Prospective multicenter evaluation of the expert system "KABISA TRAVEL" in diagnosing febrile illnesses occurring after a stay in the tropics.

BACKGROUND: KABISA TRAVEL is a clinical decision support system developed by the Institute of Tropical Medicine of Antwerp, Belgium, for the diagnosis of febrile illnesses after a stay in the tropics. This study aimed to compare the diagnostic accuracy of KABISA TRAVEL with that of expert travel physicians. METHODS: From December 2007 to April 2009, travelers with fever after a stay in the tropics were included in a multicenter trial conducted in travel referral centers in the Netherlands, Italy, Spain, and Belgium. Physicians were asked (1) to rank their first assessment diagnoses, (2) to enter in KABISA TRAVEL clinical and laboratory data available within 36 hours, and (3) to interact with the tutor until its final diagnostic ranking. Both physicians and KABISA TRAVEL rankings were then compared with the final diagnosis confirmed by reference methods. The clinical utility was also surveyed. RESULTS: A total of 205 cases with confirmed diagnosis were evaluated (male/female ratio: 1.85; mean age: 35 y). Most patients were western travelers or expatriates (60%) and were returning from sub-Saharan Africa (58%). Travel physicians and KABISA TRAVEL ranked the correct diagnosis in the first place for 70 and 72% of the cases, respectively, and within the top five both for 88% of them. Travel physicians reported having been suggested useful further investigations in 16% of the cases, and having been helped for obtaining the diagnosis in 24%. This was reported more frequently when they had initially missed the diagnosis (suggestion: 48% in missed vs 12% in found diagnoses, p < 0.001; helpful: 48% in missed vs 21% in found diagnoses, p = 0.005). CONCLUSIONS: KABISA TRAVEL performed as well as expert travel physicians in diagnosing febrile illnesses occurring after a tropical stay. Clinicians perceived the system as more helpful when they had not immediately considered the correct diagnosis.

New England souvenirs.

A 54-year-old woman presented with 2 weeks of fever after a trip to the Northeastern United States. Except for an erythematous skin lesion on her right shoulder, no physical abnormality was detected. We diagnosed concomitant borreliosis and babesiosis. Both infections were possibly acquired by one bite from Ixodes scapularis.

Declining incidence of imported malaria in the Netherlands, 2000-2007.

BACKGROUND: To describe the epidemiology and trends of imported malaria in the Netherlands from 2000 through 2007. METHODS: Based on national surveillance data regarding all reported infections of imported malaria, diagnosed 2000 through 2007, incidence and trends of imported malaria in the Netherlands were estimated. Travellers statistics were used to estimate incidence, and data on malaria chemoprophylaxis prescriptions were used to estimate the number of unprotected travellers. RESULTS: Importation of malaria to the Netherlands is declining even as more travellers visit malaria-endemic countries. On average, 82% were acquired in sub-Saharan Africa, and 75% were caused by Plasmodium falciparum. The overall incidence in imported falciparum malaria fell from 21.5 to 6.6/10,000 of unprotected travellers. The percentage of unprotected travellers rose from 47% to 52% of all travellers. The incidence of imported falciparum infections is greatest from Middle and West Africa, and decreased from 121.3 to 36.5/10,000 travellers. The import of malaria from this region by immigrants visiting friends and relatives (VFR) decreased from 138 infections in 2000, to 69 infections in 2007. CONCLUSION: The annual number of imported malaria shows a continuing declining trend, even with an increasing number of travellers visiting malaria endemic countries. VFR import less malaria than previously, and contribute largely to the declining incidence seen. The decline is not readily explained by increased use of chemoprophylaxis and may reflect a reduced risk of infection due to decreasing local malaria transmission as observed in some malaria endemic areas. Nevertheless, the increasing number of unprotected travellers remains worrisome.

Use of enzyme-linked immunosorbent assay and dipstick assay for detection of Strongyloides stercoralis infection in humans.

