Valvular fibroelastomas complicated by Coxiella burnetti endocarditis.

Cardiac papillary fibroelastoma (CPF) is a valvular tumor that may be mistaken for infective endocarditis (IE). We describe a case of CPF complicated by Coxiella burnetti IE. According to Duke's criteria, a diagnosis of IE was repeatedly considered as excluded or established during the clinical course, highlighting the criteria limitations.

Acute Diarrhea in North American Students after Relocation to Israel: A Pilot Study.

BACKGROUND: Travelers' diarrhea (TD) is frequently encountered in people traveling from high-income to low-income countries; however, its epidemiology in those traveling between high-income countries is not known. OBJECTIVES: To evaluate the incidence of diarrhea in North American students relocating to Israel. METHODS: A retrospective cohort study involving medical students from the United States and Canada relocating to Israel was conducted. Students who relocated to Israel during 2010-2016 were contacted by email to participate in an anonymous survey. Data included demographic information as well as occurrence, timing, duration, and outcome of diarrhea after relocation. RESULTS: Ninety-seven students participated in the survey. Most (93.7%) students relocated from the United States or Canada. The period-prevalence of diarrhea was 69.1%. The incidence of diarrhea declined from 34.8 cases per 100 student-months during the first month after relocation to 1.3 cases per 100 student-months after 1 year. The duration of diarrhea was up to 1 week in 72.7%. Students who reported diarrhea were younger than students who did not (mean age 24.0 ± 2.2 and 28.4 ± 1.8 years, respectively, P < 0.001). No other demographic parameter was significantly associated with a higher likelihood of diarrhea. CONCLUSIONS: A high proportion of North American medical students relocating to Israel reported diarrhea with clinical and epidemiological features similar to classic TD. Further studies are needed to elucidate the causative agents of TD in Israel.

[A RARE CASE OF ADULT MENINGOCOCCAL SUPRA-GLOTTITIS AND BACTERAEMIA DUE TO NEISSERIA MENINGITIDIS TYPE Y].

INTRODUCTION: Acute epiglottitis/supraglottitis is an acute disease with potential life-threatening complications such as airway obstruction. We present the case of an 85 year old woman hospitalized due to pain in her neck, odynophagia and unclear speech. Bacteraemia with Neisseria meningitidis type Y was detected. The patient was treated with Ceftriaxone and corticosteroids with resolution of symptoms. In a literature review we found only 21 additional cases of epiglottitis and bacteraemia due to Neisseria meningitidis, 52% of which were caused by serogroup Y. All the patients with supraglottitis caused by Neisseria meningitidis were bacteremic, and 69% of them suffered from airway compromise. Routine drawing of blood culture in supraglottitis patients can lead to higher detection rates of Neisseria meningitidis cases.

Region-Specific, Life-Threatening Diseases among International Travelers from Israel, 2004-2015.

We characterized posttravel hospitalizations of citizens returning to Israel by summarizing the returning traveler hospitalization dataset of the national referral Center for Travel Medicine and Tropical Diseases at Sheba Medical Center in Israel. Of 722 hospitalizations, 181 (25%) infections were life-threatening; most would have been preventable by chemoprophylaxis and pretravel vaccination.

Travel-Related Tick-Borne Encephalitis, Israel, 2006-2014.

During 2006-2014, four tick-borne encephalitis (TBE) cases occurred among Israeli travelers. We calculated TBE incidence at 321.0, 45.0, 13.2, and 7.5 cases/100,000 travelers/year of travel to Sweden, Switzerland, Austria, and Germany, respectively. TBE incidence among travelers to these destinations appears to justify TBE vaccination in accordance with World Health Organization recommendations.

Primaquine dosing errors: the human cost of a pharmaceutical anachronism.

Confusion between salt/base forms of primaquine may result in malaria prophylaxis failure. During 1995-2011, there were 14 malaria cases in Israel despite primaquine primary prophylaxis. In 6/14 cases, primaquine was underdosed because of confusion between salt and base forms, including two Plasmodium falciparum cases. Primaquine labeling clarification may be lifesaving.

Chronic illnesses in travelers to developing countries.

