Practical approach to a patient with fever who travelled to the tropics

By 2030, an estimated 2 billion international tourist trips are expected annually worldwide, with citizens of Poland as important contributors. Illness rates among returnees from developing regions range between 43% and 79%. Properly diagnosing fever in these travelers is vital due to potentially serious implications. After visiting tropical and subtropical zones, the main health complaints are diarrhea, fever, and skin lesions. A reliable diagnosis begins with taking a comprehensive travel history and identifying potential risks. In travelers returning from sub‑Saharan Africa, malaria caused by Plasmodium falciparum is the main cause of fever, affecting 50 in every 1000 cases. Among returnees from Southeast Asia, dengue is dominant, occurring in 50-60 per 1000 cases, and its prevalence rises significantly nowadays. Other significant diseases include chikungunya, Zika, typhoid fever, amebic liver abscess, and occasionally viral hemorrhagic fevers. SARS‑CoV‑2 and influenza viruses are crucial pathogens as well. An in‑depth assessment of the travel history, combined with knowledge on tropical diseases, are key to the diagnostic process, and algorithms may be helpful in selecting appropriate tests and treatment methods.

Beach volleyball and Cutaneous Larva Migrans

Cutaneous larva migrans can affect even athletes who travelled to play beach volleyball in Zanzibar. We describe a cluster of CLM infections in travellers who contracted the disease during their trip to Africa, rather than bringing a volleyball trophy. Despite presenting typical changes, all of them were misdiagnosed.

Lipids as a key element of insect defense systems

The relationship between insect pathogenic fungi and their insect hosts is a classic example of a co-evolutionary arms race between pathogen and target host: parasites evolve towards mechanisms that increase their advantage over the host, and the host increasingly strengthens its defenses. The present review summarizes the literature data describing the direct and indirect role of lipids as an important defense mechanism during fungal infection. Insect defense mechanisms comprise anatomical and physiological barriers, and cellular and humoral response mechanisms. The entomopathogenic fungi have the unique ability to digest the insect cuticle by producing hydrolytic enzymes with chitin-, lipo- and proteolytic activity; besides the oral tract, cuticle pays the way for fungal entry within the host. The key factor in insect resistance to fungal infection is the presence of certain types of lipids (free fatty acids, waxes or hydrocarbons) which can promote or inhibit fungal attachment to cuticle, and might also have antifungal activity. Lipids are considered as an important source of energy, and as triglycerides are stored in the fat body, a structure analogous to the liver and adipose tissue in vertebrates. In addition, the fat body plays a key role in innate humoral immunity by producing a range of bactericidal proteins and polypeptides, one of which is lysozyme. Energy derived from lipid metabolism is used by hemocytes to migrate to the site of fungal infection, and for phagocytosis, nodulation and encapsulation. One polyunsaturated fatty acid, arachidonic acid, is used in the synthesis of eicosanoids, which play several crucial roles in insect physiology and immunology. Apolipoprotein III is important compound with antifungal activity, which can modulate insect cellular response and is considered as important signal molecule.

Cutaneous Larva Migrans as a frequent problem in travellers

Dermatological disorders are among the most common complaints of patients seeking medical assistance after returning from trips to tropical countries. Among exotic dermatoses, one of the frequently encountered diagnoses is Cutaneous Larva Migrans (CLM), primarily caused by the nematodes Ancylostoma braziliense and A. caninum. Cats and dogs, which serve as the definitive hosts for these nematodes, excrete with their stool parasite eggs into the environment, where they transform into larvae. Human infection occurs through the invasive form of the larvae, which penetrate the skin, causing itching and the characteristic serpiginous, slightly raised, and enlarging lesion at the site of invasion. Diagnosis is made based on the highly characteristic clinical presentation, although in non-endemic countries, diagnostic errors and delays in initiating effective causal treatment are relatively common. Effective therapy includes oral albendazole and ivermectin. Prevention of CLM involves avoiding skin contact with potentially contaminated soil by wearing shoes and using towels and mats on the beach. Due to the high interest in travel and the risk of importing exotic diseases, it is important to promote knowledge of tropical medicine among healthcare professionals as well as the travellers.

