[Loa loa infection of the eye -- a case series]. / Loa-Loa-Infektion des Auges -- eine Fallserie.

BACKGROUND: With increasing migration tropical diseases such as Loa loa infections are becoming more frequent in Europe. While the ocular diagnosis is usually straight forward, systemic work-up and treatment requires an interdisciplinary approach. We review the diagnostic and therapeutic work-up of ocular Loa loa infections based on a series of 4 cases that presented between 1998 and 2004. HISTORY AND SIGNS: The first symptoms in all cases were ocular irritations occurring 2 months to 8 years after a trip to West Africa. One case presented with a swollen upper eyelid without a visible worm. In three patients microfilariae were detected in the blood. THERAPY AND OUTCOME: In two cases visible subconjunctival worms could be removed under the slit lamp. Three cases required systemic treatment as inpatients while one case could be observed without systemic treatment. All 4 cases had a favourable outcome with complete eradication of the disease. CONCLUSION: Surgical removal of adult Loa loa worms from the subconjunctival space only improves the ocular symptoms. An interdisciplinary approach (ophthalmology, infectious disease and parasitology) for a systemic work-up and treatment is usually required.

[Eosinophilia in a family from Bosnia]. / Eosinophilie bei einer Familie aus Bosnien.

We describe reference to a family from Bosnia that the diagnosis of Trichinellosis can be difficult despite notice of travel-history and eosinophilia but lack of further epidemiological datas and due to the rarity of this zoonosis. Clinical pattern of trichinellosis are fever, headache, myalgia, periorbital oedema, less frequently diarrhea and abdominal pain. Dreaded complications are myocarditis and encephalitis. High eosinophilia and increased creatine phosphocinase activity are the most frequently observed laboratory features. The detection of specific circulating antibodies or the parasitological examination of a muscle biopsy will confirm the diagnosis. The medical treatment includes albendazol and steroid.

[First aid kit for travelers]. / Reiseapotheke.

The first aid kit for travellers is essentially thought to permit symptomatic self-treatment of common and mostly trivial health problems abroad. If professional medical assistance is likely not to be accessible a few additional items--e.g. an antibiotic--must be considered. The indications and proper handling of any medication which requires a physician's prescription have to be carefully explained to its potential user. The decision as to recommend drugs other than those in the basic first aid kit must take into account not only the risk of particular diseases but also the ability of the traveller to applicate a drug in the correct way for defined indications.

[Malaria--chemoprophylaxis 2001]. / Malaria-Chemoprophylaxe 2001.

An estimated 20,000 to 30,000 cases of imported malaria are annually diagnosed in industrialised countries. Some 700 of them concern Swiss travellers and foreign guests. Exposure prophylaxis and chemoprophylaxis for high risk destinations lower the risk of malarial disease. The latter is defined as regular intake of antimalarial drugs in subtherapeutic dosage in order to suppress the development of clinical disease. Drugs are usually taken from one week before travel until four weeks after return from an endemic area. Mefloquine, doxycycline, chloroquine plus proguanil, and presumably soon also atovaquone plus proguanil are available in Switzerland for chemoprophylaxis.

[Travelers' diarrhea]. / Reisedurchfall.

