Case report: Loiasis with peripheral nerve involvement and spleen lesions.

Loiasis, which is caused by the filarial nematode Loa loa, affects millions of persons living in the rainforest areas and savannah regions of central Africa. Typical manifestations are calabar swellings and the eyeworm. We report a case of loiasis with unusual clinical complications: a peripheral neuropathy and focal hypo-echogenic lesions of the spleen, which disappeared after treatment with albendazole and ivermectin. The literature reports that L. loa infection can be associated with various manifestations, some of them being serious. More information is needed to better characterize the protean manifestations of the disease in loiasis-endemic areas to evaluate the true incidence of loiasis.

Colonic polyposis due to Schistosoma intercalatum.

Schistosomiasis polyps induced by Schistosoma mansoni and S. japonicum have been reported from pathological observations but this is not the case for colonic schistosomiasis infection by S. intercalatum which has always been associated with mild clinical presentations. We report the case of a 17-year-old man, native from Equatorial Guinea, with colonic polyposis associated with infection by S. intercalatum.

Severe pneumonia in Mozambican young children: clinical and radiological characteristics and risk factors.

BACKGROUND: Pneumonia is a leading cause of hospitalization and death among children in Africa. We describe the clinical presentation of severe pneumonia among hospitalized children in a malaria endemic area with a high prevalence of HIV infection. METHODS: As part of a 2-year prospective study of radiologically confirmed pneumonia, chest radiographs, malaria parasite counts and bacterial blood cultures were systematically performed for children 0-23 months admitted with severe pneumonia. Radiographs were interpreted according to WHO guidelines. HIV tests were performed during a 12-month period. RESULTS: Severe pneumonia accounted for 16% of 4838 hospital admissions among children 0-23 months; 43% of episodes had endpoint consolidation, 15% were associated with bacteremia and 11% were fatal. Fever, cough >3 days, crepitations, hypoxemia and absence of malaria parasitemia were associated with radiologically confirmed pneumonia. Nineteen per cent of children with severe pneumonia and 27% with radiologically confirmed pneumonia had clinical malaria. HIV-prevalence was 26% among children hospitalized with severe pneumonia and HIV-testing results. HIV infection, anaemia, malnutrition, hypoxemia and bacteremia were associated with fatal episodes of severe pneumonia. CONCLUSION: Treatment of admitted children with severe pneumonia is complicated in settings with prevalent HIV and malaria. Children with severe pneumonia and clinical malaria require antibiotic and antimalarial treatment. In addition to vertical programs, integrated approaches may greatly contribute to reduction of pneumonia-related mortality.

Yellow fever-associated viscerotropic disease in Barcelona, Spain.

Yellow fever vaccine is a live, attenuated viral preparation from the 17D virus strain. Since 1996, 34 cases of yellow fever vaccine-associated viscerotropic disease (YEL-AVD) have been described. We report a new case of YEL-AVD. Given the potential risks associated with the vaccine, physicians should consider vaccination only for patients truly at risk for exposure to yellow fever, especially for primovaccination.

Congenital Trypanosoma cruzi infection in a non-endemic area.

In May 2004, after launching a screening programme to detect Trypanosoma cruzi infection in the Latin American population, a case of congenital infection in a 2-year-old boy was discovered in Barcelona. Few cases of congenital transmission have been described in non-endemic areas and little is known about the epidemiological and clinical features of congenital Chagas disease in this context. The increase in Latin American immigrants in Europe and the USA requires greater epidemiological surveillance and appropriate diagnostic techniques for managing T. cruzi infections.

[How much primaquine is needed to eradicate Plasmodium vivax hypnozoites?]. / Cuánta primaquina es necesaria para erradicar los hipnozoitos de Plasmodium vivax?

INTRODUCTION: Primaquine is now the only drug available to eradicate Plasmodium vivax malaria. The optimal dose of primaquine to prevent relapses of P. vivax remains under discussion. CLINICAL CASES: We describe three cases of P. vivax malaria from different geographical areas, in which a tolerance to standard doses of primaquine and, in some cases, to much higher doses has been observed. COMMENTS: P. vivax tolerance to primaquine is an emerging problem in daily practice. Reassessment of the primaquine dose required to eradicate P. vivax intrahepatic hypnozoites is needed.

Failure of standard treatment with praziquantel in two returned travelers with Schistosoma haematobium infection.

