Aetiology of traveller's diarrhoea: evaluation of a multiplex PCR tool to detect different enteropathogens.

Traveller's diarrhoea (TD) is the most common illness reported in international travellers. TD is caused by a wide range of pathogens, including bacteria, viruses and parasites. Multiplex PCR assays can be especially useful for studying the aetiology of TD. The first objective of this study was to evaluate the utility of the commercially available multiplex PCR (xTAG(®) Gastrointestinal Pathogen Panel (GPP)) for the diagnosis of TD. A total of 185 stool specimens obtained from 174 patients were processed using the GPP assay. This test detected 86 pathogens in 67 stool samples (67/185, 36.2%). Sixteen pathogens out of 86 were also detected by routine testing. The remaining pathogens (n = 70) required further confirmation by alternative techniques. Finally, 60 out of 70 pathogens were confirmed. The second objective of this study was to analyse the aetiology of TD based on the results obtained by the GPP test and routine methods. The primary pathogens causing TD were Shigella (24.2%) followed by enterotoxigenic Escherichia coli (ETEC) (23.2%), enteroaggregative E. coli (14.7%) and Giardia (13.7%). Significant regional differences were observed for ETEC with 19.4% of TD cases acquired in Africa, 11.3% in Asia and none in South Central (SC) America (p 0.01), Giardia was found in 1.5% of cases among those who had travelled to Africa, 14.1% of those who had travelled to Asia and 3% of those who had travelled to SC America (p 0.01). In conclusion, the GPP test improved the detection of enteropathogens and allowed better assessment of the aetiology of TD.

A family cluster of giardiasis with variable treatment responses: refractory giardiasis in a family after a trip to India.

Persistence of giardiasis after some of the recommended drugs is occurring with increasing frequency. We describe the follow-up of four members of a family with giardiasis through microscopic observation, immunochromatography and PCRs of tpi and ß-giardin genes. Three patients did not respond to tinidazole but they were cured after quinacrine. However, PCR became negative at 2 months after negativization of stools in two patients and after 1 year in one patient. In all cases Giardia assemblage B was characterized with high homology between all isolates. Further studies are needed to determine the value of PCR in the diagnosis of Giardia infections.

Comparative, clinico-epidemiologic study of Schistosoma mansoni infections in travellers and immigrants in Spain.

The study presented here aimed to contrast the marked clinical differences in the presentation of Schistosoma mansoni-induced infection between immigrants and travellers entering Spain from endemic regions, and to elucidate the therapeutic implications of these infections. A total of 200 African immigrants and 80 travellers with schistosomiasis were included in the study. Among the immigrants, 25 patients were diagnosed with Schistosoma mansoni infection; 15 presented with nonspecific symptoms, and 10 were asymptomatic. Hepatosplenomegaly was observed in nine. Among the travellers, 14 were diagnosed with Schistosoma mansoni infection; four were asymptomatic, four had Katayama syndrome, four had diarrhoea, and two had prostatitis. All of the patients were treated with praziquantel. Patients diagnosed with Katayama syndrome received praziquantel and dexamethasone for 3 days, with the praziquantel treatment being repeated at 3-4 weeks. The significant differences observed in the clinical presentation of Schistosoma mansoni-induced infection, indicate that a well-differentiated therapeutic strategy is required when this infection is diagnosed in a non-immune (traveller) or a semi-immune (immigrant) patient.

[Dating anti-Toxoplasma IgM in pregnancy using VIDAS-ELFA methods]. / Datación de IgM anti-Toxoplasma en el embarazo con métodos VIDAS-ELFA.

