Vaccines - beliefs and concerns: the voice of patients with inflammatory immunomediated diseases.

BACKGROUND: Vaccination is a key issue in patients with immunomodulated inflammatory diseases on immune-mediated therapy. Still, vaccination rates in these patients are low. This study aimed to assess the knowledge and fears of patients with immune-mediated inflammatory diseases (IMIDs) regarding vaccines, with the ultimate goal of increasing vaccination rates through the definition and implementation of more effective communication strategies with the patient. METHODS: This study was conducted in a Portuguese hospital, between January 2019-December 2020, and included adult patients with an IMID. A questionnaire was developed and applied to evaluate knowledge and fears regarding vaccines. RESULTS: From the 275 included patients, more than 90% answered correctly to all questions on general knowledge, with an exception for the question related to protection from severe disease, without differences between age groups or education levels, except for the question about vaccine contraindications (P = 0.017). Regarding vaccines in immunocompromised hosts, the proportion of correct answers was lower and significantly different between education levels (P = 0.00-0.042),. More than 50% of the participants showed moderate to very high concern about several aspects of vaccines, with differences between age groups (P = 0.018). CONCLUSION: Our patients have general knowledge of vaccines but regarding vaccines in immunocompromised patients knowledge is lower and dependent on the education level. In addition, age influences the pattern of concerns related to vaccines. The information gathered in this study shall be considered to identify potential local interventions targeted to improve vaccination.

Adherence to Vaccines in Adult Patients with Immune-Mediated Inflammatory Diseases: A Two-Year Prospective Portuguese Cohort Study.

BACKGROUND: Patients with immune-mediated inflammatory diseases (IMIDs) treated with immunomodulatory therapy present an increased susceptibility to infections. Vaccination is a crucial element in the management of IMID patients; however, rates remain suboptimal. This study intended to clarify the adherence to prescribed vaccines. MATERIALS AND METHODS: This prospective cohort study included 262 consecutive adults with inflammatory bowel disease and rheumatological diseases who underwent an infectious diseases evaluation before initiating or switching immunosuppressive/biological therapy. Vaccine prescription and adherence were assessed during an infectious diseases (ID) consultation using a real-world multidisciplinary clinical project. RESULTS: At baseline, less than 5% had all their vaccines up-to-date. More than 650 vaccines were prescribed to 250 (95.4%) patients. The most prescribed were pneumococcal and influenza vaccines, followed by hepatitis A and B vaccines. Adherence to each of the vaccines ranged from 69.1-87.3%. Complete adherence to vaccines occurred in 151 (60.4%) patients, while 190 (76%) got at least two-thirds of them. Twenty patients (8%) did not adhere to any of the vaccines. No significant differences were found in the adherence rates of patients with different sociodemographic and health-related determinants. CONCLUSIONS: ID physicians can play a role in the process of increasing vaccine prescription and adherence. However, more data on patients' beliefs and vaccine hesitancy, along with mobilization of all health care professionals and adequate local interventions, shall be considered to improve vaccine adherence.

[Guidelines for the Treatment and Follow-Up of Patients with Q Fever]. / Recomendações para o Tratamento e Seguimento de Doentes com Febre Q.

Q fever (or query fever) is a zoonotic infectious disease with worldwide distribution transmitted by an intracellular Gram-negative bacterium, Coxiella burnetii. The most common identified sources of human infection are farm animals, such as sheep, goats and cattle. The disease is endemic in mainland Portugal, with most cases notified in the central and southern regions. Q fever is a complex and pleomorphic disease, with those affected presenting with a wide range of manifestations from acute self-limited flu-like symptoms with good prognosis to persistent localized forms that may harbor a poor prognosis. Cases might occur in an isolated fashion or following outbreaks with great public health repercussion, as seen recently in the Netherlands from 2007 to 2010. Given the complexity of this infection, there is no universal consensus to date on the best strategy to manage Q fever patients. These guidelines provide recommendations regarding the treatment and follow-up of these patients, based on studies, on the author's experience and on the opinion of international experts. The aim is to harmonize the management of these patients taking into account not only the clinical manifestations but also the risk factors of the host in order to reduce disease-associated morbidity and mortality.

