Severe liver fibrosis caused by Schistosoma mansoni: management and treatment with a transjugular intrahepatic portosystemic shunt.

Liver diseases are common in inhabitants and migrants of tropical countries, where the liver can be exposed not only to toxins but also to many viral, bacterial, fungal, and parasitic infections. Schistosomiasis--a common parasitic infection that affects at least 240 million people worldwide, mostly in Africa--is regarded as the most frequent cause of liver fibrosis worldwide. We present a case of a 19-year-old male refugee from Guinea with recurrent oesophageal variceal bleeding due to schistosomal liver fibrosis refractory to endoscopic therapy. This case was an indication for portosystemic surgery, which is a highly invasive non-reversible intervention. An alternative, less invasive, reversible radiological procedure, used in liver cirrhosis, is the placement of a transjugular intrahepatic portosystemic shunt (TIPS). After thorough considerations of all therapeutic options we placed a TIPS in our patient. In more than 3 years of observation, he is clinically well apart from one episode of hepatic encephalopathy related to an acute episode of viral gastroenteritis. Bleeding from oesophageal varices has not recurred. In this Grand Round, we review the diagnostic approaches and treatment options for portal hypertension due to schistosomal liver fibrosis.

Anaphylactic shock ensuing therapeutic puncture of an echinococcal cyst.

Cystic echinococcosis (CE) is a widespread zoonosis. For treating single echinococcal cysts during the last decades, therapeutic puncture of the cyst, aspiration, injection of a scolicide, and re-aspiration (PAIR) has been established as a minimal-invasive alternative method to surgery. A recent review on the complications of therapeutic cyst punctures has shown that dangerous complications occur much less frequently than previously assumed. A case is described where an allergic acute bronchospasm and arterial hypotension led to a life-threatening shock immediately after echinococcal cyst puncture. Fortunately, the situation could be managed by an experienced and well-equipped anesthesiology team. Life-threatening allergic phenomena after puncture of echinococcal cysts may occur less frequently than generally assumed; nevertheless, they must be taken into account, and precautions must be taken to manage serious adverse events.

Why do Plasmodium malariae infections sometimes occur in spite of previous antimalarial medication?

Quartan malaria due to Plasmodium malariae is commonly regarded as being preventable by current antimalarials. A case of P. malariae infection occurred in spite of previous treatment of Plasmodium falciparum malaria 4 months earlier with a full therapy course of intravenous quinine hydrochloride and oral doxycycline followed by artemether + lumefantrine. Since the patient was not anymore exposed to agents of malaria in the meantime, a new infection by P. malariae after therapy is unlikely. The present observation is difficult to explain by the current view on the origin of latent P. malariae infections and recurrences which are thought to arise from intra-erythrocytic development stages susceptible to common antimalarials. The most likely explanation of our observation is a delayed pre-erythrocytic development. The latency between infection by P. malariae and the quartan malaria fever attack might have been extended further by an initial subclinical circulation of a low number of intra-erythrocytic asexual parasites in the blood stream preceeding the clinical quartan malaria breakthrough.

Early clinical experiences with the new influenza A (H1N1/09).

BACKGROUND: Because of ongoing person-to-person transmission of the disease, the World Health Organization has declared a phase 6 pandemic alert for the new type of influenza A (H1N1/09). This means that the spread of the disease must be closely monitored. METHODS: At the Düsseldorf University Hospital, patients with flu-like symptoms and their contacts have been tested for the new type of influenza A since April 2009. RESULTS: The first patients that tested positive for H1N1/09 were treated on 20 May 2009. By mid-September, 3372 persons underwent PCR testing of a sample obtained by deep nasal swabbing, and the results were positive in 450 (13.3%). 379 of these 450 infections, or 84.2%, had been contracted abroad. Most patients came to the hospital with flu-like symptoms within three days of becoming ill. An analysis of the first 60 patients revealed a median core temperature of 37.8 degrees C and a mildly elevated C-reactive protein concentration. All patients were treated with oseltamivir. Most of the initially symptomatic patients were asymptomatic again within 3 days; the median duration of treatment was 5 days. The median time to the first negative deep nasal swab was 4 days. No oseltamivir resistance has been found to date in our patient collective. CONCLUSION: The clinical manifestations of the new type of influenza were still mild in the patient population that we studied up to mid-September 2009. At that time, the second wave of the pandemic had not yet begun in Germany. At present, however, the number of cases acquired within the country is on the rise.

Plasmodium malariae infection in spite of previous anti-malarial medication.

Plasmodium malariae is regarded as usually being susceptible to all anti-malarials whether applied for prophylaxis or treatment. We report on three cases of P. malariae infection which occurred 12-14 weeks after anti-malarial chemoprophylaxis or treatment with mefloquine or atovaquone/proguanil. The most likely explanation for the failure of mefloquine and atovaquone/proguanil to prevent quartan malaria occurring some months later is the insufficient effect on the particularly long-lasting pre-erythrocytic development stages of P. malariae.

Sonographic detection of subcutaneous fly larvae in human myiasis.

