimas constituem uma percentagem elevada das vítimas do Ébola. De momento, o tratamento disponível é apenas de suporte, mas vários fármacos serão ensaiados em humanos a curto prazo. Também ainda não existe vacina aprovada, mas várias prometedoras já se encontram no pipeline.

Angola's 2013 dengue outbreak: clinical, laboratory and molecular analyses of cases from four Portuguese institutions.

INTRODUCTION: Dengue virus (DENV) is the arbovirus with the widest impact on human health. In Africa in general, and in Angola in particular, the epidemiology and public health impact of DENV is far from clear. However, rapid population growth, unplanned urbanization, increased international travel, and the presence of virus major vector (Aedes aegypti) in the country suggest that DENV transmission may occur. METHODOLOGY: In parallel to the occurrence of a dengue outbreak affecting the capital of Angola, between March and July 2013 four Portuguese institutions diagnosed dengue infection in 146 individuals returning to Portugal. Clinical presentation, laboratory findings, and molecular analyses of partial viral genomic segments were performed. RESULTS: The mean age of the individuals included in this study was 42 years old, the majority being men of Portuguese nationality, reporting various lengths of stay in Angola. Fever was the most reported clinical sign, being frequently associated (61.0%) with myalgia and headache. Hematological values, including hematocrit, white-blood cell and platelets counts, correlated with the absence of severe or complicated cases, or coagulation disorders. No deaths were observed. Viral NS1 was detected in 56.2% of the samples, and all NS1 negative cases had anti-dengue IgM antibodies. RT-PCR indicated the presence of DENV1, which was confirmed by phylogenetic analysis of 25 partial NS5 viral sequences. CONCLUSION: The DENV cases analyzed conformed to classical and uncomplicated dengue, caused by the suggested exclusive circulation of a genetically homogeneous DENV1 of genotype III, apparently with a single origin.

Serological screening for tuberculosis in the community: an evaluation of the Mycodot procedure in an African population with high HIV-2 prevalence (Republic of Guinea-Bissau).

The immuno-dot-blot assay MycoDot, which detects lipoarabinomannan (LAM) antibodies, was evaluated for the serological diagnosis of active pulmonary tuberculosis in patients in a rural community in the Republic of Guinea-Bissau. Sera from 269 adults (age > 15) and 33 children (age < 5) were assayed for antibodies in a blind manner and the results compared to the clinical status of tuberculosis. The assay had a specificity and a sensitivity of 92.4% and 63.0% respectively, when applied to the adult population. In HIV-2 infected individuals (27/269), the specificity and sensitivity of the assay were similar, 94.7% and 62.5% respectively. The assay did not provide high sensitivity for the diagnosis of tuberculosis in children. Sera from patients with leprosy cross-reacted with the antigen of the assay. It is concluded that this easily performed assay may be useful for the presumptive diagnosis of tuberculosis in adult populations in rural areas of developing countries where routine screening is not readily available.