Selected arboviral diseases imported to Poland - current state of knowledge and perspectives for research

INTRODUCTION

Arthropod-borne viruses are important causes of human morbidity worldwide. However, the available literatur and the epidemiological data concerning the importation to Poland of globally emerging arboviral infections, such as DENV, CHIKV, WNV, or ZIKV, are scarce. Only few seroepidemiologic studies concerning WNV in animals or humans in Poland have been published.

OBJECTIVE

The aim of this review paper is to summarize and present the current state of knowledge and the perspectives for research concerning the importation and the risk posed by the introduction to Poland of the four above-mentioned arboviral diseases.

CURRENT STATE OF KNOWLEDGE

Climate change may facilitate the northward expansion of both the vectors for diseases previously unseen in Europe, as well as of the viruses themselves, resulting in autochthonous cases of diseases previously exclusively imported. Little is known about the importation of arboviral diseases to Poland because of the frequently asymptomatic or self-limiting course of the disease, lack of epidemiologic studies or effective disease reporting, as well as inadequate access to diagnostic methods.

CONCLUSIONS

Further epidemiologic studies in Polish travellers are necessary in order to prevent importation or introduction of the above-mentioned viruses, and to act against potential problems related to blood transfusion or organ transplantation from infected donors.

Malaria vaccine for travellers - where are we now?

The authors present a short summary of the current state of malaria vaccine development and the per- spectives for the availability of a malaria vaccines for travellers from non-endemic countries. There is currently no commercially available malaria vaccine for travellers. The efficacy of the RTS,S/AS01 vaccine is limited and differs dramatically from the effects of other vaccines administered in travel medicine. In the current recommendations, the use of repellents is deemed the most important measure to prevent malaria infection, and in the high-risk destinations, chemoprophylaxis is strongly advised. Many questions in malaria vaccinology remain unanswered.

Chronic symptoms persisting after travel-related infections

The authors present the current state of knowledge about the long term sequelae of the common travel-related infections associated with immunological dysregulation. Travellers' diarrhoea, chikungunya and dengue are common in travellers and protracted manifestations such as post-infectious irritable bowel syndrome (travellers' diarrhoea), arthritis (chikungunya) or post-dengue syndrome may be more prevalent than previously thought. Attention should be paid to active prevention of the infections during travel, especially when an effective treatment against long-term sequelae has not been established. Further studies should be designed in order to determine the interactions between the host, the environment and the pathogens, as well as to identify the prognostic factors for developing long-term manifestations after infections in a large group of travellers.

Imported cutaneous leishmaniasis: a 13-year experience of a Polish tertiary center

INTRODUCTION

Leishmaniasis is a vector-borne infection endemic in 98 countries. Its cutaneous form (CL) causes skin lesions on exposed parts of the body and may lead to scarring. The numbers of imported cases of CL are increasing in Europe but the incidence of CL importation in Poland is unknown.

MATERIAL AND METHODS

A list of all patients diagnosed with CL at the Department in the years 2005-2017 was obtained. The study presents their data including age, sex, areas visited, purpose of travel, time from the onset of symptoms to correct diagnosis, appearance of lesions, results of impression smears and PCR, and superinfection, if detected, as well as treatment methods and their outcomes.

RESULTS

Altogether, 14 cases of cutaneous leishmaniasis were identified. The study demonstrates an increase in the number of cases of imported CL at our center over the last 5 years. The time to correct diagnosis was long in spite of the fact that the lesions had usually an appearance typical of CL.

CONCLUSIONS

Intensified education of physicians and travelers, as well as improvement in the access to travel medicine services and to the diagnosis and treatment methods appropriate for CL, are needed in our country. In our opinion, surveillance of leishmaniasis should be introduced in Poland.

