Schistosoma haematobium infections acquired in Corsica, France, August 2013.

A 12 year-old boy in Germany developed urinary schistosomiasis in January 2014. He had bathed in rivers in south-eastern Corsica five months earlier. Before this case, human schistomiasis had not been reported on the island, although its vector, the snail Bulinus truncatus, locally transmitted the zoonotic Schistosoma bovis. The boy's father excreted S. haematobium ova that were not viable; the boy's three siblings had a positive serology against schistosomes.

[A 55-year-old woman with cough, fever, swelling of joints, and exanthema after a trip to Ecuador]. / 55-jährige Patientin mit Husten, Fieber, Gelenkschwellungen und Exanthem nach einem Urlaub in Ecuador.

A 55-year-old woman presented 18 months after a trip to Ecuador with night sweat, malaise, and an unclear lesion of the lung. Computed tomography of the lung showed a nodular lesion of 14 mm. Antibodies against Histoplasma capsulatum were detected in the complement fixation text (CFT) and IgG western blot. Re-examination of a formalin fixed paraffin embedded (FFPE) lung-biopsy revealed yeasts after silver staining, compatible with H. capsulatum , which was verified by extraction and amplification of DNA from FFPE. After therapy with itraconazole 400 mg/day, the patient showed an uneventful clinical recovery without regression of the lung lesion. The serological follow-up examination after 17 months showed CFT without pathological findings.

Plasmodium knowlesi infection imported to Germany, January 2013.

Plasmodium knowlesi was known as a plasmodium of macaques until P. knowlesi transmission to humans was recognised in Borneo and later throughout South-East Asia. We describe here a case of a P. knowlesi infection imported to Germany from Thailand. The patient had not taken antimalarial chemoprophylaxis and suffered from daily fever attacks. Microscopy revealed trophozoites and gametocytes resembling P. malariae. P. knowlesi malaria was confirmed by PCR.

[Epidemiological and clinical characteristics of patients with echinococcosis - management in an infectiological service in Germany]. / Epidemiologisch-klinische Charakteristika von Patienten mit zystischer Echinokokkose.

BACKGROUND AND OBJECTIVE: Cystic echinococcosis (CE) is a widespread zoonosis. Difficulties in patient care were investigated in order to improve the clinical management of CE patients. METHODS: 65 patients with CE attending our service between 1999 and 2011 were interviewed for their history. Previous diagnostic findings were taken into account. Diagnosis, staging and therapy relied on laboratory and imaging findings. RESULTS: 56 patients were immigrants and nine of German origin. 55 of 59 evaluable patients had been living in rural areas for many years. 34 of 35 patients recalled dog contacts. Symptoms had indicated CE in 21 of 59 (36 %) cases only, whereas CE was mostly detected accidentally. Diagnosis was hampered by false negative serological results (IHA false negative in 11 of 60 cases [18 %], EIA in 8 of 53 [15 %]), the low frequency of eosinophilia (15/61 [25 %]) and of IgE increase (27/57 [47 %]). Percutaneous treatment or surgery was performed in active CE of the liver; disseminated CE was treated non-surgically. Inactive CE cases were monitored without any intervention. Relapses occurred in 7 of 51 (14 %) patients with follow-up: one after surgery, six after conservative treatment. CONCLUSION: The diagnosis of CE is delayed by the paucity of characteristic symptoms and the inconsistency of serologic results. Assessment of cyst morphology and localisation are particularly important for diagnosis, staging and follow-up. CE requires an interdisciplinary management which should be coordinated by specialized infectious diseases centres.

TB or not TB? Difficulties in the diagnosis of tuberculosis in HIV-negative immigrants to Germany.

BACKGROUND: Immigrants to Germany and their children are at particular risk for tuberculosis (TB). - METHODS: 35 Patients (10 male / 25 female aged 2 - 59 years (median 33 years) originating mostly from high incidence countries in Asia (19 (54.3%)) in Africa (14 (40.0%) and East Europe (2 (5.7%)), attended at the Tropical Medicine Unit were analysed. - RESULTS: Primary clinical presentation was most frequently lymphadenitis (13 (37.1%)). Other organs involved included bones (7 (20.0%)), central nervous system (5 (14.3%)), urogenital organs (3 (8.6%)), lung (3 (8.6%)), mediastinum, (2 (5.7%)) and abdomen (2 (5.7%)). ESR was abnormal in 21/28 (75.0%), CRP in 20/35 (57.1%), and protein electrophoresis in 22/26 (84.6%) cases. The tuberculin skin test was strongly positive in all 15 cases where the test had been performed. Tuberculosis interferon gamma release assay (TB-IGRA) was positive in all 35 cases (100%). PCR for nucleic acids of Mycobacterium (M.) tuberculosis complex was positive in only 7/20 (35.0%) cases. M. tuberculosis was identified in 32/35 (91.4%), M. bovis in 2 (5.7%) cases. 1 case was diagnosed clinically. All patients were negative for HIV. Typical histopathology was seen in the 29 cases, where biopsies had been taken. Chest-X-ray did not reveal specific pulmonary lesions in the majority of cases (22/35 (62.9%)). Diagnosis of TB was mostly delayed (4 to 299 weeks, (median 8)). The most frequent primary suspicion was a malignancy (17/35 (48.6%)) while TB was initially suspected in 5 cases only. Diagnosis of TB is impeded by its multifaceted presentation especially in immigrants.

Cholestatic liver diseases from child to adult: the diversity of MDR3 disease.