A febre Q (do inglês query fever) é uma zoonose de distribuição mundial transmitida por uma bactéria intracelular Gram negativo, Coxiella burnetii. Os ruminantes domésticos são os principais reservatórios implicados na transmissão da doença ao ser humano. Em Portugal continental, esta doença é endémica, com o maior número de casos notificados nas regiões Centro e Sul. A doença causada por C. burnetii é complexa e polimórfica, podendo manifestar-se sob uma forma aguda autolimitada do tipo gripal, com um curso ligeiro a moderado e prognóstico benigno, e/ou sob uma forma persistente, geralmente localizada e de evolução grave ou potencialmente fatal. Pode ocorrer em casos isolados ou em contexto de surtos, alguns com importantes implicações em saúde pública, como o verificado na Holanda em 2007 - 2010. Dada a complexidade e espetro clínico da febre Q, não existe um consenso universal sobre a melhor forma de tratamento, gestão e seguimento destes doentes. Este protocolo é uma sugestão de tratamento e seguimento dos doentes com febre Q, compilando a informação de estudos e opiniões de peritos internacionais e a experiência dos autores. Pretende-se assim uniformizar a gestão destes doentes tendo em conta não só o espetro das suas manifestações clínicas, mas também os fatores de risco do hospedeiro, por forma a reduzir morbimortalidade que a doença possa causar.

Travel-Related Diseases and Injuries in Children and Adolescents: A Post-Travel Surveillance Questionnaire Assessment.

INTRODUCTION: Children and adolescents are a relevant and increasing proportion of travelers. Injuries and infectious diseases in children are safety concerns when traveling. However, data on diseases and injuries during international travels in children are not available. The aims of this study were to analyze travel-related diseases and injuries among pediatric travelers during and after international trips, to identify risk factors for travel-associated disease, and to evaluate the compliance and effectiveness of the recommendations provided in pre-travel appointments. MATERIAL AND METHODS: We enrolled travelers aged under 18 years attending a pre-travel clinic, in a tertiary hospital (2017 - 2019); 223 of the 370 pediatric travelers attending the pre-travel clinic were included. The study was based on a questionnaire designed to address health and safety issues - vaccines and chemoprophylaxis, including side effects, the occurrence of disease or injury, diagnosis, treatment, and outcomes. RESULTS: The median age at pre-travel evaluation was eight years; 39.7% of the travelers were adolescents, 52.5% were female. The participants traveled to 40 countries across four continents, with a median travel duration of 14.5 days. Asia was the most visited continent. Traveling was safe for 84.8%. From 34 travelers who had illness/injury, gastrointestinal symptoms were elicited in 41.2%. Sixteen (47.1%) travelers required an urgent medical appointment at the destination, and no one was hospitalized. Destinations in Africa and longer trips were significantly associated with a higher occurrence of disease/injury (p = 0.023 and p < 0.001, respectively). In a multivariable model, traveling to Africa was still significantly associated with travel-related disease/injury [OR = 2.736 (1.037 - 7.234)]. CONCLUSION: Disease/injury occurred in 15.2% of pediatric travelers. Even though 47.1% of the travelers required an urgent medical appointment, the developed conditions were not severe enough to warrant hospitalization. Travels to Africa and longer trips seem to be associated with a higher risk of disease and injury.