Cholera - the new strike of an old foe

Cholera is an acute bacterial gastrointestinal infection caused by ingestion of water or food containing the pathogen Vibrio cholerae. The incubation period can be very short and it takes between several hours and 5 days. During the 19th century, cholera was spreading from India across the world. Its original reservoir was located in the Ganges delta. So far, there have been six epidemics of cholera; the current outbreak is the seventh. It started in Asia, attacked Africa and then the Americas. Cholera causes thousands of illnesses and deaths annually, mostly in South Asia and Sub-Saharan Africa. The current outbreak began in Yemen in October 2016, it peaked in December with subsequent decline, then the epidemic has re-erupted in April 2017 and it still continues. It is currently the largest outbreak in the world, with 5000 new infections a day (as of August 19th, 2017 the number of cholera cases stands at 527,000 with 1997 deaths). The most common symptoms of the illness are diarrhoea, dehydration, vomiting, and abdominal cramps. Case-fatality rate is lower than 1%, if rehydration treatment is prescribed rapidly, but it can exceed 70% in patients not treated properly. Aggressive and rapid fluid repletion is the basis of treatment for cholera. In many cases, rehydration therapy, given orally or parenterally, is enough to rescue infected patients. Antibiotics, mainly fluoroquinolones, tetracyclines, and macrolides are an adjunctive therapy for patients with moderate to severe fluid loss.

A case of acalculous cholecystitis in the course of dengue fever in a traveller returned from Brazil

BACKGROUND

Dengue is the second cause of fever after malaria in travellers returning from the tropics. The infection may be asymptomatic or it may manifest itself with fever only, some patients, however, may develop haemorrhagic symptoms and shock.

MATERIALS AND METHODS

A 58-year-old woman came to the University Centre of Tropical Medicine in Gdynia after returning from a tourist journey to Brazil because of fever up to 39°C and malaise. She had lived in South America many years and then moved to Europe 3 years before hospitalisation. On admission physical examination revealed fever, dry mucosa, moderate hypotension and tachycardia. In the laboratory test results, leukopoenia, thrombocytopoenia and elevated transaminases were observed. On the second day of the hospitalisation, the patient reported epigastric pain, clinical examination revealed tenderness of the abdomen and macular rash on the skin of the trunk and thighs. The ultrasonography revealed an enlarged gallbladder with thickened walls, with hypoechogenic area surrounding it, a dilated common biliary duct of heterogenic echo, and some free fluid in the peritoneal cavity. An exploratory laparotomy was performed after 24 h because of the persisting strong abdominal pain and high fever. Intraoperatively, enlarged mesenteric lymph nodes were found, with no symptoms of gallbladder pathology. The postoperative course was uncomplicated and the positive result of immunochromatographic assay for dengue was obtained.

RESULTS

The acalculous cholecystitis has been described in the course of various diseases and conditions. The typical symptoms include pain in the right hypochondriac region, fever, positive Murphy's sign, and abnormal liver function tests, which were observed in the presented case. Cholecystectomy is not usually indicated in the course of dengue (typically a self-limiting disease) due to a high risk of bleeding.

CONCLUSIONS

The case provides a rationale for the inclusion of acalculous cholecystitis in the differential diagnosis in patients with abdominal pain returning from dengue endemic areas.

Evaluation of knowledge and use of the malaria prevention measures among the patients of the Department of Tropical and Parasitic Diseases University Center of Maritime and Tropical Medicine, Gdynia, based on a questionnaire performed in the years 2012-20

INTRODUCTION

Every year, approximately 125 million travelers visit areas where malaria prevails, located in over 100 countries. Over 10,000 of them suffer from malaria annually. Visitors to these areas may protect themselves against infection by using chemoprophylaxis, insect repellents, appropriate clothing, sleeping in airconditioned and well-screened quarters or using mosquito nets impregnated with insecticides.

AIM OF THE STUDY

The aim of this study was to gather and analyze the data about knowledge and usage of pharmacological and non-pharmacological malaria prevention methods among the patients of the University Centre for Maritime and Tropical Medicine (UCMMiT), Gdynia, Poland, in 2012-2013.

MATERIAL AND METHODS

A survey was conducted among 245 patients hospitalized in the Department of Tropical and Parasitic Diseases, UCMMiT in Gdynia, Poland in 2012 - 2013. The only criterion for inclusion was a sojourn and consent for participation in the study. The questionnaire included questions concerning mainly the use of chemoprophylaxis, opinion on the medication used for prophylaxis, side effects during its usage, the non-pharmacological prevention methods used against insect bites.

