[Spectrum of diseases occurring in refugees and asylum seekers: data from three different medical institutions in the Munich area from 2014 and 2015]

BACKGROUND

In 2014 the number of refugees and asylum seekers in Germany rose steeply. Therefore, the provision of sufficient medical care for this special group of people became a major topic. Up to now, data on the spectrum of illnesses in this group in Germany is scarce.

PATIENTS AND METHODS

Anonymized data of 548 ill refugees and asylum seekers were retrospectively evaluated. Cases from three different institutions and time periods were collected and summarized: 329 outpatients from the general medical clinic of REFUDOCS (RD, January to beginning of March 2015), 175 inpatients from the 1. medical department of the municipal hospital Schwabing (KS, June 2014 to February 2015) and 44 outpatients from the department of infectious diseases and tropical medicine of the Ludwig-Maximilians-University, Munich (AITM, 2014).

RESULTS

Health problems seen at the RD general medical clinic mostly matched the usual spectrum seen by general practitioners. Respiratory illnesses especially by unspecific viral infections (152 visits), followed by neuropsychiatric (68), and gastrointestinal illnesses (56), as well as musculoskeletal (52) and skin problems (45), were common. Infectious diseases or diseases typical or specific for the tropics were mostly treated in the specialized centers. Cases of pulmonary and extrapulmonary tuberculosis (53), malaria (53), scabies, pneumonia, and schistosomiasis were prevalent.

CONCLUSION

The results of this exemplary study mostly show the occurrence of illnesses in refugees and asylum seekers that are well known to German general practitioners and pediatricians. However, depending on the country of origin infectious / tropical diseases like tuberculosis, malaria, or relapsing fever have to be considered. Rapid diagnosis of these illnesses is warranted to prevent severe cases or further spreading of contagious diseases.

Neurogenic inflammation and colliquative lymphadenitis with persistent orthopox virus DNA detection in a human case of cowpox virus infection transmitted by a domestic cat

Cowpox viruses are orthopoxviruses that may survive in the environment for years. Rodents are regarded as the primary hosts, but transmission to other species has been reported. This report describes a cowpox virus infection in a cat with subsequent transmission to its owner leading to protracted, atypical and severe clinical signs. A young cat presented with multiple crusts and plaques on the neck, muzzle and tail base. The owner developed an erythematous lesion with elevated margins, central necrosis and crust formation below the left breast, a neurogenic inflammation, enlarged regional lymph nodes, a colliquative lymphadenitis and concomitant flu-like symptoms. Cultures were taken at the first visit from the cat's lesional skin and the patient's skin, and polymerase chain reaction with sequencing of the haemagglutinin region of both were positive for cowpox virus. The patient was treated with various antibiotics and methylprednisolone and was in clinical remission after 7 months.

Taenia solium metacestode preparation in rural areas of sub-Saharan Africa: a source for diagnosis and research on cysticercosis

BACKGROUND

Taenia solium metacestodes/cysts obtained from pig carcasses constitute a primary source for diagnostic tools used for the detection of human cysticercosis. Data on T. solium cyst preparation in Africa is still scarce but required to establish independent reference laboratories.

OBJECTIVES

The aim of the present study is a) to present the likely yield of T. solium cyst material by the use of two different preparation methods in the field and b) to investigate its suitability for immunodiagnosis of human cysticercosis.

METHODS

In Zambia, Uganda and Tanzania 670 pigs were screened for T. solium infection. Cysts were prepared by 'shaking method' and 'washing method'. Generated crude antigens were applied in a standard western blot assay.

RESULTS

46 out of 670 pigs (6.9%) were found positive for T. solium (Zambia: 12/367, 3.3%; Uganda: 11/217, 5.1%; Tanzania 23/86, 26.7%). Mean values of 77.7 ml whole cysts, 61.8 ml scolices/membranes and 10.9 ml cyst fluid were obtained per pig. Suitability of collected material for the use as crude antigen and molecular diagnostic techniques was demonstrated.

CONCLUSION

This study clearly shows that T. solium cyst preparation in African settings by simple field methods constitutes an effective way to obtain high quality material as source for diagnostic tools and research purposes.