Introdução: As crianças e adolescentes representam uma proporção relevante e crescente de viajantes. As doenças infeciosas e as lesões em crianças durante viagens internacionais são motivo de preocupação relacionada com segurança; no entanto, os dados na idade pediátrica são amplamente desconhecidos. Os objetivos deste estudo foram analisar as doenças e lesões relacionadas com as viagens ocorridas em viajantes em idade pediátrica, durante e após viagens internacionais, identificar fatores de risco para a ocorrência de doenças associadas à viagem, e avaliar o cumprimento e a eficácia das recomendações fornecidas na consulta pré-viagem. Material e Métodos: Incluímos viajantes com idade inferior a 18 anos avaliados na consulta do viajante num hospital terciário (2017 - 2019). O estudo baseou-se num questionário, desenhado para abordar questões de saúde e segurança ­ vacinas e quimioprofilaxia, incluindo efeitos colaterais, ocorrência de doença ou lesão, diagnóstico, tratamento e resultado. Resultados: Foram incluídos 223 dos 370 viajantes pediátricos observados na consulta do viajante. A mediana da idade à data da consulta era oito anos, 39,7% eram adolescentes e 52,5% eram do sexo feminino. Os participantes viajaram para 40 países, em quatro continentes, e a mediana da duração da viagem foi 14,5 dias. O continente asiático foi o mais visitado. A viagem foi segura em 84,8% dos casos. Nos 34 viajantes que apresentaram doença/lesão, verificaram-se sintomas gastrointestinais em 41,2%. Dezasseis (47,1%) viajantes necessitaram de consulta médica urgente no destino e nenhum foi hospitalizado. Destinos em África e viagens mais longas foram associados, significativamente, a maior ocorrência de doença/lesão (p = 0,023 e p < 0,001, respetivamente). No modelo multivariável, viajar para África foi associado, significativamente, a doença/lesão [OR = 2,736 (1,037 - 7,234)]. Conclusão: A viagem associou-se a doença/lesão em 15,2% dos viajantes pediátricos. Embora não requerendo hospitalização, 47,1% dos viajantes necessitaram de consulta médica urgente. África e viagens mais longas parecem estar associados a risco maior de doenças/lesões.

Infectious Risk Mitigation in Patients with Multiple Sclerosis under Disease-Modifying Therapies - the Experience of a Collaborative Neurology-Infectious Diseases Approach.

BACKGROUND: Multiple sclerosis treatment has changed in the last years with the emergence of new disease-modifying therapies (DMTs). Despite a better efficacy profile, these drugs raise concerns about infectious risk, which needs to be mitigated. OBJECTIVE: To analyze the results of a systematic collaborative approach between Neurology and Infectious Diseases (ID) Departments in the management of infectious risk and complications in MS patients treated with DMT. METHODS: Retrospective collection of MS patients' demographic and clinical data from clinical records of MS and ID outpatient clinics (2011-2017). RESULTS: We included 149 patients: most had evidence of previous contact with Herpesviridae, and half of them were not immune to hepatitis A and B viruses (HAV and HBV). Vaccines for HAV, HBV, and Streptococcus pneumoniae were administered in 91%, 78%, and 88% of non-immune patients, respectively. JC virus serology monitoring prevented natalizumab (NTZ) initiation or prompted its switch in 34/122 patients. Forty patients had latent tuberculosis, in which 88% were treated. Infectious events occurred in 33 patients, mostly mild urinary, respiratory, and herpes virus group infections. Only three patients required inpatient care. CONCLUSION: Facing the expansion of the new DMT, we highlight the benefits of an interdisciplinary approach for safer use of the chosen treatment.

COVID-19 in gastroenterology: Where are we now? Current evidence on the impact of COVID-19 in gastroenterology.

BACKGROUND: The COVID-19 pandemic has created unprecedented challenges in all fields of society with social, economic, and health-related consequences worldwide. In this context, gastroenterology patients and healthcare systems and professionals have seen their routines changed and were forced to adapt, adopting measures to minimize the risk of infection while guaranteeing continuous medical care to chronic patients. OBJECTIVE: At this point, it is important to evaluate the impact of the pandemic on this field to further improve the quality of the services provided in this context. METHODS/RESULTS/CONCLUSION: We performed a literature review that summarizes the main aspects to consider in gastroenterology, during the pandemic crisis, and includes a deep discussion on the main changes affecting gastroenterology patients and healthcare systems, anticipating the pandemic recovery scenario with future practices and policies.