RESULTS

Due to travel destination, malaria chemoprophylaxis should have been recommended for 73 (30%) individuals prior to the travel. It should not have been recommended for the group of 129 patients reporting long-term sojourns (over a year) and for 43 persons (17%) due to their travel to non-endemic countries. In fact, chemoprophylaxis in the “recommended” group was used by 32 persons which constituted 44%, while in the “long sojourn” group prophylaxis was used by 7 persons and in the “not recommended group” by 1 person. The number of people who reported proper use of chemoprophylaxis (an appropriate drug and mode of usage) amounted to 26 (36%) in the “recommended” group. Among bite prevention methods, usage of window mosquito nets was reported by 154 people (63%), bed mosquitonets by 39 (16%), insect repellents by 52 (21%) and insecticides by 52 (21%) patients. Adverse effects associated with chemoprophylaxis were reported by 10 persons (26%) but none of them stopped taking the medication.

CONCLUSIONS

In spite of the availability of information on the Internet and the access to pre-travel medical counseling, the knowledge of correct prophylaxis against malaria among the people traveling to tropical countries is still unsatisfactory, leading to increased risk of Plasmodium infections. Better understanding of prophylaxis rules among travelers may increase usage of non-pharmacological methods and highlight the factors affecting usage of prevention methods.

An attempt to estimate the minimal number of Poles infected and treated for malaria in Poland and abroad

BACKGROUND

Malaria is one of the three most dangerous infectious diseases in the world. According to official statistics, there are a few dozen cases in Poland annually while the number of Poles treated abroad or self-treating remains unknown. Poland has been declared to be malaria-free since 1963 and nowadays all cases are imported. The aim of the study is to determine the minimal number of malaria cases in Poles at home and abroad in the last decade.

MATERIALS AND METHODS

The medical records of 4,710 patients tested for malaria in the Department of Tropical Parasitology in the years 2003-2012 were analysed. Two spreadsheets were created, which only included people with a history of malaria diagnosed in the reference centre where indirect immunofluorescent-antibody assay (IFA) for Plasmodium falciparum antigen proved positive. The minimum number of Poles who have had malaria at home and abroad was calculated on the basis of positive IFA results; the rate of all treated malaria patients in Poland in relation to those treated in the reference centre and the actual number of Poles with malaria diagnosed at home was calculated.

RESULTS

A group of 376 people with positive serologic tests results in indirect immunofluorescent antibody assay with titre ≥ 1:20 were received, including 227 patients with positive serologic results with titre ≥ 1:80. The rate of the overall number of malaria cases in Poland compared to the number of malaria cases in the University Centre for Maritime and Tropical Medicine Hospital was determined as 3.47:1. It was demonstrated that every year at least 174 to 211 Poles staying abroad may suffer from malaria.

CONCLUSIONS

This is the first attempt to estimate the minimal number of Poles infected and treated for malaria in Poland and abroad. The estimated number is 8-10 times greater than the number of registered cases in Poland.

Clinico-laboratory profile of dengue patients returning from tropical areas to Poland during 2010-15

BACKGROUND & OBJECTIVES

Dengue is a mosquito-borne viral disease, incidences of which have increased rapidly in the past decade. About 400 million new infections are recorded annually worldwide, and 40% of the human population lives in the areas at risk of dengue transmission. In this study, the clinical and laboratory profile of dengue diagnosed patients returning to Poland from tropical areas has been analyzed.

METHODS

This is a retrospective study of 65 patients based on clinical symptoms and serological tests conducted in the Department of Tropical Parasitology of Institute of Maritime and Tropical Medicine (IMTM) in Gdynia, Poland during 2010-15. The diagnosis of dengue virus (DENV) infection was based on the detection of specific immunoglobulin M (IgM) and IgA antibodies performed by specific ELISA assays. The samples were considered as positive, if the absorbance was >10% above the cut-off value.

RESULTS

Among 65 persons with dengue selected for the analysis, 59 patients were admitted to the hospital because of clinical symptoms of the disease; the six persons initially asymptomatic were hospitalized due to routine control treatment returning from tropical regions. Patients reported various destinations, purpose and duration of their travels. All of them had returned from dengue endemic regions and were positive for IgM antibodies against DENV. Common clinical symptoms observed were fever (ranging from 38 to 40°C in 43% of patients), weakness, headache and rash. Laboratory tests revealed elevated levels of transaminase activity, leukopenia and thrombocytopenia in 35.3, 24.6 and 20% of patients, respectively.