Infection-induced anaemia: a cross-sectional study of 14,636 German travellers aged 20-49 years

BACKGROUND

Anaemia is a frequently diagnosed condition which can develop as a consequence of numerous factors, including infectious diseases (IDs). Travelling, especially in sub-/tropical regions, leads to an elevated risk of contracting IDs. The aim of our study was to assess the epidemiological significance of IDs in inducing anaemia among a large cohort of returned travellers.

METHODS

This was a cross-sectional study in which data on 17,009 returned travellers aged 20-49 years who consulted the travel medicine clinic of the University of Munich between 1999 and 2011 were retrieved and analysed.

RESULTS

Of the returned travellers, 8.3 % (6.0 % of males/10.4 % of females) were diagnosed with anaemia. The prevalence of anaemia was significantly elevated among patients of African (21.4/28.3 %) and Asian (11.6/15.7 %) origin. When the study population was restricted to the 14,636 travellers of German origin, 7.1 % of the returned travellers (4.6/9.6 %) were diagnosed with anaemia. The prevalence was significantly elevated among patients who travelled for >30 days (5.7 of males/10.6 % of females) and for male travellers visiting friends and relatives (7.7 %). However, these correlations were confounded by malaria. The prevalence of anaemia was significantly elevated only among returned travellers diagnosed with malaria (36.1 of males/26.9 % of females) and with symptomatic intestinal Entamoeba histolytica infections (30.0/33.3 %).

CONCLUSION

Following the exclusion of confounding by malaria from the statistical analysis, the prevalence of anaemia was found to be significantly elevated among patients of African and Asian origin, and among patients of German origin who had travelled for >30 days, it could be mainly attributable to chronic, long-lasting causes. Although more than 550 travel-associated IDs were assessed in our study, only symptomatic intestinal Entamoeba histolytica infections and, to an even larger extent, malaria were determined to be of epidemiological significance for inducing anaemia among travellers.

[Severe oral mucositis in a patient with HIV infection]

HISTORY AND CLINICAL FINDINGS

A 50-year-old man with HIV infection (first diagnosed > 20 years ago) presented at our hospital with fulminant oral mucositis. Antiretroviral therapy (tenofovir, emtricitabine, raltegravir) had been started 2 months ago. Previously he had no opportunistic infections and no other pre-existing illnesses. He had not travelled outside Europe but stayed in Spain for several weeks during summer.

INVESTIGATIONS

Physical examination revealed swelling of the lips and severe ulcerative mucositis of the gums and pharynx. The patient complained of painful swallowing. The blood-chemistry showed no abnormalities. The microscopical analysis of a smear and a biopsy of the buccal mucosa revealed amastigotes of leishmania. By means of PCR technique, Leishmania donovani complex was specified.

TREATMENT AND COURSE

The patient was treated with liposomal amphotericin B (1 mg/kg) for 21 days. Because of the immunosuppression he was put on maintenance therapy afterwards (liposomal amphotericin B every 3 weeks). However, 4 months later there was a clinical relapse of the mucositis and a new cultural and PCR detection of leishmania in a buccal biopsy. After another course of 21 days with liposomal amphotericin B (3 mg/kg) and miltefosine (150 mg/d), the mucositis subsided. Therapy with liposomal amphotericin B (3 mg/kg single dose every 3 weeks) has since been maintained. The antiretroviral therapy was changed meanwhile to lamivudin, abacavir and raltegravir because of kidney failure with elevated urea and creatinine. The patient has been clinically stable ever since without any other HIV-related problems. The latest CD4 count was 456/µl and the HIV load 340 copies/ml.

CONCLUSION

Leishmaniasis is a severe infection in HIV-positive patients. Clinical manifestations can be atypical in immunosuppressed patients and the treatment is complicated with HIV coinfection. This is also due to a lifelong persistence of the parasite with potential reactivation especially in patients with suppressed CD4 cells. Therefore maintenance therapy after standard therapy of leishmaniasis is mandatory at least for a CD4 count below 350/µl. Especially in HIV patients with a leishmaniasis relapse lifelong maintenance therapy should be considered.

Skin disorders among travellers returning from tropical and non-tropical countries consulting a travel medicine clinic

OBJECTIVE

To evaluate the causes and risks for imported skin disorders among travellers.

