Intestinal helminthic infections: a narrative review to guide the hepatogastroenterologist.

Intestinal helminthic infections are not uncommon in Western Europe, mainly due to modern travel, emigration and globalization. Moreover, some helminthic infections are endemic in Western Europe and are part of the everyday clinical practice. The hepatogastroenterologist should therefore recognize and manage these patients or at least refer them to appropriate reference centers. Signs and symptoms are often unspecific or even absent. Discerning the disease at an early stage avoids expensive diagnostic testing, life-threatening complications and in some cases even further spread of the disease. This review article aims to guide the hepatogastroenterologist when suspecting a helminthic infection by addressing the most prevalent symptoms, summarizing the most probable associated helminthic entities, highlighting practical steps in diagnosis and available treatments.

The risk of transmission of the novel coronavirus (SARS-CoV-2) with human heart valve transplantation: evaluation of cardio-vascular tissues from two consecutive heart donors with asymptomatic COVID-19.

We report on two living donors of explanted hearts while receiving heart transplantation that tested positive for SARS-CoV-2 on the day of donation, although clinically asymptomatic. They underwent heart transplantation for ischaemic and hypertrophic obstructive cardiomyopathy, respectively. After evaluation of donor hearts, we cryopreserved and stored two pulmonary valves for clinical application and one aortic valve for research. Light microscopy of myocardium, mitral valve and aortic and pulmonary arterial wall and RT-PCR SARS-CoV-2 test of myocardium, mitral and tricuspid valve and aortic wall for detection of SARS-CoV-2 were performed. Presence of ACE2 in tissues was assessed with immunostaining. Light microscopy revealed a mild eosinophilic myocarditis in the ischemic cardiomyopathy heart, whereas enlarged cardiomyocytes with irregular nucleus and some with cytoplasmic vacuoles in the hypertrophic obstructive cardiomyopathy heart. Aortic and pulmonary wall were histologically normal. Immunostaining revealed diffuse presence of ACE2 in the myocardium of the heart with eosinophilic myocarditis, but only discrete presence in the hypertrophic cardiomyopathy heart. The RT-PCR SARS-CoV-2 test showed no presence of the virus in tested tissues. Despite eosinophilic myocarditis in the ischemic cardiomyopathy heart, no viral traces were found in the myocardium and valve tissues. However, ACE2 was present diffusely in the ischemic cardiomyopathy heart. SARS-CoV-2 could not be detected in the cardiac tissues of these COVID-19 asymptomatic heart donors. In our opinion, clinical application of the valves from these donors presents negligible risk for coronavirus transmission. Nonetheless, considering the uncertainty regarding the risk of virus transmission with the human tissue transplantation, we would not release in any case the pulmonary valve recovered from the eosinophilic myocarditis heart. In contrast, we may consider the release of the pulmonary valve from the dilated cardiomyopathy heart only for a life-threatening situation when no other similar allograft were available.

Performance evaluation of the Diasorin LIAISON® XL Zika capture IgM CLIA test.

Because Zika virus (ZIKV) can cause serious birth defects and is involved in cases of Guillain-Barré syndrome, the ZIKV outbreak in the American continent in 2015 resulted in an enormous need for ZIKV diagnostic tools. We evaluated the LIAISON® XL Zika Capture IgM test on 106 samples from patients, mainly travelers, with a confirmed or probable ZIKV infection. Sensitivity between 0 and 84 days after onset of symptoms was 92.5%. Specificity was evaluated on a panel of 56 samples known to cause possible cross-reactions. Cross-reaction with DENV antibodies was limited (10.5%) but false-positive results occurred in samples from patients with malaria, CMV and EBV infections.

A case of giant cell arteritis associated with culture-proven Coxiella burnetii aortitis.

A case of proven Coxiella burnetii aortitis, possibly associated with giant cell arteritis (GCA), is reported. A 72-year-old man, who is a hunter, presented with weight loss, fever, jaw claudication, and hardened temporal arteries associated with a persistent inflammatory syndrome and arteritis of the whole aorta, including the brachiocephalic arteries, as seen on 18F-fluorodeoxyglucose positron emission tomography/computed tomography. The diagnosis of GCA was retained, and treatment with prednisolone was started. Given the aneurysm of the abdominal aorta, the patient underwent replacement of the abdominal aorta with an allograft. Histology showed intense chronic arteritis attributed to atherosclerosis with dissection. However, Coxiella burnetii infection was confirmed by serology and then by culture and molecular biology on the surgical specimen. A combination of hydroxychloroquine and doxycycline was added to tapered prednisolone and the outcome was favourable.

Diagnostic accuracy of a rapid E1-antigen test for chikungunya virus infection in a reference setting.

