Eosinophilia à deux: a brain nagging souvenir from the Philippines.

Angiostrongylus cantonensis is the most common cause of eosinophilic meningitis. Although a rare condition among travelers, increased travel and global transportation of food products may result in more cases across non-endemic, developed countries in the future. We here describe two men with headache and painful skin after visiting the Philippines as presenting symptoms. Subsequently, confusion and focal neurologic symptoms developed. Both had increased serum eosinophils; however, CSF eosinophilia was only demonstrated after repeated lumbar puncture. In the CSF of both, Angiostrongylus spp. DNA was detected. Both were treated with albendazole combined with corticosteroids, after which symptoms improved.

Beyond the association. Toxoplasma gondii in schizophrenia, bipolar disorder, and addiction: systematic review and meta-analysis.

OBJECTIVE: To perform a meta-analysis on studies reporting prevalence of Toxoplasma gondii (T. gondii) infection in any psychiatric disorder compared with healthy controls. Our secondary objective was to analyze factors possibly moderating heterogeneity. METHOD: A systematic search was performed to identify studies into T. gondii infection for all major psychiatric disorders versus healthy controls. Methodological quality, publication bias, and possible moderators were assessed. RESULTS: A total of 2866 citations were retrieved and 50 studies finally included. Significant odds ratios (ORs) with IgG antibodies were found in schizophrenia (OR 1.81, P < 0.00001), bipolar disorder (OR 1.52, P = 0.02), obsessive-compulsive disorder (OR 3.4, P < 0.001), and addiction (OR 1.91, P < 0.00001), but not for major depression (OR 1.21, P = 0.28). Exploration of the association between T. gondii and schizophrenia yielded a significant effect of seropositivity before onset and serointensity, but not IgM antibodies or gender. The amplitude of the OR was influenced by region and general seroprevalence. Moderators together accounted for 56% of the observed variance in study effects. After controlling for publication bias, the adjusted OR (1.43) in schizophrenia remained significant. CONCLUSION: These findings suggest that T. gondii infection is associated with several psychiatric disorders and that in schizophrenia reactivation of latent T. gondii infection may occur.

Low prevalence of Blastocystis sp. in active ulcerative colitis patients.

Ulcerative colitis (UC) is thought to originate from a disbalance in the interplay between the gut microbiota and the innate and adaptive immune system. Apart from the bacterial microbiota, there might be other organisms, such as parasites or viruses, that could play a role in the aetiology of UC. The primary objective of this study was to compare the prevalence of Blastocystis sp. in a cohort of patients with active UC and compare that to the prevalence in healthy controls. We studied patients with active UC confirmed by endoscopy included in a randomised prospective trial on the faecal transplantation for UC. A cohort of healthy subjects who served as donors in randomised trials on faecal transplantation were controls. Healthy subjects did not have gastrointestinal symptoms and were extensively screened for infectious diseases by a screenings questionnaire, extensive serologic assessment for viruses and stool analysis. Potential parasitic infections such as Blastocystis were diagnosed with the triple faeces test (TFT). The prevalence of Blastocystis sp. were compared between groups by Chi-square testing. A total of 168 subjects were included, of whom 45 had active UC [median age 39.0 years, interquartile range (IQR) 32.5-49.0, 49 % male] and 123 were healthy subjects (median age 27 years, IQR 22.0-37.0, 54 % male). Blastocystis sp. was present in the faeces of 40/123 (32.5 %) healthy subjects and 6/45 (13.3 %) UC patients (p = 0.014). Infection with Blastocystis is significantly less frequent in UC patients as compared to healthy controls.

Subtype determination of Blastocystis isolates by matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS).

The pathogenic role of the enteric parasite Blastocystis remains controversial. Recent studies have suggested that various subtypes (STs) found in human samples could be correlated to the presence or absence and variability of clinical manifestations, and that STs can differ with respect to drug sensitivity. Polymerase chain reaction (PCR) techniques used to determine these STs are expensive and are usually restricted to research laboratory settings. This study evaluates the potential application of the inexpensive matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS) technique to discriminate Blastocystis STs. A database of parasitic protein signatures was constructed for five Blastocystis STs, and the reference spectra were challenged with those from 19 axenic cultures of ST1, ST2, ST3, ST4 and ST8 and those from nine xenic liquid cultures of ST3 and ST4. Samples from axenic cultures were prepared using standard formic acid extraction and direct deposition procedures. The reference spectra revealed five distinct spectral profiles, and the database library allowed for discrimination between all of the cultures with reliability indices ranging from 2.038 to greater than 2.8 when an extraction was performed. The direct deposition procedure resulted in greater variability in the discrimination and direct MALDI-TOF MS identification from xenic liquid cultures was effective in 3 out of 9 samples. MALDI-TOF MS proved to be an effective technology for efficiently discriminating Blastocystis STs in axenic cultures.