Diarrhea is the most common health problem of travelers to tropical destinations, affecting up to over 50%, with however considerable regional and seasonal variation. Orally acquired bacterial pathogens, particularly enterotoxigenic Escherichia coli, are the most frequent etiology of travelers' diarrhea occurring during the first three weeks of travel. Protozoal infections, e.g. giardia and Entamoeba histolytica, are more often the cause of diarrhea and prolonged problems of intestinal motility of the returning traveler--as are postinfectious irritable bowel syndromes. Prevention seems theoretically simple by avoiding any potentially contaminated food and drinks, but the principle of 'cook it, boil it, peel it, or avoid it is obviously a goal difficult to achieve. Several antibiotics have shown to be able to prevent diarrhea for a short period of time, but the potential of adverse effects and selection of resistant pathogens calls for a restrictive use for short trips of particularly vulnerable subjects only. The use of probiotics--e.g. Saccharomyces boulardi, Streptococcus faecium--gave conflicting results--both in prevention and treatment. The basics of treatment is appropriate fluid replacement--mostly by the oral route. Although this measure can safely bridge the time until spontaneous remission, it fails to reduce the duration of illness. Appropriate antibiotics are fairly effective to reduce the duration of travelers' diarrhea, especially if combined with loperamid. The administration of the later is contraindicated in small children. The most commonly used and well documented antibiotics belong to the fluoroquinolones. Alternatives for pediatric use are azithromycin and cotrimoxazole. Considering the mostly short duration of travelers' diarrhea the administration of antibiotics can be limited to cases of acute febrile dysentery and violent diarrhea when rapid relief is essential. In cases of febrile diarrhea malaria must be considered if the patient has been exposed to the risk of transmission.

[1998 malaria therapy]. / Malaria-Therapie 1998.

A review of the principal antimalarial drugs is presented as the basis for specific recommendations on the treatment of malaria. These are adapted to conditions in Switzerland. Considering that the majority of Plasmodium falciparum infections imported into this country are acquired in areas with a high prevalence of chloroquine resistance, mefloquine is generally considered the first-line drug for the treatment of uncomplicated falciparum malaria. For severe tropical malaria, or if parasitaemia exceeds 2%, quinine remains the drug of choice. The pharmacological decision must estimate the risk of drug-resistant malaria and consider the clinical condition, possible intolerance and drug interactions. Prognosis is always difficult in falciparum malaria; hence hospitalization is always strongly recommended if the course is in doubt and if close monitoring of the patient is not otherwise guaranteed. In hospital, ancillary treatment (e.g. exchange transfusion) must receive timely consideration. Special considerations must be borne in mind with regard to the treatment of malaria in children and during pregnancy.

[Return from the tropics: relevant diagnosis and rational therapy]. / Tropenrückkehrer: Relevante Diagnostik und rationale Therapie.

Gastrointestinal disorders, particularly diarrhoea, are the main reason to consult a physician after travelling to the tropics. Although mostly of infectious origin specific pathogens frequently cannot be demonstrated. As the majority of acute diarrhoeal episodes resolve without any specific therapy, bacterological and parasitological investigations should initially be ordered with reserve and economically. Fever after a stay in the tropics has to be always a matter of concern as it could be the expression of a potentially dangerous infection, e.g. falciparum malaria. The primary objective must be the exclusion of potentially life-threatening infections requiring a specific treatment. Numerous asymptomatic travellers returning from the tropics want their physicians to exclude an inapparent exotic infection. The value of such check-ups can be questioned, and there are just a few rational investigations in this particular context.

[Intensive care aspects in severe tropical malaria: clinical aspects, therapy and prognostic factors]. / Intensivmedizinische Aspekte bei schwerer Malaria tropica: Klinik, Therapie und prognostische Faktoren.

