Taeniosis and cysticercosis in Serbia, 1990-2018: Significance of standard of living.

OBJECTIVES: As is the case for all of Southeast Europe, Serbia is an area traditionally endemic for Taenia saginata and Taenia solium infections. This study was performed to analyse the epidemiological data on taeniosis and cysticercosis in Serbia for the period 1990-2018. METHODS: Data on cases of T. saginata and T. solium infection were collected via a systematic search of published articles, the grey literature, and official reports, as well as by performing clinical observational studies of patients treated in the departments for infectious diseases of hospitals and university clinics in Serbia. RESULTS: A total of 212 cases of taeniosis were reported, all between 1997 and 2004 when taeniosis was notifiable (incidence range 0.04-0.9/100 000 population/year). From 1990 to 2018, 170 cases of cysticercosis (all but one of neurocysticercosis), were registered (incidence range 0-0.29/100 000 population/year), with a strong decrease since 2000 and a single case in the last 9 years. The annual number of cases of both taeniosis (Pearson's r = 0.914, p = 0.001) and cysticercosis (Pearson's r = 0.582, p = 0.014) correlated with the consumer price index. CONCLUSIONS: In Serbia, T. saginata and T. solium infections are autochthonous but occur only sporadically. However, the potential for re-emergence exists, depending on the socio-economic state of the country.

Correction to: Epidemiology of taeniosis/cysticercosis in Europe, a systematic review: eastern Europe.

In the original article [1], the authors Dr Jasmin OMERAGIC and Dr Davor ALAGIC were erroneously omitted from the co-authors list.

Epidemiology of taeniosis/cysticercosis in Europe, a systematic review: eastern Europe.

BACKGROUND: Taenia solium and Taenia saginata are food-borne parasites of global importance. In eastern Europe only fragmented information is available on the epidemiology of these zoonotic parasites in humans and animal populations. In particular for T. solium, on-going transmission is suspected. The aim of this systematic review was to collect the available data and describe the current knowledge on the epidemiology of T. solium and T. saginata in eastern Europe. METHODS: Literature published in international databases from 1990 to 2017 was systematically reviewed. Furthermore, local sources and unpublished data from national databases were retrieved from local eastern European experts. The study area included 22 countries. RESULTS: Researchers from 18 out of the 22 countries provided data from local and unpublished sources, while no contacts could be established with researchers from Belarus, Kosovo, Malta and Ukraine. Taeniosis and human cysticercosis cases were reported in 14 and 15 out of the 22 countries, respectively. Estonia, the Former Yugoslav Republic of Macedonia, Lithuania, Moldova, Poland, Romania, Serbia, and Slovakia reported cases of porcine cysticercosis. Croatia, Czech Republic, Estonia, Former Yugoslav Republic of Macedonia, Moldova, Poland, Romania, Serbia, Slovakia, and Ukraine reported bovine cysticercosis. CONCLUSIONS: There is indication that taeniosis and cysticercosis are present across eastern Europe but information on the occurrence of T. solium and T. saginata across the region remains incomplete. Available data are scarce and species identification is in most cases absent. Given the public health impact of T. solium and the potential economic and trade implications due to T. saginata, notification of taeniosis and human cysticercosis should be implemented and surveillance and notification systems in animals should be improved.

Clinical characteristics of imported malaria: An 11-year experience in a Serbian referral center.

INTRODUCTION: Due to intercontinental traffic, population migration trends, natural disasters, and climate change, imported malaria remains important to consider in a febrile returning traveler. This study aims to raise awareness about malaria and help European clinicians maintain a working knowledge of this disease by reviewing the most important clinical characteristics in a non-endemic setting. METHODOLOGY: Using medical records, a retrospective study was performed on clinical and laboratory data in order to analyze 103 malaria cases managed at the Clinic for Infectious and Tropical Diseases in Belgrade, from 2000 to 2010. Descriptive statistics, Chi-squared test, Spearman's rank correlation, and analysis of variance were used. RESULTS: Patients were predominantly male (89.3%) with a mean age of 46.66 ± 12.45 years, and most (98.06%) returned from Africa without having taken chemoprophylaxis (72.88%). Fever, arthralgia, myalgia, headache, vomiting, dark urine, and cough were common at presentation. Hepatosplenomegaly, jaundice, neurological and pulmonary findings, and thrombocytopenia were dominant findings on physical and laboratory examinations. Most (73.48%) were infected with P. falciparum. Few patients (17.55%) who were hyperparasitemic had significantly higher values of bilirubin and more frequent neurological complications. All patients were treated with artemisinin-based drug combinations regardless of Plasmodium species. Three (2.9%) patients succumbed to P. falciparum malaria. CONCLUSION: We suggest a high index of suspicion of malaria be maintained when evaluating febrile patients returning from endemic regions, especially if thrombocytopenia and hemolysis are present. Hyperparasitemia, high bilirubin levels, and neurological symptoms are associated with severe malaria. The importance of adequate malaria chemoprophylaxis cannot be overstated.