OBJECTIVES: Rapid diagnostic tests targeting virus-specific antigen could significantly enhance the diagnostic capacity for chikungunya virus infections. We evaluated the accuracy of an immunochromatographic antigen test for diagnosis of chikungunya in a reference laboratory for arboviruses. METHODS: An immunochromatographic rapid test that uses mouse monoclonal antibodies as a tracer against the E1-envelope protein of chikungunya (ARKRAY, Inc. Kyoto, Japan) was evaluated. Sensitivity was tested in sera from travellers with RT-PCR confirmed chikungunya virus infection (Eastern/Central/Southern African (ECSA) genotype) (n=9) and from patients diagnosed during the 2014-2015 chikungunya outbreak on Aruba (Asian genotype, n=30). Samples from patients with other febrile and non-febrile illnesses (n=26), sera spiked with Flavivirus and Alphavirus reference strains (n=13, including non-spiked serum), and samples containing other selected pathogens (n=20) were used to test specificity of the E1-antigen test. RESULTS: Sensitivity of the E1-antigen test was 8/9 (88.9%, 95% CI 56.5-98.0) for the ECSA genotype, but only 10/30 (33.3%, 95% CI 19.2-51.2) for the Asian genotype. Overall diagnostic specificity was 49/59 (83.1%, 95% CI 71.5-90.5). CONCLUSIONS: The E1-antigen test we evaluated had fair diagnostic sensitivity for ECSA genotype chikungunya, but low sensitivity for Asian genotype, and poor overall specificity. Antibodies that react across genotypes will be required for further development of a rapid test for chikungunya. Performance of new tests should be evaluated against different chikungunya genotypes.

Antibiotic susceptibility profiles among Campylobacter isolates obtained from international travelers between 2007 and 2014.

Campylobacter infection is a common cause of diarrhea among international travelers. We studied antibiotic resistance patterns among Campylobacter isolates obtained from international travelers according to travel destination. Three collections of isolates obtained from international travelers between 2007 and 2014 (Institute of Tropical Medicine, the "Laboratoire Hospitalier Universitaire de Bruxelles "and the Belgian National Reference Centre for Campylobacter) were used. Isolates were tested for minimal inhibitory concentration (MIC) values (E-test macromethod) for fluoroquinolones, macrolides, tetracyclines, amoxicillin-clavulanic acid, and meropenem. Single isolates from 261 travelers were available; median (IQR) age was 25.4 (4-42) years, 85.8% were symptomatic (information for 224 patients available). Overall resistance to ciprofloxacin was 60.9%, ranging from 50.8% in Africa to 75.0% in Asia. Resistance to erythromycin was 4.6%, with the highest rate observed for Southern Asia (15.2%, seven isolates, six of them recovered from patients returning from India). A total of 126 isolates (48.3%) were resistant to tetracycline. No resistance to amoxicillin-clavulanic acid or meropenem was detected. Ciprofloxacin resistance tended to increase over time (53.9% in 2007 versus 72.2% in 2014), erythromycin resistance remained stable (median annual resistance 4.2%). Most (86.2%) ciprofloxacin-resistant isolates had MIC values ≥32 mg/l, and all erythromycin-resistant isolates had MIC values ≥256 mg/l. Co-resistance to ciprofloxacin and erythromycin was observed in 11 (4.2%) isolates, seven of which came from Southern Asia. Among all regions of travel, more than half of Campylobacter isolates were resistant to ciprofloxacin. Overall resistance to erythromycin was below 5% but reached 15.2% in Southern Asia.

Q Fever Serological Survey and Associated Risk Factors in Veterinarians, Southern Belgium, 2013.

A sero-epidemiological survey was organized among veterinarians working in Southern Belgium to estimate the seroprevalence of Q fever and the risk factors associated with exposure. A total of 108 veterinarians took part to this cross-sectional study, with a majority practicing with livestock animals. The overall seroprevalence was 45.4%, but it increased to 58.3% among veterinarians having contact with livestock. Three main serological profiles were detected (relatively recent, past and potentially chronic infections). The contact with manure during the prior month was the risk factor associated with seropositivity after multivariate logistic regression analysis. Classification and regression tree analysis identified the age as the most predictive variable to exclude potentially chronic infection in apparently healthy seropositive veterinarians. In conclusion, livestock veterinarians practicing in Southern Belgium are highly exposed to Q fever, a neglected zoonosis for which serological and medical examinations should be envisaged in at risk groups.

Evaluation of different confirmatory algorithms using seven treponemal tests on Architect Syphilis TP-positive/RPR-negative sera.