A homemade enzyme-linked immunosorbent assay (ELISA) (Academic Medical Center ELISA [AMC-ELISA]) and a dipstick assay for the detection of anti-Strongyloides stercoralis antibodies in serum were developed and evaluated together with two commercially available ELISAs (IVD-ELISA [IVD Research, Inc.] and Bordier-ELISA [Bordier Affinity Products SA]) for their use in the serodiagnosis of imported strongyloidiasis. Both commercially available ELISAs have not been evaluated previously. The sensitivities of the assays were evaluated using sera from 90 patients with parasitologically proven intestinal strongyloidiasis and from 9 patients with clinical larva currens. The sensitivities of the AMC-ELISA, dipstick assay, IVD-ELISA, and Bordier-ELISA were 93, 91, 89, and 83%, respectively, for intestinal strongyloidiasis. In all tests, eight of nine sera from patients with larva currens were positive. The specificity was assessed using a large serum bank of 220 sera from patients with various parasitic, bacterial, viral, and fungal infectious diseases; sera containing autoimmune antibodies; and sera from healthy blood donors. The specificities of AMC-ELISA, dipstick assay, IVD-ELISA, and Bordier-ELISA were 95.0, 97.7, 97.2, and 97.2%, respectively. Our data suggest that all four assays are sensitive and specific tests for the diagnosis of both intestinal and cutaneous strongyloidiasis.

Patterns of imported malaria at the academic medical center, Amsterdam, the Netherlands.

BACKGROUND: In the Netherlands, cases of imported malaria peaked in the late 1990s to around 500 (60% Plasmodium falciparum) annually. About 30% to 40% of all cases and 57% to 69% of the falciparum cases presented in the Academic Medical Center, Amsterdam. In 1991 to 1994, a shift in population groups to more semi-immune patients, mostly settled immigrants visiting friends and relatives (VFRs), was noticed, when compared to 1979 to 1988. This study shows the ongoing trend in 2000 to 2002. METHODS: All the patients diagnosed with malaria in the Academic Medical Center, Amsterdam, during 2000 to 2002 were analyzed. Nonimmune and semi-immune patients were analyzed separately. RESULTS: A total of 302 patients were diagnosed with malaria: 207 (69%) were male; mean age was 34.0 years (range 1-74 years). Of the 302 patients, 105 (35%) were nonimmune travelers and 197 (65%) were considered semi-immune. In 248 (82%) patients, P falciparum was found. In 28 (9.3%), 15 (5.0%), and 6 (2.0%) cases, Plasmodium vivax, Plasmodium ovale, and Plasmodium malariae were diagnosed, respectively. Of the 248 falciparum cases, 233 (94%) were infected in sub-Saharan Africa; 90% of them had a parasitemia and <2 and 4% had a parasitemia exceeding 5% (maximum 43.7%). The majority of the falciparum cases (96%) were diagnosed within 30 days after return. The number of nonimmune patients with falciparum malaria decreased sharply from 42 in 2000 to 31 in 2001 to 13 in 2002, accounting for the decrease in all malaria cases, from 118 in 2000 to 82 in 2002. Fifty-four percent of vivax infections were acquired in Southeast Asia and 46% in Latin America and sub-Saharan Africa; 71% of the patients presented after 30 days (delayed primary attacks). All the P ovale infections were acquired in sub-Saharan Africa (73% delayed primary attacks). CONCLUSIONS: During 2000 to 2002, the total number of patients with falciparum malaria was steadily decreasing due to a decrease in nonimmune patients. The number of semi-immune patients, mostly VFRs and visitors, remained stable. The increasing use of more convenient chemoprophylactic drugs, like atovaquone/proguanil, appears to improve compliance in those who can afford the drug.

Chronic leg ulcer caused by Mycobacterium immunogenum.