A single 40 mg/kg dose of praziquantel (PZQ) continues to be the standard treatment for schistosomiasis caused by S. mansoni and S. haematobium in all clinical settings. Experimental development of drug resistance and the recent isolation of S. mansoni strains with a natural tolerance to high doses of PZQ have raised concerns over the adequacy of such a dose. We describe two Spanish travelers with genitourinary schistosomiasis caused by S. haematobium in whom repeated standard treatment failed to clear the infection.

[Molecular epidemiological surveillance of markers for antimalarial drugs in Plasmodium falciparum isolates imported to Barcelona, Spain]. / Vigilancia epidemiológica mediante marcadores moleculares de resistencia frente a antimaláricos en aislados de Plasmodium falciparum importados a Barcelona, España.

BACKGROUND AND OBJECTIVE: There have been described compelling correlations between mutations in some Plasmodium falciparum genes and resistance to antimalarial drugs. To apply molecular techniques in the mechanisms of epidemiological surveillance in the Hospital Clínic of Barcelona and to map potential levels of resistance, we investigated the presence of mutations in the relevant codons of genes associated with resistance in P. falciparum isolates imported by travellers. PATIENTS AND METHOD: The genes pfctr, pfmdr1, dhfr, dhps and cytochrome b were analyzed by PCR and enzymatic restriction in P. falciparum isolates from 53 persons attending the Tropical Medicine Department after a trip to a malaria endemic area. RESULTS: 63% of patients were infected with a P. falciparum isolate with the K76T mutation in pfctr. Tyr86 in pfmdr1 was found in 54% of the isolates. Mutations in codons 51, 59 and 108 in dhfr were found in 33%, 49% and 44% of the isolates, respectively. Mutations in codons 436, 437 and 540 in dhps were found in 35%, 35% and 8.5% of the isolates. 30% of travellers were infected by parasites displaying 3 or more mutations in any of the codons of dhps and dhfr. None of the patients had a mutation in the Tyr268 codon of the cytochrome B gene. CONCLUSIONS: The high prevalence of mutations in the imported isolates suggests a fast development and expansion of resistance against most of the antimalarial drugs commonly used. The concurrence of more than one mutation in different loci suggests the expansion of multiple resistances.

Vigilancia epidemiológica mediante marcadores moleculares de resistencia frente a antimaláricos en aislados de Plasmodium falciparum importados a Barcelona, España / Molecular epidemiological surveillance of markers for antimarial drugs in Plasmodium falciparum isolates imported to Barcelona, Spain

Fundamento y objetivo: Se han descrito correlaciones convincentes entre mutaciones en determinados genes de Plasmodium falciparum y la resistencia contra antimaláricos. Con la intención de aplicar las técnicas moleculares en los mecanismos de vigilancia epidemiológica en el Hospital Clínic de Barcelona, y para mapear grados potenciales de resistencia, investigamos la presencia de mutaciones en los codones relevantes de genes asociados a resistencias en aislados de P. falciparum importados por viajeros. Pacientes y método: Se analizó mediante reacción en cadena de la polimerasa (PCR) y restricción con enzimas el genotipo de los genes pfctr, pfmdr1, dhfr, dhps y citocromo B en cepas de P. falciparum aisladas de 53 pacientes diagnosticados en el Servicio de Medicina Tropical con síntomas de malaria después de haber realizado un viaje a zonas endémicas de malaria. Resultados: El 63% de los pacientes presentó un aislado de P. falciparum con la mutación K76T en pfctr. En el 54% de los aislados se encontró Tyr86 en pfmdr1. Las mutaciones en los codones 51, 59 y 108 de dhfr se encontraron en el 33, el 49 y el 44% de los aislados, respectivamente. Las mutaciones en los codones 436, 437 y 540 de dhps se encontraron en el 35, el 35 y el 8,5% de los aislados. El 30% de los viajeros estaba infectado por parásitos que presentaban 3 o más mutaciones en alguno de los codones de dhps y dhfr. Ninguno de los pacientes presentó mutado el codón Tyr268 en el gen del citocromo B. Conclusiones: La alta prevalencia de mutaciones en los aislados importados sugiere el rápido desarrollo y la expansión de resistencias a la mayoría de los antimaláricos comúnmente usados. La concurrencia de más de una mutación en localizaciones diferentes sugiere la expansión de resistencias múltiples, lo que pone así de manifiesto la ineficacia de la monoterapia con los antipalúdicos más comunes