METHODS

Data of 34,162 travellers returning from tropical and non-tropical countries and presenting at the outpatient travel medicine clinic of the University of Munich, Germany, between 1999 and 2009 were analyzed for this study. Of these, 12.2% were diagnosed with skin disorders.

RESULTS

Main destinations visited were Asia (40%), Africa (27%) and Latin America (21%). Tourism in the form of adventure travel/backpacking (47%) and package holidays (23%) was the most common purpose of travel. The leading causes of skin disorders were arthropodal (23%), bacterial (22%), helminthic (11%), protozoan (6%), viral (6%), allergic (5%) and fungal (4%). The 10 most frequently diagnosed specific skin diseases associated with specific destinations were insect bites (17%, Southern Europe), cutaneous larva migrans (8%, Asia and Latin America), cutaneous leishmaniasis (2.4%, Mediterranean Region/Middle East), dengue fever (1.5%, Asia), rickettsioses (1.3%, Southern Africa), myiasis (0.8%, Central America), filarioses (0.7%, Africa), tick bites (0.6%, Central/Eastern Europe), schistosomiasis (0.6%, Africa) and tungiasis (0.6%, Africa). Travellers in sub-Saharan Africa had the highest relative risk of acquiring skin disorders.

CONCLUSION

As more than 20% of all skin disorders among returned travellers were caused by arthropods and about 50% by infectious pathogens, pre-travel consultations should include specific prophylaxis and consider the most important risk factor for the travel destination.

Epidemiological, clinical, and diagnostic data on intestinal infections with Entamoeba histolytica and Entamoeba dispar among returning travelers

BACKGROUND

Among travelers returning from the tropics, Entamoeba spp. are among the most frequently detected intestinal parasites, mainly the presumable apathogenic E. dispar and the pathogenic E. histolytica.

METHODS

Among 5,378 travelers seeking diagnosis and treatment for intestinal infections at the travel clinic of the University of Munich between 2005 and 2009, 103 laboratory-confirmed amebiasis cases were detected. The study compares the results of various diagnostic tests among these patients, analyzes data on co-infections and clinical symptoms, and determines the risk for acquiring amebiasis.

RESULTS

Initial screening tests (stool microscopy, coproantigen enzyme-linked immunosorbent assay [ELISA]) were positive in 82.5 and 93.9%, respectively. Fecal samples from patients with positive screening test results were subjected to polymerase chain reaction (PCR), which detected E. histolytica in 9.7% and E. dispar in 88.3% of the cases. The majority of E. histolytica cases and more than half of the E. dispar cases had intestinal symptoms typical for amebiasis. In 53.4% of the cases, intestinal co-infections were found, mostly Blastocystis hominis (39.8%), Giardia lamblia (10.7%), Campylobacter spp. (4.9%), and Salmonella typhi (2.9%). The risk for travelers to be infected with E. histolytica or E. dispar was highest for destinations in West Africa, East Africa, and South and South-East Asia.

CONCLUSION

Stool microscopy and coproantigen ELISA are appropriate screening tests for intestinal Entamoeba infections among travelers, but intestinal co-infections are common. PCR is highly recommended as the diagnostic method of choice for the differentiation of Entamoeba spp. The presumable apathogenic E. dispar seems to provoke intestinal symptoms.

Chikungunya fever in two German tourists returning from the Maldives, September, 2009

This report describes the first isolation and molecular characterisation of a chikungunya virus from two German tourists who became ill after a visit to the Maldives in September 2009. The virus contained the E1 A226V mutation, shown to be responsible for an adaptation to the Asian tiger mosquito Aedes albopictus. The E1 coding sequence was identical to chikungunya virus isolates from Sri Lanka and showed three nt-mismatches to the only available E1 nt sequence from the Maldives.

Chikungunya fever in two German tourists returning from the Maldives, September, 2009

This report describes the first isolation and molecular characterisation of a chikungunya virus from two German tourists who became ill after a visit to the Maldives in September 2009. The virus contained the E1 A226V mutation, shown to be responsible for an adaptation to the Asian tiger mosquito Aedes albopictus. The E1 coding sequence was identical to chikungunya virus isolates from Sri Lanka and showed three nt-mismatches to the only available E1 nt sequence from the Maldives.