INTERPRETATION & CONCLUSION

The number of Polish travelers to subtropics and tropics increases every year. As cases of fever and other symptoms appear to be increasingly in Polish people returning from tropical regions of Asia, America and Africa, their screening and management should be taken seriously. The study also suggests that the disease might be more widespread than it was known previously.

Investigations on the occurrence of Plasmodium knowlesi in travellers returning from the endemic areas of simian malaria

Malaria remains an important public health issue all over the world. Among 5 Plasmodium species invasive to humans, Plasmodium knowlesi has been identified most recently. It is sometimes difficult to differentiate this species from P. malariae with the use of microscopic examination. However, P. knowlesi infection may be associated with rapidly increasing parasitaemia and severe clinical course with the risk of death. Samples from Polish travellers returning from areas where simian malaria is endemic were examined with the use of polymerase chain reaction (PCR). The small subunit of ribosomal RNA (SSU rRNA) genes was subjected to analysis using nested PCR reaction. No positive results of P. knowlesi were obtained. Due to morphological similarities to P. malariae, potentially severe clinical course of infection and P. knowlesi endemic regions being a common tourist destination, diagnostic and clinical vigilance is necessary, including molecular methods use for precise parasite identification.

Different serotypes of dengue virus (DENV) imported by Polish travellers from dengue endemic areas to Poland

BACKGROUND

Dengue viruses are the most widespread arboviruses (transmitted mainly by Aedes aegypti and Ae. albopictus mosquitoes), which have shown an unexpected geographic expansion. There are four dengue virus serotypes: DENV-1, DENV-2, DENV-3, and DENV-4. Subsequent infections increase the risk of developing severe dengue fever.

MATERIALS AND METHODS

Samples from travellers returning from the endemic area of dengue fever were examined with the reverse transcription-polymerase chain reaction method. Primers amplified 743 bp fragment of the NS5 and 3'UTR genomic region of mosquito-borne flaviviruses of JEV group were used.

RESULTS

The sequences from the 10 examined patients were compared to available DENV sequences in GenBank database and the basic local alignment search tool (BLAST) results confirmed that the infective virus was DENV-1 (6 patients), DENV-2 (2 patients) and DENV-3 (2 patients).

CONCLUSIONS

For the first time in Poland, dengue virus serotypes were determined in travellers returning from dengue-endemic areas.

From Exhaustion to Disengagement via Self-Efficacy Change: Findings from Two Longitudinal Studies among Human Services Workers

This longitudinal research examined the relationship direction between burnout components (exhaustion and disengagement) within the context of personal resources measured by self-efficacy and social support. In line with the conservation of resources theory we hypothesized that exhaustion may trigger a spiral loss of personal resources where self-efficacy declines and subsequently, social support also declines and in turn predict disengagement. Participants in Study 1 were mental healthcare providers (N = 135) working with U.S. military personnel suffering from trauma. Participants in Study 2 were healthcare providers, social workers, and other human services professionals (N = 193) providing various types of services for civilian trauma survivors in Poland. Baseline and 6-month follow-up measurements included burnout components, burnout self-efficacy and perceived social support. The path analysis showed consistent results for both longitudinal studies; exhaustion measured at Time 1 led to disengagement at Time 2, after controlling for baseline disengagement levels. Across Study 1 and Study 2 these associations were mediated by self-efficacy change: Higher exhaustion led to greater decline in self-efficacy which in turn explained higher disengagement at the follow-up. Social support, however, did not mediate between self-efficacy and disengagement. These mediating effects were invariant across Studies 1 and 2, although the mean levels of burnout and personal resources differed significantly. The results contribute to a discussion on the internal structure of job burnout and a broader understanding of the associations between exhaustion and disengagement that may be explained by the underlying mechanism of change in self-efficacy.