Imported leishmaniasis in the Netherlands from 2005 to 2012: epidemiology, diagnostic techniques and sequence-based species typing from 195 patients.

Leishmaniasis is an imported disease in the Netherlands. We report data for the period between 2005 and 2012, on clinical presentation, country where leishmaniasis was acquired, and causative species, for 195 civilian and military patients who had travelled abroad. Most patients were affected by cutaneous leishmaniasis (CL) (n=185 patients), while visceral leishmaniasis (VL) (n=8 patients) and mucocutaneous leishmaniasis (n=2 patients) were less frequently observed. All VL patients had been infected in Europe. CL was mainly acquired in Afghanistan, Surinam, Morocco and Spain. The majority of CL patients consisted of military personnel (55%, 102/185), 78 of whom had been infected during an outbreak in Afghanistan. Parasitological diagnosis was made by a combination of polymerase chain reaction (PCR), microscopy and culture. Compared to a standard of parasitological proof by any method other than the one under consideration, sensitivities of the individual methods ranged from 73% to 98%. Microscopy was least sensitive, but is fast and cheap. Mini-exon repeat PCR combines high sensitivity and specificity, and allows differentiation between species by sequencing of the PCR product. Eight different species or species complexes were identified, allowing species-specific therapy. Four patients proved infected with Leishmania naiffi, a hitherto rarely described cause of leishmaniasis. In comparison to previous decennia, an increase in cutaneous leishmaniasis was observed in our hospital, both in civilian and military patients who had travelled abroad. This calls for increased awareness among clinicians, availability of diagnostic tests and species-specific treatment guidelines in non-endemic countries.

First case of Echinococcus vogeli infection imported to the Netherlands, January 2013.

In January 2013 in the Netherlands, a man in his 50s from Suriname underwent hemihepatectomy because of a cystic liver mass, assumed to be a cystadenoma. Pathology revealed an echinococcal infection. PCR analysis of cyst material identified Echinococcus vogeli, causing polycystic hydatid disease. This echinococcus species is rarely diagnosed outside South America. The patient received adequate treatment, but this case emphasises the importance of awareness of this infection when treating patients with cystic tumours from endemic areas.

Chagas disease in European countries: the challenge of a surveillance system.

A study of aggregate data collected from the literature and official sources was undertaken to estimate expected and observed prevalence of Trypanosoma cruzi infection, annual incidence of congenital transmission and rate of underdiagnosis of Chagas disease among Latin American migrants in the nine European countries with the highest prevalence of Chagas disease. Formal and informal data sources were used to estimate the population from endemic countries resident in Europe in 2009, diagnosed cases of Chagas disease and births from mothers originating from endemic countries. By 2009, 4,290 cases had been diagnosed in Europe, compared with an estimated 68,000 to 122,000 expected cases. The expected prevalence was very high in undocumented migrants (on average 45% of total expected cases) while the observed prevalence rate was 1.3 cases per 1,000 resident migrants from endemic countries. An estimated 20 to 183 babies with congenital Chagas disease are born annually in the study countries. The annual incidence rate of congenital transmission per 1,000 pregnancies in women from endemic countries was between none and three cases. The index of under diagnosis of T. cruzi infection was between 94% and 96%. Chagas disease is a public health challenge in the studied European countries. Urgent measures need to be taken to detect new cases of congenital transmission and take care of the existing cases with a focus on migrants without legal residency permit and potential difficulty accessing care.

Cutaneous leishmaniasis in three Dutch military cohorts following jungle training in Belize.

Skin lesions occur frequently in travelers to tropical countries. Military personnel acquire skin lesions regularly during jungle training as did Dutch troops who trained in the jungle of Belize in 1998, 2004 and 2009, in an area endemic for cutaneous leishmaniasis. Demographic and clinical data were collected retrospectively. Diagnostic investigations for cutaneous leishmaniasis included Giemsa stain, culture, PCR and NASBA and histopathology of biopsies. Treatment of leishmaniasis was with sodium stibogluconate, given intravenously or intralesionally, the latter with cryotherapy. In 1998 and 2004 cutaneous leishmaniasis due to Leishmania braziliensis and Leishmania mexicana infection was diagnosed in 25 persons out of 99 (attack rate 25.2%) and 14 persons out of 80 (attack rate 17.5%) respectively. In 2009 cutaneous leishmaniasis was not acquired. Skin problems were common during and after jungle training. Cutaneous leishmaniasis was important in the first two cohorts but not observed in the third cohort. Factors that could have played a role in the absence of cutaneous leishmaniasis in the third cohort include variability in transmission and availability of better preventive measures and adherence to these. Sodium stibogluconate treatment, intralesional or intravenous, was effective.

