Outbreak of tungiasis following a trip to Ethiopia.

Tungiasis is a skin disease caused by the ectoparasite sand flea Tunga penetrans. Although tungiasis is an important health problem in endemic areas, mainly South America and sub-Saharan Africa, it is reported uncommonly in travelers. We describe an outbreak of tungiasis in a group of travelers to Ethiopia. Following the diagnosis of tungiasis in a member of a group of 17 Israeli travelers to Ethiopia, other affected members were identified by photograph assisted self diagnosis. The characteristics, including relevant demographic and epidemiologic data were recorded using a telephone interview and computerized questionnaire, and analyzed subsequently. The attack rate of tungiasis in the travel group was 53% (9 patients). Most of the patients (89%) wore open sandals during prolonged periods of their journey, but the pattern of shoeware use was similar in unaffected group members. An insect bite was not felt by any patient. The median number of skin lesions was one, and most lesions were located on the foot (7 of 9 travelers), but the hands were also affected in 2 travelers. All skin lesions healed without a need for a major intervention and without major sequela within 5 weeks of their appearance. Tungiasis may be underdiagnosed in travelers. Medical personnel should include tungiasis in pre-travel recommendations, and post-travel assessment.

A retrospective six-year national survey of P. multocida infections in Israel.

Pasteurella multocida is the commonest organism infecting pet bites. Anecdotal reports tend to overemphasize dramatic outcomes. We aimed to study a large database of P. multocida infections. This retrospective survey of P. multocida infections in Israeli hospitals refers to the y 2000-2005. Clinical microbiologists were contacted by email and asked to perform a back-search of their hospital's records for isolates of P. multocida. The charts of patients growing P. multocida were abstracted into a structured questionnaire. 77 cases were identified in 12 hospitals, yielding an annual incidence of 0.19/100,000. The mean age was 49.2+/-26.5 y and the mortality rate was 2.6%. Those who died were >65 y of age, had diabetes mellitus or cirrhosis and were bacteraemic. One-third of the cases occurred in people aged > or =65 y. Cats caused most of these infections (54%). Surgery for debridement was common (53.7%), but no-one required amputation; a second- and third-look operation was necessary for these patients. Bacteraemia was found in 32.5% of patients and was significantly more common among those aged >60 y (p =0.044). Hospitalized patients with P. multocida have a favourable prognosis, apart from elderly and bacteraemic patients with comorbidities. Surgery and reoperations may be required in about half of the patients.

Enterococcal-associated lower respiratory tract infections: a case report and literature review.

We report a rare case of bacteremic enterococcal pneumonia in an 81-year-old man, with an indolent disease course. We reviewed the literature concerning lower respiratory tract infections associated with enterococci for the burden, the pathogenesis and the clinical characteristics of these unusual infections.

The added value of peripheral blood cell morphology in the diagnosis and management of infectious diseases--part 1: basic concepts.

As automated blood cell analysers and sophisticated diagnostic technologies become widespread, requests for peripheral blood smear (PBS) examination--for the diagnosis of infectious diseases--diminish. Yet, PBS examination can provide rapid and invaluable information on infection--host susceptibility, aetiology, severity, and systemic impact. Besides direct visualisation of certain microorganisms (for example, Plasmodium, Ehrlichia), PBS examination may detect characteristic footprints left by various infections on the morphology of blood cells, thus yielding the cytologic clues of the disease (for example, Döhle bodies, haemophagocytosis). Additionally, PBS examination may disclose certain infection predisposing conditions (for example, May-Hegglin anomaly, hyposplenism), and several infection related haematological and systemic complications. Combined with a careful medical history and physical examination data, all this information may yield a speedy diagnosis, a rationalised diagnostic work-up, and timely initiation of treatment. The intention of the following review is to highlight the value of PBS, and recommend that PBS examination should be fostered in the diagnostic work-up of infectious diseases.

The added value of peripheral blood cell morphology in the diagnosis and management of infectious diseases--part 2: illustrative cases.

The previous review dealt with the diagnostic yield of peripheral blood smear examination with regard to diagnosis of infectious diseases. In addition to the clinical data, it can provide information of major clinical significance. At times, it can even replace additional, costly and time-consuming diagnostic modalities. The following clinical vignettes, which are discussed briefly, support these arguments.

Formal adult infectious disease outpatient consultations: a retrospective 6-year survey.

