Spectrum of disease and relation to place of exposure among ill returned travelers

[Immigration and HIV: pulmonary, cutaneous and genitourinary syndromes. Eosinophilia]

Infectious diseases are the leading cause of mortality in less developed countries, many of which are located in tropical areas. These diseases have particular features than can hamper diagnosis unless clinicians are familiar with their characteristics. The present article describes the clinical pattern of pulmonary, cutaneous and genitourinary tropical diseases and the main principles of their diagnosis. Emphasis is placed on their geographical distribution and the influence of HIV infection.

Cutaneous leishmaniasis with lymphadenopathy due to Leishmania donovani

We describe a case of cutaneous leishmaniasis with lymphadenopathy due to Leishmania donovani, which was successfully treated with oral miltefosine. Given the increased prevalence of travelling, patients presenting with lymph-node enlargement should have leishmaniasis included in the differential diagnosis even in the absence of typical ulceration.

Eosinophilia in returning travelers and migrants

INTRODUCTION

Eosinophilia in travelers returning from tropical countries is often caused by helminths. The high eosinophil counts arise particularly from tissue migration of invasive larvae.

METHODS

Review of literature selected by means of a Medline search using the MeSH terms "eosinophilia" and "helminth."

RESULTS

The patient's geographic and alimentary history may suggest infection with particular parasitic worms. A targeted diagnostic approach is suggested. The physician should concentrate on the principal signs and be guided by the geographic and alimentary history. Elaborate diagnostic measures are seldom indicated.

DISCUSSION

Although eosinophilia alone has low positive predictive value for a worm infection, it points clearly to helminthosis if the patient has recently returned from the tropics and the eosinophilia is new.

The role of the traveler in emerging infections and magnitude of travel

Travel and trade have grown immensely. Travelers interact with people and microbes during their journeys, and can introduce infectious agents to new areas and populations. Studying illnesses in travelers is a source of knowledge into diseases of resource-poor regions and the control of these diseases. Travel-associated illnesses also serve to detect emerging infections.

Geographic expansion of dengue: the impact of international travel

Dengue has emerged as an international public health problem. Reasons for the resurgence of dengue in the tropics and subtropics are complex and include unprecedented urbanization with substandard living conditions, lack of vector control, virus evolution, and international travel. Of all these factors, urbanization has probably had the most impact on the amplification of dengue within a given country, and travel has had the most impact for the spread of dengue from country to country and continent to continent. Epidemics of dengue, their seasonality, and oscillations over time are reflected by the epidemiology of dengue in travelers. Sentinel surveillance of travelers could augment existing national public health surveillance systems.

Health problems in returning travelers consulting general practitioners

Over a 2-month period, 43 of 143 participating general practitioners included 97 patients with 113 health impairments, mainly gastrointestinal problems (35%), respiratory tract infections (30%), and skin diseases (11%). Systemic febrile illness or imported tropical disease accounted for less than 4% of cases.

[Imported infectious diseases in Spain]

In Spain, owing to the rise of international travels and immigration, the number of patients with imported infectious diseases has increased, many of them from tropical or subtropical areas. In parallel, there has been a multiplication in the number of scientific papers with Spanish authors about imported infections due to parasites, fungus, mycobacteriae, bacteriae or viruses. The risk for public health is low, althought for their correct prevention and control it is important to ease an universal access to healthcare and fair socioeconomic conditions, along with maintaining an updated clinical and epidemiological training of the health personnel. These nationwide measures must be supplemented with worldwide initiatives of global control of these infections.

Seasonality, annual trends, and characteristics of dengue among ill returned travelers, 1997-2006

Atypical patterns may indicate onset of epidemic activity.

We examined seasonality and annual trends for dengue cases among 522 returned travelers reported to the international GeoSentinel Surveillance Network. Dengue cases showed region-specific peaks for Southeast Asia (June, September), South Central Asia (October), South America (March), and the Caribbean (August, October). Travel-related dengue exhibited annual oscillations with several epidemics occurring during the study period. In Southeast Asia, annual proportionate morbidity increased from 50 dengue cases per 1,000 ill returned travelers in nonepidemic years to an average of 159 cases per 1,000 travelers during epidemic years. Dengue can thus be added to the list of diseases for which pretravel advice should include information on relative risk according to season. Also, dengue cases detected at atypical times in sentinel travelers may inform the international community of the onset of epidemic activity in specific areas.

International travel and exposure risks in solid-organ transplant recipients

BACKGROUND

Although solid-organ transplant recipients (SOTR) have an increased risk of acquiring illnesses, they may not receive optimal pretravel care. We conducted a cross-sectional survey of travel activities and outcomes among SOTR.