BACKGROUND: Data regarding travelers with chronic illnesses (TCI) traveling to developing countries is limited. METHODS: A retrospective cohort study of travelers. We analyzed demographics, travel destinations, travel dates and duration, as well as the medical history (chronic illnesses, chronic medications, and allergies) of the travelers. RESULTS: Of 16,681 travelers evaluated, 3046 (18%) were TCI, of who, 2221 (13%) were taking chronic medications. The percentage of TCI ranged from 4% in the first decade of life to 65% in the 8th decade. The highest number of TCI (1085) was among the 20­30 years age group. The median age (IQR) of TCI was 39.0 (23.1­58.2), compared to 24.2 (22.0­32.1) years, of healthy travelers (p < 0.001). The major pre-existing medical conditions among TCI were endocrine/metabolic (38%), cardiovascular (26%) and pulmonary illnesses (16%). Within age groups, no difference was found in itinerary and other travel characteristics. However, 20­30 years old TCI, who were using chronic medications had significantly shorter travel duration (P < 0.001). CONCLUSIONS: TCI form a significant proportion of travelers among all age groups and travel destinations. Chronic illnesses appear to have little impact on travel itinerary and characteristics, but chronic medication use is associated with shorter travel duration to developing countries.

Potential drug interactions in travelers with chronic illnesses: a large retrospective cohort study.

BACKGROUND: Data regarding the prevalence of potential interactions between travel-related medications (TRM) and chronic medications in use, or medical conditions of travelers to developing countries are limited. METHODS: A retrospective cohort study of travelers to low income countries. We extracted data on demographics, travel destinations, use of chronic medications, drug allergies, and relevant medical conditions. The following TRM were evaluated: mefloquine, primaquine, doxycycline, atovaquone/proguanil, fluoroquinolone antibiotics, rifaximin, azithromycin, and acetazolamide. RESULTS: A total of 16,263 travelers were included in the analysis, of whom 3299(20%) suffered from chronic illnesses and 2316(14%) reported chronic medication use. A potential drug-drug interaction with TRM was identified in 1047(45%) of travelers using chronic medication. Fluoroquinolones and azithromycin were the most commonly implicated TRMs. A potential medical condition interaction with TRM was identified in 717(22%) of travelers having chronic illnesses. acetazolamide, primaquine and mefloquine, were the most commonly TRMs implicated. Drug allergies, which can pose a relative contraindication for use of acetazolamide, were reported by 1323(8.1%) of all travelers. CONCLUSIONS: Potential drug-drug and drug-disease interactions involving TRM might occur in a significant proportion of travelers with chronic medical conditions. Education of health practitioners regarding such potential drug interactions and caution when in prescribing travel-related medications is warranted.

The changing epidemiology of human African trypanosomiasis among patients from nonendemic countries--1902-2012.

BACKGROUND: Although human African trypanosomiasis (HAT) is uncommon among patients from non-endemic countries (NEC), there has been an increase in the number of cases reported in recent years. METHODS: A systematic review of the literature was performed. The number of incoming tourists to HAT endemic countries was obtained from the United Nations World Tourism Organization. All HAT cases diagnosed in patients from NEC were included. Immigrants and refugees were excluded. We compared patients during and after the colonial period, and analyzed the relationship between the number of incoming travellers and the number of HAT cases. RESULTS: Between 1902 and 2012, HAT was reported in 244 patients. Most HAT cases were reported before 1920, and after the year 2000. In the colonial era the average age of patients was lower (32.5±7.8 vs. 43.0±16.1 years, P<0.001), the proportion of females was lower (10.0% vs. 23.9%, P<0.01], most cases were diagnosed in expatriates, missionaries and soldiers (74.3%), and Gambian trypanosomiasis accounted for 86/110, (78%) of cases. In the post-colonial era most patients 91/125 (72.8%) were short-term tourists to game parks in Eastern and South-Eastern Africa (mainly in Tanzania); Rhodesian trypanosomiasis accounted for 94/123 (76.4%) of cases. Between 1995 and 2010 there has been a constant linear increase in the number of incoming tourists to Tanzania, and HAT cases occurred in small outbreaks rather than following a similar linear pattern. CONCLUSIONS: In recent decades HAT patients from NEC are older, and more likely to be tourists who acquired the disease while visiting game-parks in Eastern and South-Eastern Africa. While Rhodesian trypanosomiasis is relatively uncommon among Africans, it now accounts for most cases reported among patients from NEC. Returning febrile travellers without an alternative diagnosis should be evaluated for HAT. Cases among travellers may serve as sentinels for Rhodesian trypanosomiasis "hot spots" in Africa.

A large outbreak of Salmonella Paratyphi A infection among israeli travelers to Nepal.