Enfermedad Neuroinvasiva por Virus del Nilo Occidental: por qué debería considerarse en la Península Ibérica / West Nile Virus Neuroinvasive Disease: why it should be considered in the Iberian Peninsula

Introduction: West Nile virus has caught attention given the spike of European cases in the season of 2018. The number of infected humans exceeded the total cases of the past seven years and the virus expanded to area previous disease-free, causing significant morbimortality. Objectives: To highlight from a clinical standpoint West Nile virus as a possible aetiology in neuroinvasive disease on humans in the Iberian Peninsula. Materials and Methods: Data was obtained from Centres for Disease Control and Prevention and the European Centre for Disease Prevention and Control and it was conducted a review of the literature in PubMed electronic database. Results and Discussion: West Nile virus can be transmitted by mosquitoes’ bites, blood transfusion, and organ transplant. Although most infections are asymptomatic, <1% of patients develop neuroinvasive disease presenting as meningitis, encephalitis or acute flaccid paralysis. West Nile virus should be considered as a differential diagnosis in the face of neurological symptoms of unknown aetiology in the appropriate epidemiological circumstances. Diagnosis in the clinical setting is based in serological analysis. As available treatment is only supportive, preventive measures are key to diminish this virus’ impact. The future of West Nile virus is difficult to predict, even though ongoing global changes could be factors influencing its course. Conclusion: West Nile virus depicts the unpredictability around zoonotic diseases, hence, justifying the need of further surveillance and information in the Iberian Peninsula, considering the existence of the vector and the already recorded human/animal cases. (AU)

[Human Rabies: Optimization of Prevention and Paths Towards the Cure]. / Raiva Humana: Optimização da Prevenção e Caminhos Para a Cura.

INTRODUCTION: Rabies is one of the oldest and deadliest infectious diseases known by human beings and is commonly transmitted by animal bites. Dogs have a major role in the transmission of the virus. Rabies has no approved curative therapy, and its prevention, even though it is highly effective, it is complex, expensive and challenging in terms of accessibility, particularly regarding immunoglobulin. This review aims to provide a practical approach to cost-effective prevention as well as the future perspectives regarding the development of an effective and secure cure. MATERIAL AND METHODS: This review article was based on a search in PubMed using the following MeSH terms: rabies, preexposure and postexposure prophylaxis, rabies immune globulin, treatment, Milwaukee Protocol. RESULTS: Concerning rabies infection, it's important to apply the prevention protocols effectively as early as possible due the unpredictable time window between infection and the appearance of symptoms. The literature shows that is possible to reduce the vaccination dosage and maintain the efficiency of the immunization, and booster vaccination is only required in specific risk groups/populations. DISCUSSION: The current philosophy of cost-effective prevention which consists of canine vaccination, restriction of vaccine overdosage used in humans and the appropriate use of rabies immunoglobulin - could make the prevention of the disease accessible for those countries that need it the most. There are several therapies in development but they're all in early stages of development. CONCLUSION: The development of new and more effective therapeutic and prophylactic approaches is a goal not yet achieved and relies on a better understanding of the disease pathophysiology.