METHODS

Two thousand five hundred fifty-four consecutive living SOTR from Mayo Clinic were surveyed regarding travel practices, pretravel counseling, exposure risks, and illness using a previously standardized and validated questionnaire.

RESULTS

One thousand one hundred thirty SOTR (44%) responded to the survey and were included in the study. The most common transplanted organs were liver (519 patients) and kidney (515 patients). Three hundred and three (27%) respondents reported travel outside of the United States or Canada after their transplant. Liver recipients were more likely to travel than other organ recipients. Ninety-six percent of travelers reported that they did not seek specific pretravel healthcare before their trip. Forty-nine SOTR (16%) traveled to destinations at higher risk for infectious diseases; travelers to these destinations were more likely to be men (73% vs. 54% of low-infection risk travelers, P=0.018) or born outside the United Stated or Canada (29% vs. 6% P<0.0001). Twenty-four travelers (8%) required medical attention because of illness; illness was more likely among travelers to high-infection risk (18%) than low-risk (6%) destinations, P=0.004.

CONCLUSIONS

International travel was common after solid organ transplantation, although the majority traveled to destinations at low risk for infectious disease. Although generally SOTR were able to travel safely, travelers to destinations at high-risk for infection had a significant rate of illness. Pretravel counseling and interventions were infrequent and should be improved.

Dengue vaccines for travelers

Dengue is an arthropod-borne infection caused by a flavivirus and spread by the Aedes mosquitoes. Many of the countries where dengue is endemic are popular tourist destinations and the disease is an increasingly important problem encountered by international travelers. Personal protection against the day-feeding dengue vectors is problematic, indicating the urgent need for a dengue vaccine. This review discusses the challenges of vaccine development, current vaccine strategies and the prospects for the availability of a vaccine for travelers in the future. Cost-effectiveness studies will need to take into account many factors, including the attack rate of dengue in travelers, the proportion of travelers who will need hospitalization, the cost of altered travel itineraries, the cost of the vaccine, duration of travel, destination and season. To be licensed as a travelers' vaccine, vaccine trials must address safety, immunogenicity, duration of protection, schedules and boosters in adults (in particular in immunologically naive adults), trials that may differ from those conducted in endemic countries. Vaccine schedules with long intervals would be a major obstacle to the uptake of the vaccine by travelers. Enhanced reactogenicity or interference with immunization must be effectively excluded for travelers with prior or concurrent vaccination against other flaviviruses, such as yellow fever or Japanese encephalitis. Licensing dengue as a travelers' vaccine poses unique challenges beyond the development of a vaccine for the endemic population.

African tick bite fever in elderly patients: 8 cases in French tourists returning from South Africa

BACKGROUND

African tick-bite fever, a tickborne disease caused by Rickettsia africae, is endemic in rural areas of sub-Saharan Africa and in the French West Indies. Most cases reported in the literature occurred in middle-aged, otherwise-healthy persons and corresponded to benign diseases. The course of African tick bite fever in elderly people is less well documented.

METHODS

The medical records of 8 elderly patients infected with R. africae during a trip to South Africa in 2005 are presented to summarize the epidemiologic, clinical, microbiological, treatment, and disease course characteristics.

RESULTS

Eight patients, aged 63-75 years, developed African tick bite fever symptoms after a trip to South Africa. R. africae was grown from cutaneous eschar biopsy specimens obtained from 4 patients, confirming African tick bite fever. We observed unusual findings in this elderly population. Rash was frequent (present in 87.5% of patients), vesicular (in 100% of patients with rash), and often associated with an enanthema (in 50% of patients with rash). Severe clinical manifestations occurred: lymphangitis and myocarditis in 1 patient and suspected brain involvement in 2 patients. We observed severe and long-lasting general symptoms, including fever (in 75% of patients), chills (87.5%), asthenia (50%), anorexia (50%), and weight loss (12.5%). With doxycycline therapy, the outcome was favorable in all cases, but complete recovery was slow.

CONCLUSION

Ecotourism to sub-Saharan Africa is expanding, and people of advanced age, often with underlying chronic diseases, account for an increasing proportion of travelers. African tick bite fever appears to be more symptomatic in this population. Recommendations advising personal prophylactic measures to prevent tick bites in travelers to regions of endemicity may be particularly important for elderly individuals.

Gastrointestinal infection among international travelers globally

BACKGROUND

Data on relative rates of acquisition of gastrointestinal infections by travelers are incomplete. The objective of this study was to analyze infections associated with oral ingestion of pathogens in international travelers in relation to place of exposure.

METHODS

We performed a multicenter, retrospective observational analysis of 6,086 travelers ill enough with any gastrointestinal infection to seek medical care at a GeoSentinel clinic after completion of travel during 2000 to 2005. We determined regional and country-specific reporting rate ratios (RRRs) in comparison to risk in northern and western Europe.

