Leprosy chemoprophylaxis of household contacts: A survey of Canadian infectious disease and tropical medicine specialists.

BACKGROUND: Leprosy is uncommon in Canada. However, immigration from leprosy-endemic areas has introduced the infection to a Canadian context, in which most doctors have little knowledge of the disease. Although post-exposure chemoprophylaxis (PEP) is reported to decrease leprosy transmission, no Canadian guidelines advise clinical decision making about leprosy PEP. Here, we characterize the practice patterns of Canadian infectious disease specialists with respect to leprosy PEP and screening of household contacts by yearly physical examinations. METHODS: Canadian infectious disease specialists with known experience treating leprosy were identified using university faculty lists. An online anonymous survey was distributed. Certain questions allowed more than one response. RESULTS: The survey response rate was 46.5% (20/43). Thirty-five percent responded that PEP is needed for household contacts, 40.0% responded that PEP is not needed for household contacts, and 25.0% did not know whether PEP is needed (multinomial test p = 0.79). Twenty-five percent responded that PEP should be given to all household contacts, 62.5% responded that PEP should be given to contacts of multibacillary cases, and 25.0% responded that PEP should be given to contacts who are genetically related to the index case. For specialists who prescribe PEP, 57.1% use rifampicin, ofloxacin (levofloxacin), and minocycline; 14.3% prescribe single-dose rifampicin; and 28.6% prescribe multiple doses of rifampicin (multinomial test p = 0.11). In addition, 68.4% recommend yearly screening of household contacts, whereas 31.6% do not (multinomial test p = 0.17). CONCLUSION: Consensus among Canadian infectious diseases specialists is lacking regarding leprosy PEP and screening of household contacts.

HISTORIQUE: La lèpre est peu courante au Canada. Cependant, en raison de l'immigration de régions où la lèpre est endémique, cette infection existe, mais la plupart des médecins du Canada la connaissent peu. Même s'il est établi que la chimioprophylaxie post-exposition (PPE) réduit la transmission de la lèpre, il n'existe aucune directive canadienne pour éclairer les décisions cliniques sur la PPE de la lèpre. Les chercheurs caractérisent les schémas d'exercice des infectiologues canadiens au sujet de la PPE de la lèpre et du dépistage des contacts familiaux par des examens physiques annuels des aspects dermatologiques et nerveux périphériques. MÉTHODOLOGIE: Les chercheurs ont répertorié les infectiologues canadiens qui ont une expérience démontrée du traitement de la lèpre grâce aux listes des professeurs universitaires. Ils ont distribué un sondage anonyme en ligne. Pour certaines questions, les participants pouvaient fournir plus d'une réponse. Ils pouvaient aussi sauter certaines questions. RÉSULTATS: Le taux de réponse au sondage s'élevait à 46,5 % (20 cas sur 43). De cette proportion, 35,0 % ont répondu que les contacts familiaux avaient besoin d'une PPE, 40,0 %, qu'ils n'en avaient pas besoin, et 25,0 %, qu'ils ne le savaient pas (test multinomial, p = 0,79). Sur l'ensemble des répondants, 25,0 % ont répondu que tous les contacts familiaux devraient recevoir une PPE, 62,5 %, qu'elle devait être administrée aux contacts des cas multibacillaires, et 25,0 %, aux contacts génétiquement apparentés au cas de référence. Chez les spécialistes qui prescrivent une PPE, 57,1 % utilisent de la rifampicine, de l'ofloxacine (lévofloxacine) et de la minocycline, 14,3 %, une seule dose de rifampicine, et 28,6 %, de multiples doses de rifampicine (test multinomial p = 0,11). De plus, 68,4 % recommandent le dépistage annuel des contacts familiaux, et 31,6 % ne le recommandent pas (test multinomial p = 0,17). CONCLUSION: Il n'y a pas de consensus chez les infectiologues canadiens au sujet de la PPE de la lèpre et du dépistage des contacts familiaux.

Cutaneous and mucocutaneous leishmaniasis in travellers and migrants: a 20-year GeoSentinel Surveillance Network analysis.