Introdução: A raiva é uma das doenças infecciosas mais antigas e fatais conhecidas pelo ser humano e é maioritariamente transmitida por mordeduras de animais. O cão é o principal vector. A raiva não possui uma terapia curativa aprovada e a sua prevenção ainda que possua altas taxas de eficácia, é complexa, dispendiosa e nem sempre conseguida, muito devido às dificuldades de acesso da imunoglobulina. Esta revisão pretende analisar uma abordagem prática de uma prevenção custo-efectiva e as perspectivas futuras em desenvolvimento de uma cura eficaz e segura.Material e Métodos: Foi utilizada a base de dados da PubMed para pesquisa bibliográfica. Usaram-se os termos MeSH: 'rabies', 'preexposure prophylaxis', 'postexposure prophylaxis', 'rabies immune globulin', 'treatment' e 'Milwaukee Protocol'.Resultados: Relativamente à raiva, é importante executar os protocolos de prevenção atempadamente, devido à imprevisível janela de tempo entre a infecção e a sintomatologia. A literatura mostra que é possível reduzir a dose de vacina mantendo uma eficiente imunização, e que doses de reforço só são necessárias em grupos/populações de risco.Discussão: A actual filosofia de uma prevenção custo-efectiva, que assenta na vacinação canina, restrição de sobredose das vacinas usadas em seres humanos e o uso inteligente da imunoglobulina rábica ­ irá permitir maior acessibilidade da prevenção da doença aos países que mais carecem dela. Encontram-se em progresso terapias promissoras, ainda em estadios precoces de estudo.Conclusão: O desenvolvimento de novas abordagens terapêuticas e profilácticas mais eficazes é um objectivo ainda não alcançado e depende de uma melhor compreensão da patogénese subjacente à doença.

Prospective study of blood viral load of Epstein-Barr virus, herpes virus type 6 and human parvovirus B19 in Crohn's disease: Does therapy matter?

BACKGROUND: The interplay between inflammatory bowel disease (IBD) and DNA viruses, such as Epstein-Barr (EBV), human parvovirus B19 (HPVB19) and human herpes type 6 (HHV6) is scarcely studied. The main aim of this prospective study is to screen for EBV, HSV6, and HPVB19 DNA viremia in adult patients with stable Crohn's disease (CD), correlating the results with IBD treatment. METHODS: From July 2015 - March 2017, 100 patients were enrolled and divided in four groups of 25 participants each, according to in course treatment. Blood collections were performed every 5 months in all patients. Antibodies for EBV and HPVB19 were screened and repeated if negative. Blood EBV DNA, HPVB19 DNA, and HHV6 DNA were quantified by quantitative real-time Polymerase Chain Reaction. RESULTS: Patients had evidence of EBV (100 %) and HPVB19 (70 %) past infection. Across the study timeline, EBV-DNA, HPVB19-DNA, and HHV6-DNA were detected in the blood of 25, 11, and 7 patients, respectively. Viremia was detected only once in 72 %, 73 %, and 86 % of the patients in the studied period, for EBV, HPVB19, and HHV6, respectively. We did not find significant differences between treatment groups, independently of the viral cut-off for the three viruses. CONCLUSIONS: The detection of EBV, HPVB19, and HHV6 viremia, in stable CD patients, was not impacted by biological/immunosuppressant therapy. Although attractive as a non-invasive technique, this approach did not prove to be useful in stable patients. More and larger studies are needed to address the relevance of these viruses on IBD course, in stable patients and during exacerbations.

The daily impact of COVID-19 in gastroenterology.

A new strain of coronavirus, called SARS-CoV-2, emerged in Wuhan, China, in December 2019, probably originating from a wild-animal contamination. Since then, the situation rapidly evolved from a cluster of patients with pneumonia, to a regional epidemic and now to a pandemic called COrona VIrus Disease 2019 (COVID-19). This evolution is related to the peculiar modes of transmission of the disease and to the globalization and lifestyle of the 21st century that created the perfect scenario for virus spread. Even though research has not evidenced particular susceptibility of inflammatory bowel disease (IBD) patients to SARS-CoV-2 infection, immunosuppressive and immunomodulatory treatments were considered potential risk factors. In this context, initiating treatments with these agents should be cautiously weighted and regular ongoing treatments shall be continued, while the dose of corticosteroids should be reduced whenever possible. Due to the increased risk of contamination, elective endoscopic procedures and surgeries should be postponed and IBD online appointments shall be considered. IBD patients shall also follow the recommendations provided to the general population, such as minimization of contact with infected or suspected patients and to wash hands frequently. In the absence of effective treatments and vaccines, this pandemic can only be controlled through prevention of SARS-CoV-2 transmission with the main objectives of providing patients the best healthcare possible and reduce mortality.