The Architect Syphilis TP is considered to be a suitable screening test due to its high sensitivity and full automation. According to the International Union against Sexually Transmitted Infections (IUSTI) 2014 guidelines, however, positive screening tests need confirmation with Treponema pallidum particle agglutination (TP.PA). Among Architect-positive results, samples with a negative non-treponemal test present the major diagnostic challenge. In this multicenter study, we investigated if other, preferable less labor-intensive treponemal tests could replace TP.PA. A total of 178 rapid plasma reagin (RPR)-negative sera with an Architect value between 1 and 15 S/CO were prospectively selected in three centers. These sera were analyzed with TP.PA and six alternative treponemal tests: three immunoblots and three tests on random-access analyzers. The diagnostic performance of the treponemal tests differed substantially, with the overall agreement between the six alternative tests ranging from 44.6 to 82.0%. Based on TP.PA as the gold standard, the INNO-LIA IgG blot, the BioPlex 2200 IgG, and the Syphilis TPA showed a high sensitivity, while the EUROLINE-WB IgG blot, recomLine Treponema IgG blot, and the Chorus Syphilis screen showed a high specificity. However, an Architect cut-off of 5.6 S/CO can serve as an alternative for these confirmatory treponemal tests in case of an RPR-negative result. Treponemal tests show poor agreement in this challenging group of Architect-positive/RPR-negative sera. The most optimal algorithm is obtained by assigning sera with an Architect value >5.6 S/CO as true-positives and sera with a value between 1 and 5.6 S/CO as undetermined, requiring further testing with TP.PA.

Twelve years of dengue surveillance in Belgian travellers and significant increases in the number of cases in 2010 and 2013.

During 12 years of surveillance in Belgium, dengue virus (DENV) infection was diagnosed in 676 of 7771 (8.7%) returning travellers by the use of ELISA, RT-PCR, and/or antigen detection. Men and women were equally infected. The mean age of the patients was 36.78 years (range, 3-77 years). Most of the infections occurred after a stay in Asia (55.9%), followed by the Americas (31.8%), Africa (7.2%), Oceania (1.0%), and Europe (0.4%). The number of patients coming from Africa increased as of 2009, to reach a proportion of 17% in 2011. The most prevalent serotype was DENV-1, followed by DENV-2, DENV-3, and DENV-4. Two remarkable increases in dengue incidence were noticed in 2010 and 2013.

Recovery of dengue virus from urine samples by real-time RT-PCR.

Recently, reverse transcription polymerase chain reaction (RT-PCR) for dengue virus (DENV) has been reported to test positive in urine samples for a longer time frame than in serum. We evaluated two RNA extraction procedures from urine and investigated the stability of DENV RNA in urine and serum up to 1 year at different storage temperatures. In addition, 24 urine samples collected from patients with a recent infection were tested with DENV real-time RT-PCR and compared to the RT-PCR results on serum. Five patients with an acute DENV infection were followed up for 6 months by RT-PCR on urine. The automated extraction method with the MagNA Pure LC 2.0 device had a higher yield of DENV RNA compared to the manual QIAGEN method, explained by the higher volume used in the former method. DENV RNA in both serum and urine was stable at room temperature up to 1 month and at 4 °C and -20 °C for at least 1 year. The detection rate by RT-PCR on urine was 50 % (4/8) until day 7, 100 % (6/6) between 1 and 3 weeks after symptom onset, and 25 % (2/8) thereafter. Generally, DENV RNA concentrations are higher in serum than in urine up till day 7, switching to lower concentrations in serum thereafter. Peak concentrations in urine are reached around day 10, and RNA becomes undetectable 3 to 4 weeks following disease onset. This diagnostic tool is of added value in clinical settings by extending the period during which DENV infections are diagnosed by RT-PCR.

Concomitant leptospirosis-hantavirus co-infection in acute patients hospitalized in Sri Lanka: implications for a potentially worldwide underestimated problem.

Two global (re-)emerging zoonoses, leptospirosis and hantavirus infections, are clinically indistinguishable. Thirty-one patients, hospitalized in Sri Lanka for acute severe leptospirosis, were after exclusion of other potentially involved pathogens, prospectively screened with IgM ELISA for both pathogens. Of these, nine (29·0%) were positive for leptospirosis only, one (3·2%) for hantavirus only, seven (22·5%) for both pathogens concomitantly, whereas 13 (41·9%) remained negative for both. Moreover, in a retrospective study of 23 former patients, serologically confirmed for past leptospirosis, six (26·0%) were also positive in two different IgG ELISA hantavirus formats. Surprisingly, European Puumala hantavirus (PUUV) results were constantly higher, although statistically not significantly different, than Asian Hantaan virus (HTNV), suggesting an unexplained cross-reaction, since PUUV is considered absent throughout Asia. Moreover, RT-PCR on all hantavirus IgM ELISA positives was negative. Concomitant leptospirosis-hantavirus infections are probably heavily underestimated worldwide, compromising epidemiological data, therapeutical decisions, and clinical outcome.

