Systemic anaplastic large cell lymphoma presenting with cutaneous manifestations in a young man: a case report.

Skin lesions can be a sign of internal disease. When they are associated with persisting systemic signs, the possibility of an internal malignancy should always be considered. We describe a 25-year-old man who presented with weight loss, fatigue, subpyrexia, xerostomia and skin rash of 6 months duration. Physical examination showed a dry red skin, most prominent in the face, the palms of the hands and the soles of the feet. Laboratory investigations revealed signs of inflammation and a high level of antinuclear antibodies. Retroperitoneal lymph nodes were visualized on a CT scan of the abdomen. CT-guided biopsy of an abdominal lymph node revealed the presence of an anaplastic large cell lymphoma (ALCL), ALK-positive. A biopsy of the skin showed non-specific signs of inflammation.The patient underwent 8 cycles of chemotherapy according to the CHOP protocol. A complete remission was obtained. Non-Hodgkin lymphoma can indeed be associated with skin lesions. They result from direct invasion by malignant cells or are of paraneoplastic origin, as was the case in this patient.

The clinical spectrum of Exophiala jeanselmei, with a case report and in vitro antifungal susceptibility of the species.

Exophiala jeanselmei is clinically redefined as a rare agent of subcutaneous lesions of traumatic origin, eventually causing eumycetoma. Mycetoma is a localized, chronic, suppurative subcutaneous infection of tissue and contiguous bone after a traumatic inoculation of the causative organism. In advanced stages of the infection, one finds tumefaction, abscess formation and draining sinuses. The species has been described as being common in the environment, but molecular methods have only confirmed its occurrence in clinical samples. Current diagnostics of E. jeanselmei is based on sequence data of the Internal Transcribed Spacer (ITS) region of ribosomal DNA (rDNA), which sufficiently reflects the taxonomy of this group. The first purpose of this study was the re-identification of all clinical (n=11) and environmental strains (n=6) maintained under the name E. jeanselmei, and to establish clinical preference of the species in its restricted sense. Given the high incidence of eumycetoma in endemic areas, the second goal of this investigation was the evaluation of in vitro susceptibility of E.jeanselmei to eight conventional and new generations of antifungal drugs to improve antifungal therapy in patients. As an example, we describe a case of black grain mycetoma in a 43-year-old Thai male with several draining sinuses involving the left foot. The disease required extensive surgical excision coupled with intense antifungal chemotherapy to achieve cure. In vitro studies demonstrated that posaconazole and itraconazole had the highest antifungal activity against E. jeanselmei and E. oligosperma for which high MICs were found for caspofungin. However, their clinical effectiveness in the treatment of Exophiala infections remains to be determined.

A traveler with neurobrucellosis.

An Indian traveler developed fever and neurological symptoms after a visit to East Africa. He was treated with suramin, melarsoprol and prednisolone for presumed East African trypanosomiasis. His condition deteriorated and cerebral lesions developed. Neurobrucellosis was diagnosed. Combination antibiotic therapy led to gradual clinical improvement and regression of the brain lesions. Misdiagnosis of East African trypanosomiasis followed by treatment with potentially lethal medication should be avoided by not relying on insufficient evidence during the diagnostic process.

Selective ambulatory management of imported falciparum malaria: a 5-year prospective study.

The ambulatory management of imported Plasmodium falciparum malaria is controversial because criteria for safe selection of patients are imprecise. The aim of the present study was to investigate the evolution and outcome of patients diagnosed with Plasmodium falciparum malaria at a Belgian referral institute in order to assess the safety of the institute's current selective ambulatory management protocol. From 2000 to 2005, all patients diagnosed with P. falciparum infection at the Institute of Tropical Medicine and the University Hospital of Antwerp were enrolled prospectively. Ambulatory treatment was offered to nonvomiting patients if they exhibited none of the 2000 World Health Organization criteria of severity and had parasitemia below 1% at the initial assessment. The treatment of choice was quinine (plus doxycycline or clindamycin) for inpatients and atovaquone-proguanil for outpatients. P. falciparum malaria was diagnosed in 387 patients, of whom 246 (64%) were Western travelers or expatriates and 117 (30%) were already on antimalarial therapy. At diagnosis, 60 (15%) patients had severe malaria. Vital organ dysfunction was initially seen in 34 and developed later in five others. Five patients died. Of the 327 patients initially assessed as having uncomplicated malaria, 113 (35%) were admitted immediately; of these, 4 developed parasitemia >/=5% at a later stage but without any clinical consequence. None of the 214 individuals initially treated as outpatients experienced any malaria-related complications, including 10 who were admitted later. Vital organ dysfunction was observed in only 2 of the 214 patients with initial parasitemia <1% who had not taken antimalarial agents (both patients had impaired consciousness at presentation). Ambulatory treatment is safe in treatment-naive malaria patients with parasitemia <1% who do not vomit and who do not exhibit any criteria of severe malaria.