Rare tropical skin diseases are seen more frequently in Western countries because of the increased popularity of visiting tropical regions. A 55-year-old white man developed a painless leg ulcer after traveling in Guatemala and Belize. A mycobacterium was cultured from a biopsy specimen and was identified as Mycobacterium immunogenum by 16S recombinant deoxyribonucleic acid sequence analysis. The leg ulcer healed after 6 months of compression therapy and hydrocolloids; a hypopigmented depressed scar remained.

Use of rapid dipstick and latex agglutination tests and enzyme-linked immunosorbent assay for serodiagnosis of amebic liver abscess, amebic Colitis, and Entamoeba histolytica Cyst Passage.

A homemade enzyme-linked immunosorbent assay (ELISA) and a dipstick assay (Dipstick) for the detection of anti-Entamoeba histolytica antibodies in serum were developed and evaluated together with a commercially available latex agglutination test (LAT; Laboratoires Fumouze) for their use in serodiagnosis of amebiasis. The sensitivity of these assays was evaluated with sera from 27 patients with radiologically proven, cellulose acetate precipitation (CAP) test-positive amebic liver abscess, 7 patients with parasitologically and PCR-proven amebic colitis, and 11 patients with parasitologically and PCR-proven E. histolytica cyst passage. The sensitivities of the ELISA, Dipstick, and LAT were all 93.3% (42/45). With a combination of Dipstick and LAT, all abscess and colitis patients had at least one positive result. The specificity was assessed with 238 sera from patients with various parasitic, bacterial, viral, and fungal infectious diseases, sera containing autoimmune antibodies, and sera from healthy blood donors. The specificities of the ELISA, Dipstick, and LAT were 97.1%, 98.1%, and 99.5%, respectively. Of 61 sera from patients with PCR-proven E. dispar infection, 60 (98.4%) were negative in both Dipstick and LAT and 59 (96.7%) were negative in ELISA. Our data suggest that all three assays are sensitive serological tests. The rapid LAT and Dipstick provide fast results and can easily be applied in routine laboratories in order to facilitate the diagnosis of amebiasis.

Presentation and diagnosis of imported schistosomiasis: relevance of eosinophilia, microscopy for ova, and serology.

BACKGROUND: In nonendemic countries a steady rise in cases of imported schistosomiasis has been observed. The objective of this study was to describe the presentation of patients diagnosed with schistosomiasis in the Outpatient Department (OPD) for Tropical Diseases in the Academic Medical Center, Amsterdam, the Netherlands. METHODS: In a retrospective study, patients with schistosomiasis from our OPD (1997-1999), including a subgroup of persons asking for screening for schistosomiasis and found positive, were analyzed. Diagnosis was based on freshwater exposure in an endemic area and positive serology for schistosomal antibodies. The following data were recorded: age, gender, country of birth, travel destination, symptoms, eosinophil count, and results of serology and stool and urine microscopy. RESULTS: Seventy-eight patients (42 travelers, 16 expatriates, and 20 immigrants) were diagnosed with schistosomiasis; 47% were infected in southern Africa. Twenty-four percent had specific symptoms, 57% had eosinophilia, and in 17 patients (22%) Schistosoma ova were found. Eleven travelers suffered from Katayama syndrome. Of the subgroup of 42 persons screened for schistosomiasis, 15 (36%) had schistosomal antibodies; the majority of these persons (10/15 [67%]) were infected in southern Africa. CONCLUSION: In our OPD schistosomiasis was diagnosed in about 26 patients per year, 3% of all new presentations. Infections were almost exclusively acquired in Africa. In travelers high eosinophilia was due to acute schistosomiasis; in immigrants it was due to concomitant helminthic infections. One of three people asking to be screened for schistosomiasis had schistosomal antibodies. Eosinophilia was indicative but an insufficient screening tool, and stool and urine microscopy for ova were not sensitive. Screening by serology is easy and reliable and the method of choice in asymptomatic persons with a history of freshwater exposure in a high-risk area.