[A 35-year old male patient with fever and painful swelling of the pectoral glands following a short visit to Sri Lanka]. / Ein 35jähriger Patient mit Fieber und schmerzhafter Brustdrüsenschwellung nach Aufenthalt in Sri Lanka.

HISTORY AND CLINICAL FINDINGS: One week after returning from a two-week holiday in Sri Lanka a 35-year-old man started to have recurrent bouts of fever, up to 39.2 degrees C, as well as pain over the left upper abdomen, the back of the right thorax and bilateral pain on pressure with swelling of both breasts. He went to the Tropical Institute in Munich to have malaria excluded. There signs of cholestasis were noted and sonography revealed multiple round foci in the liver. As he had lost 10 kg in 3 weeks he was admitted to a medical unit for further tests. Physical examination now showed bilateral gynaecomastia and marked pressure resistance in the upper abdomen. Proprioceptor reflexes were greatly increased but equal bilaterally. INVESTIGATIONS: Inflammatory parameters were raised (C-reactive protein 22.6 mg/dl, ferritin level 2674 micrograms/l, erythrocyte sedimentation rate 50/82 mm), there also were a leucocytosis (20,600 WBC/mm3) and a raised lactate dehydrogenase level of 613 U/l. In addition, thyroid stimulating hormone was reduced to < 0.03 microU/ml, while free thyroxine was raised to 2.7 ng/dl. The pregnancy test was positive. On quantitative analysis the human beta-chorionic gonadotropin (hCG) level was markedly raised to 193,200 mIU/ml. Abdominal and thoracic computed tomography revealed multiple round metastasis-like masses in the liver and in the lung, and a thickened cardia. Serology for malaria, amoebiasis and echinococciasis was negative, sonography of the testes and thyroid was unremarkable. Endoscopy revealed a polypoid tumour at the gastro-oesophageal junction which histologically was an undifferentiated hCG-positive choriocarcinoma. TREATMENT AND COURSE: The neoplasm at first responded with partial remission (hCG minimally 39 mIU/ml) to chemotherapy (PEI schema: cisplatin, etoposide, ifosfamide) but then progressed, also under treatment of recurrences with paclitaxel, ifosfamide and cisplatin. The patient has since received high-dosage chemotherapy with autologous stem-cell transplantation.

Adverse reactions to Japanese encephalitis vaccine in travellers.

Vaccination against Japanese Encephalitis (JE) has been carried out extensively in many Asian countries for the past 20 years. The vaccine was generally considered to be effective and of low reactogenity. However, since 1989 an unusual number of systemic reactions characterized mainly by generalized urticaria and/or angioedema following JE vaccination were reported from Australia, Canada and Denmark, 860 travellers were recruited during a period of 16 months for a prospective study with the aim to investigate the type and incidence of side effects following JE vaccination (JEV) in German travellers. 826 received a primary immunization (2 injections at days 0 and 7-14) and 34 received a single booster injection. A detailed standardized questionnaire was distributed to all vaccinees after the first injection. A total of 509 questionnaires could be evaluated, which represents a return rate of 59.2%. 46% of the vaccinees reported about no adverse events at all. 54% reported about one or more adverse effects. Local reactions at the injection site were observed by 209 vaccinees, while 65 reported about systemic side effects like headache, fever, dizziness and generalized rash. There was no significant difference following first or second injection of the primary immunization or the booster injection, respectively, regarding incidence, severity or type of side effects. 2.2% of the vaccinees reporting reactions sought medical advice and 1.8% were judged unfit for work for an average of 2.2 days. The amount of systemic reactions might indicate a potential hazard of serious anaphylactic reactions. Unlike hepatitis A. Japanese encephalitis is an extremely rare disease in travellers. Therefore, the risk of acquiring the disease when travelling to affected areas without prior immunization should be considered against the risk of developing serious side effects after vaccination. We conclude that JEV should remain restricted to travellers with an increased risk of acquiring JE.

Stand-by treatment of suspected malaria in travellers.

Travellers to malarious areas are increasingly advised to carry an emergency medication for self-treatment of suspected malaria in absence of medical attention. However, no data are available so far how travellers cope with self-diagnosis and stand by treatment (SBT). We therefore investigated the frequency, circumstances and outcome of emergency self-treatment for suspected malaria in German travellers. 3434 travellers were recruited for an open prospective study by 28 different travel clinics in Germany. 2867 travellers (90.1%) who returned questionnaires after their journey were analyzed. 40 travellers (1.4%) reported about SBT during their journey. Significant Plasmodium falciparum antibody levels could be demonstrated in only 4 of 37 SBT users (10.4%). In another 127 travellers with febrile episodes but without SBT use, no malaria was indicated by follow-up and/or serology.

Imported rickettsioses in German travelers.

Twenty-two cases of rickettsiosis imported to Germany (13 men, nine women, average age 42 years) in a 5-year period were analyzed retrospectively regarding the travel histories, symptoms and clinical findings, laboratory features and course of the disease. The two primary rickettsial diseases were boutonneuse fever (18 patients) and scrub typhus (three patients). One patient had murine typhus. The main symptom was fever in 91% followed by headache (64%), myalgia (40%), arthralgia (50%) and diarrhea (36%). The most frequent clinical finding was lymphadenopathy in 65%. Eschar was detectable in 55% of patients with Rickettsia conori infection and in one patient with Rickettsia tsutsugamushi infection. All patients with R. tsutsugamushi infection as well as 33% of the patients with R. conori infection had a macular exanthema. One patient with scrub typhus had pleural and pericardial effusions. Seventy-three percent had an increased ESR. Three patients had leucocytosis, three increased transaminases and two normochromic anemia. The incubation period for R. conori infection was 5 to 28 days (average 14 days), for R. tsutsugamushi infection 7 to 21 days (average 16 days). Twenty-one patients were treated with tetracycline or doxycycline, one with erythromycin. All patients were cured. One patient had a relapse. Due to the fact that the symptoms are often not characteristic and that the routine laboratory findings are of only marginal help, the diagnosis of rickettsial diseases is often not easy. A detailed travel history sometimes gives an important hint for diagnosis.