Excision of pre-ulcerative forms of Buruli ulcer disease: a curative treatment?

BACKGROUND

Previous investigations have revealed that Mycobacterium ulcerans is extensively distributed spatially throughout ulcerative lesions, including in the margins of excised tissue. In contrast, bacilli in pre-ulcerative lesions are assumed to be concentrated in the center of the lesion. In order to assess the extent to which the surgical excision of pre-ulcerative lesions is capable of removing all infected tissue, we subjected the excision margins of pre-ulcerative lesions to laboratory analysis.

PATIENTS AND METHODS

Eleven patients with laboratory-confirmed pre-ulcerative lesions were included in the study. The diameter of the lesion and excised tissue and the "surgical distance" between the border of the lesion and excision margin were measured. The entire excision margin was cut into segments and subjected to IS2404 PCR.

RESULTS

The results from the PCR analysis on the samples of excision margins were highly significantly associated with the surgical distance (p < 0.001). The margin samples of nodules were significantly more often PCR positive than the plaques (p = 0.025). The size of the lesion and the size of the excised tissue did not significantly influence the PCR results. Statistically, a surgical distance of more than 9 mm was found to reduce the risk of remaining infected tissue to less than 10%, that of 13 mm to reduce the risk to less than 5%, and that of 25 mm to reduce the risk to nearly 0%.

CONCLUSION

The results of this study show that in preulcerative Buruli ulcer disease, bacilli may extend beyond the actual size of the lesion and that there is a strong correlation between the presence of M. ulcerans in the margin samples and the surgical distance. Excision with a surgical distance of 25 mm avoided the risk of remaining mycobacteria in this study. However, no recurrences occurred in the patients with M. ulcerans-positive excision margins. The need of postoperative antimycobacterial treatment in these patients remains to be determined.

[Acute febrile disease with splenomegaly and pancytopenia. A 66-year-old Greek patient with a prosthetic mitral valve]

We report on a 66-year-old patient originating from Greece and living in Germany with a prosthetic mitral valve because of a combined vitium following juvenile rheumatic fever. The patient fell ill with acute fever, splenomegaly, and pancytopenia. After unsuccessful antibiotic therapy because of presumed endocarditis or sepsis with unknown focus, visceral leishmaniasis was suspected because of recent travel to Greece. Subsequently, this diagnosis was confirmed by serology. Considering thrombocytopenia and concurrent anticoagulation after prosthetic mitral valve replacement, we avoided a bone marrow biopsy usually required for definite proof of leishmania infection. Instead, infection with Leishmania infantum was diagnosed by PCR of a peripheral blood sample. After treatment with liposomal amphotericin B the patient recovered fully.

33-jährige Libanesin mit rezidivierenden Hämoptysen und zystischer Raumforderung in der Lunge

A 33 year old woman from Lebanon presented with recurrent hemoptysis, subfebrile temperature, dyspnoe in stress, fatigue, weight loss, and pruritus. Serological tests and results from chest X-ray and computer tomography revealed cystic echinococcosis with pulmonary involvement. After refusal of surgical therapy a medical treatment with albendazole was implemented. Two months after the start of the therapy only a small fibrotic residuum in the lung was seen. A spontaneous healing success seems unlikely because of the duration of the pulmonary cyst and the progressive symptoms before treatment.

Tsutsugamushi-Fieber nach Südostasienreise

HISTORY AND CLINICAL FINDINGS

A 49-year-old travel guide fell ill during his return from a 6-week-stay in Vietnam, Myanmar and Thailand. He developed high fever and severe headache. On admission, the body temperature was at 39.5 degrees C with relative bradycardia. A black, crusted skin lesion of approximately 5 mm diameter was noted on the chest wall and was interpreted as an insect bite.

INVESTIGATIONS

CRP and liver enzymes were elevated. Total leucocyte count was normal but the differential count showed a left shift and aneosinophilia. Imaging procedures revealed splenomegaly and small pleural effusions on both sides.

TREATMENT AND COURSE

The patient was treated with a parenteral quinolone based on the initial suspicion of typhoid fever. Failure of this treatment and negative blood cultures raised concerns about the possibility of Tsutsugamushi fever, based on travel history and a re-evaluation of the skin lesion as an eschar. Tsutsugamushi fever was suspected on epidemiological and clinical grounds and was confirmed by the detection of specific IgM to Orienta tsutsugamushi and by seroconversion of IgG antibodies during follow-up. Even before immunodiagnostic confirmation was available, a course of doxycycline was started. This led to rapid improvement of the patient's condition.