Retrospective PCR-based species identification of Leishmania in two patients with visceral leishmaniasis in Serbia.

INTRODUCTION: Retrospective molecular identification of Leishmania parasites in two patients with visceral leishmaniasis (VL) previously treated in Serbia was carried out. DNA was isolated from unstained bone marrow smears (BMSs) kept for 11 and 8 years. Genus-specific real-time PCR was combined with conventional PCR and sequencing for detection and species identification. CASE PRESENTATION: In 2003, a 40-year-old Serbian male was admitted to the Clinical Centre of Serbia (CCS) with fever, sweating, fatigue and splenomegaly, which developed over a period of 7 weeks. He had frequently travelled around Europe. VL was confirmed by microscopy of Giemsa-stained BMS. Treatment by pentavalent antimonials was successfully completed. Two years later, the patient developed post-kala-azar dermal leishmaniasis. Treatment resulted in symptom resolution. Later on, Leishmania infantum was identified as the causative agent of the VL by sequencing of the ITS (internal transcribed spacer) region; mixed Leishmania spp. infection could not be excluded. In 2006, a 33-year-old female from Vojvodina, Serbia, with pre-existing diabetes mellitus and chronic meningoencephalitis and a history of frequent visits to the Montenegrin seacoast, was admitted to the CCS with fever, pancytopenia and moderate hepatosplenomegaly. A stained BMS revealed abundant Leishmania amastigotes. Indirect haemagglutination analysis was positive with a titre of 1 : 2048, and a rapid dipstick rK39 test was also positive. Treatment by liposomal amphotericin B was successful; however, shortly after, the patient developed neural infection and pneumonia and died. The causative agent was identified as L. infantum. CONCLUSION: Molecular diagnosis of VL and species delineation using DNA from unstained BMSs stored for several years is possible.

HUMAN SUBCUTANEOUS DIROFILARIASIS - CASE REPORT.

INTRODUCTION: Human dirofilariasis is a zoonotic disease caused by Dirofilaria repens and Dirofilaria immitis. It usually presents as a nodular lesion in the lung, subcutaneous tissues or eyes. In animals, dirofilariasis is a very common disease with serious cardiovascular and respiratory manifestations. If adequate therapy is not given at the beginning ofthe disease, dirofilariasis can lead to animal death. On the contrary, human dirofilariasis is frequently mild, sporadic and asymptomatic disease. Complications in humans are very rare. In Europe, human dirofilariasis is a very rare zoonotic disease even in endemic areas such as Italy, Spain and the Mediterranean. CASE REPORT: The authors reported the case of a 43-year-old male with a subcutaneous nodule caused by Dirofilaria repens. The patient who lives in Budva, Montenegro, had a nodule in the right-hand side of the anterior abdominal walljust below the sternum with maximum diameter of 3 cm. His health condition was good and all laboratory analyses were normal. The lesion was surgically removed and the histopathological examination confirmed the parasitic infection by Dirofilaria repens. After surgical excision, the patient was treated with dual antimicrobial therapy (100 mg doxycycline per os twice a day for 28 days and 200 mg albendazole per os twice a day for 10 days). CONCLUSION: It is very difficult to make the diagnosis of a subcutaneous nodule. The difficulties arise in the differential diagnosis because subcutaneous nodules are suspected to be malignant neoplasm or other pathologies such as tuberculosis, fungal infections, sebaceous cysts, hamartomas, abscesses, and so on. Although human dirofilariasis is a rare disease, the number of reported cases has recently been increasing worldwide.

Clinical significance of molecular methods in the diagnosis of imported malaria in returning travelers in Serbia.

OBJECTIVES: The goal of this study was to assess the clinical significance of conventional and PCR-based molecular diagnosis in patients with imported malaria in Serbia. METHODS: Giemsa microscopy, the rapid diagnostic test, and quantitative real-time PCR (qPCR) were used to detect Plasmodium species in 109 whole-blood samples from patients after their return from malaria endemic areas, including those clinically suspected for malaria (n=97) and healthy travelers (n=12) examined as part of epidemiological surveillance. RESULTS: A total of 45 patients were diagnosed with malaria: 42 (93.3%) by microscopy and three (6.7%) additional ones by qPCR. The agreement between the results of species-specific qPCR and microscopy was 73.3%; it was as high as 90.6% for Plasmodium falciparum infections. Follow-up analysis demonstrated persistence of Plasmodium sp DNA for a mean 6 days after the disappearance of parasitemia on microscopy. CONCLUSIONS: Due to its sensitivity and specificity, qPCR is a helpful method complementary to microscopy, particularly in cases of low parasitemia. In addition, it is superior to microscopy for species identification.