BACKGROUND: In Asia, Salmonella Paratyphi A is an emerging infection, and travelers are increasingly at risk. During October 2009-November 2009, an outbreak in S. Paratyphi A infection was noted in Israeli travelers returning from Nepal. METHODS: An outbreak investigation included a standardized exposure questionnaire admitted to all patients and medical chart abstraction. Isolates were tested for antimicrobial susceptibility and pulsed-field gel electrophoresis (PFGE). RESULTS: During 1 October 2009-30 November 2009, 37 Israeli travelers returning from Nepal were diagnosed with S. Paratyphi A bacteremia. All 37 case isolates had an identical pattern on PFGE, and all were nalidixic acid resistant. Only 1 food venue was frequented by all the outbreak cases, with the largest number of exposures occurring around the Jewish New Year. All patients recovered without complications. Time to defervescence in 17 patients treated with ceftriaxone and azithromycin combination was 3.2 days (± 1.7), whereas in 13 cases treated with ceftriaxone monotherapy, the time to defervescence was 6.6 days (± 1.8; P < .001). CONCLUSIONS: A point-source, "Paratyphoid Mary"-like outbreak was identified among Israeli travelers to Nepal. Combination Ceftriaxone-Azithromycin therapy may provide a therapeutic advantage over monotherapy, and merits further clinical trials.

Effectiveness of short prophylactic course of atovaquone-proguanil in travelers to sub-saharan Africa.

BACKGROUND: Current guidelines recommend continuation of atovaquone-proguanil (AP) malaria prophylaxis for 7 days after leaving Plasmodium falciparum endemic areas. Evidence from clinical studies suggests that discontinuation of AP 1 day after exposure ends may be safe and effective. Our objective was to assess the effectiveness of short-course AP prophylaxis among travelers to sub-Saharan Africa. METHODS: To detect prophylactic failures associated with short-course AP prophylaxis discontinued 1 day after return, we conducted active surveillance during the years 2010 and 2011, by a retrospective telephone survey 1 to 6 months after travelers' return. Passive surveillance data were obtained from the Israel Ministry of Health (MOH) malaria registry. RESULTS: Among 485 travelers to sub-Saharan Africa (cumulative exposure of 4,979 days), 421 (87%) discontinued AP 1 day after leaving the endemic region (cumulative exposure of 4,337 days). None of the 485 travelers reported malaria infection. The MOH malaria registry survey included 363 P. falciparum-infected patients during the years 2003 to 2011. The majority (n = 305; 84%) did not use any malaria prophylaxis. None of the patients had used AP (neither regular nor short course AP) for malaria prophylaxis. CONCLUSIONS: We did not detect prophylaxis failures among a group of travelers who discontinued AP prophylaxis 1 day after leaving malaria-endemic areas. Passive surveillance in Israel did not detect any P. falciparum cases among AP users. We recommend further validation of our findings by clinical trials, prospective studies, and active surveillance in larger cohorts to assess the effectiveness of short-course AP prophylaxis in travelers.

Malignant diseases and mortality in blood donors infected with human T-lymphotropic virus type 1 in Israel.

OBJECTIVES: The natural history of blood donors infected with human T-lymphotropic virus type 1 (HTLV-1) in Israel has never been assessed. The aim of this study was to evaluate the prevalence of malignant disorders and mortality among a cohort of Israelis diagnosed as HTLV-1 carriers during routine blood unit screening. METHODS: This was an observational retrospective cohort study. All HTLV-1 cases among Israeli blood donors between 1995 and 2009 were included. Data regarding malignant diseases were extracted from the Israel National Cancer Registry. Mortality data were extracted from the Israel Population Registry. RESULTS: Between January 9, 1995 and December 31, 2009, 1574497 blood donors were screened for HTLV-1 in the central blood bank services. Of these, 90 were found to be HTLV-1 carriers. This cohort of HTLV-1-infected blood donors was followed for an average of 9.2 ± 6 years. Among them six (6.7%) were diagnosed as having malignant diseases, four of them with adult T-cell leukemia/lymphoma (ATLL). The incidence of ATLL was 0.37 (95% confidence interval 0.13-1.08)/100 HTLV-1 carrier-years. CONCLUSIONS: We found a high rate of malignant diseases among HTLV-1-infected blood donors.

[The profile of Israeli travelers to developing countries: perspectives of a travel clinic].

