[Vaccinations for travel abroad]. / Impfungen für Auslandreisen.

Travel to the developing world by Swiss citizens has been increasing. Vaccine-preventable diseases challenges the physician to provide pre-travel advice. Each traveler's itinerary, duration of stay and medical history, including previous immunization, should be reviewed. Vaccinations are required or recommended according to the requirements and the epidemiology of countries being visited. This article summarizes updated recommendations to individual vaccines and immunoglobulins.

[Business travel and staying abroad]. / Berufsreisen und Aufenthalte im Ausland.

The growing internationalization of business and the economy is leading more and more working people to spend short or even long stays abroad. With fast journeys across several time zones, travellers are mainly confronted with problems of time difference adjustment, commonly known as "jet lag". For longer stays, especially when the family comes along too, a number of additional difficulties may arise which are not normally faced by tourists. People's physical ability to tolerate a long stay in the tropics is rarely questioned nowadays, except in cases of serious physical illness. However, the effects of such stays on an individual's psychological condition are receiving increasing attention. Inoculations and advice are largely determined by the epidemiology of infectious diseases and the medical infrastructure of the country of destination. Death caused by illness can almost always be avoided through the appropriate prophylaxis and/or therapy. Unfortunately, the same does not apply to accidents. The local medical infrastructure in the larger cities of the developing countries and the range of flights available for sick and injured people are continually improving with a few exceptions.

Liver disease in rural Tanzania--a diagnostic approach.

In a prospective study on the aetiology of liver disease and its diagnostic approach in a District hospital in rural Tanzania, 48 consecutive patients with evidence of liver disorders were investigated by physical examination, biochemical tests, laparoscopy and histology. Liver cirrhosis (posthepatic, alcoholic) was found in 31%; non cirrhotic alcoholic liver disease in 15%; viral, bacterial and protozoal liver disorders in 33%, and neoplastic liver changes in 21% of all patients. Clinical impression alone coincided with the final diagnosis in 40% of all cases. This figure was increased to 46%, when haematological and biochemical results were included, and to 71%, when laparoscopy (without histology) was used in addition. Laparoscopy was particularly decisive in the diagnosis and further management of cirrhosis, liver abscess and neoplastic liver disorders. The additional information obtained from histology led to the final diagnosis. Histology was specially useful for the diagnosis of alcoholic liver disease, tropical splenomegaly syndrome and non specific reactive hepatitis. The usefulness of laparoscopy as a diagnostic tool in a district hospital is discussed.

Iron chelators: in vitro inhibitory effect on the liver stage of rodent and human malaria.

The activity of desferrioxamine (Desferal) and desferrithiocin (a newly developed oral iron chelator) was evaluated against the liver stage of Plasmodium yoelii and P. falciparum in the rodent and the human hepatocyte in vitro culture system. The two iron chelators were found to inhibit the liver schizogony of both the rodent and the human Plasmodium species at concentrations achievable in vivo. P. falciparum proved to be more sensitive (ic 95% below 20 micromol/l than P. yoelii (ic 95% 50-100 micromol/l). As assessed by electron microscopy, drug administration was associated with focal clarification of the cytoplasm thought to be reversible. As desferrioxamine and desferrithiocin are known to be equally active on the blood stage of rodent and human plasmodia, iron chelators are deserving of further investigation as potential alternative candidates to existing drugs for radical cure of malaria.

[Cutaneous diphtheria imported from tropical countries]. / Importierte Hautdiphtherie aus tropischen Ländern.

Two cases of imported cutaneous diphtheria from tropical areas are described. Vacationing in the Seychelles, a 29-year-old man injured his left malleolus a few weeks before his return to Switzerland. The wound did not heal and an ulcer developed. Microbiologic investigation yielded toxinogenic Corynebacterium diphtheriae. There were no signs of systemic intoxication. The man had not been vaccinated against diphtheria since childhood. In the second case a 51-year-old woman returned from Thailand and Nepal with two very painful ulcers between the toes of her right foot, which was reddish-coloured. Microbiologic investigation again yielded toxinogenic Corynebacterium diphtheriae and there was no sign of systemic intoxication. Treatment with erythromycin brought about complete healing of the ulcers.

Chloroquine administration for malaria suppression after abdominal surgery.

Administration of chloroquine after major surgery is indicated in malaria endemic areas. In emergencies it is commonly administered parenterally after the operation. The present study, undertaken at St. Francis Hospital, Ifakara (Kilombero District), Tanzania, compared plasma chloroquine levels after oral and subcutaneous administration of 300 mg of chloroquine base in 14 patients after abdominal, non-bowel-resective surgery and in 12 controls. There were no significant differences in the plasma chloroquine levels of all groups, and the chloroquine concentrations reached suppressive levels for at least 3 days (greater than 0.1 nmol/ml). Oral administration was well tolerated in both patients and controls. In all areas where the Plasmodium strains are still sensitive to chloroquine and where parenteral chloroquine may not be easily available, oral chloroquine represents a cheap, easy and safe alternative for postoperative prophylactic malaria suppression. It can be applied after abdominal non-bowel-resective emergency surgery.

[Selection of chloroquine-resistant Plasmodium falciparum strains in tourists under chemoprophylaxis]. / Selektionierung von chloroquinresistenten Plasmodium-falciparum-Stämmen bei Touristen unter Chemoprophylaxe.