Hyperreactive malaria in expatriates returning from sub-Saharan Africa.

The extreme presentation of hyperreactive malaria is hyperreactive malarial splenomegaly syndrome (HMS). Some patients present with a less pronounced syndrome. To investigate whether the degree of splenomegaly correlates with the degree of immune stimulation, whether prophylaxis or recent treatment play a role, and whether short therapy alone is effective, we examined retrospectively the medical records of expatriates with exposure to P. falciparum who attended our outpatient department from 1986 to 1997, particularly subacute symptoms or signs, strongly elevated malarial antibodies and elevated total serum IgM. We analysed duration of stay, prophlyaxis intake, spleen size, serum IgM levels and response to antimalarial treatment. Serum IgM levels were significantly higher in patients with larger splenomegaly. The use of chloroquine alone as treatment for presumptive or proved malaria attacks was correlated with larger spleen size. Short adequate antimalarial therapy resulted in marked improvement or complete recovery. In nine patients the hyperreactive response reappeared after re-exposure, in four of them twice. We conclude that patients with subacute symptoms but without gross splenomegaly may have very high levels of IgM and malarial antibodies, and relapse on re-exposure, suggesting the existence of a variant of the hyperreactive malarial splenomegaly syndrome without gross splenomegaly.

The hypereosinophilic syndrome after residence in a tropical country: report of 4 cases.

Severe eosinophilia may be complicated by acute or chronic visceral damage. The underlying origin of the hypereosinophilia may be infectious, allergic, toxic, malignant or systemic (the secondary or reactive hypereosinophilic syndrome), but in a number of cases no cause can be found (the idiopathic hypereosinophilic syndrome). We describe 4 cases with hypereosinophilia and secondary visceral damage after residence in a tropical region. In three cases a helminthic infection was the obvious cause, the brain and the heart were the target organs. After treatment of the infection both the hypereosinophilia and the neurological and cardiac lesions disappeared. The fourth patient died of multi-organ disease. No definite trigger of the hypereosinophilia could be found. We discuss clinical findings, necessary investigations and therapeutic strategies.

Ebola hemorrhagic fever in Kikwit, Democratic Republic of the Congo: clinical observations in 103 patients.

During the 1995 outbreak of Ebola hemorrhagic fever in the Democratic Republic of the Congo, a series of 103 cases (one-third of the total number of cases) had clinical symptoms and signs accurately recorded by medical workers, mainly in the setting of the urban hospital in Kikwit. Clinical diagnosis was confirmed retrospectively in cases for which serum samples were available (n = 63, 61% of the cases). The disease began unspecifically with fever, asthenia, diarrhea, headaches, myalgia, arthralgia, vomiting, and abdominal pain. Early inconsistent signs and symptoms included conjunctival injection, sore throat, and rash. Overall, bleeding signs were observed in <45% of the cases. Typically, terminally ill patients presented with obtundation, anuria, shock, tachypnea, and normothermia. Late manifestations, most frequently arthralgia and ocular diseases, occurred in convalescent patients. This series is the most extensive number of cases of Ebola hemorrhagic fever observed during an outbreak.

Organization of patient care during the Ebola hemorrhagic fever epidemic in Kikwit, Democratic Republic of the Congo, 1995.