BACKGROUND: The field of outpatient infectious disease (ID) consultations is expanding. Surprisingly, limited data are available regarding the scope of formal, adult, outpatient ID consultations. METHODS: The computerized records of all adult outpatient ID consultations conducted by a single ID expert over the years 2001-2007 were retrospectively analyzed. Demographic, clinical and management characteristics were studied. RESULTS: We identified 619 eligible cases, mostly women (61.4%). The mean age (+/- SD) was 39 +/- 15.5 years, and each patient had 1.3 +/- 0.7 visits on average. In 12% of the cases, symptoms have been fluctuating for > or = 1 year. Most of the cases (54.3%) have been referred for the purpose of management rather than diagnostics. Largest areas leading to ID consultation were post-travel medical conditions (15.5%) and pregnancy-related infections (11%); specific leading categories were viral infections (17.3%), skin and soft tissue syndromes (15.2%) and gastrointestinal syndromes (7.6%). Recurrent, well-characterized infections plus ill-defined syndromes constituted a substantial part of all referrals. Newly discovered findings were elicited in the medical history and physical examination in 3.7% and 2.7% of cases, respectively. CONCLUSIONS: Formal outpatient ID consultations have unique aspects, which differ from "traditional" inpatient consultations. The field offers exciting medical research possibilities and new themes for healthcare executives.

Hand infections following penetrating fish fins or bones injuries (FFBI): a large, hospital based, retrospective study.

BACKGROUND: The incidence of hand infections caused by penetrating fish fins or bones injuries (FFBI) is likely to increase following worldwide constant growth of fishery production and consumption. Because data on these infections are scarce, the purposes of this study were to describe their clinical characteristics and disease course, and to analyze risk factors for a complicated disease course. METHODS: We studied retrospectively all cases of hospitalized patients with hand infections following FFBI over the years 1999-2006 in a single medical center. Demographic data, underlying diseases, clinical characteristics and disease course were analyzed for each case. Univariate and multivariate analysis were used for analyzing risk factors for a complicated hospitalization course. RESULTS: There were 122 separate episodes of hand infections following FFBI among 116 patients, with a mean age (+/- SD) of 52 +/- 19.7. The majority of cases were women (51.6%), and they arrived significantly later to the hospital after injury. Predisposing conditions (diabetes mellitus, liver disease, rheumatologic disorder, malignancy or chronic steroid treatment) were present in 25% of cases. Most of the cases presented with cellulitis. Cultures of either blood or wound were obtained in approximately 1/3 of cases, and 40% of them yielded an isolate. Ceftazidime and doxycycline were administered to 68.8% and 96.7% of cases, respectively. Surgical debridement was performed in 34.4% of cases, but there was no case of death or limb amputation. The presence of fever (p = 0.0005) and a predisposing condition (p = 0.035) were independently correlated with a complicated hospitalization course. CONCLUSIONS: The overall prognosis in this largest cohort of hand infections following FFBI was favorable, but immune dysfunction carried a complicated course.

Flight-associated headaches-prevalence and characteristics.

Environmental factors in airplanes may precipitate headaches. We conducted a questionnaire-based study among consecutive travellers to determine the rate, severity and duration of flight-associated headaches (FAHA). Of the 906 eligible travellers (mean age 33.3 +/- 13.8 years), 22.3% reported headaches at least once per month. FAHA occurred in 52 travellers (5.7%), of whom 34 were women (P = 0.0023 vs. none FAHA). The duration of pain was 4.0 +/- 10.2 h after takeoff and continued for 5.7 +/- 14.2 h after landing. Migraine was diagnosed in 19.2% of those with FAHA. The magnitude of headache was 6 +/- 2 (on a scale of 1-10). Among those who suffer from FAHA, 45.4% reported that their pain was unilateral, in contrast to 72.7% among those with 'non-flight' headaches (P = 0.019). Nine travellers had headaches when descending to -400 m below sea level, and nine upon climbing to high altitude. This preliminary observation indicates that FAHA is not uncommon and should be further investigated.

Fluoroquinolones in community-acquired pneumonia when tuberculosis is around: an instructive case.

Fluoroquinolones are increasingly used for the treatment of community-acquired pneumonia. However, their use has been associated with a delay in the diagnosis and treatment of pulmonary tuberculosis. We describe the clinical and insightful bacteriological course of a 39-year-old patient with pulmonary tuberculosis who had presented as having community-acquired pneumonia and was treated empirically with levofloxacin. The case highlights a major problem associated with the indiscriminate use of fluoroquinolones.

Psychiatric problems in returning travelers: features and associations.