CONCLUSION

In febrile travellers returning from Southeast Asia, Tsutsugamushi fever has to be considered in the differential diagnosis. The causative agent, Orienta tsutsugamushi is transmitted by larvae of trombiculid mites (chiggers). Leading symptoms are fever continua, cephalgia, and a primary lesion (eschar) at the site of cutaneous inoculation. The Eschar is easily overlooked and has to be searched carefully. Diagnosis is confirmed by the detection of specific antibodies. However, serology may be negative in the beginning. Therefore, treatment with doxycycline should be initiated on clinical grounds.

[52-year-old patient with subcutaneous space-occupying lesion in immunosuppression]

We report the case of a 52-years-old male patient, who was diagnosed with subcutaneous alveolar echinococcosis 6 months after liver transplantation for HCV-related cirrhosis. Nether the explanted nor the transplantated liver revealed an echinococcus focus. Therefore a rare primary extrahepatic manifestation was likely. Interestingly, the echinococcal larvae had developed protoscolices. The development of mature tapeworms in human is a rarity, which could be related to the immunosuppressive therapy after liver transplantation. The patient was curatively treated by surgical removal of the subcutaneous tumor and a postoperative therapy with albendazole. Furthermore, HCV reinfection (genotype 2b) was successfully treated with interferone alpha 2b and ribavirine for 6 months.

Fatal Malaria in a German Couple Returning from Burkina Faso

We report on a German couple found dead at home 7 days after returning from Burkina Faso. Postmortem evaluation revealed Plasmodium falciparum infection with a parasitemia of approximately 80% in both cases. No pathological findings of the organs were present at autopsy except moderate splenomegaly in both cases and myocarditis in one case. Typical findings of fatal malaria like petechial hemorrhages of the brain or other organs, or sequestration of parasitized erythrocytes in venules and capillaries were absent. Lack of sequestration with excessive hyperparasitemia leading to systemic hypoxemia and host cytokine release may have contributed to the rapid fatal course in these nonimmune patients.

Prophylaxis failure due to probable mefloquine resistant P falciparum from Tanzania

Failures of mefloquine prophylaxis in travellers returning from Africa have been reported repeatedly. Non-compliance to chemoprophylaxis is considered to be a major factor for failure. Only few reports on mefloquine prophylaxis failure in sub-Saharan Africa were able to report blood levels of the drug that were sufficient for prophylactic effectiveness. We report the case of a 44-year-old German female who travelled to Tanzania for 3 weeks. The patient reported that she never missed a dose of mefloquine during her weekly prophylaxis schedule. Four weeks after returning from Tanzania, the patient presented with fever, headache and myalgia. Only a few trophozoites of Plasmodium falciparum were found in a thick film. Blood levels of mefloquine at that stage were at 1400 ng/ml, thus largely excluding non-compliance and malabsorption. To our knowledge, this is the first case of confirmed prophylaxis failure due to mefloquine resistance in East Africa.

Sensitivity and specificity of ELISA and immunoblot for diagnosing neurocysticercosis

In patients with neurocysticercosis (NCC), clinical manifestations and the results of neuroimaging procedures vary widely and often do not facilitate a definite diagnosis. In order to determine the value of immunodiagnosis for NCC, 222 serum and cerebrospinal fluid samples from patients with NCC and healthy subjects were examined. The samples represented patients from various endemic regions, those with other neurological disorders from an endemic area (Mexico), persons with various helminth infections other than NCC, and a group of healthy volunteers. All specimens were tested by enzyme-linked immunosorbent assay and immunoblot for the presence of Taenia solium-specific antibodies. The sensitivities of the enzyme-linked immunosorbent assay and the immunoblot test in NCC patients were almost identical (80% and 81.7%, respectively). For both tests, the sensitivity was higher when cerebrospinal fluid (86%) was tested compared with serum (75%). The overall specificity of enzyme-linked immunosorbent assay was only 75.3% because of frequent false-positive results in patients with other helminth infections, especially in those with echinococcosis. The specificity (99.4%) of the immunoblot test was clearly superior. It is concluded that enzyme-linked immunosorbent assay as a screening method and immunoblot as a confirmatory test contribute considerably to the diagnosis of NCC.

