Consensus definitions in imported human schistosomiasis: a GeoSentinel and TropNet Delphi study.

Terminology in schistosomiasis is not harmonised, generating misunderstanding in data interpretation and clinical descriptions. This study aimed to achieve consensus on definitions of clinical aspects of schistosomiasis in migrants and returning travellers. We applied the Delphi method. Experts from institutions affiliated with GeoSentinel and TropNet, identified through clinical and scientific criteria, were invited to participate. Five external reviewers revised and pilot-tested the statements. Statements focusing on the definitions of acute or chronic; possible, probable, or confirmed; active; and complicated schistosomiasis were managed through REDCap and replies managed in a blinded manner. Round 1 mapped the definitions used by experts; subsequent rounds were done to reach consensus, or quantify disagreement, on the proposed statements. Data were analysed with percentages, medians, and IQRs of a 5-point Likert scale. The study was terminated on the basis of consensus or stability-related and time-related criteria. 28 clinicians and scientists met the criteria for experts. 25 (89%) of 28 experts replied to Round 1, 18 (64%) of 28 to Round 2, 19 (68%) of 28 to Round 3, and 21 (75%) of 28 to at least two rounds. High-level consensus (79-100% agreement and IQRs ≤1) was reached for all definitions. Consensus definitions will foster harmonised scientific and clinical communication and support future research and development of management guidelines for schistosomiasis.

Eosinophilic Liver Abscess: A Case of Locally Acquired Fasciola hepatica in Alberta, Canada.

Fasciola hepatica is a trematode causing acute and chronic infection. A 33-year-old Canadian woman with eosinophilic liver abscesses and no relevant travel was diagnosed with F hepatica infection. F hepatica is reported in livestock in Alberta. This is the first case of locally acquired fascioliasis in Canada in >100 years.

Intestinal protozoa in returning travellers: a GeoSentinel analysis from 2007 to 2019.

BACKGROUND: Prolonged diarrhoea is common among returning travellers and is often caused by intestinal protozoa. However, the epidemiology of travel-associated illness caused by protozoal pathogens is not well described. METHODS: We analysed records of returning international travellers with illness caused by Giardia duodenalis, Cryptosporidium spp., Cyclospora cayetanensis, or Cystoisospora belli, reported to the GeoSentinel Network during January 2007-December 2019. We excluded records of travellers migrating, with an unascertainable exposure country, or from GeoSentinel sites that were not located in high-income countries. RESULTS: There were 2517 cases, 82.3% giardiasis (n = 2072), 11.4% cryptosporidiosis (n = 287), 6.0% cyclosporiasis (n = 150), and 0.3% cystoisosporiasis (n = 8). Overall, most travellers were tourists (64.4%) on long trips (median durations: 18-30 days). Cryptosporidiosis more frequently affected people < 18 years (13.9%) and cyclosporiasis affected people ≥40 years (59.4%). Giardiasis was most frequently acquired in South-Central Asia (45.8%) and Sub-Saharan Africa (22.6%), cryptosporidiosis in Sub-Saharan Africa (24.7%) and South-Central Asia (19.5%), and cyclosporiasis in South East Asia (31.3%) and Central America (27.3%). and cystoisosporiasis in Sub-Saharan Africa (62.5%). Cyclosporiasis cases were reported from countries of uncertain endemicity (e.g. Cambodia) or in countries with no previous evidence of this parasite (e.g. French Guiana). The time from symptom onset to presentation at a GeoSentinel site was the longest among travellers with giardiasis (median: 30 days). Over 14% of travellers with cryptosporidiosis were hospitalized. CONCLUSIONS: This analysis provides new insights into the epidemiology and clinical significance of 4 intestinal protozoa that can cause morbidity in international travellers. These data might help optimize pretravel advice and post-travel management of patients with travel-associated prolonged gastrointestinal illnesses. This analysis reinforces the importance of international travel-related surveillance to identify sentinel cases and areas where protozoal infections might be undetected or underreported.

Necrotizing Soft-Tissue Infections: A Case-Based Review.

GENERAL PURPOSE: To review the assessment and management of necrotizing fasciitis. TARGET AUDIENCE: This continuing-education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Identify the etiologic pathogens for necrotizing fasciitis.2. Summarize assessment guidelines for patients who present with signs of necrotizing fasciitis.3. Explain recommended treatment protocols for patients who have necrotizing fasciitis.

Necrotizing fasciitis is a rapidly progressive soft-tissue infection with tissue necrosis and a high mortality rate. This case-based review provides an overview of an approach to the diagnosis and management of necrotizing fasciitis for clinicians.

Dengue outbreak amongst travellers returning from Cuba-GeoSentinel surveillance network, January-September 2022.

Increasing numbers of travellers returning from Cuba with dengue virus infection were reported to the GeoSentinel Network from June to September 2022, reflecting an ongoing local outbreak. This report demonstrates the importance of travellers as sentinels of arboviral outbreaks and highlights the need for early identification of travel-related dengue.

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.

Mycobacterium tuberculosis peritonitis in peritoneal dialysis patients: A scoping review.