Asymptomatic reactivation of hepatitis B virus after prolonged treatment with etanercept.

Etanercept is an anti-tumor necrosis factor ɑ (anti-TNFɑ) drug used for treating immunomediated inflammatory diseases. It is least associated with hepatitis B virus (HBV) reactivation. We present a 71-year-old man with psoriasis refractory to phototherapy and acitretin, which led to etanercept monotherapy. Before anti-TNFɑ treatment, past contact with HBV was elicited; antibodies to HBc and HBs were positive whereas HBsAg was negative. Seven years after treatment initiation, while the patient was completely asymptomatic, a transaminase elevation was found and a reactivation of HBV was documented, with a high viral load of the virus. He started entecavir therapy and, after a 14-month follow-up, the viral load is still detectable at a low level, as well as HBsAg. We emphasize the late and asymptomatic reactivation of HBV associated with soluble anti-TNFɑ monotherapy. This case reinforces the importance of current recommendations for periodic monitoring of viral load and HBV markers in all patients that have had prior contact with HBV (positive anti-HBc), with or without indication for treatment of HBV (HBsAg and HBV-DNA negative).

Cat scratch disease during adalimumab therapy: a case report / Enfermedad por arañazo de gato durante el tratamiento con adalimumab: a propósito de un caso

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Mononeuritis multiplex: an uncommon neurological manifestation of cytomegalovirus reactivation in an HIV-infected patient.

BACKGROUND: Cytomegalovirus (CMV) reactivation with neurological involvement in patients with acquired immunodeficiency syndrome (AIDS) is increasingly rare since the introduction of antiretroviral therapy (ART). Manifestations include encephalitis, myelitis, polyradiculopathy and, less commonly, mononeuritis multiplex (MNM). We report a case of disseminated CMV disease with gastrointestinal and peripheral and central nervous system involvement in a patient with AIDS, manifesting primarily as MNM. CASE PRESENTATION: A 31-year old woman with AIDS presented with a clinical picture of MNM. Electromyography confirmed the clinical findings. CMV DNA was detected in cerebrospinal fluid (CSF) and blood. Gastrointestinal involvement was histologically documented. HIV RNA was also detected in CSF and brain MRI was consistent with HIV encephalopathy. A diagnosis of disseminated CMV disease (with esophagitis, colitis, encephalitis and MNM) and HIV encephalopathy was made. Treatment consisted of ganciclovir and foscarnet, followed by maintenance therapy with valganciclovir. Evolution was favorable and valganciclovir was stopped after sustained immune recovery following ART initiation. CONCLUSION: We discuss the diagnostic approach to CMV neurological disease, with a focus on MNM and CMV encephalitis. Combination therapy with ganciclovir and foscarnet should be considered for all forms of neurological involvement, although available data are scarce. Since there is significant overlap between CMV encephalitis and HIV encephalopathy, ART drugs with higher CSF penetration may have to be considered. ART and immune recovery are essential to improve outcomes.

[What do Portuguese Travellers Know About Malaria? Pre-Travel Medicine Appointment Evaluation]. / O que Sabem os Viajantes Portugueses Sobre Malária? Avaliação Pré-Consulta de Medicina de Viagem.