BACKGROUND: To study the usefulness of IgG and IgM titration, and avidity of IgG to date IgM anti-Toxoplasma gondii. METHODS: VIDAS Toxo IgG, VIDAS Toxo IgM and VIDAS Toxo IgG Avidity tests were used. 64 sera containing both IgM and IgG T. gondii antibodies were analyzed, 32 from 12 individuals infected 40 weeks previously (group I), and the remainder from 17 individuals with an infection of more than 40 weeks (group II). RESULTS: An IgM index < 1.05 was associated with an infection > 12 weeks. An avidity index > 0.164 excluded 100% infections of < or = 12 weeks. Avidity indexes > 0.26 and 0.45 excluded infections of < or = 20 and < or = 40 weeks, respectively. CONCLUSIONS: The serology methods used in this study can adequately identify residual IgM anti-T. gondii, often avoiding the need of a new blood extraction to analyze IgG kinetics in pregnant women.

[Seroprevalence of toxoplasmosis in women of childbearing age, 1992-1999].

UNLABELLED: To determine the need of prenatal screening for toxoplasmosis in our hospital from a seroepidemiological point of view. PATIENTS AND METHODS: The prevalence of IgG anti-T. gondii was retrospectively analyzed in 7.090 women of childbearing age attended in the Hospital Clínic of Barcelona from February 1992 to April 1999. The association among the seroprevalence and the variables year, age, birthplace (province of Barcelona/other provinces) and place of residence (urban/rural) was analyzed. A decreasing trend was observed in the prevalence (p < 0.001), currently being < 40% in the average women between 15 and 45 years. Infection was also directly related to age of women (p < 0.001) and birthplace out of the province of Barcelona (p = 0.001). Habitat (rural or urban) was not associated with seroprevalence. Prenatal screening for toxoplasmosis is necessary due to the high rate of seronegative women exposed to infection and the evidence of a high number of primoinfections in the childbearing period.

Design of a one-tube hemi-nested PCR for detection of Toxoplasma gondii and comparison of three DNA purification methods.

The aims of the present study were to design an easy and sensitive DNA amplification method for detection of Toxoplasma gondii with low risk of accidental contamination, and to find a rapid method for purification of clinical samples containing potential inhibitors of the amplification reaction. With a pair of primers amplifying a 619-bp fragment of the B1 gene of this parasite it was possible to detect DNA equivalent to 10 parasites. When a third primer was added to the same tube, sensitivity increased to 0.1 parasite. In a comparison of different DNA purification methods, the High Pure PCR Template Preparation Kit (Boehringer Mannheim, Germany) gave the best results. With this purification method and the one-tube hemi-nested PCR, T. gondii DNA was detected in 14 (87.5%) of 16 clinical specimens (amniotic fluid, broncho-alveolar lavage, bone marrow, blood, liver biopsy) in which the parasite was demonstrated by cell culture.

[Analysis of a case of severe congenital toxoplasmosis]. / Análisis de un caso de toxoplasmosis congénita grave.

BACKGROUND: To describe a case of severe congenital toxoplasmosis because of inadequate surveillance of a seronegative pregnant woman and to evaluate the usefulness of different microbiological diagnostic methods after birth. METHODS: We applied serology, DNA amplification by one-tube semi-nested PCR, cell culture and mice inoculation analysis. RESULTS: Anti. T. gondii serology was useful for the diagnosis of congenital toxoplasmosis. PCR analysis of neonate cerebrospinal fluid and peripheral blood were positive, and yielded negative results after a few days of specific treatment. Cellular culture and mice inoculation yielded negative results. CONCLUSIONS: Our results suggest that serology and PCR are useful methods for the diagnosis of toxoplasmosis in newborns. Prenatal toxoplasmosis screening and suitable follow up of the seronegative pregnant women are necessary to prevent cases of severe infection in our area.

[Schistosomiasis imported by Spanish travelers: clinico-epidemiologic study of 80 cases]. / Esquistosomiasis importada por viajeros españoles: estudio clínico epidemiológico de 80 casos.