In contrast with procedures in previous Ebola outbreaks, patient care during the 1995 outbreak in Kikwit, Democratic Republic of the Congo, was centralized for a large number of patients. On 4 May, before the diagnosis of Ebola hemorrhagic fever (EHF) was confirmed by the Centers for Disease Control and Prevention, an isolation ward was created at Kikwit General Hospital. On 11 May, an international scientific and technical committee established as a priority the improvement of hygienic conditions in the hospital and the protection of health care workers and family members; to this end, protective equipment was distributed and barrier-nursing techniques were implemented. For patients living far from Kikwit, home care was organized. Initially, hospitalized patients were given only oral treatments; however, toward the end of the epidemic, infusions and better nutritional support were given, and 8 patients received blood from convalescent EHF patients. Only 1 of the transfusion patients died (12.5%). It is expected that with improved medical care, the case fatality rate of EHF could be reduced.

Recurrence of blackwater fever: triggering of relapses by different antimalarials.

Five cases of blackwater fever (BWF) are described, all of whom had a history of recent quinine therapy. In two cases a second haemolytic crisis was induced by halofantrine, in one case also a third. Increasing frequency of this syndrome with its dramatic clinical presentation is to be expected as imported P. falciparum infection, parasite resistance to chloroquine and the use of quinine and other related antimalarials become more frequent.

Kabisa: an interactive computer-assisted training program for tropical diseases.

In Europe, tropical pathology is usually taught in special short courses, intended for those planning to practise in developing countries. The theoretical knowledge to be assimilated during this short period is considerable, and turning such newly acquired knowledge into competence is difficult. Kabisa is a computer-based training program for tropical diseases. Instead of concentrating on strictly tropical diseases, students are trained in recognizing diseases in patients presenting randomly in an imaginary reference hospital in a developing country. Databases are compiled by experts from experiences in various parts of Africa, Asia and tropical America. Seven languages and three levels of competence can be chosen by the student. Updating of all databases is possible by teachers who want to describe a particular setting. A 'consistency checker' verifies the internal consistency of a new configuration. The logical engine is based upon both a 'cluster' and a Bayesian logic, with built-in corrections for related disease characteristics. This correction allows calculated probabilities to stay closer to real probabilities, and avoids the 'probability overshoot' that is inherent to 'idiot Bayes' calculations. The program provides training in diagnostic skills in an imaginary second-line setting in a tropical country. It puts tropical and cosmopolitan diseases in perspective and combines applied clinical epidemiology and pattern recognition within varying sets of presenting symptoms. Students are guided in searching for the most relevant disease characteristics, in ranking disease probability, and in deciding when to stop investigating.

[Sleeping sickness as an import pathology following a stay in Zaire]. / Slaapziekte als importpathologie na verblijf in Zaïre.

A 32-year-old Italian man developed fever and general malaise 3 weeks after arrival in Zaïre. Malaria was diagnosed by a thick blood film, but consequent treatment with quinine was unsuccessful. After repatriation, the diagnosis of early stage sleeping sickness was established. Treatment with eflornithine (Ornidyl) resulted in complete recovery.

Diagnosis of amoebic infection of the liver: report of 36 cases.

The classical clinical picture of amoebic infection of the liver consists of fever, right upper quadrant pain and hepatomegaly. In recent years, the widespread availability of ultrasound and serology made an early diagnosis possible, which could result in less prominent clinical pictures. Thirty six cases of liver amoebiasis diagnosed in Antwerp between 1985 and 1992, were reviewed. Three patients acquired their infection in Belgium. For the other patients, the average delay between arrival in Belgium and the first symptoms was 5.64 months. The classical triad of clinical signs (fever, right upper quadrant pain and hepatomegaly), was observed in only 13.9% of the patients, whereas it was much more frequent in earlier studies (68-75%). The right lobe was the most frequently affected (94%). The colour of the liquid, obtained by puncture, was brown in 61% of patients in whom it was reported. Amoebic cysts were found in the stools of only one patient. Amoebic serology was initially negative in only one patient, but became positive on second testing. Chest X-rays were abnormal in 34% of the patients. All patients who develop unexplained fever during the year after a stay in tropical countries should undergo an abdominal ultrasound examination and serological testing for Entamoeba histolytica.

Eosinophilic myositis resulting from sarcocystosis.

Muscle sarcocystosis is a parasitic infection acquired by ingestion of sporocysts of Sarcocystis species. A case is described where symptoms of fever, chronic myositis and eosinophilia were present. Diagnosis was made via muscle biopsy. Improvement and cure coincided with treatment with cotrimoxazole. A limited review of human muscle sarcocystosis and an outline of the gaps in the knowledge of this infection is presented.