[Ciguatera: eight imported cases]. / Ciguatera: ocho casos importados.

INTRODUCTION: Ciguatera poisoning is a clinical syndrome associated to consumption of marine fish with toxins as ciguatoxin, maitotoxin, scariotoxin, palytoxin and okadaic acid, produced by dinoflagellates present in seas with coral reefs. It has a wide distribution in tropic ans sub-tropic areas. MATERIAL AND METHODS: We review the clinical records of 8 patients diagnosed of ciguatera from 1993 of 2001. Diagnosis was based on clinical picture and the antecedent of eating fish from endemic area. RESULTS: All patients were travelers, and all showed neurological symptoms, as parestesias and paradoxical dysesthesia. Five patients received treatment with intravenous mannitol, with fast improvement. DISCUSSION: Travelers to danger zones, mainly Caribbean area, Indic Ocean and Pacific Ocean regions, should be noticed about the risk of ciguatera.

Ciguatera: ocho casos importados / Ciguatera: eight imported cases

Introducción. La intoxicación por ciguatera es un síndrome clínico asociado con el consumo de pescado marino que contiene toxinas como ciguatoxina, maitotoxina, escariotoxina, palitoxinay ácido okadoico producidas por dinoflagelados presentes en mares de arrecifes coraliformes. Tiene una amplia distribución en zonas tropicales y subtropicales. Material y métodos. Se revisan las historias clínicas de 8 pacientes diagnosticados de ciguatera entre los años 1993 y 2001. El diagnóstico se basó en el cuadro clínico y el antecedente epidemiológico de consumo de pescado en zona endémica. Resultados. Los 8 casos correspondían a viajeros, presentando todos ellos síntomas neurológicos, como parestesias y disestesia paradójica. Cinco pacientes recibieron tratamiento con manitol por vía intravenosa, con rápida mejoría. Discusión. Los viajeros a zonas de riesgo, principalmente el Caribe y las regiones del Índico y del Pacífico, deben ser advertidos del riesgo de contraer la enfermedad

Introduction. Ciguatera poisoning is a clinical syndrome associated to consumption of marine fish with toxins as ciguatoxin, maitotoxin,scariotoxin, palytoxin and okadaic acid, produced by dinoflagellates present in seas with coral reefs. It has a wide distribution in tropic ans sub-tropicareas. Material and methods. We review the clinical records of 8 patients diagnosed of ciguatera from1993 of 2001. Diagnosis was based on clinical picture and the antecedent of eating fish from endemic area. Results. All patients were travelers, and all showed neurological symptoms, as parestesias and paradoxical dysesthesia. Five patients recibed treatment with intravenous mannitol, with fast improvement. Discussion. Travelers to danger zones, mainly Caribbean area, Indic Ocean and Pacif Oceanregions, should be noticed about the risk of ciguatera

[Cutaneous larva migrans: 34 outside cases]. / Larva migrans cutánea: 34 casos importados.

Cutaneous larva migrans (CLM) is a frequent dermal disease in travelers, caused by larvae of nonhuman ancylostoma. We describe 34 outside cases of CLM diagnosed since January 1991 to June 2002. Nineteen male and female. Age: 35.7 years (20-60). The total number of CLM infestations was 73, 83.5% in feet. In five cases the cutaneous lesion was vesiculoampollous (14.7%). Ivermectin, utilized in 3 cases with a single dose of 12 mg, failed in one patient (33.3%). Thiabendazole was effective in 6 (85.7%) of 7 cases and 4 (57.1%) patients showed side effects. Albendazole at doses of 400 mg/ 12 hours/3 days was effective in 22 (84.6%) of 26 cases. Possibly it is advisable to use albendazole more than 3 days in order to prevent the failures (15.4%) as those in our series.

Two cases of imported gnathostomiasis in Spanish women.