INTRODUCTION: The knowledge of transmission, prevention and symptoms of malaria is essential for travellers' safety. In real life, what do Portuguese travellers know about malaria before a Travel Medicine consultation? How can we, through this consultation, improve their knowledge? MATERIAL AND METHODS: Before an appointment with a specialist in Travel Medicine, 80 adult travellers filled a questionnaire that included demographic aspects, characteristics of the trip and knowledge about malaria. Data were analysed using descriptive statistics and multifactorial variance analysis. RESULTS: The travellers' ages fell in the range 20 - 80 years, 51% were male and 74% of the travellers had a university degree level of education. For 74% of the travellers, this was the first Travel Medicine consultation. Half of the travellers planed trips lasting no more than 14 days, mainly for tourism. The average percentage of correct answers about malaria given by a traveller was 63%. Travellers who had previously attended a Travel Medicine appointment exhibit a statistically significant difference in knowledge comparing to those who attend Travel Medicine appointment for the first time, and this was more evident in the sample composed of travellers without higher education. The clinical manifestations and prevention had the lowest number of correct answers among the travellers. DISCUSSION: These travellers appear to have good knowledge about malaria but some misconceptions prevail. CONCLUSION: The Travel Medicine consultation seems important to raise awareness in the population about malaria, particularly for travellers without higher education. The prevention and the recognition of malaria symptoms must be prioritized during Travel Medicine consultations and the information given adapted to the traveller's characteristics.

Introdução: O conhecimento das formas de transmissão, prevenção e clínica de malária é fundamental para a proteção dos viajantes nas deslocações para zonas endémicas. O que sabem os viajantes portugueses sobre malária previamente à consulta de Medicina de Viagem? Como poderemos através dessas consultas colmatar falhas nesse conhecimento?Material e Métodos: A 80 viajantes adultos, foi solicitado, antes da entrada na consulta, o preenchimento de um questionário dividido em dados demográficos, características da viagem e questões sobre malária. Na análise estatística dos resultados usámos métodos de Estatística Descritiva e de Análise de Variância Multifatorial. Resultados: Os viajantes tinham idades entre 20 - 80 anos, 51% eram do sexo masculino e 74% tinham escolaridade superior. Para 74% dos viajantes esta foi a primeira Consulta de Medicina de Viagem. Em metade dos viajantes a duração da viagem era inferior a 14 dias e maioritariamente viajaram por lazer. Em média cada viajante respondeu corretamente a 63% das questões. Viajantes com consultas prévias evidenciam uma diferença estatísticamente significativa nesse conhecimento relativamente aos que recorrem pela primeira vez, que, na nossa amostra, se observou sobretudo nos viajantes que não têm escolaridade superior. O reconhecimento de manifestações clínicas e formas de prevenção revelam menos respostas corretas. Discussão: Nestes viajantes os conhecimentos sobre malária revelaram-se razoáveis mas persistem conceções erradas. Conclusão: A consulta de Medicina de Viagem é importante para o conhecimento sobre malária, sobretudo nos viajantes sem escolaridade superior. Prevenção e sintomas de malária devem ser especialmente focados e a informação deve-se adequar às características do viajante.

Screening, prophylaxis and counselling before the start of biological therapies: A practical approach focused on IBD patients.

The standard of care in the management of immune-mediated inflammatory conditions relies on immunomodulators, glucocorticoids, and biologicals (including anti-tumour necrosis factor -α and other monoclonal antibodies). These agents have an overall favourable benefit/risk ratio; however, they modulate the immune response as part of their mechanisms of action, and therefore they may increase the risk of developing infections, particularly in older patients or in patients with concomitant corticosteroids. Some of these infections may be preventable by immunization, chemoprophylaxis or counselling. AIM: screening for and monitoring infections throughout these therapies is so mandatory to ensure patients' safety. Still, standardized guidelines focused on these procedures have yet to be established. This review aims to fill such a gap. The authors searched for articles published in English from 2009 until 2017 using PUBMED, with the terms "immunomodulators", "biological drugs", "anti-TNF α", "inflammatory bowel diseases", "immunomediated inflammatory diseases", "risk of infection", "infection prevention", "screening", "immunization", "tuberculosis", "latent tuberculosis", "listeriosis", "endemic mycosis", "Pneumocystis jiroveci pneumonia", "granulomatous infection", "varicella", "herpes virus", "hepatitis B", "hepatitis A", "hepatitis C" and identified the journal articles. Based on the literature and in their own experience the authors established recommendations and a practical guide for infections' screening, monitoring and prevention before and during immunomodulatory and biological therapies.