Human case of fasciolosis in Serbia treated with triclabendazole.

INTRODUCTION: The number of humans infected by Fasciola hepatica is increasing worldwide. Humans can become accidental hosts by ingesting drinking water or plants contaminated with metacercariae. CASE REPORT: We reported a case of a 68-year-old Serbian woman, in which the diagnosis of acute fasciolosis had been established after serious diagnostic concerns. Based on clinical picture (episodic right upper quadrant abdominal pain, febrility and generalized body pain) and biochemical analyses (high eosinophilia and high activity of alkaline phosphatase), she was appointed as suspected to the acute fasciolosis. Stool and duodenal aspirate exams were negative for Fasciola ova. In the absence of adequate serologic diagnostic for fasciolosis in Serbia, the diagnosis was confirmed using enzyme immunoassays and immunoblot at the Institute for Tropical Diseases in Hamburg, Germany. Soon after triclabendazole was administered, the symptoms disappeared and biochemical values returned to normal. CONCLUSION: The diagnosis of human fasciolosis may be problematic and delayed, especially in non endemic areas, because physicians rarely encounter this disease and a long list of other diseases must be considered in the differential diagnosis. The syndrome of eosinophilia, fever, and right upper quadrant abdominal pain suggest acute fasciolosis. Unclear source does not rule out fasciolosis.

[Family outbreak of cryptosporidiosis in Serbia: case report].

INTRODUCTION: Cryptosporidiosis is an acute infectious parasitic disease of the gastrointestinal tract, considered as zoonosis underestimated in immunocompetent population. The pathogen is primarily the cause of devastating diarrhea in AIDS patients. Solitary cases and small outbreaks in immunocompetent persons are rarely discovered. There is also a human strain of cryptosporidium. CASE OUTLINE: In December 2010, we examined three family members among whom each successively developed acute gastroenteritis. Their stools were liquid, light brown, without mucus or blood. All of them had abdominal cramps and generalized muscle pains. The daughter had fever and vomited during the first two days. The patients were administered symptomatic therapy. Complaints resolved after 10-17 days, with general condition moderately changed. Cryptosporidium was confirmed in the stool of patients who were second and third to contract the disease. We presumed that the first person released pathogen before the time of examination, although she still had diarrhea. All of them recovered completely. By epidemiologic survey we were unable to presume with certainty the source of infection. CONCLUSION: This is the first description of cryptosporidiosis in immunocompetent individuals in Serbia, which proves that it is present in our country, and that search for it should be included into a routine parasitological check-up of stool. Taking into account the distance in onset time complaints, all combinations are possible; from infection among family members (shortest incubation period) to family members infected from an identical source (different incubation period). Negative finding of the sample collected on the 7th day from the beginning of symptoms does not exclude the diagnosis in this particular situation. Further epidemiologic studies of this disease are necessary as it is clear that it exists in our population. At that moment we were unable to do typization.

Imported malaria in Belgrade, Serbia, between 2001 and 2009.

Since 2000, travel of Serbian citizens to tropical areas has been slowly but steadily increasing. To determine the epidemiological and clinical characteristics of imported malaria in Serbia, we analyzed clinical history data of all travelers who presented at the Clinic for Infectious and Tropical Diseases in Belgrade after their return from tropical and subtropical areas between 2001 and 2009. The study series involved a total of 2981 travelers, and included both those with (847) and without (2134) health problems. Malaria was diagnosed in 102 cases (3.4% of all travelers; 12.0% of travelers with febrile episodes). Occurring at a rate of 6 to 16 cases per year, it was predominantly imported from Africa (92.2%), particularly from Equatorial Guinea (38.2%) and Nigeria (15.7%). The most frequent reason for travel was work/business. Patients were predominantly (87.3%) male, and the majority (66.7%) was between 40 and 59 years of age. A total of 15 (14.7%) patients took some form of anti-malarial chemoprophylaxis. The dominant causative species was Plasmodium falciparum (78), alone (70) or in mixed infection with P. vivax (5) and P. malariae (3). P. vivax, P. ovale and P. malariae as single agents were each identified in 11, 1 and 1 cases, respectively. Of the 11 cases in which the parasite was not detected, six appeared to be true submicroscopic cases. The clinical course of the disease was severe in 13 patients, all with falciparum malaria, of which three (2.9%) died. Rather than for all travelers, in Serbia screening for malaria should be mandatory in all travelers to endemic regions who present with fever irrespective of chemoprophylaxis history. Inadequate sensitivity of conventional diagnostic methods, illustrated by the cases of submicroscopic malaria, requires introduction of molecular diagnosis in routine practice.