Reported here are two new cases of imported cutaneous gnathostomiasis that occurred in two Spanish women. The first patient acquired the helminth infection while travelling in Southeast Asia and the second in Mexico. Although the highest prevalence of gnathostomiasis infection is in Southeast Asia, the disease is now an emerging public health problem in some countries of Latin America. The cases reported here demonstrate the increasing frequency with which human gnathostomiasis is being diagnosed in nonendemic countries as a result of more extensive international travel and migration.

Diagnostic utility of a multiplex herpesvirus PCR assay performed with cerebrospinal fluid from human immunodeficiency virus-infected patients with neurological disorders.

We used a multiplex nested-PCR assay for the simultaneous detection in cerebrospinal fluid (CSF) of five human herpesviruses (HVs) (cytomegalovirus [CMV], Epstein-Barr virus [EBV], varicella-zoster virus [VZV], herpes simplex virus [HSV], and human herpesvirus 6 [HHV-6]) in a clinical evaluation of human immunodeficiency virus (HIV)-infected patients with neurological disorders. This method, which has the advantages of being rapid and economical, would be of particular interest for the diagnosis of neurological syndromes caused by more than one HV. We studied 251 CSF samples from 219 patients. HV DNA was demonstrated in 93 (37%) of the CSF samples (34% of the patients). CMV was the HV most frequently detected in our patients (25%), while EBV, VZV, HSV, and HHV-6 DNAs were present in significantly fewer cases (7, 4, 3, and 1%, respectively). When results were compared with the final etiological diagnoses of the patients, the multiplex HV PCR showed high specificity for the diagnosis of CMV and VZV neurological diseases and for cerebral lymphoma (0.95, 0.97, and 0.99, respectively). The sensitivity of the assay was high for CMV disease (0.87), was low for cerebral lymphoma (0.33), and was not evaluable for VZV disease due to the small number of patients with this diagnosis. Nevertheless, detection of VZV DNA had possible diagnostic value in four of the nine cases, and EBV DNA amplification always predicted the diagnosis of cerebral lymphoma in patients with cerebral masses. Detection of HSV DNA was frequently associated with CMV amplification and fatal encephalitis. HHV-6 was not considered to have a pathogenetic role in the three cases in which it was detected. This multiplex HV PCR assay is a specific and clinically useful method for the evaluation of HIV-infected patients with neurological disorders related to HV.

[Listeriosis: an infrequent infection in patients with HIV]. / Listeriosis: una infección poco frecuente en pacientes con VIH.

Although resistance to Listeria monocytogenes infection requires intact T-cell mediated immunity, listeriosis is an infrequent problem in patients with HIV infection and only about 50 patients have been reported to date. Only two patients with HIV and L. monocytogenes have been attended in our hospital since the beginning of aids epidemic in 1981. Case 1: a man with HIV and 364 CD4+ cells/mm3 presented fever and occipital headache. The cerebral scan was normal and L. monocytogenes grew in licuor culture. He was outcome after treatment with ampicillin and tobramycin. Case 2: a 47 years old man with HIV, 44 CD4+ cells/mm3 and hepatic virus C cirrhosis was admitted to the hospital because fever and abdominal distension. He was on menstrual pentamidine prophylaxis for Pneumocystis carinii pneumonia (PCP). Bacterial peritonitis was diagnosed and the patient begun treatment with ceftriaxone. The patient dead 72 hours later with hepatic encepholopathy. Postmortem L. monocytogenes grew. Listeriosis is an infrequent disease in patients with HIV that causes difficult diagnostic problems, principally in patients without prophylaxis with cotrimoxazole for PCP.

[Which are the vaccines that human immunodeficiency virus infected patients must receive?]. / Qué vacunas deben recibir los pacientes con infección por el virus de la inmunodeficiencia humana?