BACKGROUND: The number of Israeli travelers is increasing, including the number of travelers to developing countries. AIM: This study aimed to characterize the profile of Israeli travelers to developing countries. METHODS: Data regarding demographics, travel destinations, trip duration and the purpose of travel were collected on travelers attending the pre-travel clinic at the Sheba Medical Center during a period of 9 years. RESULTS: Between the dates 1/1/1999 and 31/12/2007, 42,771 travelers presented for consultation at the Sheba Medical Center pre-travel clinic. The average age was 30.8 +/- 13.4 years and 54% of the travelers were males. The female proportion increased from 42% in 1999 to 49% in 2006. There was a steady increase in the number of travelers attending our clinic, except in 2003 (coinciding with the SARS epidemic). Post-army backpackers (20-25 year-old age group) were only 43% of the travelers. Children (<18 years), and elderly (>60 years) comprised 4.4% and 4.6% of the travelers, respectively. The favorite destinations were Asia (55%), followed by Latin America (27%) and Africa (13%). The distribution of travel destinations varied significantly during the study period. Of note is the sharp decline in travel to Africa following the terrorist attack in Mombassa, Kenya (November 2002). The median trip duration changed during the study period, from 30 to 45 days, between 1999-2004 and 2005-2007 respectively. The majority (87%) of voyagers traveled for pleasure, 6% went for business, and 7% were representatives of governmental organizations. CONCLUSION: This study found an increasing diversity in the traveler population (more women, more children and older travelers) and more diversity in travel destinations. Disease outbreaks and terrorist attacks had transient negative impacts on the number of travelers.

Epidemiology of human T-cell lymphotropic virus type 1 infection in blood donors, Israel.

The prevalence of infection with human T-cell lymphotropic virus type 1 (HTLV-1) in blood donors from Israel is 1 infection/100,000 persons. In donors originating from Eastern Europe, the Middle East, and Latin America, prevalences are 7.7, 14.6, and 20.4, respectively. HTLV-1 prevalence may be high outside areas where HTLV-1 previously was known to be endemic.

Epidemiology of travel-related hospitalization.

BACKGROUND: Limited information exists on causes of hospitalization in patients returning from the tropics, and most is focused on febrile diseases. We evaluated all causes of post-travel hospitalization in a tertiary care hospital in Israel. METHOD: Demographics, diagnoses, and destinations of patients admitted between January 1999 and December 2003 with a history of recent travel were recorded. Demographics and destination of healthy travelers presenting to our pretravel clinic at the same period were recorded. RESULTS: Of 211 patients admitted, 71% were males, 8% were immigrants/foreign workers, and febrile diseases accounted for 77% of admissions. The most common diagnoses were malaria in 54 (26%), unidentified febrile disease in 34 (16%), and dengue fever in 27 (13%). New World cutaneous leishmaniasis was the most common cause of admission among nonfebrile patients (18 [9%]). Diarrheal diseases accounted for only 11% of admissions. Regarding destination, 101 (48%) patients had been to Asia, 71 (34%) to Africa, and 43 (20%) to the Americas. Of our healthy traveler population, 59% traveled to Asia, 20% to Africa, and 20% to the Americas. Travel to Africa carried the highest risk of being hospitalized (OR 1.85, 95% CI 1.16-2.97; p = .01). Most (59%) patients returning from Africa had malaria. The principal health problem originating in Asia was dengue fever (27%), and from Latin America, cutaneous leishmaniasis (48%). Males comprised 71% of the patients, and 59% of the healthy traveler population (p < .0001). Males were more likely to acquire malaria (OR 2.15, 95% CI 1.13-4.09; p = .02) and leishmaniasis (OR 3.41, 95% CI 0.97-11.89; p = .05). CONCLUSIONS: Febrile diseases were the most common cause for hospitalization, with malaria, unidentified febrile diseases, and dengue fever being the most common. Diseases were destination related; travel to Africa was associated with a higher rate of hospitalization. Malaria and cutaneous leishmaniasis had a substantially male predominance, probably due to risk-taking behavior.

[Viral encephalitis caused by biowarfare agents].

Many viruses may cause encephalitis. Three such viruses of the Alpha genus (Venezuelan equine encephalitis (VEE), Western equine encephalitis (WEE) and Eastern equine encephalitis (EEE)) may be used as biological warfare agents. The clinical course of the diseases caused by these viruses is not specific, and resembles a broad range of bacterial and viral diseases. Several attenuated and inactivated vaccines were developed, but their efficacy in the biological warfare scenario is questionable. There is no effective drug therapy for the treatment of these diseases, and treatment is mainly supportive. Several VEE outbreaks were reported in humans and horses in South America and southern United States. This virus usually causes a febrile illness, which might be complicated with encephalitis, mainly in the cases of children and elderly patients. The EEE virus causes the most severe form of disease, with severe encephalitis and high proportion of sequel. It is prevalent mainly in the eastern parts of Northern America. The WEE virus, which is hybridization between the Sindbis virus and the EEE virus, causes encephalitis mainly in children. The severity of the disease caused by WEE and the sequel rate is much lower than that of EEE.