[An outbreak of measles at an emergency room]. / Een uitbraak van mazelen op de Spoedeisende Hulp.

A small outbreak of measles occurred after a 33-year-old female aircrew (cabin) member presented at an emergency room with fever. Three members of the hospital staff were infected: a 42-year-old man, a 33-year-old woman, and a 26-year-old woman. The first 2 patients had not been immunised, and the third had received 2 immunisations according to the Dutch National Immunisation Programme. Vaccination of the 2 sero-negative patients within 48 h after exposure with the measles-mumps-rubella vaccine (MMR) did not prevent the development of measles. Vaccination was deemed unnecessary in the third patient. No tertiary cases occurred. The same measles virus (genotype D5) was detected by PCR and sequencing in all 4 patients. Measles remains a risk for hospital staff members who have not acquired natural immunity. The current policy of immunising patients within 72 h after exposure to measles may not be sufficient. It also appears that immunisation through the Dutch National Immunisation Programme does not always protect against nosocomial infection. Providing MMR vaccination or boosters to hospital staff in certain departments might be beneficial.

[Tropical or non-tropical sprue?]. / Inheemse of uitheemse spruw?

A 57-year-old Dutch man presented with weight loss and fatigue 6 months after a visit to West Papua, when he had suffered from serious diarrhoea. Macrocytic anaemia and vitamin B12 deficiency were diagnosed. A gastroduodenoscopy with biopsies of the small intestine was performed revealing no macroscopic abnormalities but partial villous atrophy was found microscopically, suggesting tropical sprue or coeliac disease. Antibodies against endomysium and tissue transglutaminase were negative, ruling out coeliac disease. The patient was successfully treated with vitamin B12, folic acid and doxycycline. This case shows that tropical sprue should be considered in the differential diagnosis of chronic diarrhoea in patients with a history of travel in tropical regions. The most frequent medical problem that travelers to the tropics experience is diarrhoea with an incidence of 30%. A small proportion of these patients eventually present with chronic diarrhoea. At that moment, the relation to their previous travelling may not be immediately clear. One of the causes of this chronic diarrhoea to be considered is tropical sprue.

[Infestation with the tapeworm Diphyllobothrium latum after eating raw fish]. / Infestatie met de lintworm Diphyllobothrium latum na het eten van rauwe vis.

A 31-year-old man with no relevant medical history encountered a white, ribbon-shaped object, 15 cm long and approximately 1 cm wide, in his faeces. It turned out to be Diphyllobothrium latum, a tapeworm that has fish as the intermediate host. The patient had eaten raw fish and shellfish during a holiday in Brazil 5 months before. He recovered after a single dose of praziquantel.

Changing pattern of imported cutaneous leishmaniasis in the Netherlands.

Cutaneous leishmaniasis (CL) in western countries seems to be appearing more frequently. Our aim was to determine if there has been a shift in countries where CL is acquired and whether the incidence has changed, and to assess current diagnostic procedures and treatment modalities. In a retrospective study medical records of patients with the diagnosis of CL at the Departments of Tropical Dermatology and Tropical Medicine, Academic Medical Center, Amsterdam, the Netherlands, from 1990 to 2000 were analysed. CL was diagnosed in 78 patients. The majority was acquired in Belize, Surinam, French Guyana and Bolivia. Giemsa stains were positive for the parasite in impression smears from 43% and in biopsies from 71%. Seventy-eight per cent of cases were culture-positive and 89% were PCR-positive. Sixty-two patients were treated systemically: pentavalent antimony (32), pentamidine isetionate (11), itraconazole (19), and 13 locally, the majority with a combination of cryosurgery and intralesional pentavalent antimony. Imported CL is becoming more frequent, with South and Middle American countries being important sources of infection. Multiple tests, of which PCR is the most sensitive, are required to confirm the diagnosis. Systemic treatment was given to the majority of the patients.

High mortality among patients with bacterial meningitis in a rural hospital in Tanzania.

Although the disease is an important cause of mortality in the region, most published reports on bacterial meningitis in East Africa are from urban referral hospitals. Poor laboratory facilities make diagnosis difficult in the area and treatment is limited to inexpensive antibiotics. The case-fatality 'rate' in one rural hospital in Tanzania, the Ndala Mission Hospital (NMH), appears to have increased dramatically over recent years, perhaps as the result of increasing resistance to ampicillin and chloramphenicol. The aim of the present study, which was partially retrospective and partially prospective, was to review the number, characteristics and outcome of children admitted to this hospital with bacterial meningitis and to investigate possible resistance of the causative micro-organisms to the antibiotics used. Data from the 181 children who were admitted with bacterial meningitis [confirmed by the examination of Gram-stained smears of cerebrospinal fluid (CSF)] between 1999 and 2002 were retrospectively reviewed. The overall mortality among these children was 51%. No seasonal pattern was observed in the number of cases. In a 2-month prospective study in 2002, CSF samples from 19 consecutive cases were collected in Trans-Isolate medium and shipped to the Academic Medical Center in Amsterdam for culture and analysis of antibiotic susceptibility. For only eight (42%) of the cases was there agreement between the species of bacterium identified, by Gram-staining, in Tanzania and that identified, by culture, in The Netherlands. As there was no evidence of resistance to ampicillin and the antibiotics used in the NMH were found to be of good quality, the cause of the high mortality in the NMH remains uncertain. Poor laboratory testing, long doctor-patient delays and/or poor drug administration on the wards may all be contributory factors. Attempts will now be made to address each of these problems.

[Recurrent, itching and creeping skin lesions in (former) travellers to the tropics: strongyloidiasis]. / Recidiverende, jeukende en zich verplaatsende huidafwijkingen bij (voormalige) tropenreizigers: strongyloidiasis.

Two patients, a woman aged 24 and a man aged 86, had suffered from recurrent, itchy, linear, creeping skin lesions, notably on the thighs, buttocks and lower abdomen, for 9 months and more than 50 years, respectively. The woman had been in South America, and the man had worked on the Burma railway as a prisoner of war during World War II. In both patients 'larva currens' was observed. The clinical diagnosis of 'strongyloidiasis' was supported by eosinophilia and raised antibody titres against Strongyloides stercoralis in the blood. No larvae could be detected in either patient. Treatment with albendazole, and ivermectin, respectively, resulted in disappearance of the complaints. S. stercoralis is found in many parts of the world. In the Netherlands the major risk groups in which strongyloidiasis should be considered are people from, and visitors to, South-America (Surinam) and South-East Asia (Indonesia, former prisoners of war).

[Malaise after a trip to Africa: amoebic liver abscess]. / Malaise na een Afrika-reis: amoebenabces van de lever.

During a flight to Kenya, a 42-year-old man took a therapeutic dose of chloroquine because of fever. He regularly travelled to Africa and always took chloroquine and proguanil for malaria prophylaxis. The fever disappeared but he did not fully recover. He complained of malaise and weight loss. Fourteen years previously he had suffered from amoebic dysentery. One month after the onset of the patient's complaints, an amoebic liver abscess was suspected on the basis of his medical history, an elevated ESR and a slight leukocytosis. The diagnosis was confirmed by ultrasonography and serology.