[Fever, malaise and eosinophilia after consumption of raw fish in Italy: infection by a liver fluke (Opisthorchis felineus)]. / Koorts, malaise en eosinofilie na eten van rauwe vis in Italië: infectie met leverbot (Opisthorchis felineus).

BACKGROUND: Infection by a liver fluke (trematode) is rare in Western Europe, but recently a few outbreaks caused by this parasite have been described after consumption of raw freshwater fish caught in Italy. CASE DESCRIPTION: A 35-year-old Dutch woman presented with fever, without localising symptoms. Laboratory tests showed pronounced eosinophilia. Microscopy of the faeces showed a liver fluke egg. Upon inquiry, it appeared that she had consumed raw fish (carpaccio of tench) three weeks earlier in a restaurant in Northern Italy. In Italy, 45 people with comparable symptoms were found to be infected by the same parasite. All patients had eaten in the same restaurant. They were treated successfully with praziquantel. The stool egg was from the trematode Opisthorchis felineus. CONCLUSION: O. felineus lives in the bile ducts of fish-eating mammals. Its life cycle includes freshwater snails and fish. Acute symptoms are fever, malaise and abdominal pain and complications such as liver and bile duct abscesses and cholangitis. Diagnosis is made by microscopic examination of the faeces, confirmed by PCR or by serology.

[Patient with haemolytic uremic syndrome and Escherichia coli (EHEC) infection]. / Een patiënt met hemolytisch-uremisch syndroom en infectie met enterohemorragische Escherichia coli (EHEC).

BACKGROUND: In infection with the enterohaemorrhagic Escherichia coli (EHEC), toxins produced by the bacteria can induce the potentially lethal disease haemolytic uremic syndrome (HUS). CASE DESCRIPTION: A 71-year-old woman was seen at the Emergency Department with abdominal cramps and bloody diarrhoea. Diagnostic tests revealed ischaemia of the intestinal mucosa. A few days after admission the patient developed acute malfunction of the kidneys and thrombocytopenia. HUS was diagnosed, which was later shown to be caused by infection with EHEC. The patient was treated with plasmapheresis and haemodialysis, which brought her kidney function back to normal. History taking revealed that the patient had visited northern Germany where the EHEC epidemic was raging. CONCLUSION: In cases of bloody diarrhoea, clinicians should consider infection with EHEC - a bacterium for which antibiotics are not appropriate treatment. If the infection becomes complicated by the development of HUS, then the treatment of choice should be administration of fluids, and haemodialysis possibly combined with plasmapheresis.

[Unexplained lymphadenopathy: Whipple disease]. / Onbegrepen lymfadenopathie: ziekte van Whipple.

A 58-year-old man was referred to the internal medicine outpatient department because of abdominal pain and lymphadenopathy. CT imaging revealed multiple mediastinal, para-aortic, mesenteric and pelvic lymphoma. Biopsy of an inguinal lymph node for histology purposes revealed granulomatous lymphadenitis. A watchful waiting approach was adopted. Two and a half years after first presentation, the patient presented with weight loss, fever and night sweats. CT imaging showed progressive lymphadenopathy and hepatosplenomegaly. Histopathological examination of a laparoscopically removed lymph node showed extensive infiltration with macrophages with stained rod-shaped bacteria (periodic acid-Schiff staining), which is typical of Whipple disease. PCR and biopsies of the small intestine confirmed the diagnosis. Antibiotic therapy was started with rapid clinical and biochemical improvement. A year later PCR of the duodenal biopsies was negative and the antibiotics were discontinued. Whipple disease is a rare chronic infection caused by Tropheryma whipplei. Clinical symptoms can vary, so it often takes a long time to diagnose.

Practical diagnostic management of patients with clinically suspected deep vein thrombosis by clinical probability test, compression ultrasonography, and D-dimer test.

PURPOSE: To evaluate a new noninvasive diagnostic strategy for ruling out deep vein thrombosis consisting of either a combination of low clinical probability and normal ultrasonography or a combination of moderate-to-high clinical probability, normal ultrasonography, and a normal D-dimer test. SUBJECTS AND METHODS: We studied 811 patients with clinically suspected deep vein thrombosis using a diagnostic management strategy that combined clinical probability, ultrasonography, and measurement of D-dimers. The primary endpoint was venous thromboembolism occurring during a 3-month follow-up. RESULTS: Of the 280 patients (35%) with a low clinical probability, 30 (11%) had an abnormal initial ultrasonography and were treated. Of the other 250 untreated patients with low clinical probability and a normal ultrasonography, 5 (2%; 95% confidence interval [CI]: 1% to 5%) developed a nonfatal venous thromboembolism during follow-up. Of the 531 patients (65%) with a moderate-to-high clinical probability, 300 (56%) had an abnormal ultrasonography. Of the remaining 231 patients with a normal ultrasonography, 148 had a normal D-dimer test; none of these patients developed deep vein thrombosis during follow-up (0%; 95% CI: 0% to 3%). Of the 83 patients with an abnormal D-dimer test, 77 underwent repeat ultrasonography about 1 week later; none of the 64 patients with a second normal ultrasound developed symptomatic deep vein thrombosis during follow-up (0%; 95% CI: 0% to 6%). CONCLUSIONS: This management strategy, which combines clinical probability, ultrasonography, and D-dimer measurements, is practical and safe in ruling out deep vein thrombosis in patients with clinically suspected thrombosis and reduces the need for repeat ultrasonography.