BACKGROUND: Cutaneous leishmaniasis (CL) may be emerging among international travellers and migrants. Limited data exist on mucocutaneous leishmaniasis (MCL) in travellers. We describe the epidemiology of travel-associated CL and MCL among international travellers and immigrants over a 20-year period through descriptive analysis of GeoSentinel data. METHODS: Demographic and travel-related data on returned international travellers diagnosed with CL or MCL at a GeoSentinel Surveillance Network site between 1 September 1997 and 31 August 2017 were analysed. RESULTS: A total of 955 returned travellers or migrants were diagnosed with travel-acquired CL (n = 916) or MCL during the study period, of whom 10% (n = 97) were migrants. For the 858 non-migrant travellers, common source countries were Bolivia (n = 156, 18.2%) and Costa Rica (n = 97, 11.3%), while for migrants, they were Syria (n = 34, 35%) and Afghanistan (n = 22, 22.7%). A total of 99 travellers (10%) acquired their disease on trips of ≤ 2 weeks. Of 274 cases for which species identification was available, Leishmania Viannia braziliensis was the most well-represented strain (n = 117, 42.7%), followed by L. major (n = 40, 14.6%) and L. V. panamensis (n = 38, 13.9%). Forty cases of MCL occurred, most commonly in tourists (n = 29, 72.5%) and from Bolivia (n = 18, 45%). A total of 10% of MCL cases were acquired in the Old World. CONCLUSIONS: Among GeoSentinel reporting sites, CL is predominantly a disease of tourists travelling mostly to countries in Central and South America such as Bolivia where risk of acquiring L. V. braziliensis and subsequent MCL is high. The finding that some travellers acquired leishmaniasis on trips of short duration challenges the common notion that CL is a disease of prolonged travel. Migrants from areas of conflict and political instability, such as Afghanistan and Syria, were well represented, suggesting that as mass migration of refugees continues, CL will be increasingly encountered in intake countries.

Case Report: Two Cases of Strongyloidiasis Presenting with Thrombotic Events.

We report two unusual cases of clinical strongyloidiasis that present as extensive thrombosis: a case of hyperinfection with concurrent eosinophilia and a case of disseminated infection as a complication of immunosuppression. We discuss risk factors for the development of Strongyloides stercoralis infection and thromboembolism, and the recommended management.

Case Report: Central Nervous System Strongyloidiasis: Two Cases Diagnosed Antemortem.

Central nervous system (CNS) strongyloidiasis is a known but rare form of disseminated infection. The diagnosis is often made postmortem, with only five published cases of an antemortem diagnosis. We report two fatal cases of CNS strongyloidiasis diagnosed antemortem, with Strongyloides stercoralis larvae visualized in the CNS sample in one case. Risk factors for disseminated strongyloidiasis common to both cases included origination from the Caribbean, underlying human T-lymphotropic virus-1 infection, and recent prednisone use. Both cases occurred in Canada, where the occurrence of Strongyloides is uncommon, and serve as a reminder to maintain a high index of suspicion in patients with epidemiologic or clinical risk factors for dissemination.

Case Report: Filaria or Megasperm? A Cause of an Ultrasonographic "Filarial Dance Sign".

Bancroftian filariasis can cause genital abnormalities related to chronic inflammation and obstruction of the afferent lymphatic vessels, and may demonstrate a "filarial dance sign" on scrotal ultrasound with mobile echogenic particles observed. We present a patient with a positive "filarial dance sign," travel within Latin America, and negative filarial serology.

Business travel-associated illness: a GeoSentinel analysis.

Background: Analysis of a large cohort of business travelers will help clinicians focus on frequent and serious illnesses. We aimed to describe travel-related health problems in business travelers. Methods: GeoSentinel Surveillance Network consists of 64 travel and tropical medicine clinics in 29 countries; descriptive analysis was performed on ill business travelers, defined as persons traveling for work, evaluated after international travel 1 January 1997 through 31 December 2014. Results: Among 12 203 business travelers seen 1997-2014 (14 045 eligible diagnoses), the majority (97%) were adults aged 20-64 years; most (74%) reported from Western Europe or North America; two-thirds were male. Most (86%) were outpatients. Fewer than half (45%) reported a pre-travel healthcare encounter. Frequent regions of exposure were sub-Saharan Africa (37%), Southeast Asia (15%) and South Central Asia (14%). The most frequent diagnoses were malaria (9%), acute unspecified diarrhea (8%), viral syndrome (6%), acute bacterial diarrhea (5%) and chronic diarrhea (4%). Species was reported for 973 (90%) of 1079 patients with malaria, predominantly Plasmodium falciparum acquired in sub-Saharan Africa. Of 584 (54%) with malaria chemoprophylaxis information, 92% took none or incomplete courses. Thirteen deaths were reported, over half of which were due to malaria; others succumbed to pneumonia, typhoid fever, rabies, melioidosis and pyogenic abscess. Conclusions: Diarrheal illness was a major cause of morbidity. Malaria contributed substantial morbidity and mortality, particularly among business travelers to sub-Saharan Africa. Underuse or non-use of chemoprophylaxis contributed to malaria cases. Deaths in business travelers could be reduced by improving adherence to malaria chemoprophylaxis and targeted vaccination for vaccine-preventable diseases. Pre-travel advice is indicated for business travelers and is currently under-utilized and needs improvement.