BACKGROUND: The clinical syndrome of Mycobacterium tuberculosis (M. tuberculosis) peritoneal dialysis (PD) peritonitis is poorly understood. Whether local tuberculosis (TB) patterns modify the clinical syndrome, and what factors associate with poor outcomes is also unknown. METHODS: A scoping review identified published cases of TB PD peritonitis. Cases from low- and high-TB burden areas were compared, and cases that did or did not suffer a poor clinical outcome were compared. RESULTS: There were 216 cases identified. Demographics, presentation, diagnosis, treatment and outcomes were described. Significant delays in diagnosis were common (6.1 weeks) and were longer in patients from low-TB burden regions (7.3 vs. 3.7 weeks). In low-TB burden areas, slower diagnostic methods were more commonly used like PD fluid culture (64.3% vs. 32.7%), and treatment was less likely with quinolone antibiotics (6.9% vs. 34.1%). Higher national TB incidence and lower GDP per capita were found in cases that suffered PD catheter removal or death. Diagnostic delays were not longer in cases in which a patient suffered PD catheter removal or death. Cases that suffered death were older (51.9 vs. 45.1 years) and less likely female (37.8% vs. 55.7%). Removal of PD catheter was more common in cases in which a patient died (62.0% vs. 49.1%). CONCLUSIONS: Outcomes in TB PD peritonitis are best predicted by national TB incidence, patient age and sex. Several unique features are identified to alert clinicians to use more rapid diagnostic methods that might enhance outcomes in TB PD peritonitis.

Epidemiological and Clinical Characteristics of Alveolar Echinococcosis: An Emerging Infectious Disease in Alberta, Canada.

Human alveolar echinococcosis (AE) is a zoonotic cestode infection which is usually fatal in the absence of treatment. Treatment involves major surgery or indefinite antiparasitic therapy. The incidence is rising in Europe and Asia, with an increased risk observed in immunocompromised individuals. Previously, AE acquisition in North America was extremely rare, except for one remote Alaskan Island. Recent studies have demonstrated a new European-like strain of Echinococcus multilocularis (Em) in wildlife and in human AE in western Canada. We report the experience of all AE patients diagnosed in Alberta. Each was diagnosed by histopathology, serology, and PCR-confirmed by a reference laboratory. Seventeen cases of human AE, aged 19-78 years, nine females, were diagnosed between 2013 and 2020: all definitely or probably acquired in Alberta. Six lived in urban areas, and 14 had kept dogs. In eight, the lesions were found incidentally on abdominal imaging performed for other indications. Six were immunocompromised to varying degrees. Six were first diagnosed at surgery. All have been recommended benzimidazole therapy. One died of surgical complications. Clinicians should be aware of this diagnostic possibility in patients presenting with focal nonmalignant hepatic mass lesions. Greater urbanization of coyotes, the predominant definitive host of Em in Alberta, and growing numbers of immune suppressed individuals in the human population may lead to increasing recognition of AE in North America.

The cost-effectiveness of schistosomiasis screening and treatment among recently resettled refugees to Canada: an economic evaluation.

BACKGROUND: Many refugees and asylum seekers from countries where schistosomiasis is endemic are infected with the Schistosoma parasite when they arrive in Canada. We assessed, from a systemic perspective, which of the following management strategies by health care providers is cost-effective: testing for schistosomiasis and treating if the individual is infected, treating presumptively or waiting for symptoms to emerge. METHODS: We constructed a decision-tree model to examine the cost-effectiveness of 3 management strategies: watchful waiting, screening and treatment, and presumptive treatment. We obtained data for the model from the literature and other sources, to predict deaths and chronic complications caused by schistosomiasis, as well as costs and net monetary benefit. RESULTS: Presumptive treatment was cost-saving if the prevalence of schistosomiasis in the target population was greater than 2.1%. In our baseline analysis, presumptive treatment was associated with an increase of 0.156 quality-adjusted life years and a cost saving of $405 per person, compared with watchful waiting. It was also more effective and less costly than screening and treatment. INTERPRETATION: Among recently resettled refugees and asylum claimants in Canada, from countries where schistosomiasis is endemic, presumptive treatment was predicted to be less costly and more effective than watchful waiting or screening and treatment. Our results support a revision of the current Canadian recommendations.

A case of tick-borne relapsing fever in pregnancy.

Tick-borne relapsing fever (TBRF) is an infection caused by Borrelia spirochetes. In North America, Borrelia hermsii is the most common cause for TBRF. This vector-borne disease is transmitted by Ornithodoros hermsi, a soft-bodied tick found in high altitudes in northwestern United States and southwestern Canada. Once bitten by the tick and infected by B. hermsii, episodes of fever alternating with afebrile periods can occur. A case of TBRF in a pregnant host was complicated by Jarisch-Herxheimer reaction requiring critical care. This case emphasizes the importance of maintaining a high index of suspicion in TBRF. Clinician recognition, diagnosis and treatment of TBRF as well as public awareness of strategies to prevent tick bites should be strengthened.

Exploring Tropical Infections: A Focus on Scrub Typhus.

Scrub typhus is caused by Orientia tsutsugamushi and has a near global prevalence. It is associated with local and systemic manifestations that lead to morbidity and mortality. Given the nonspecific presentation of fever in a returning traveler, a high index of suspicion and thorough skin examination for eschar are critical to establishing a diagnosis. Early treatment is crucial to avoid severe outcomes, further highlighting the need to include scrub typhus in differential diagnosis. An accompanying narrative case explores the epidemiology, diagnosis, and management of scrub typhus.

Exploring Tropical Infections: A Focus on Cutaneous Larva Migrans.

GENERAL PURPOSE: To provide information about infection with cutaneous larva migrans (CLM). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, NPs, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Distinguish the clinical features, diagnosis, and management of CLM.2. Explain the epidemiology of CLM. ABSTRACT: Cutaneous larva migrans is a hookworm infection and one of the most common skin diseases of tourists in tropical countries. Most commonly, the infection is transmitted by contact with feces of dogs and cats containing hookworm eggs. This case-based review explores the epidemiology, diagnosis, clinical features, and management of cutaneous larva migrans infection.

Cutaneous larva migrans is a hookworm infection and one of the most common skin diseases of tourists in tropical countries. Most commonly, the infection is transmitted by contact with feces of dogs and cats containing hookworm eggs. This case-based review explores the epidemiology, diagnosis, clinical features, and management of cutaneous larva migrans infection.