Miltefosine treatment of Leishmania major infection: an observational study involving Dutch military personnel returning from northern Afghanistan.

In a retrospective, observational study involving 34 patients with Leishmania major infection, 31 of whom had experienced unsuccessful treatment with intralesional antimony (ilSb(v)), miltefosine proved effective. Thirty patients experienced cure after receipt of miltefosine, 3 after receipt of additional ilSb(v), and 1 after 28 daily intravenous injections of antimony. Temporary diminution of ejaculate volume was reported by 21 patients.

Severe cerebral toxoplasma infection cannot be excluded by a normal CT scan.

A fatal case is reported concerning a severely immunocompromised 50-year-old female renal transplant recipient who developed fever and confusion. Cerebral imaging with contrast-enhanced computed tomography (CT) scans showed no abnormalities while subsequently performed magnetic resonance imaging (MRI ) showed clear abnormalities in the basal ganglia. By that time serology and polymerase chain reaction had confirmed the diagnosis of cerebral toxoplasmosis. Because of the suboptimal sensitivity of these tests negative results should be handled with care. Once cerebral toxoplasmosis is suspected in at-risk patients, treatment should be started empirically pending the confirmation of the diagnosis. A normal cerebral CT scan does not preclude cerebral toxoplasmosis.In these situations MRI can give important additional information.

[Infestation with the tapeworm Diphyllobothrium latum after eating raw fish]. / Infestatie met de lintworm Diphyllobothrium latum na het eten van rauwe vis.

A 31-year-old man with no relevant medical history encountered a white, ribbon-shaped object, 15 cm long and approximately 1 cm wide, in his faeces. It turned out to be Diphyllobothrium latum, a tapeworm that has fish as the intermediate host. The patient had eaten raw fish and shellfish during a holiday in Brazil 5 months before. He recovered after a single dose of praziquantel.

[Dientamoeba fragilis: possibly an important cause of persistent abdominal pain in children]. / Dientamoeba fragilis: een mogelijk belangrijke oorzaak van persisterende buikpijn bij kinderen.

OBJECTIVE: To determine the effect of an antiprotozoic treatment on children with persistent abdominal pain and infection with Dientamoeba fragilis. DESIGN: Retrospective. METHOD: A total of 43 children with D. fragilis infection and persistent gastrointestinal complaints were included in the study. Of these 27 were treated with clioquinol and 16 with a nitroimidazole drug: metronidazole or tinidazole. The parasitological and clinical effects of the treatment were assessed. RESULTS: In 33 of the 43 (77%) children, no parasites were detected during follow-up with a triple faeces test: 22/27 following treatment with clioquinol and 11/16 following treatment with a nitroimidazole drug. In 27 of the 33 (82%) children with a negative follow-up result, gastrointestinal complaints were considerably less or had completely disappeared. In 2 of the 10 (20%) children in which D. fragilis had not disappeared in the follow-up period, the complaints were less or had disappeared. CONCLUSION: Effective treatment of D. fragilis infection in children with longstanding gastrointestinal complaints often resulted in a reduction or disappearance of the complaints.

Usefulness of quantitative nucleic Acid sequence-based amplification for diagnosis of malaria in an academic hospital setting.

The aim of the present study was to evaluate the usefulness of quantitative nucleic acid sequence-based amplification (QT-NASBA) to detect Plasmodium spp. in diagnostic specimens of patients suspected of having malaria in a clinical setting in a non-endemic country. During the 4-month recruitment period, 113 patients were enrolled in the study, of which 93 were diagnosed as non-malaria and 20 as malaria cases on the basis of clinical and microscopic criteria. All microscopically positive cases had QT-NASBA counts of >0.1 parasites/ micro l and there was a significant positive correlation between the parasite counts obtained with both diagnostic methods. Of the 93 microscopically negative cases, six had a positive QT-NASBA result. Three of these cases had a recent history of malaria for which specific treatment was taken. In the other three cases there was no history of malaria and QT-NASBA results in these cases were near the cut-off level (>0.1 parasites/ micro l) of the test. The results demonstrate that QT-NASBA is a useful technology for the diagnosis of malaria in a reference laboratory, and it is very helpful in cases of low parasitemia.