Outbreak of leptospirosis during a scout camp in the Luxembourg Belgian province, Belgium, summer 2012.

An outbreak of leptospirosis occurred in the South of Belgium, during August 2012, in teenagers who participated in two consecutive adventure scout camps near the Semois river. Among the symptomatic patient population (ten scouts), clinical manifestations included headache (70%), myalgia (50%), fever (50%), bilateral conjunctival injection (50%), general malaise (30%), vomiting (20%), anorexia (20%) and cough (20%). Some of the cases presented elevated blood creatinine (40%), or proteinuria (30%). Three patients were confirmed by serology and one by polymerase chain reaction. Potential risk factors included direct contact with a muskrat and indirect contact with potentially contaminated environments including the river water. Prospective environmental investigation carried out near the river banks 2 weeks after the outbreak identified Ondatra zibethicus (muskrat) as one Leptospira sp. reservoir.

Chikungunya virus and West Nile virus infections imported into Belgium, 2007-2012.

Arboviral infections are emerging among tourists travelling to (sub)tropical regions. This study aims to describe the importation of chikungunya virus (CHIKV) and West Nile virus (WNV) into Belgium over a 6-year period from 2007 to 2012. Clinical samples were obtained from travellers presenting at the outpatient clinic of the Institute of Tropical Medicine (ITM), Antwerp, Belgium or submitted to the Central Laboratory for Clinical Biology of the ITM. Testing was performed by serology and/or by real-time reverse transcriptase-polymerase chain reaction. A total of 1288 returning travellers were investigated for CHIKV infection resulting in 34 confirmed and two probable diagnoses (2·80%). Out of 899 patients, four confirmed and one probable imported WNV infections were diagnosed (0·55%). No locally acquired cases have been registered in Belgium until now and the geographical origin of the imported infections reflects the global locations where the viruses are circulating.

Syphilis reinfections pose problems for syphilis diagnosis in Antwerp, Belgium - 1992 to 2012.

Persons with multiple syphilis reinfections may play an important role in syphilis transmission. We analysed all syphilis tests carried out for people attending the HIV/sexually transmitted infection (STI) clinic at the Institute of Tropical Medicine, Antwerp, Belgium, from 1992 to 2012 to evaluate the extent to which syphilis reinfections were contributing to the syphilis epidemic in Antwerp. We then characterised the features of the syphilis infections in individuals with five or more episodes of syphilis. A total of 729 syphilis episodes were diagnosed in 454 persons. The majority of syphilis episodes occurred in people who had more than one episode of syphilis (445/729; 61%). A total of 10 individuals had five or more episodes of syphilis diagnosed over this period. All were men who have sex with men, HIV positive and on antiretroviral therapy. They had a total of 52 episodes of syphilis diagnosed and treated. In 38/42 of the episodes of repeat syphilis in these 10 individuals, they presented without any signs or symptoms of syphilis. Given that the majority of cases of incident syphilis in our clinic were persons with reinfections and that they frequently presented without signs of symptoms of syphilis, there is a strong case for frequent and repeated screening in all persons with a diagnosis of syphilis.

A nephrotic syndrome of tropical origin: case report and short review of the aetiology.

We present a case of nephrotic syndrome in a 38-year-old man of Ivorian origin. In the search of the cause of his illness an infection with Plasmodium malariae (P. malariae) was diagnosed by serology and by microscopy of a Giemsa thin blood smear which revealed rare gametocytes of P. malariae. Proteinuria significantly diminished within three months after antimalarial treatment. Antibodies against Schistosoma were detected as well. Examination of kidney biopsy revealed a discrete mesangioproliferative glomerulonephritis. This case highlights that a thorough history-taking may be essential and that infectious diseases should be included in the differential diagnostic thinking process when a nephrotic syndrome is diagnosed.

[Clinical case of the month. Amoebic liver abscess contracted in India with diagnosis confirmed by PCR]. / Abcès hépatique amibien contracté en Inde avec confirmation du diagnostic par PCR.

Amoebiasis is a disease of parasitic origin responsible for dysentery and extra-intestinal complications. The infection is by Entamoeba histolytica, an amoeba whose geographical distribution is cosmopolitan, but that is more prevalent in tropical areas. Only a few infections are symptomatic and some of them may cause extra-intestinal complications. Hepatic amoebiasis is the most frequently observed. We report the case of a Belgian woman who developed an amoebic liver abscess after returning from a trip to India. The diagnosis was confirmed by PCR detection of E. histolytica DNA performed on the abscess fluid. The epidemiological, diagnosis and treatment aspects are discussed.