Dengue antibodies in Polish travellers returning from the tropics. Evaluation of serological tests

Dengue is a viral disease caused by an RNA virus of the genus Flavivirus, family Flaviviridae, occurring as four serotypes (DEN-1, -2, -3, -4). It is transmitted to humans by the Aedes mosquitoes, mainly A. aegypti. The occurrence of dengue is strictly related with their preferred breeding areas. Dengue endemic regions are inhabited by some 2.5 billion people. 50-100 million cases of dengue fever and up to 1 million cases of dengue haemorrhagic fever are noted worldwide in more than 100 countries every year. The aim of the reported examinations was to diagnose dengue virus infections in returning travellers. In the years 2006-2009 serological tests were performed in 753 persons. In the diagnostics we used ELISA to find IgM and/or IgG class of antibodies against dengue virus, rapid immunochromatographic (cassette) test, NS1 viral antigen detection by ELISA, and virus RNA detection by RT-PCR method. IgM or IgG class antibodies, and both classes simultaneously, were detected in 19.8% of the examined cases. The greatest number of infections came from India and the Far East, next from South and Central America, and the smallest number from Africa. Sixteen patients with diagnosed dengue, including three cases of dengue haemorrhagic fever, were hospitalized.

[Difficulties in diagnostics in recurrent abdominal pains in 71-years-old patient]

Neoplasm of B-cell origin is the most frequent malignant disease of the lymphatic tissue. It is usually presented as enlargement of lymph nodes, hepatosplenomegaly, skeletal pains and gastrointestinal dysfunction. Splenic lymphoma can cause the difficulties in diagnostic procedures (ultrasound and computed tomography). It may be nearly anechoic and mimic a cyst, abscess or parasitic mass. We describe a course of the disease and diagnostic troubles noted in 71-years-old patient, in whom splenic cysts enlarging rapidly were observed. Splenectomy due to presented difficulties in diagnosis such as clinical disquiet about subsequent course of the disease was performed. It let us to recognize malignant lymphoma and initiate a correct treatment strategy.

[Evaluation of medical instructions designed by hospitals for expectant mothers]

The proper prenatal care decreases the risk of morbidities and complications during the pregnancy. The high level of the gestational knowledge supplied to woman and her family, permits to recognize the signs of threats and immediately go to a specialist and get proper help. A women consciousness of the proper gestation hygiene simplifies to avoid the risk of fetal development disorders. Because of this, the medical personnel is obligated to promote good behaviors adequate for that period. The pregnancy is a condition in which the salubrious promotion is most effective because at this time women and their families are disposed to change the wrong health behavior. The object of the study was to assess the health education process among pregnant women. One hundred women after the delivery was examined by means of self-created questionnaire. None of the required issues was properly discussed with the pregnant women.

[Analysis of women nutritional status during pregnancy--a survey]

The proper diet is one of the most important factor during pregnancy. The general knowledge about proper nourishment during pregnancy allows the women to avoid quantitative and qualitative nourishment mistakes. Because of this--the salubrious education in this aspect is very important. The aim of the study is to analyze the proper nourishment during pregnancy particularly in professionally active women and those who don't work during pregnancy.

[Assessment of mass-scale primary prevention of nervous system defects]

Nervous system defects are one of the main reasons of neonate mortality in Poland. In reply to that fact a special program for prophylaxis of nervous system defects was established in 1998. It includes three activity fields for women at reproductive age. These are following: propagation of nourishment rich in vitamin B and folic acid, recommendation for the day-to-day taking of 0.4 mg folic acid, improvement of the nutritive food value by adding such nutrients as folic acid. The aim of this article is to evaluate the efficiency of the prophylaxis of the nervous system defects.

[Prevention of premature birth in the population of pregnant women in Silesian region]

A great number of premature deliveries is one of the main problems in present-day perinatology. Although the ability of premature babies to survive has increased, they are vulnerable to many complications. Statistical data showed that the grade of premature deliveries and related complications in Silesian region is one of the highest in our country. Therefore, it is necessary to offer the intensive and systematic health care for pregnant women and establish the prophylactic programme for premature deliveries. The aim of this article is to evaluate the level of knowledge, skills and motivation to follow the prophylaxis directions among pregnant women.

[Husband's presence at childbirth in light of obstetric psychoprophylaxis]

Contemporary obstetric psychoprophylaxis gives prospective parents wide opportunities to prepare to the pregnancy period and delivery. It is educationally-minded and points the importance to modify the life style, introduces exercises accompanied by the relative during the pregnancy and delivery. The survey portrays husband's--child father's role in obstetric psychoprophylaxis. The importance to continue the psychoprophylaxis in the delivery room was spotted in the survey, too. The continuation might be reached by close relative's presence.