Leprosy in Refugees and Migrants in Italy and a Literature Review of Cases Reported in Europe between 2009 and 2018.

Leprosy is a chronic neglected infectious disease that affects over 200,000 people each year and causes disabilities in more than four million people in Asia, Africa, and Latin America. The disease can appear with a wide spectrum of clinical forms, and therefore the clinical suspicion is often difficult. Refugees and migrants from endemic countries affected by leprosy can remain undiagnosed in Europe due to the unpreparedness of clinicians. We retrospectively describe the characteristics of 55 refugees/migrants with a diagnosis of leprosy established in Italy from 2009 to 2018. Continents of origin were Africa (42%), Asia (40%), and South and Central America (18%). The symptoms reported were skin lesions (91%), neuropathy (71%), edema (7%), eye involvement (6%), fever (6%), arthritis (4%), and lymphadenopathy (4%). Seven patients (13%) had irreversible complications. Overall, 35% were relapses and 66% multibacillary leprosy. Furthermore, we conducted a review of 17 case reports or case series and five nationwide reports, published in the same decade, describing 280 migrant patients with leprosy in Europe. In Europe, leprosy is a rare chronic infectious disease, but it has not completely disappeared. Diagnosis and treatment of leprosy in refugees and migrants from endemic countries are a challenge. European guidelines for this neglected disease in this high-risk population would be beneficial.

Schistosomiasis in immigrants, refugees and travellers in an Italian referral centre for tropical diseases.

BACKGROUND: Schistosomiasis is one of the most important neglected tropical diseases. If unrecognised and untreated, the chronic infection can lead to irreversible complications. METHODS: Retrospective observational study aimed at describing clinical history, laboratory findings and imaging presentation of imported schistosomiasis diagnosed at the Centre for Tropical Diseases, Sacro Cuore Don Calabria Hospital of Negrar, Verona, Italy from 2010 to 2014. The aim of our study was to assess differences in demographic characteristics, clinical presentation, laboratory data and ultrasound findings between immigrants/visiting friends and relatives (VFR) from endemic countries (endemic group) and expatriates/travellers (non-endemic group). RESULTS: A total of 272 patients were retrieved: 234 in the endemic and 38 in the non-endemic group. Most of the patients acquired schistosomiasis in Africa (97.4%). Symptoms were reported by 52.9% of the patients; abdominal pain (36%), macroscopic hematuria (11.3%), and genito-urinary symptoms (7.4%) being the most frequently reported. Increased IgE and blood eosinophilia were observed in 169 (63.8%) and 130 (47.8%) patients, respectively. The proportion of positive serology was 250/272 (91.9%).The Circulating Cathodic Antigen CCA for Schistosoma mansoni was positive in 14/61 individuals (23%). At microscopy, infected subjects were 103/272 (37.9%). The species of Schistosoma found were S. haematobium (47.6%), S. mansoni (46.6%) or both (5.8%). Schistosomiasis was classified as confirmed in 103 (37.9%), probable in 165 (60.6%) and suspected in 4 (1.5%) cases using clinical presentation, laboratory data and ultrasound findings. The infection was further classified based on organ involvement: intestinal (17.9%), hepatosplenic (5.1%), urogenital (48.9%), and indeterminate (43.8%). The comparative analysis of endemic and non-endemic patients highlighted differences in sex and age. Endemic patients had more frequent ova identification (41.9% vs. 13.2%, P < 0.001) and increased IgE (70% vs. 26.3%, P < 0.001) when compared with non-endemic. Multivariate analyses showed that younger age, abnormal ultrasound findings and blood eosinophilia were significantly associated with positive microscopy (OR = 0.94, OR = 2.12, OR = 1.98, respectively). CONCLUSIONS: Symptoms, eosinophilia and abnormal ultrasound findings were present in about half of patients, without differences between groups. Many patients had positive serology but negative microscopy, indicating that schistosomiasis might be misdiagnosed. A combination of diagnostic tools may facilitate the diagnosis.

The hidden epidemic of schistosomiasis in recent African immigrants and asylum seekers to Italy.