In a prospective study 20 P. falciparum isolates imported from Africa by non-immune tourists were investigated for chloroquine sensitivity using the in vitro microtest and the results were compared with the plasma chloroquine concentration. All 6 patients taking correct chloroquine prophylaxis (chloroquine plasma levels between 0.1-0.5 nmol/ml) harboured highly resistant P. falciparum strains (schizont maturation at 3.2 and 6.4 nmol/ml blood in 3 patients each). In the 4 patients with inadequate prophylaxis (plasma levels between 0.02-0.1 nmol/ml) the degree of resistance was lower (at 1.6 and 6.4 nmol/ml blood in 2 patients each). Chloroquine-sensitive strains were found only in patients with chloroquine plasma levels below 0.02 nmol/ml and in 4 of 5 patients who did not show chloroquine in the plasma. Selection of chloroquine-resistant P. falciparum strains under short term chloroquine chemoprophylaxis appears to be highly probable.

[Poisoning by domestic vipers (Vipera berus and Vipera aspis). A retrospective study of 113 patients]. / Vergiftungen durch einheimische Vipern (Vipera berus und Vipera aspis). Eine retrospektive Studie an 113 Patienten.

In a retrospective study, 113 bites which occurred in Switzerland within a 16-year period by either of the two indigenous adders (Vipera berus and Vipera aspis) were analyzed. 13 patients showed no signs of envenomation. Out of the other 100, 62 patients had merely minor (local edema only) and 24 moderate envenomation (vomiting, diarrhea, cramps, hypotension), while 24 had severe envenomation (shock and angioneurotic edema of the tongue and lips). No fatalities were recorded. In residents of the endemic area the bites occurred accidentally in 86% of the cases, while tourists were bitten after manipulating the snake in 42%. Specific antivenin was given to 49 of 95 hospitalized patients. In cases of severe envenomation (n = 14) a reduction of the median duration of hospitalization from 10 days in patients without antivenin therapy (n = 4) to 5 days in patients with antivenin therapy (n = 10) was obtained. In cases of moderate (n = 21) or minor envenomation (n = 49), antivenin therapy did not influence the hospital stay of 4 and 2 days respectively. In the 11 patients with bites not followed by envenomation the antivenin treatment increased the duration of hospitalization from 1 day (in 6 patients without antivenin) to 2 days (in 5 patients with antivenin). Side effects of the antivenin treatment, such as urticaria, angioneurotic edema, respiratory distress, fever and lymphadenopathy were noted in 4 out of 49 patients.

[Snake bites and coagulation disorders]. / Schlangenbisse und Gerinnungsstörungen.

Within a period of 6 years 8 patients with 12 bites by potentially hemotoxic snakes (crotalids, viperids) were hospitalised in various clinics of the Basle area. All the patients were snake owners. One patient was hospitalized 3 times, 2 patients twice and the others once. In two cases no signs of envenomation were noted after an observation period of 12 hours. Ten bites were followed by local cytotoxic symptoms e.g. oedema and suffusions. Among this group only 6 cases had further signs of systemic, hemotoxic envenomation with decrease of the activity of various coagulation factors. Complete defibrination was seen in 4 patients, but only in 2 cases with additional thrombopenia did overt clinical symptoms of bleeding complications (urological bleeding) occur. Bleeding complications of the central nervous system or of the gastrointestinal tract were not seen. Antivenin was used in three patients and coagulation mechanisms recovered within 24 hours. One patient with complete defibrination, thrombopenia and overt bleeding (macrohematuria) refused antivenin. His coagulation parameters started to improve after 7 days and became normal on day 11.

[The anti-arrhythmia drug quinidine as an alternative in the treatment of severe falciparum malaria]. / Das Antiarrhythmikum Chinidin als Alternative in der Behandlung der schweren Falciparum-Malaria.

Parenteral quinine is the most effective treatment for severe falciparum malaria. It is not easily available in Switzerland and so dangerous delays treating patients may occur. The antiarrhythmic drug quinidine, usually stocked by hospitals, is an alternative drug for malaria treatment. We report the cases of two patients with severe malaria imported from Kenya. They were treated first with intravenous quinidine sulfate over 3 days and for another 4 days with peroral quinidine sulfate. The therapeutic response was excellent. During the 2 months posttherapeutic period no recrudescence of Plasmodium falciparum occurred. 20 mg/kg b.w./die of quinidine given intravenously seems to be an adequate dose in severe falciparum malaria.

[Hematuria in Schistosoma mansoni bilharziosis]. / Hämaturie bei Bilharziose durch Schistosoma mansoni.

Following a stay of a few months in Africa, a 9 year old boy developed gross hematuria, dysuria and pollakisuria. Two urine cultures remained sterile, the intravenous urography was normal. Therefore a tropical disease was looked for. Eggs of Schistosoma mansoni in the urine sediment, a significant level of schistosomal antibodies, and blood eosinophilia proved our suspected diagnosis of schistosomiasis to be correct. An ultrasonic examination of the urinary tract showed a thickened bladder wall. Very unusual in this case is the primary infection of the bladder with Schistosoma mansoni which normally affects the intestine.