Diagnostic significance of blood eosinophilia in returning travelers

This study was conducted to investigate the predictive value of blood eosinophilia (total white blood cell count with > or =8% eosinophils) for the diagnosis of travel-related infections in 14,298 patients who returned from developing countries. The data show that blood eosinophilia in travelers returning from developing countries has only limited predictive value for the presence of travel-related infections. However, the likelihood of the presence of helminth infections increases considerably with the extent of eosinophilia.

Zoonotic potential of Enterocytozoon bieneusi

The reservoirs and the modes of transmission of the most frequent microsporidial species in humans, Enterocytozoon bieneusi, are still unknown. We have examined fecal samples of 26 humans and 350 animals from 37 species to find 18 samples containing this parasite from humans, cats, pigs, cattle, and a llama. Genotypic characterization of the internal transcribed spacer of the rRNA gene resulted in 14 different genotypes, 6 of them previously undescribed. Phylogenetic analysis revealed the lack of a transmission barrier between E. bieneusi from humans and animals (cats, pigs, and cattle). Thus, E. bieneusi appears to be a zoonotic pathogen.

Rapid, simple, and culture-independent detection of rpsL codon 43 mutations that are highly predictive of streptomycin resistance in Mycobacterium tuberculosis

The substitution of codon 43 in the gene rpsL is the single most common mutation found in streptomycin-resistant Mycobacterium tuberculosis. The characterization of this mutation has been hampered by the need for prior cultivation of the mycobacteria, the need for DNA sequencing, or both. In this report we describe a simple and culture-independent technique to detect this mutation directly from sputum samples, requiring little more than a polymerase chain reaction (PCR) machine and a simple agarose minigel. There is no need for labeled probes or DNA sequencing. In a preliminary test of feasibility, interpretable results were obtained from all of 16 smear-positive and 1 of 4 smear-negative, culture-positive samples. Two of two samples containing M. tuberculosis with rpsL codon 43 mutations were correctly identified.

[Malaria--rapid diagnostic tests and emergency self-medication]

WHO recommendations have adopted the option of stand-by emergency treatment (SBT) for travellers to areas where malaria is endemic and medical attention may not be obtained within 24 hours after onset of symptoms. Indication and choice of drugs for SBT depend on use and kind of a chemoprophylactic regimen, situation of plasmodial resistance at the destination, and contraindications and tolerability in the individual traveller. However, the diagnosis of malaria on clinical grounds alone is unreliable, and fever occurs frequently during travel to malaria endemic areas from various reasons. The possibility of malaria has to be considered in all cases of unexplained fever that starts after the 7th day of stay in an endemic area. Studies in European travellers have shown that only 0.5-1.4% of all travellers to whom SBT medication has been prescribed, will finally use it. SBT use in febrile travellers (8.1-10.4% of all travellers) has been 4.9-17%, but plasmodial infection could be confirmed retrospectively in 10.8-16.7% of SBT-users only. The recent introduction of rapid diagnostic tests (RDT) for malaria has provided a potential tool to self-diagnose and treat a possible malaria attack when medical attention or microscopic diagnosis is not available. However, the utilisation of currently available RTDs by travellers has been shown to be technically problematic. Healthy volunteers were able to learn how to perform the tests, especially when standard written instructions were supplemented with verbal information (75 vs. 90% successful performance). But their interpretation of test results was unsatisfactory, with a high rate of false-negatives (14.1%). In another study in febrile European tourists in Kenya, only 68% of patients were able to perform the RDTs correctly, and 10 out of 11 with microscopically confirmed malaria failed to diagnose themselves accurately. Thus, besides appropriate training before departure, technical improvements are required before such RDT kits can be recommended for self-use by travellers.