The prevalence of schistosomiasis among recent refugees from sub-Saharan Africa in Italy is unknown. This is a retrospective review of African immigrants screened at Centre for Tropical Diseases of Negrar from March 2014 to February 2016. Of the 373 immigrants tested, 34% were positive at least at one schistosomiasis test. The proportion of positive ELISA serology was 103/373 (27.6%). At microscopy, infected subjects were 65/373 (17.4%), (51% Schistosoma haematobium, 38% Schistosoma mansoni, 11% both). CCA antigen for S. mansoni was positive in 47/373 individuals (12.6%). We found a particularly high positivity rate in subjects from Mali (72.1%) and Ivory Coast (48%). This "hidden epidemic" of schistosomiasis cannot be longer neglected, considering the risk of severe complications, and the effective and inexpensive treatment available.

Early hyperreactive malarial splenomegaly and risk factors for evolution into the full-blown syndrome: a single-centre, retrospective, longitudinal study.

BACKGROUND: The hyperreactive malarial splenomegaly (HMS) represents a chronic, potentially fatal complication of malaria. Case definition includes: gross splenomegaly, high level of anti-malarial antibody and IgM, response to long-term anti-malarial prophylaxis. In this study, a large series of patients not fully meeting the case definition was tentatively classified as early hyperreactive malarial splenomegaly (e-HMS). The main research questions was: does "e-HMS" tend to evolve to the full-blown syndrome? And if so, what are the main factors influencing this evolution? METHODS: Retrospective, longitudinal study. The patient database was searched to retrieve all potentially eligible patients. e-HMS was defined by splenomegaly of any size (with or without raised IgM), high anti-malarial antibody titre and exclusion of other causes of splenomegaly. The clinical outcome at following visits was analysed in relation to re-exposure to malaria, and to treatment (only part of the patients with e-HMS were treated with a single anti-malarial treatment and advised to follow an effective anti-malarial prophylaxis, if re-exposed). The association of the outcome with the main independent variables was first assessed with univariate analysis. A stepwise logistic regression model was then performed to study the association of the outcome with the main independent variables. RESULTS: One hundred and twenty-six subjects with e-HMS were retrieved. Eighty-one had at least one follow-up visit. Of 46 re-exposed to malaria for a variable period, 21 (46 %) had progressed, including 10/46 (22 %) evolving to full-blown HMS, while of 29 patients not re-exposed, 24 (93 %) had improved or cured and five (7 %) progressed (p < 0.001). At logistic regression re-exposure was confirmed as a major risk factor of progression (OR 9.458, CI 1.767-50.616) while treatment at initial visit was protective (OR 0.187, CI 0.054-0.650). CONCLUSION: e-HMS should be regarded as a clinical condition predisposing to HMS. Although the case definition may include false positives, e-HMS should be treated just as the full-blown syndrome. A single anti-malarial treatment is probably adequate, followed by effective prophylaxis for patients exposed again to malaria transmission.

Evaluation of an indirect immunofluorescence assay for strongyloidiasis as a tool for diagnosis and follow-up.

The diagnostic accuracy of an indirect immunofluorescence antibody test (IFAT) for Strongyloides stercoralis at different serum antibody titers was evaluated. To assess diagnostic sensitivity, sera from 156 patients with known strongyloidiasis were collected. Negative control sera were obtained from a composite group of 427 subjects (blood donors and hospitalized patients). With an area under the receiver-operating characteristic plot of 0.98, the IFAT showed a high level of diagnostic accuracy for strongyloidiasis. An antibody titer of > or = 1:20, with 97% sensitivity and 98% specificity, was identified as the diagnostic threshold with the best overall performance. Cross-reactions were evaluated with 41 additional samples from patients with other known helminth infections, and the IFAT detected low-titer positivity in only one subject with filariasis. A positive IFAT result at an antibody dilution of > or = 1:80 was virtually 100% specific, with 71% sensitivity. To test the usefulness of the IFAT as a monitoring tool, the changes in specific-antibody titers after treatment in a group of 155 patients were evaluated. Seroreversion or a decrease in antibody titer of twofold or more was observed in 60% of the patients. Response to treatment was directly correlated to the initial antibody titer, and a baseline titer of > or = 1:80 was identified as the best predictor of response. In conclusion, a positive IFAT result at an antibody dilution of >/=1:20 is the optimal cutoff for screening. A titer of > or = 1:80, with virtually no false-positive result, is a reliable cutoff for a serological assessment of treatment efficacy and for inclusion in clinical trials.