In a retrospective study we analyzed the clinical and blood chemical data of 12 patients with severe tropical malaria in the intensive care units of the University Hospital Zurich and the Stadtspital Triemli, Zurich, between 1991 and 1994. None of the 12 patients had been exposed to malaria before or had taken drugs for chemoprophylaxis. 7 patients survived, 5 died from complications of malaria. According to the criteria of severe tropical malaria defined by the WHO, the following pathological clinical and blood chemical parameters were noted on admission: cerebral coma (2/12); blood hemoglobin < 5 g/dl (0/12), < 8 g/dl (2/12); serum creatinine > 265 mumol/l (3/12); blood glucose < 2.2 mmol/l (0.12); circulatory collapse/shock (0/12); bleeding/signs of disseminated intravascular coagulation in laboratory tests (4/12); acidosis with pH < 7.25 (1/12). Further signs of severe tropical malaria were: hyperparasitemia > 5% (9/12); qualitative and quantitative disturbances of consciousness (6/12); thrombocytopenia < 30 x 10(9)/l (9/12); hyponatremia 125-135 mmol/l (9/12), < 125 mmol/l (2/12); rhabdomyolysis with creatine kinase > 1000 U/l (4/12). The basic treatment consisted of parenteral quinine hydrochloride in all patients; doxycycline was added in 8 cases, clindamycin in 3. Adjuvant therapy with desferrioxamin was given in 3 cases. 6 patients had exchange transfusions. Parasitemia cleared in all patients within 5 to 6 days. Later in the course, 5 patients developed acute respiratory distress syndrome, 6 required hemofiltration due to oliguria, and one became comatose.(ABSTRACT TRUNCATED AT 250 WORDS)

[The traveler returning from the tropics in clinical practice]. / Der Tropenrückkehrer in der Praxis.

Travellers returning from the tropics frequently consult a physician even if they have no actual symptoms. Physical check-ups in asymptomatic returnees rarely detect dangerous conditions. The most common laboratory finding is intestinal parasites. Blood eosinophilia may indicate helminthic infections, such as strongyloidosis, filariasis, schistosomiasis and others. If there are no diagnostically suggestive symptoms a systematic, step-by-step workup is recommended (stool parasitology, serology, and special methods to demonstrate parasites in blood or tissues). The most common symptom of returnees from the tropics is diarrhea, or other disorders of intestinal motility. Appropriate investigations include parasitological and bacteriological tests, and--if the course is more chronic--endoscopy. If diarrhea is associated with fever, systemic infections (e.g. falciparum malaria) must be considered. Fever as a leading sign may mask a number of potentially dangerous infections. If there are no other obvious signs or symptoms indicating a particular etiology, the diagnostic approach should consider first of all those systemic infections, which are potentially life-threatening and can be cured by specific therapy, i.e. bacterial meningitis, falciparum malaria, septicemia (including typhoid fever), extraintestinal amebiasis, and African trypanosomiasis.

[Prevention for travel to the tropics]. / Prophylaxe für Tropenreisen.

The Swiss Working Group for Health Advice to Travellers regularly publishes its recommendations for malaria prophylaxis and vaccination as supplement to the 'Bulletin' of the Federal Office of Public Health. In this review the strategy with respect to information, to clever behavior abroad, to chemoprophylaxis and immunization prophylaxis is analyzed. A critical evaluation of emergency self-therapy describes remaining questions in particular.

[Suspected adult-onset Still's disease: unexpected manifestation of leprosy]. / Vermeintlicher Morbus Still des Erwachsenen: unerwartete Manifestation einer Lepra.

A 23-year old male from Sri Lanka was admitted to hospital with symmetrical inflammatory peripheral polyarthritis, fever of 39 degrees C and poly-lymphadenopathy. At first we suspected adult onset Still's disease. The histological findings from axillary lymph node biopsy strongly suggested the diagnosis of leprosy, for which we had had little evidence thus far. Typical skin lesions were absent, skin smears were negative and neurological symptoms only became obvious much later when fever and arthritis had subsided under anti-inflammatory treatment. At this time a right ulnar palsy developed, with atrophy of the interosseous muscles and thickening of the ulnar nerves at both medial epicondyles. Fite-stains of a sural nerve biopsy confirmed the diagnosis when mycobacteria were detected. Leprosy displays a clinico-pathological spectrum caused by variations in host resistance. A widely accepted classification is the five group system of Ridley and Jopling. At one extreme of this spectrum are patients with lepromatous or low resistance leprosy with numerous bacilli, and at the other those with high resistance or tuberculous leprosy where few or no bacilli are found. The numerous bacilli in the sural nerve biopsy classified the disease as lepromatous in our case. Of the various manifestations of the lepra reaction occurring in lepromatous leprosy, one is acute arthritis, but a more common one is erythema nodosum leprosum. Our patient's clinical presentation was interpreted to be a rheumatic manifestation of a type-2 reaction. This form of immunological response in leprosy is an immune complex syndrome and may mimic different rheumatic diseases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Halofantrine in the treatment of imported malaria in nonimmune travelers]. / Halofantrin zur Behandlung der importierten Malaria bei nicht-immunen Reisenden.