Patterns of Plasmodium falciparum drug resistance in nonimmune travellers to Africa

Falciparum malaria is a major cause of morbidity and mortality among tourists returning from endemic areas. Treatment of infected travellers is frequently standardised, and resistance tests are rarely done as they are difficult to perform and interpret. In vitro tests of resistance to chloroquine, mefloquine, quinine, halofantrine, tetracycline, and sulfadoxine/pyrimethamine were performed on Plasmodium falciparum isolates obtained from 52 German travellers returning from malarious areas in sub-Saharan Africa. All patients were treated successfully with a standard dose of mefloquine. No in vivo resistance was observed. Although 20 (38.5%) isolates showed no signs of in vitro resistance, the remaining 32 (61.5%) were resistant to at least one of the tested antimalarial agents. Of these 32 isolates, 11 were multiresistant. Resistance to chloroquine was most frequently observed (55.8%), followed by sulfadoxine/pyrimethamine (11.5%), mefloquine (9.6%), quinine (3.8%), and halofantrine (1.9%). In vitro resistance to tetracycline was not detected in this study group. Treatment of falciparum malaria without resistance testing appears to be effective in most cases, but possible therapeutic failure due to emerging drug resistance should be kept in mind.

Heteroresistance in Mycobacterium tuberculosis

SETTING

Drug resistance in Mycobacterium tuberculosis is often linked to specific mutations in a limited number of resistance genes. Detection of these mutations in a cultured isolate can predict the resistant phenotype. Genotypic analysis of the mycobacteria directly in a clinical specimen would result in considerable time saving for resistance prediction.

OBJECTIVE

To find out whether resistance-predicting genotypes of mycobacteria found after cultivation always give a good reflection of those in the original clinical sample.

DESIGN

Restriction fragment length polymorphisms of repetitive polymerase chain reaction (PCR) amplification and cloning of PCR products were used as nonintegrative methods to describe the composition of katG, rpsL and embB genotypes involved in resistance to isoniazid, streptomycin and ethambutol, respectively, in the original sample. This result was then compared to the phenotypic resistance profile after cultivation.

RESULTS

Using both methods, mixed, heteroresistant populations could be detected in almost every fifth analyzed sample (katG: 5 of 16; rpsL: 3 of 17; embB: 1 of 21). Direct sequencing, a widely used integrative method, repeatedly failed to detect heteroresistance.

CONCLUSION

Heteroresistance is a valid phenomenon in clinical tuberculosis. It is not rare and not restricted to a particular resistance gene, and is obscured by cultivation as well as by some, not all, culture-independent resistance prediction tests.

Clinical features and epidemiology of tick typhus in travelers

BACKGROUND

Epidemiologic features of tick typhus among German travelers has not been surveyed recently.

METHODS

Clinical features, travel and medical histories in 78 patients with tick typhus who presented to a German outpatient clinic for Infectious and Tropical Diseases were investigated, in order to identify common epidemiological factors and potential strategies of prevention. Diagnosis was confirmed by serological detection of IgG- and IgM-antibodies to Rickettsia conorii by indirect immunofluorescence.

RESULTS

The majority of patients (71.8%) had visited southern Africa prior to presentation. All patients presented with fever as the main symptom. An eschar was still present in 68 patients (87.2%) with regional lymphadenitis in 19.2%. However, only a minority of patients (17.9%) remembered a tick bite at the location of the eschar.

CONCLUSION

Efforts to reduce the incidence of tick typhus in travelers should focus on preventive measures targeting behavioral changes. Avoiding tick bites during travel to endemic areas appears to be the single most important prophylactic action. Taking this into consideration, it should be possible to decrease the number of travelers returning with tick typhus significantly by adequate pretravel counseling.

Detection of embB codon 306 mutations in ethambutol resistant Mycobacterium tuberculosis directly from sputum samples: a low-cost, rapid approach

Substitutions of codon 306 in the gene embB are the most common mutations found in ethambutol resistant Mycobacterium tuberculosis. The characterization of these mutations has been hampered by the need for prior cultivation of the mycobacteria, or the need for DNA sequencing, or both. Here, we describe a simple and culture-independent technique to detect embB codon 306 mutations directly from sputum samples, requiring little more than a PCR machine and a simple agarose minigel. There is no need for labelled probes or DNA sequencing. In a preliminary test of feasibility, interpretable results were obtained from 21 of 24 selected sputum samples, 12 of which were determined to contain ethambutol resistant M. tuberculosis after culture. All of six samples with embB codon 306 mutations were correctly identified. Although an exact validation of this technique is beyond the scope of this technical report, we conclude from well-known embB codon 306 mutation prevalence figures that approximately one half of EMB resistant cases could already be predicted within 2 working days, with little equipment or hands-on time needed, instead of weeks required for conventional resistance testing.