BACKGROUND: Travelers may return from the tropics with psychological problems. The literature regarding features and associations of these psychological problems is limited. METHODS: Case histories of 15 consecutive returning travelers seen at our psychiatric service during the last 8 years. RESULTS: The median age of this group was 25 years, 10 were males, and the length of trip ranged from 10 days to 8.5 months. None of these travelers had prior psychopathology. The most common presentation was anxiety (with or without depression, n = 11), 3 suffered from acute psychosis, and 1 had pure depression. Eight of the travelers have used illicit drugs, which in 5 cases probably served as a trigger. Antimalarials may have played a role in 3 travelers. Six travelers needed antidepressants and supportive therapy, 3 neuroleptics, and 1 psychotherapy. These treatments lasted for 6 months and over in 6 of the travelers. CONCLUSION: Psychiatric problems among travelers to the tropics are multifarious in nature, multifactorial, have a strong relation to drug abuse, and may require a long and intensive therapy. Travelers should be better educated about the risks of using illicit drugs.

Serious adverse events of mefloquine in relation to blood level and gender.

Mefloquine is widely used for prophylaxis in areas with chloroquine-resistant falciparum malaria. As the use of mefloquine has increased, so have the reports on its adverse effects. We sought to evaluate the possible association between serum levels of mefloquine and serious side effects caused by this drug by means of a case-control design study. The study population included 17 patients who presented to emergency rooms or travel clinics with symptoms suggesting serious adverse effects of mefloquine and 28 controls (healthy people, still taking mefloquine after travel). The mean age of the patients and the controls was 31.5 +/- 11.6 years and 34 +/- 12.2 years, respectively. The percentage of women among the patients was higher than in the control population (76% versus 40%, respectively; P = 0.03). Most of the complaints were related to the central nervous system (13 of 17); 5 patients interrupted their trip and 2 others were hospitalized. No difference in the level of mefloquine in the blood was found between the patients and the control groups. Also, no significant difference was found between mefloquine levels in the blood of men and women. These results suggest that blood levels of mefloquine do not correlate with its severe adverse events. Women tended to be more susceptible than men, despite having similar blood levels of the drug.

Candida sepsis following transcervical chorionic villi sampling.

BACKGROUND: The use of invasive devices and broad spectrum antibiotics has increased the rate of candidal superinfections. Candida sepsis associated with pregnancy is rare. Candida sepsis following chorionic villi sampling (CVS) has never been reported. CASE: A 31 -year-old pregnant woman presented with signs of sepsis one day after undergoing transcervical CVS. Blood culture and curettage material yielded C. albicans. She was treated with 400 mg of fluconazole daily for 4 weeks and completely recovered. CONCLUSION: Candida sepsis should be considered in the differential diagnosis of sepsis following CVS.

Inadequate protection against yellow fever of children visiting endemic areas.

The guidelines of the World Health Organization call for immunization against yellow fever at least 10 days before travel to endemic areas. The goal of this study was to determine whether these guidelines have been applied in 2 travel clinic settings in teaching hospitals in Israel and the United Kingdom specifically for children traveling to endemic areas. Two groups of children aged 9 months to 15 years (n = 98), who were planning to travel to yellow fever-endemic areas, were evaluated regarding characteristics related to the administration of yellow fever vaccine before travel. Overall, 19 children in both clinics (19.4%; 95% confidence interval, 12.1-28.6) had received their yellow fever vaccination < 10 days before departure (no interclinic difference). Eleven of these children received the vaccine < 7 days before departure. We found that the World Health Organization guidelines for yellow fever vaccination are frequently not followed. An initiative to explain to the public the importance of vaccination well before travel to endemic areas should be undertaken.

Changing epidemiology of dengue fever in travelers to Thailand.

A study was conducted to evaluate the incidence and seasonal pattern of dengue fever occurring among Israeli travelers to Southeast Asia. The illness was diagnosed by Israeli physicians stationed abroad and by serological methods carried out in Israel. Between 1994 and 1998 dengue fever was confirmed in 103 travelers, 80 of whom were diagnosed in Israel. A sharp increase in the incidence was noted in 1998 as compared with the previous 4 years. The attack rate during 1998 in a defined group of travelers was 3.4/1,000 and reached a peak of 5/1,000 during the dry season of 1998.

Lack of hepatitis E infection among backpackers to tropical countries.

Hepatitis E virus (HEV) is a feco-orally transmitted virus that occurs primarily among the indigenous populations of the Indian subcontinent, Central America and Africa. Most recognized cases of HEV occur after contamination of water supplies such as after monsoon flooding.1,2 In contrast with hepatitis A infection, secondary person-to-person spread is rare. Most cases of HEV are reported in epidemics, but sporadic cases also occur. Backpackers traveling from developed to developing countries are potentially at increased risk for acquisition of feco-orally transmitted organisms. The risk of acquisition of HEV among backpackers is unclear. We aimed at studying prospectively the rate of HEV in a group of backpackers and its association with lifestyle.