Triple Faeces Test: an effective tool for detection of intestinal parasites in routine clinical practice.

Microscopic examination of stool specimens is the cornerstone of detection of intestinal parasites in parasitology laboratories. In Europe, fresh, nonpreserved stool specimens are generally used for examination. Because intestinal parasites are shed intermittently, patients are asked to deliver multiple stool samples for examination. The limitation of this diagnostic approach is that detection of the vegetative stages of protozoa may be missed because of delays in processing and/or low compliance with the request to submit multiple stool samples. To overcome this limitation, a diagnostic test that combines multiple sampling (on 3 consecutive days), a fixative (SAF; sodium acetate acetic acid formalin), a concentration method and an easy-to-use permanent stain (chlorazol black dye) was developed for use in routine clinical practice. The results of the test, called the "Triple Faeces Test" (TFT), were compared with those of the conventional diagnostic method, i.e. ether sedimentation of a single fresh stool specimen. Stool samples from 544 patients were examined. Vials from the TFT-sets were filled by patients precisely according to instructions in 462 of 544 (85%) of the cases. Using the conventional method and the TFT, 106 and 209 patients, respectively, were diagnosed with infection by one or more parasitic species ( P<0.005). Pathogenic species were detected by the conventional method and by the TFT in 39 and 94 cases, respectively, and nonpathogenic species were detected in 124 and 288 cases, respectively ( P<0.05). Additional costs for the sampling device, laboratory reagents and handling of the TFT were acceptable. The results of this study suggest that the TFT is an effective method for detection of intestinal parasites in stool samples in routine clinical practice.

[Severe diarrhea and eosinophilic colitis attributed to pinworms (Enterobius vermicularis)]. / Hevige diarree en eosinofiele colitis toegeschreven aan aarsmaden (Enterobius vermicularis).

In a 32-year-old woman suffering from severe diarrhoea, eosinophilic infiltration of colonic mucosa and a peripheral eosinophilia, microbiological investigations only revealed large numbers of Enterobius vermicularis (pinworm) in the faeces. Treatment with mebendazole resulted in a rapid resolution of symptoms and disappearance of the eosinophilia, which strongly suggested a causative role of this pinworm in the clinical syndrome of the patient. E. vermicularis is generally regarded as an innocent nematode, which at most causes perianal pruritus due to migration of worms from the colon and expulsion of eggs onto the perianal skin. Although the pinworm maturates and lives in the gut, gastrointestinal symptoms have seldom been reported. E. vermicularis infection should be considered in patients with unexplained eosinophilic enteritis.

[Recurrent, itching and creeping skin lesions in (former) travellers to the tropics: strongyloidiasis]. / Recidiverende, jeukende en zich verplaatsende huidafwijkingen bij (voormalige) tropenreizigers: strongyloidiasis.

Two patients, a woman aged 24 and a man aged 86, had suffered from recurrent, itchy, linear, creeping skin lesions, notably on the thighs, buttocks and lower abdomen, for 9 months and more than 50 years, respectively. The woman had been in South America, and the man had worked on the Burma railway as a prisoner of war during World War II. In both patients 'larva currens' was observed. The clinical diagnosis of 'strongyloidiasis' was supported by eosinophilia and raised antibody titres against Strongyloides stercoralis in the blood. No larvae could be detected in either patient. Treatment with albendazole, and ivermectin, respectively, resulted in disappearance of the complaints. S. stercoralis is found in many parts of the world. In the Netherlands the major risk groups in which strongyloidiasis should be considered are people from, and visitors to, South-America (Surinam) and South-East Asia (Indonesia, former prisoners of war).

[Malaise after a trip to Africa: amoebic liver abscess]. / Malaise na een Afrika-reis: amoebenabces van de lever.

During a flight to Kenya, a 42-year-old man took a therapeutic dose of chloroquine because of fever. He regularly travelled to Africa and always took chloroquine and proguanil for malaria prophylaxis. The fever disappeared but he did not fully recover. He complained of malaise and weight loss. Fourteen years previously he had suffered from amoebic dysentery. One month after the onset of the patient's complaints, an amoebic liver abscess was suspected on the basis of his medical history, an elevated ESR and a slight leukocytosis. The diagnosis was confirmed by ultrasonography and serology.