Influence of rheumatoid factor on the specificity of a rapid immunochromatographic test for diagnosing dengue infection

In order to determine the influence of rheumatoid factor in serum specimens on the specificity of an immunochromatographic test for the detection of antibodies against dengue virus, 50 clinical specimens containing rheumatoid factor were evaluated for cross reactivity with a commercially available assay. While specificity for the detection of immunoglobulin (Ig) G antibodies was 100%, the IgM component of the test showed false-positive results in 26% of cases. Thus, it is important to consider interference by rheumatoid factor when using immunochromatographic assays for the detection of specific IgM produced during dengue infection.

[Psychosocial, economic and physical status of former leprosy patients in Uganda]

This study investigates the general living condition, the psychosocial, economical and physical situation of 161 leprosy patients previously treated at the St. Francis Leprosy Hospital at Buluba/Uganda, basing on interviews and clinical examinations. The results point to a negative correlation between general education and specific knowledge of leprosy and highlight a serious psychosocial situation of previously treated leprosy patients. The most important conclusion is that besides leprosy-specific chemotherapy, lifelong extensive general and leprosy-specific health education and posttreatment care can prevent disabilities in leprosy patients.

Disequilibria in the distribution of rpoB alleles in rifampicin-resistant M. tuberculosis isolates from Germany and Sierra Leone

The effectiveness of culture-independent resistance predictions by molecular techniques is dependent on the number and the frequency of accessible resistance-associated genomic mutations. We have characterized an rpoB gene region involved in rifampicin resistance in 49 Mycobacterium tuberculosis isolates resistant to rifampicin from Germany and Sierra Leone. The determined frequencies of mutations differed between both countries of origins as well as with respect to previously reported distributions of resistance mutations. It is concluded that at least for some isolates the acquisition of mutations leading to rifampicin resistance in clinical samples of M. tuberculosis is a non-random process which may lead to a geographical and temporal dependence of the sensitivities of molecular typing techniques for rifampicin resistance predictions.

Epidemiology of giardiasis in German travelers

BACKGROUND

Giardiasis has been well characterized in individuals traveling from areas of low to high endemicity.

METHODS

Clinical features, travel and medical histories in 352 patients with giardiasis who presented to a German outpatient clinic for Infectious and Tropical Diseases were investigated in order to identify common epidemiological factors and potential strategies of prevention.

RESULTS

Compared to the total patient population of the outpatient clinic during the period of investigation (n=13, 566 patients), patients who presented with giardiasis traveled longer (median 28 days versus 19 days, p <.001). While only 19.2% of the total patient population had traveled to the Indian subcontinent prior to referral, 32.1% of the patients with giardiasis acquired the infection there (p <.0001). Similar results were obtained for West Africa: in contrast to 19% of patients with giardiasis (p <. 0001), only 5.4% of the total patient population traveled there.

CONCLUSION

The risk of infection appears to be highest when making an extended journey to the Indian subcontinent. Short-time visitors to other parts of Asia and Latin America are apparently at a markedly lower risk. Risk factors such as type, duration and destination of the journey should be considered in pretravel counseling.

Close genotypic relationship between Enterocytozoon bieneusi from humans and pigs and first detection in cattle

The reservoirs and the routes of transmission of Enterocytozoon bieneusi are still unknown. In humans, it is the most commonly found microsporidial species. It has also been found repeatedly in pigs, too. The first detection of E. bieneusi in cattle is reported herein. Two distinct genotypes were characterized and compared with 4 other genotypes from humans, 6 from pigs, and 1 from a cat. From these 13 E. bieneusi genotypes known to date, 25 polymorphic sites could be identified in the internal transcribed spacer of the rRNA gene. The spectrum of polymorphisms within and between each of the 4 host species indicates a close relationship between E. bieneusi strains from humans and pigs, whereas those from cattle are more distantly related. The data suggest the absence of a transmission barrier between pigs and humans for this pathogen.