Fulminant hepatic failure from hepatitis E in a non-pregnant female traveller.

A non-pregnant Canadian woman returning from India presented with a 1-week history of jaundice and malaise. Subsequently, she developed fulminant hepatic failure caused by hepatitis E virus (HEV). HEV can cause fulminant hepatic failure, most commonly in pregnant women and those with chronic liver disease; however, all travellers are at risk.

Cutaneous Strongyloides Infection Postchemotherapy.

BACKGROUND AND OBJECTIVE: While clinical symptoms of strongyloidiasis are often nonspecific, larva currens (with erythematous, serpiginous, and pruritic papules and plaques) should prompt investigation including stool microscopy, serology, and skin biopsy of the lesion. Appropriate diagnosis and treatment with ivermectin is necessary, especially in the immunocompromised patient who is at increased risk for hyperinfection syndrome and disseminated disease. CONCLUSION: We present a 61-year-old immunocompromised man with presentation of larva currens of cutaneous strongyloides infection without symptoms of hyperinfection or disseminated disease.

Epidemiology of Zika virus, 1947-2007.

INTRODUCTION: Since 1947, Zika virus has been identified sporadically in humans in Africa and Asia; however, clinically consequential Zika virus disease had not been documented prior to the current outbreak in the Americas. Considering 6 decades have passed since the first identification of the virus, it is perhaps unexpected that Zika virus was recognised only recently as capable of causing disease epidemics. Substantial work on understanding the epidemiology of Zika virus has been conducted since the virus' first outbreak in 2007 in Micronesia; however, there has been little study of the earlier data on Zika virus. METHODS: A systematic literature search was conducted to identify evidence of Zika virus infection in humans from 1947 to 2007. Data extracted included seroprevalence of Zika virus infection, age distributions of positive test results and serologic test modalities used. Country-level and age-specific seroprevalence was calculated. Estimates of seroprevalence by different serologic test modalities were compared. RESULTS: 12 026 citations were retrieved by the literature search, and 76 articles were included in this review. Evidence of Zika virus infection in humans was found in 29 countries in Africa, 8 countries in Asia and 1 country in Europe. Country-level seroprevalence of Zika virus infection ranged from 0.4% to 53.3%. Seroprevalence of Zika virus infection was found to increase across the lifespan; 15-40% of reproductive-age individuals may have been previously infected. No significant difference was found between estimates of seroprevalence by different serologic test modalities. DISCUSSION: Zika virus has likely been endemic for decades in certain regions of the world; however, the majority of reproductive-age individuals have likely not been infected. Historical evidence of Zika virus infection exists regardless of the serologic test modality used.

A unique retinal epitheliopathy is associated with amyotrophic lateral sclerosis/Parkinsonism-Dementia complex of Guam.

BACKGROUND: The aim of this work was to examine whether a linear retinal pigment epitheliopathy is associated with the amyotrophic lateral sclerosis/parkinsonism-dementia complex of Guam. METHODS: A total of 918 Guamanian Chamorros, with and without amyotrophic lateral sclerosis/parkinsonism-dementia complex, were examined cross-sectionally for linear retinal pigment epitheliopathy (LRPE). Overall, 239 Guamanians, who were neurologically asymptomatic, were followed for up to 20 years to determine the risk of developing amyotrophic lateral sclerosis/parkinsonism-dementia complex. RESULTS: The epitheliopathy was present in 59.7% (117 of 196) patients with amyotrophic lateral sclerosis/parkinsonism-dementia complex, but in only 24.7% (178 of 722) of subjects who were neurologically asymptomatic (age- and sex-adjusted risk difference: 35.0%; 95% confidence interval [CI]: 27.5-42.6; p < 0.0001). Prospectively, 15 of 50 cases with epitheliopathy developed amyotrophic lateral sclerosis/parkinsonism-dementia complex, compared to 4 of 189 cases without epitheliopathy (age- and sex-adjusted hazard ratio: 13.1; 95% CI: 4.0-43.1; P < 0.0001). CONCLUSION: Amyotrophic lateral sclerosis/parkinsonism-dementia complex is associated with an LRPE and predicts future neurological disease. Identifying the cause of this retinopathy could provide an understanding about the pathogenesis of amyotrophic lateral sclerosis/parkinsonism-dementia complex and related diseases.

Failure of ivermectin per rectum to achieve clinically meaningful serum levels in two cases of Strongyloides hyperinfection.

Two cases of Strongyloides hyperinfection are presented. Ivermectin was initially administered orally and per rectum pending the availability of subcutaneous (SC) preparations. In neither case did rectal suppositories of ivermectin achieve clinically meaningful serum values. Clinicians should use SC preparations of ivermectin as early as possible in Strongyloides hyperinfection and dissemination.