Patients with aids are at increased risk of opportunistic and non opportunistic infections. It is now known that the incidence can be reduced by prophylactic measures and/or the use of vaccines. HIV infection produces an elevated frequency of severe pneumococcal disease with a rate of bacteriemia caused by Streptococcus pneumoniae 150-300 fold greater than rates reported in non-HIV infected people. For this reason, pneumococcal vaccine should be administered as early as possible in the course of the infection. Besides, the antibody response may be significantly higher for asymptomatic persons. Acute hepatitis caused by hepatitis B virus is milder than in non HIV infected patients but chronic disease is more frequent. The prognosis is worse and there is higher risk for infecting another persons. Hepatitis B vaccine is indicated for all the patients with HIV and negative serology for hepatitis B virus. Influenza vaccine is of limited effectiveness due to the high variability of the virus. Besides, influenza incidence is low among approximately young adults, HIV related immunodeficiency increased influenza risk only minimally, the vaccine is administered yearly and HIV-replication can increase in temporal association with vaccination. For all these reasons, fewer hospitalizations and deaths are prevented making it a far less cost-effective prevention strategy than pneumococcal vaccination. The risk of Haemophilus influenzae infections is elevated, but the vaccine is not routinely recommended because the more frequent serotype in HIV infected patients is b. For these subjects, passive immunization with immunoglobulin may also be necessary to provide protection. In conclusion, pneumococcal and hepatitis B vaccination is a reasonable prevention strategy for HIV infected patients at all stages of immunodeficiency. Influenza and H. influenzae vaccination are not recommended and alternative prevention strategies may be done.

Visceral leishmaniasis in patients infected with the human immunodeficiency virus.

The experience with 52 episodes of visceral leishmaniasis diagnosed in 43 patients is reported. The most common symptoms were fever (81%), splenomegaly (65%), hepatomegaly (63%), and pancytopenia (73%). In 79% of the patients, CD4+ cell counts were < 100 cells/mm3. Prior or simultaneous diagnosis of AIDS was made in 29 (67%) patients. Diagnosis was considered fortuitous in 19% of the episodes. In 27% of the episodes, the diagnosis was made on the basis of demonstration of parasites outside the reticuloendothelial system, chiefly blood (7 cases) and gastrointestinal mucosa (5 cases). Parasites were frequently observed or cultured from blood (22/37 episodes) or the digestive tract (8/9 episodes). High antimony doses were more effective than low doses in achieving clinical or parasitological cure (rate of cure, 80% vs. 40%, p = 0.11). Severe toxicity was observed in six (11.7%) of the 51 treated episodes. Severe AIDS-related diseases [odds ratio (OR) 10, p < 0.05] and CD4+ counts (OR 12, p < 0.05) were independent factors for early death. Prophylaxis with monthly pentamidine was not useful in reducing relapses of visceral leishmaniasis.

[Gastrointestinal disease due to cytomegalovirus in patients infected with the human immunodeficiency virus]. / Enfermedad gastrointestinal por citomegalovirus en pacientes infectados por el virus de la inmunodeficiencia humana.

OBJECTIVE: To describe all the clinical settings, endoscopic findings and response to therapy in a series of HIV-positive patients with biopsy proven gastrointestinal CMV disease. PATIENTS: We retrospectively reviewed the medical records of all HIV-infected patients who underwent digestive endoscopies at our Hospital from June 1990 to October 1993. RESULTS: Twelve (7.5%) of 158 HIV-positive patients had gastrointestinal CMV disease. Sites of prove infection included the esophagus (n = 6, 50%), stomach (n = 2, 17%), duodenum (n = 4, 33.3%), ileum (n = 1, 8.5%) and colon (n = 2, 17%). The most common endoscopic findings were focal or diffuse mucosal ulcers. Three patients had pseudotumoral mucosal lesions. Cytomegalic cells were observed in 11 patients (91.6%) and immunohistochemical staining was positive in 9 (81.8%) of 11 patients tested. Eight patients completed a course of treatment with ganciclovir or foscarnet and all of them showed clinical improvement. The median survival time of our AIDS patients with CMV gastrointestinal disease was 7 weeks (range 1-39 weeks). CONCLUSIONS: Gastrointestinal CMV disease may damage any site of the digestive tract in AIDS patients. Routine histopathologic examination was better than immunohistochemical staining for the diagnosis. Treatment improves the clinical situation in most of them. The mean survival is low and it is related to the degree of immunosuppression.