Background and objective: There have been described compelling correlations between mutations in some Plasmodium falciparum genes and resistance to antimalarial drugs. To apply molecular techniques in the mechanisms of epidemiological surveillance in the Hospital Clínic of Barcelona and to map potential levels of resistance, we investigated the presence of mutations in the relevant codons of genes associated with resistance in P. falciparum isolates imported by travellers. Patients and method: The genes pfctr, pfmdr1, dhfr, dhps and cytocrhome b were analyzed by PCR and enzymatic restriction in P. falciparum isolates from 53 persons attending the Tropical Medicine Department after a trip to a malaria endemic area. Results: 63% of patients were infected with a P. falciparum isolate with the K76T mutation in pfctr. Tyr86 in pfmdr1 was found in 54% of the isolates. Mutations in codons 51, 59 and 108 in dhfr were found in 33%, 49% and 44% of the isolates, respectively. Mutations in codons 436, 437 and 540 in dhps were found in 35%, 35% and 8.5% of the isolates. 30% of travellers were infected by parasites displaying 3 or more mutations in any of the codons of dhps and dhfr. None of the patients had a mutation in the Tyr268 codon of the cytochrome B gene. Conclusions: The high prevalence of mutations in the imported isolates suggests a fast development and expansion of resistance against most of the antimalarial drugs commonly used. The concurrence of more than one mutation in different loci suggests the expansion of multiple resistances

Blackwater fever in children, Burundi.

Blackwater fever is characterized by acute intravascular hemolysis with hemoglobinuria in patients with Plasmodium falciparum malaria. Its pathogenesis and management are still debated. Nine cases of this syndrome occurred in 2003 at Kiremba Hospital in Burundi in children receiving multiple quinine treatments.

[Histoplasma capsulatum infection in a group of travelers to Guatemala]. / Infección por Histoplasma capsulatum en un grupo de cooperantes en Guatemala.

OBJECTIVE: To analyze the epidemiological and clinical characteristics of Histoplasma capsulatum infection in a group of volunteers who had traveled to Guatemala. METHODS: A review was performed of the clinical records of nine patients who consulted at the Tropical Medicine Outpatient Unit of Hospital Clinic in Barcelona, Spain. RESULTS. All patients were attended for travelers' diarrhea. In addition, one student had also presented with respiratory symptoms and fever while in Guatemala and her chest X-ray showed interstitial infiltrates. The epidemiological history recognized risk factors for histoplasmosis in all patients (all of them had been working in the reconstruction of an old school building). The intradermal histoplasmin test was performed and was positive in all nine patients. None of the students required treatment. CONCLUSIONS: Histoplasmosis should be included in the differential diagnosis of returning travelers' fever. The diagnosis would have been missed in all of our patients if not for a directed clinical history taking. It is important to reinforce prevention measures, e.g. the use of face masks, when working in an environment with a risk for acquiring histoplasmosis.

Infección por Histoplasma capsulatum en un grupo de cooperantes en Guatemala / Histoplasma capsulatum infection in a group of travelers to Guatemala

Objetivo. Analizar las características epidemiológicas y clínicas de un grupo de cooperantes que presentó infección por H. capsulatum después de un viaje a Guatemala. Métodos. Revisión de historias clínicas de 9 pacientes atendidos en la Consulta de Medicina Tropical del Hospital Clínic. Resultados. El motivo de consulta fue diarrea del viajero en todos los casos, aunque una de las pacientes presentó sintomatología respiratoria y fiebre durante su estancia en Guatemala con infiltrados intersticiales en la radiología de tórax. La encuesta epidemiológica detectó factores de riesgo para la adquisición de Histoplasma (todos habían trabajado en la rehabilitación de una escuela vieja), motivo por el cual se realizó la prueba de histoplasmina, que resultó positiva en los 9 casos. Ningún paciente necesitó tratamiento. Conclusiones. La histoplasmosis debe incluirse en el diagnóstico diferencial de la fiebre del viajero. En nuestro grupo el diagnóstico hubiese pasado desapercibido en ausencia de una anamnesis dirigida. Es importante no olvidar y reforzar las medidas de prevención de la enfermedad en viajeros (p. ej., utilización de mascarillas de protección respiratoria si se trabaja en un entorno de riesgo) (AU)

Objective. To analyze the epidemiological and clinical characteristics of Histoplasma capsulatum infection in a group of volunteers who had traveled to Guatemala. Methods. A review was performed of the clinical records of nine patients who consulted at the Tropical Medicine Outpatient Unit of Hospital Clinic in Barcelona, Spain. Results. All patients were attended for travelers' diarrhea. In addition, one student had also presented with respiratory symptoms and fever while in Guatemala and her chest X-ray showed interstitial infiltrates. The epidemiological history recognized risk factors for histoplasmosis in all patients (all of them had been working in the reconstruction of an old school building). The intradermal histoplasmin test was performed and was positive in all nine patients. None of the students required treatment. Conclusions. Histoplasmosis should be included in the differential diagnosis of returning travelers' fever. The diagnosis would have been missed in all of our patients if not for a directed clinical history taking. It is important to reinforce prevention measures, e.g. the use of face masks, when working in an environment with a risk for acquiring histoplasmosis (AU)

[Imported malaria from Senegal: about 17 cases in year 2000]. / Paludismo importado de Senegal: a propósito de 17 casos en el año 2000.