Non-falciparum malaria imported mainly from Africa: a review from a Portuguese hospital.

BACKGROUND: Non-falciparum malaria (NFM) has been reported to be responsible for around 25% of imported malaria cases in Europe but is often neglected due to its less severe clinical course when compared to Plasmodium falciparum. Differentiation between species is however crucial for a correct approach. The objective of this study is to report the cases of this often missed aetiology of malaria in a tertiary hospital in Portugal. METHODS: Data were retrospectively analysed from patients admitted from January 2006 to August 2016 with a NFM diagnosis based on microscopy, rapid diagnostic tests (RDT) (BinaxNow®) and/or PCR. Epidemiologic and clinical aspects were reviewed. RESULTS: A total of 19 NFM cases were diagnosed, corresponding to 8.4% of the total 225 cases of malaria. Seventeen (89%) were male with a median age of 41 years. All but one case were imported from sub-Saharan Africa, with 12 (63%) of the cases returned from Angola. Microscopy was positive for all patients and correctly identified the species in 12 (63%) patients. BinaxNOW® was performed in all patients and it was positive in 11 cases, showing a sensitivity of 58%. PCR was performed in nine patients and was positive in eight of them, being responsible for the identification of the species in four cases. Plasmodium malariae accounted for 37% (n = 7) of the cases, Plasmodium ovale for 32% (n = 6) and Plasmodium vivax for 17% (n = 3). In three (16%) patients, morphology was suggestive of P. vivax or P. ovale, but precise species identification was not possible. Regarding presentation, fever was the most reported symptom, and the most frequent laboratory finding was thrombocytopaenia. Quinine-doxycycline was prescribed in eleven patients (58%), chloroquine in six cases (32%) and artemether-lumefantrine in two (11%). All of the patients showed clinical improvement. CONCLUSIONS: NFM remains an important cause of imported malaria in patients from sub-Saharan Africa, alone or as mixed infection with P. falciparum. Access to PCR techniques facilitates diagnosis, as low sensitivity from RDTs and microscopy are to be expected.

Serial Tuberculosis Screening in Inflammatory Bowel Disease Patients Receiving Anti-TNFα Therapy.

BACKGROUND AND AIMS: One of the adverse effects of the tumour necrosis factor alpha [[TNFα] monoclonal antibodies for the treatment of immune-mediated inflammatory diseases is a higher propensity for tuberculosis development. The aim of this study was to explore the utility and sensitivity of serial tuberculosis screening during anti-TNFα treatment. METHODS: A cohort of 46 inflammatory bowel disease patients receiving infliximab was prospectively recruited and followed for 26 months. During this period of time, a tuberculosis skin test and two different interferon ϒ release assays [QFT-GIT and T-SPOT.TB] were applied at 4-6-month intervals. RESULTS: Overall, 16 patients were diagnosed with latent tuberculosis infection after having at least one test conversion: 12 patients had a positive tuberculosis skin test, seven patients had a positive T-SPOT.TB, and two patients had a positive QFT-GIT. Active tuberculosis was excluded in all; 15 were treated with isoniazid. A comparison between tests showed a moderate accuracy [72% to 85%] but low kappa values [0.063 to 0.377]. Concerning association with demographic and clinical characteristics, test conversion was more common among the male gender and those with a longer disease duration. CONCLUSIONS: Tuberculosis tests conversions were common in inflammatory bowel disease patients treated with infliximab alone or in association with immunomodulators. In these immunosuppressed individuals, the classical tuberculosis skin test seems to have a higher sensitivity than the modern tests based on the release of interferonϒ.