Sonographers increasingly face imported diseases such as subcutaneous myiasis. In myiasis, some fly species such as the American Dermatobia hominis and the African Cordylobia anthropophaga use humans as intermediate hosts for the maturation of their larvae. High-resolution gray-scale and color Doppler sonography enabled us to identify D hominis larvae in 2 travelers to Central America by visualizing their typical shape, segmentations, and the continuous fluid transport inside the larval body cavity and spiracles. The small C anthropophaga larva in an individual returning from Namibia was initially not detected. Only when using color Doppler sonography was the larva discerned by its intralarval fluid transport. Sonography enables clinicians to locate viable subcutaneous larvae in suspected cases of myiasis.

Arthritis associated with Strongyloides stercoralis infection in HLA B-27-positive African.

A 44-year old West-African living in Germany since 18 years presented because of persistent painful swelling of both ankle joints and diffuse lymphoedema of feet occurring after a trip to Morocco. Laboratory tests revealed inflammation and eosinophilia. HLA-B27 was positive. Antinuclear antibodies and rheuma factors were not found. There was no evidence of an infection with bacteria or viruses known to cause arthritis. Filariasis was excluded. Microscopy of fresh stool revealed larvae of Strongyloides stercoralis. Symptoms resolved after specific antihelminthic therapy with ivermectin 0.2 mg kg(-1) day(-1) for 2 days and non-steroidal anti-inflammatorials. Reactive arthritis is known to be caused by various bacterial agents. In some individuals, arthritis may be due to helminths, such as S. stercoralis. Patients with strongyloidiasis may respond to non-steroidal anti-inflammatorials but must not undergo treatment with corticosteroids before having received antihelminthic therapy because immunosuppression may result in life-threatening strongyloides hyperinfection syndrome.

Co-reactivity of plasmodial histidine-rich protein 2 and aldolase on a combined immuno-chromographic-malaria dipstick (ICT) as a potential semi-quantitative marker of high Plasmodium falciparum parasitaemia.

The combined immuno-chromographic-malaria dipstick (ICT) for the rapid diagnosis of malaria detects both Plasmodium falciparum (P.f.)-specific, histidine-rich protein 2 (HRP-2) and a plasmodial aldolase expressed by all Plasmodium species pathogenic to humans. ICT was applied in 674 febrile returnees from malaria-endemic regions attending our Tropical Diseases Unit. Microscopy confirmed malaria in 69/674 cases, of whom 67/69 had returned from Africa or Madagascar, and 2/69 from the Caribbean. Monoparasitic P.f. infection occurred in 52/69, mixed infection was due to P.f.+ P. ovale (P.o.) in 3/69, and P.f.+P. malariae (P.m.) in 1/69 cases. Monoparasitic P. vivax (P.v.) infection occurred in 8/69 , P.o. in 3/69, and P.m. in 2/69 cases . Whereas a positive HRP-2 band on the test was a highly sensitive indicator for P.f. infection (52/52 patients; sensitivity 100%), this was not the case for a positive aldolase band (25/52 patients; sensitivity 48.1%). Sensitivity of aldolase band for non-falciparum plasmodia was even lower: aldolase was positive in only 3/8 (37.5%) of patients with vivax malaria, and in 0/5 cases with P.o.- or P.m. infection. Co-reaction of both bands occurred more frequently in patients with P.f. parasitaemia of > or =40,000/microl (20/25, 80.0%) as compared to patients with P.f. parasitaemia <40,000/microl (5/27, 18.5%; P<0.00005), and to patients with mixed infection (P.f.+ P.o., P.f.+ P.m.: 2/4, 50.0%; diff. n.s.). In our series, co-reaction of HRP-2 and aldolase indicated monoparasitic falciparum malaria with high P.f. parasitaemia, rather than mixed infection. Whereas the aldolase band is not a reliable qualitative marker for malaria, co-reaction of HRP-2 and aldolase band may have a potential for indicating high parasitaemia in falciparum malaria.

Case report: Plasmodium ovale infection acquired in Malawi.

Malaria due to Plasmodium ovale is uncommon outside West Africa. A 37-year-old male German who had returned from Malawi four months previously presented in September 2003 because of fever recurring every two days. The patient had never been to West Africa. Microscopy of stained thick and thin blood films revealed P. ovale. This is the first report of a P. ovale infection acquired in Malawi, East Africa. Malaria surveillance centres should monitor the possible emergence of autochtonous transmission of P. ovale in the area.

Performance of an immunochromatographic test for the rapid diagnosis of malaria.

The immunochromatographic test (ICT) for the rapid diagnosis of malaria has been marketed for several years. In a study in which three Centres of Tropical Medicine participated and data were pooled, performance of the test varied considerably when comparing the results between each centre. The sensitivity of ICT in 2,343 patients tested in our services was 100% and the specificity 99.74%. Moreover, two patients with a positive ICT would initially have been missed by expert microscopy, with Plasmodium falciparum malaria being confirmed microscopically some hours later. The principal reasons for the better performance of the test in our series appear to be blood collection in EDTA vials and considerable experience with handling and interpreting the ICT test.