The phospholipidfloppase MDR3 (gene symbol: ABCB4) is expressed in the canalicular membrane of hepatocytes and mediates the biliary excretion of phosphatidylcholine, which is required for the formation of mixed micelles in bile. Several mutations of ABCB4 have been identified, which cause cholestatic liver diseases of varying severity including progressive familial intrahepatic cholestasis type 3 (PFIC-3), intrahepatic cholestasis of pregnancy (ICP) and the low phospholipid associated cholelithiasis syndrome (LPAC). Here, we report on four new (S1076N; L 23Hfs16X; c.286 + 1G > A; Q 1181E) and one known (S27G) MDR3 mutations in eight patients of three families. The patients presented with a wide spectrum of liver diseases. The clinical presentation and decisive laboratory findings or the association to a trend-setting family history led to the identification of the genetic background in these patients. Even the same mutation may be associated with varying disease progression.

[Cutaneous larva migrans (creeping eruption) acquired in Germany]. / In Deutschland erworbene Larva migrans cutanea.

HISTORY AND FINDINGS: Cutaneous larva migrans (CLM) is a zoonotic hookworm infection. Since survival and mobility of the worm larvae depend on external temperature, CLM is most frequently acquired in subtropical or tropical areas. Two women, aged 39 and 60 years, respectively, presented themselves in the outpatient department with pruriginous skin lesions, first noted several days before. Neither had been abroad, but both had been walking around a dredged lake in North Rhine-Westphalia some days before. The characteristic serpiginous skin lesions were identified as larva migrans cutanea ("creeping eruption"; sandworm). It is caused by the larvae of a zoonotic hookworm infection. TREATMENT AND COURSE: The lesions regressed after a single dose of ivermectin 0.2 mg/kg body weight. CONCLUSION: CLM occurs most frequently in warm regions. It may sometimes also occur autochtchoneusly in Germany, especially in sandy soil, during the summer months. This must be taken into account when patients with pruriginous skin lesions are seen. Therapy with ivermectin is efficacious and safe.

Autochthonous cystic echinococcosis in patients who grew up in Germany.

Human cystic echinococcosis (CE) is a widespread zoonosis. Cases occurring in Germany are considered to result from imported infection and it is unclear if Echinococcus granulosus (sensu lato) is still transmitted in Germany. Therefore, exposure was investigated in 15 patients with cystic echinococcosis (7 female, 8 male; age-range 16-68, with a median of 48 years) who grew up in Germany. Fourteen patients had most likely acquired their infection in rural Germany, 11 from local dogs, one from an imported dog, two without obvious dog contacts. Taking into account multiple conceivable confounding factors might also account for some of infections: contacts with imported dogs or contact with dogs during travel in highly endemic regions, and ingestion of food contaminated by worm ova, whether in Germany or abroad. However, in at least two cases autochthonous transmission is beyond doubt, because these patients had never left Germany. The long pre-symptomatic development of cystic echinococcosis does not allow for a precise evaluation of the actual epidemiological situation. Compulsory notification of human cystic echinococcosis is an important instrument in the surveillance of the disease in humans. Regular inquiries at laboratories carrying out work in the field of veterinary medicine and at slaughterhouses, supervision of dogs at risk as well as genetic investigations on the strain or species of the causal agent of cystic echinococcosis are needed.

[Parenteral combined quinine-artesunate therapy in life-threatening malaria]. / Parenterale Chinin-Artesunat-Kombinationstherapie bei lebensbedrohlicher Malaria.

HISTORY AND CLINICAL FINDINGS: A 31-year old French woman of congolese origin was referred to the intensive care unit of our University Hospital after a visit to the Democratic Republic of Congo in a highly febrile and semi-conscious status. INVESTIGATIONS: Microscopy of stained thin and thick blood films revealed Plasmodium falciparum trophzoites with a high parasitaemia of 50 % and confirmed the clinical suspicion of a life-threatening malaria. TREATMENT AND COURSE: Immediate intravenous quinine with a loading dose of 20 mg/kg body weight was initiated followed by 10 mg/kg every 8 hrs. Since the patient lost consciousness, artesunate was added six hours later in the recommended dose of 2.4 mg/kg immediately, repeated after 12 and 24 hrs, followed by a daily dose of 2.4 mg/kg. Furthermore, clindamycin at a dose of 20 mg/kg body weight / d i. v. was given. Anaemia was corrected by 4 erythrocyte concentrates until a haemoglobina concentration of 9.6 g/dl was reached. Now the patient rapidly recovered, and parasitaemia dropped to 0.1 % within 24 hrs. Already the following day blood films cleared completely from malaria parasites. CONCLUSION: The case illustrates the rapid efficacy of a combined parenteral quinine-artesunate therapy in life-threatening falciparum malaria with an unusually high parasitaemia.

[Infection with Gnathostoma spinigerum as a cause of eosinophilic oesophagitis]. / Infektion mit Gnathostoma spinigerum als Ursache einer eosinophilen Osophagitis.

HISTORY AND ADMISSION FINDINGS: A 63-year-old man, who had travelled extensively in Asia and had lived in South Africa, presented with increasing dysphagia. Physical examination showed no abnormalities. EXAMINATIONS: Upper gastrointestinal endoscopy showed a concentric oesophageal stenosis, 5 cm long, consisting of thickening of the wall without any sign of malignancy or mucocutaneous lesions. The histological examination of this lesion demonstrated infiltrations of eosinophilic cells. Serology was positive for Gnathostoma spinigerum. TREATMENT AND CLINICAL COURSE: After treatment with albendazole 400 mg per day for 3 weeks the clinical, histological and serological symptoms resolved completely. CONCLUSION: In case of any eosinophilia or local infiltrations of eosinophilic cells, parasitic disease have to be considered.