The efficacy (criteria: cure rate, time to resolution of fever or absence of parasites) and safety (criteria: clinical side effects, altered laboratory parameters) of halofantrin were investigated in a multi-centre study of 96 non-immune patients (71 men, 25 women, mean age 34.3 [21-62] years) with malaria imported from regions of high resistance into Germany or Switzerland. The initial 63 patients received one-day treatment (three doses of 500 mg halofantrin), while the last 33 patients received an additional course of treatment one week later. Treatment was curative in all patients in the second group, but relapses occurred in five of the 41 patients (12.2%) with falciparum malaria who received one-day therapy. Fever resolved after a mean of 45 hours and parasites were absent after a mean of 66 hours. There were small increases in transaminase values (most probably because of the infection) in five patients, but all became normal again within a few days. Halofantrin is a safe drug and is suitable for both therapy and stand-by therapy of resistant Plasmodium infections. Treatment should be repeated after 7 days.

[Possibilities and limitations of malaria therapy in general practice]. / Möglichkeiten und Grenzen der Malariatherapie in der Praxis.

Malaria infections by Plasmodium (P.) vivax. P. ovale or P. malariae follow mostly a benign course, and ambulatory treatment is safe, provided there is no other significant morbidity. Ambulatory treatment for falciparum malaria must be considered only if a number of conditions are met, making potential complications most unlikely. Furthermore, it is imperative that the patient can be reliably supervised at home. Taking into account the increase of P. falciparum strains resistant to chloroquine, cases meeting the criteria for ambulatory care can mostly be treated with mefloquine, pyrimethamine/sulfadoxine or pyrimethamine/sulfadoxine/mefloquine. Chloroquine remains the first choice for treatment of malaria due to P. vivax, P. ovale or P. malariae.

[Vaccinations for travel abroad]. / Impfungen für Auslandreisen.

Travel to the developing world by Swiss citizens has been increasing. Vaccine-preventable diseases challenges the physician to provide pre-travel advice. Each traveler's itinerary, duration of stay and medical history, including previous immunization, should be reviewed. Vaccinations are required or recommended according to the requirements and the epidemiology of countries being visited. This article summarizes updated recommendations to individual vaccines and immunoglobulins.

[Visceral leishmaniasis as an opportunistic infection. Case report and literature review]. / Die viszerale Leishmaniose als opportunistische Infektion. Kasuistik und Literaturübersicht.

With increasing numbers of immunocompromised patients a rise in the incidence of visceral leishmaniasis has to be expected. Presenting a case of visceral leishmaniasis in an HIV-infected patient and reviewing the literature, we discuss general aspects of this parasitic disease and special features of it as an opportunistic infection.

[Fasciola hepatica infection. Successful therapy using triclabendazole]. / Infektion mit Fasciola hepatica. Erfolgreiche Therapie mit Triclabendazol.

We report a case of human fascioliasis treated successfully with a single dose of triclabendazole, a benzimidazole compound. The most obvious effect was the rapid cessation of faecal egg excretion, which had been refractory to two previous treatment courses of albendazole. Cure seems to be confirmed by the absence of Fasciola eggs in repeated stool examinations after six months, achievement of clinical wellbeing, and normalization of laboratory tests. The only side effect of the treatment was a brief episode of fever and right upper abdominal pain occurring four days after administration of triclabendazole. The syndrome was probably due to disintegrating dead parasites; further observations are needed to explain the pathogenesis of this episode.