BACKGROUND: Swimming in rivers or lakes is a risk activity, in areas where the life cycle of schistosomiasis occurs. This report presents and analyzes the clinical presentation and epidemiological data of 80 Spanish travellers. PATIENTS AND METHODS: Descriptive longitudinal and retrospective study that includes clinicoepidemiological and the laboratory data and imaging diagnosis. Patients were seen at the Section of Tropical Medicine, Hospital Clínic i Provincial, Barcelona. RESULTS: Most patients acquired the infection in the Dogon country of Mall. 25% of them presented with symptoms related to the genital tract. In some groups, 45% of travellers that swam, contracted the infection. The most prevalent species diagnosed was S. haematobium and 10 travellers presented with mixed infections. CONCLUSIONS: The trip to the Dogon country should be considered as "a risk activity". Travellers Advice Clinics should include the subject of swimming in infected waters in their routine counselling. Genital tract localizations were registered for three species of schistosome. The classical clinical presentation of schistosomiasis in the endemic areas differs considerably from that seen in travellers.

Pleural and peritoneal leishmaniasis in an AIDS patient.

The case of an AIDS patient who developed pleuritis and peritonitis in the course of relapsing visceral leishmaniasis is reported. Visceral leishmaniasis, considered an opportunistic infection in patients infected with the human immunodeficiency virus (HIV) who live in endemic areas, has a chronic relapsing course. Typical manifestations such as fever, hepatosplenomegaly, lymphadenopathy, weight loss, or pancytopenia are not specific in advanced HIV infection. Atypical clinical presentations are becoming more frequent. This is believed to be the first report of peritoneal involvement by Leishmania in an AIDS patient.

[Chronic enteropathy of unknown etiology in patients with AIDS. An analysis of 40 cases]. / Enteropatía crónica de etiología desconocida en pacientes con SIDA. Análisis de 40 casos.

BACKGROUND: Data about the etiology of chronic enteropathy in AIDS patients are scarce and are very dependent upon the geographical area. The aim of this study was to detect microorganisms potentially associated with chronic enteropathy in AIDS patients with diarrhoea for more than one month, and initial negative routine stool bacterial cultures and examinations for ova and parasites. The degrees of associated intestinal malabsorption and immunodeficiency were also analysed. PATIENTS AND METHODS: Forty consecutive patients were recruited from January 1993 to December 1994. The following studies were performed: Intestinal absorption tests (d-xylose and 14C-triolein), CD4/CD8 cell counts, microbiological studies (standard stool cultures for detection of bacteria and examinations for ova and parasites including the detection of Enterocitozoon bieneusi spores by the Weber's stain), upper gastrointestinal endoscopy or colonoscopy with intestinal biopsies and blood cultures for CMV and mycobacteria. RESULTS: The median duration of diarrhoea was 4 months and the mean weight loss was 8.4 kg. Ninety percent of patients had less than 0.1 x 10(9) CD4+ cells/l, with a mean CD4+ cell count of 0.035 x 10(9)/l. Malabsorption was found in 84% of patients. An etiological diagnosis of chronic enteropathy was reached in 60% of the patients. The yield of pathological examination was 37% and the microbiological test using samples of faeces and blood were positive in 45% and 20% of cases respectively. The most frequently identified microorganisms were CMV (10 cases), E. bieneusi (9), enterobacteria (8), Cryptosporidium parvum (5), Leishmania donovani (2). Patients with enteropathy caused by E. bieneusi had lower count of CD4 cells (p = 0.005) and with higher serum levels of alkaline phosphatase (p = 0.02) than patients with CMV enteropathy. CONCLUSIONS: Stool Weber's stain and CMV and mycobacterial blood cultures should be added to the standard work-up diagnosis in patients with chronic diarrhoea and a CD4+cells count below 0.1 x 10(9) l. Upper and/or lower gastrointestinal endoscopies with intestinal biopsies should be performed only in patients with persistent diarrhea without microbiological diagnosis or a lack of response to treatment.