BACKGROUND AND OBJECTIVE: Senegal is increasingly becoming a touristic target for many people. In 2000, there was a greater number of cases of malaria in patients from this country. Our objective was to analyze such increase, to describe the characteristics of these patients and to identify the reasons for it. PATIENTS AND METHOD: From 1999 to 2002 we prospectively collected the clinical and epidemiological data of all consecutive malaria cases seen in the Unit of Tropical Medicine of the Hospital Clinic (Barcelona, Spain). RESULTS: We attended 276 patients, 74 of them during 2000; of them, 17 had travelled to Senegal and Gambia. Their mean age was 36.58 (6.9) years and 12% were women. 59% patients were Spaniards, 35% were native of Senegal and 6% of Gambia. Reason of travel was tourism in 9 cases (53%) and a visit to the family in 7 cases (41%). Mean duration of the visit was 31 (20.6) days and only 17.6% patients did a right prophylaxis. Plasmodium falciparum was the commonest species (88%). The number of patients with malaria who had visited Senegal ranged from 6.6% in 1996 to 20% in 2000 to 6.3% in 2002 (p<0.05). CONCLUSIONS: There was an unexpected increase of malaria imported from Senegal in 2000 in our Unit. Changes in both the dynamics of malaria transmission and tourism offers may account for an unsuspected increase of malaria cases.

Paludismo importado de Senegal: a propósito de 17 casos en el año 2000 / Imported malaria from Senegal: about 17 cases in year 2000

FUNDAMENTO Y OBJETIVO: Senegal es uno de los países que está despertando un creciente interés como destino turístico. En el año 2000 hubo un mayor número de casos de paludismo en pacientes procedentes de dicho país. El objetivo del presente trabajo es constatar dicho aumento, describir las características de los pacientes e identificar los motivos de este incremento. PACIENTES Y MÉTODO: Durante los años 1999-2002 se recogieron de forma prospectiva los datos clínicos y epidemiológicos de todos los casos de paludismo atendidos de forma consecutiva en el servicio de Medicina Tropical del Hospital Clínico de Barcelona. RESULTADOS: Se atendió a un total de 276 pacientes, 74 durante el año 2000; de ellos, 17 habían viajado a Senegal y Gambia. Su edad media era de 36,58 (6,9) años, y el 12% eran mujeres. El 59% eran españoles, un 35% senegaleses y un 6% gambianos. El motivo del viaje fue turismo en 9 (53%) casos, y visita a familiares en 7 (41%). La duración media de la visita fuede 31 (20,6) días y sólo el 17,6% de los viajeros realizó profilaxis correcta. Plasmodium falciparum fue la especie más frecuente (88%). El porcentaje de pacientes con paludismo que habían visitado Senegal varió desde un 6,6% en el año 1996 a un 20% en el año 2000 y un 6,3% el año 2002 (p < 0,05). CONCLUSIONES: En el año 2000 hubo un aumento no esperado de paludismo importado de Senegal en nuestra unidad. Los cambios en la dinámica de transmisión del paludismo y de las ofertas turísticas podrían ser causas de un aumento insospechado de los casos de esta enfermedad

BACKGROUND AND OBJECTIVE: Senegal is increasingly becoming a touristic target for many people. In 2000, there was a greater number of cases of malaria in patients from this country. Our objective was to analyze such increase, to describe the characteristics of these patients and to identify the reasons for it. PATIENTS AND METHOD: From 1999 to 2002 we prospectively collected the clinical and epidemiological data of all consecutive malaria cases seen in the Unit of Tropical Medicine of the Hospital Clínic (Barcelona, Spain). RESULTS: We attended 276 patients, 74 of them during 2000; of them, 17 had travelled to Senegal and Gambia. Their mean age was 36.58 (6.9) years and 12% were women. 59% patients were Spaniards, 35% were native of Senegal and 6% of Gambia. Reason of travel was tourism in 9 cases (53%) and a visit to the family in 7 cases (41%). Mean duration of the visit was 31(20.6) days and only 17.6% patients did a right prophylaxis. Plasmodium falciparum was the commonest species (88%). The number of patients with malaria who had visited Senegal ranged from 6.6% in 1996 to 20% in 2000 to 6.3% in 2002 (p<0.05). CONCLUSIONS: There was an unexpected increase of malaria imported from Senegal in 2000 in our Unit. Changes in both the dynamics of malaria transmission and tourism offers may account for an unsuspected increase of malaria cases

[Ciguatera poisoning in Spanish travellers]. / Intoxicación por ciguatoxina en viajeros.