Ehrlichiosis associated vasculitis.

OBJECTIVE: To test the hypothesis that some cases of primary vasculitis are caused by ehrlichiosis. DESIGN: A retrospective case study and serological analysis of stored sera. SETTING: University hospital. SUBJECTS: Fifty-five patients discharged with any type of vasculitis over a 6-year period. MAIN OUTCOME MEASURES: Serology for human monocytic ehrlichiosis, and the human granulocytic ehrlichiosis agent, and polymerase chain reaction (PCR) analysis of biopsy specimens. RESULTS: Three patients (5.5%) had titres of 1 : 128 or higher against E. chaffeensis; none was positive for the human granulocytic ehrlichiosis agent. Skin biopsies of these patients showed lesions compatible with polyarteritis nodosa, allergic purpura and unspecified vasculitis. PCR analysis of the biopsies was unrevealing. CONCLUSIONS: Infection with human monocytic ehrlichiosis may underlie some forms of vasculitis. If confirmed, these findings may help identify patients with vasculitis who would benefit from antibiotic treatment.

Controlled trial of the effect of cinnamon extract on Helicobacter pylori.

BACKGROUND: Helicobacter pylori has been associated with the pathogenesis of antral gastritis, duodenal ulcer, and gastric lymphoma. Eradication of H. pylori has been shown to reverse or prevent relapse of these diseases. Antimicrobials employed in the eradication of H. pylori are not without adverse effects. Newer treatment modalities, therefore, are required. In vitro studies have shown the effectiveness of cinnamon extract against H. pylori and its urease. In this pilot study, we tested the activity of an alcoholic extract of cinnamon in a group of patients infected with H. pylori. MATERIALS AND METHODS: Fifteen patients (11 women, 4 men) aged 16 to 79 years were given 40 mg of an alcoholic cinnamon extract twice daily for 4 weeks; eight patients aged 35 to 79 (7 women, 1 man) received placebo. The amount of H. pylori colonization was measured by the 13C urea breath test before and after therapy. RESULTS: The mean urea breath test counts in the study and control groups before and after therapy were 22.1 and 23.9 versus 24.4 and 25.9, respectively. The cinnamon extract was well tolerated, and side effects were minimal. CONCLUSIONS: We concluded that cinnamon extract, at a concentration of 80 mg /day as a single agent, is ineffective in eradicating H. pylori. Combination of cinnamon with other antimicrobials, or cinnamon extract at a higher concentration, however, may prove useful.

Pyomyositis of the thigh due to Prevotella melaninogenica.

Pyomyositis is an uncommon infection in temperate climates, however, it is being more frequently reported among patients with diabetes or malignancy, or those who are immunocompromised. It is predominantly caused by Staphylococcus aureus, and rarely by Bacteroides species. Pyomyositis due to Prevotella melaninogenica has not previously been reported. We describe an elderly patient with pyomyositis of the thigh due to P. melaninogenica which was successfully treated by surgical incision and drainage in combination with metronidazole therapy.

Neuropsychiatric problems in 2,500 long-term young travelers to the tropics.

BACKGROUND: The prevalence and features of travel associated neuropsychiatric problems (NPP) and their relation to previous psychological consultations, antimalarials and recreational drug use have not been adequately studied. METHODS: A two-phase postal and telephone survey has been conducted among 2,500 young travelers to tropical countries. We measured the rate and duration of NPP, characterized their features, and their association with previous psychological profiles, itinerary, type of travel, consumption of recreational drugs, and malaria prophylaxis. RESULTS: First phase: Out of 1,340 respondents, 151 (11.3%) indicated that they had NPP during travel, in contrast with 2.3% who needed psychological consultation before travel (p<.001). Second phase: 117 of 151 responded to the study questionnaire. The mean age of the respondents was 24.4 years, 54.7% were female, and the mean stay abroad was 5.3 months. The most common NPP were sleeping disturbances (52.1%), fatigue (48.7%) and dizziness (39.3%). Thirty-three travelers (2.5%) had severe symptoms, and 16 (1.2%) had symptoms lasting more than 2 months. Seven travelers had pure or mixed depressive symptoms. Consumption of recreational drugs was admitted by 22.2%. Mefloquine was used significantly more often by those who suffered NPP, than by the entire cohort (98.2% vs. 70.7%; p<.001). CONCLUSIONS: Long-term travel to the tropics was associated, in this cohort, with a considerable rate of neuropsychiatric symptoms. The majority of the responding travelers were females, used mefloquine as prophylaxis, and at least one fifth used recreational drugs.