[Myositis caused by Pleistophora in a patient with AIDS]. / Miositis por Pleistophora en un paciente con sida.

The third case in the literature is reported of an infection produced by Pleistophora. The clinical detail of the three cases are discussed. Two of the patients-including the reported one-were infected by HIV. All patients suffered from myositis with fever, resting and at palpation myalgia, and progressive weakness. Blood tests showed anaemia and high levels of muscle enzymes. Necrotic muscle fibrosis induced disabling contractures. Diagnosis was obtained by detecting the protozoon in a muscle biopsy. The spores may be detectable by means of different staining methods at light microscopy although electron microscopy remains the most reliable technique. Since this is such a rare condition there is no known treatment. Whether the albendazole could be as useful as occurs in patients infected by other genera of microsporidia in still uncertain.

[Pneumocystis carinii pneumonia in the transplant recipient]. / Neumonía por Pneumocystis carinii en el receptor de trasplante.

BACKGROUND: The aim of the present was to study the clinical characteristics and prognostic factors of 20 cases of pneumonia by Pneumocystis carinii (NPC) diagnosed over the last 10 years in renal, renopancreatic, liver and bone marrow transplant recipients. METHODS: The clinical histories of all the patients transplanted in the authors' hospital from 1985 to 1994 who developed NPC were analyzed. Diagnosis was established by visualization of cysts in methenamine silver staining of bronchialveolar lavage (BAL) samples. RESULTS: The global incidence of NPC in our transplant population was 1%. However, the incidence was 3% in the recipients who did not receive prophylaxis. No patient in this series received prophylaxis at the time of diagnosis. Ninety percent of the patients had history or rejection. Pneumonia was observed in 15 (75%) in the first 6 months post transplantation. The mean length of the symptoms prior to diagnosis was 10 days. Ninety-five percent of the patients presented cough, dysnea and fever. Radiology demonstrated diffuse alveolointerstitial infiltrates in 18 patients (90%). Basal arterial PO2 was lower than 60 mmHg in 14 (70%) patients and the alveoloarterial gradient of oxygen was greater than 60 mmHg in 9 (45%). Mechanical ventilation was required in 50% of the patients. BAL demonstrated cytologic alterations compatible with CMV infection in 50% of the cases and in two Aspergillus fumigatus was associated. Mortality was 35%. The only variable significantly associated with bad prognosis was the need for mechanical ventilation (p = 0.003). CONCLUSIONS: The incidence of pneumonia by P. carinii in a population of transplant recipients was 1%. No patient received primary prophylaxis at the time of diagnosis. Most of the episodes were observed during the first 6 months post transplant. Mortality was 35% with the only variable with prognostic significance being the need for mechanical ventilation.

[Taeniasis and primary care]. / Teniasis y atención primaria.

OBJECTIVE: To evaluate the therapeutic guidelines used in evaluating taeniasis in primary care (mebendazole, pyrantel pamoate) and to show the low availability of first choice drugs (niclosamide, praziquantel). DESIGN: A retrospective, descriptive study. SETTING: A clinic for travellers abroad in the Tropical Medicine section (Infectious Diseases Service) of the Hospital Clínic, Barcelona. PARTICIPANTS: 68 medical histories of cases of Taeniasis seen at this clinic between 1984 and 1994. RESULTS: 72.3% had not travelled to the tropics (autochthonous Taeniasis). The most common symptoms were epigastralgia, anal pruritus, diarrhoea, weight loss and bulimia. 71.2% had previously attended other medical services and all had been correctly diagnosed. 91.8% had received ineffective treatment (the most common treatment was with mebendazole and pyrantel pamoate), sometimes on different occasions. Time elapsed between diagnosis and correct treatment varied from 1 day to 36 months. CONCLUSION: Taeniasis is an easily diagnosed infestation. Its treatment is comfortable and effective, with an average cure period of 24 hours. However, the particular medicines are not available in primary care, which hampers and delays treatment.