BACKGROUND AND OBJECTIVE: Ciguatera poisoning appears after ingestion of contaminated fish from tropical coral reefs. Due to the diversity of clinical symptoms and the absence of a specific test in humans, the diagnosis is often difficult. PATIENTS AND METHOD: A retrospective study of 10 patients consulting for a clinical and epidemiological picture compatible with ciguatera poisoning after a trip to tropical countries between 1993 and 2000. RESULTS: Most infections but one were acquired in the Caribbean area and there were 8 females. Clinical manifestations started within the first 24 hours after fish ingestion. Chief symptoms were diarrhea and nausea, followed by neurological symptoms, mainly limbs paresthesias that persisted for several weeks. CONCLUSIONS: The severity of clinical symptoms was variable and not related to age or initial symptoms. Ciguatera poisoning has to be considered in the diagnosis of acute gastroenteritis affecting travellers to tropical areas.

Intoxicación por ciguatoxina en viajeros / Ciguatera poisoning in Spanish travellers

FUNDAMENTO Y OBJETIVO: La ciguatera es un síndrome de intoxicación alimentaria provocada por la ingestión de pescado procedente de mares tropicales coralinos. El diagnóstico es difícil dada la amplia variedad de síntomas clínicos y la ausencia de un test diagnóstico específico en humanos. PACIENTES Y MÉTODO: Estudio retrospectivo desde el año 1993 al 2000 de 10 pacientes que acudieron a la Sección de Medicina Tropical del Hospital Clínic de Barcelona por presentar, durante su viaje a un país tropical, un cuadro clínico compatible con la intoxicación por ciguatoxina tras comer pescado. RESULTADOS: Los pacientes tenían una edad comprendida entre 18 y 47 años, 8 eran mujeres; la mayoría de ellos había viajado a la zona del Caribe. El cuadro se inició en las primeras 24 h tras el consumo de pescado. La manifestación clínica predominante fue gastrointestinal, la más frecuente fue la diarrea, seguida de náuseas, y posteriormente aparecieron las manifestaciones neurológicas, principalmente parestesias en las extremidades, que en algunos pacientes perduraron varias semanas. CONCLUSIONES: Hay diferencias en la presentación clínica y en la evolución de la ciguatera, que no es predecible según la edad ni la clínica de inicio. La intoxicación por ciguatoxina debe formar parte del diagnóstico diferencial en los cuadros de gastroenteritis padecidos por personas que han viajado recientemente a zonas endémicas (AU)

[Imported diseases in African immigrants in Spain: study of 1,321 patients]. / Enfermedades importadas en inmigrantes Africanos: estudio de 1.321 pacientes.

BACKGROUND: Immigrants can carry diseases characteristic from their countries of origin. These are known as imported diseases (ID) and can be classified into tropical diseases (TD) or cosmopolitan diseases (CD). The aim of this study was to analyse the ID in African immigrants and evaluate their repercussion in the Spanish Public Health. PATIENTS AND METHOD: Observational study, retrospective protocol, carried from 1984 to 1994 in African immigrants seen in a reference Hospital. Not infectious chronic ID were excluded. The repercussion in public health was divided in 3 categories according to transmission risk to the host population: a) ID without current risk; b) ID with potential risk and, c) ID of risk. RESULTS: 1,321 African immigrants were considered. Most of them were from Sub-Saharan Africa. The most frequent TD were helminthiases and among CD, tuberculosis, sexually transmitted diseases and parasitoses. ID without transmission risk were 26.7% (2.4% CD and 24.3% TD), ID with potential risk 35.2% (33.6% CD and 1.6% TD) and ID with risk 38% (all CD). CONCLUSIONS: The CD and their association with poverty suppose a higher risk of transmission to the host country population. Global policies of helping social and economic insertion of immigrant populations, combined with international health collaboration, will rebound positively in the general population's health.