RESULTS

Travel to sub-Saharan Africa (RRR = 282), South America (RRR = 203), and South Asia (RRR = 890) was associated with the greatest rate of gastrointestinal infections. RRRs were moderate (25-142) for travel to Oceania, the Middle East, North Africa, Central America, the Caribbean, and Southeast Asia. RRRs were least (<28) following travel to southern, central, and eastern Europe; North America; Northeast Asia; and Australasia. Income level of the country visited was inversely proportional to the RRR for gastrointestinal infection. For bacterial and parasitic infections examined separately, the regions group in the same way. RRRs could be estimated for 28 individual countries and together with regional data were used to derive a global RRR map for travel-related gastrointestinal infection.

CONCLUSIONS

This analysis of morbidity associated with oral ingestion of pathogens abroad determines which parts of the world currently are high-risk destinations.

A retrospective study of 230 consecutive patients hospitalized for presumed travel-related illness (2000-2006)

A good knowledge of morbidity profiles among ill-returned travelers is necessary in order to guide their management. We reviewed the medical charts of 230 patients hospitalized in one infectious diseases department in France for presumed travel-related illnesses. The male-to-female ratio was 1.6 and the median age was 33 years (interquartile range [IQR], 25–50). Most patients (70.9%) were returning from sub-Saharan Africa. The median duration of travel was 28 days (IQR, 15–60) and the median time from return of travel to hospitalization was 13 days (IQR, 7–21). Malaria was the most frequent diagnosis (49.1%), which was especially encountered in patients returning from sub-Saharan Africa (95.6%), without adequate chemoprophylaxis (78.2%). Imported diseases at risk of secondary transmission were also diagnosed, including pulmonary tuberculosis (n = 8), viral hepatitis (n = 8), typhoid fever (n = 6), human immunodeficiency virus (HIV) (six new diagnosis), non-typhoid salmonellosis (n = 5), severe acute respiratory syndrome, and Crimean-Congo hemorrhagic fever. This study underlines the need to maintain tropical expertise for infectious diseases physicians, even in Europe.

Epidemiological and clinical characteristics of hookworm-related cutaneous larva migrans

Hookworm-related cutaneous larva migrans is caused by the migration of animal hookworm larvae in the human skin. The disease mainly occurs in resource-poor communities in the developing world, but it is also reported sporadically in high-income countries and in tourists who have visited the tropics. Diagnosis is made clinically in the presence of a linear serpiginous track moving forward in the skin, associated with itching and a history of exposure. Itching is typically very intense and can prevent patients from sleeping. Bacterial superinfection occurs as a result of scratching. Treatment is based on oral drugs (albendazole or ivermectin) or the topical application of tiabendazole. To control hookworm-related cutaneous larva migrans at the community level, regular treatment of dogs and cats with anthelmintic drugs is necessary, but this is seldom feasible in resource-poor settings. Animals should be banned from beaches and playgrounds. For protection at the individual level, unprotected skin should not come into contact with possibly contaminated soil.

Oligosymptomatic dengue infection: a potential cause of Guillain Barré syndrome

BACKGROUND: Dengue infection may cause neurological manifestations such as encephalitis, myelitis, mononeuropathies, acute disseminated encephalomyelitis, and Guillain Barré syndrome (GBS). In endemic regions, the infection course can be oligosymptomatic making difficult the diagnosis of the neurological picture associated with dengue infection. OBJECTIVE: To report dengue infection and GBS association, even in oligosymptomatic cases of this infection. METHOD: During the dengue epidemic in Rio de Janeiro city we looked for GBS cases, testing IgM antibodies for dengue and dengue polymerase chain reaction (PCR) in the cerebrospinal fluid (CSF) and serum. RESULTS: We report seven cases (46.6%), presenting dengue positive IgM in serum but with poor or without clinical symptoms of the previous infection. Two of them had also positive IgM antibodies in CSF. CONCLUSION: These data show that search for dengue infection should be a routine in GBS cases living in endemic areas.

Prevalence and risk factors of hookworm-related cutaneous larva migrans in a rural community in Brazil

The epidemiology of hookworm-related cutaneous larva migrans (HrCLM) in endemic communities is not well understood. To describe the prevalence of HrCLM and to identify environmental and behavioural risk factors for the infestation, two cross-sectional surveys were conducted in a small village in an endemic area of north-eastern Brazil - one in the rainy season and the other in the dry season. The members of each household were examined clinically for the presence of HrCLM, and information on possible risk factors was collected. HrCLM, which was diagnosed in 45 individuals in the rainy-season survey and in 17 in the dry-season survey, was significantly more prevalent in the rainy season (4.4% v. 1.7%; P<0.001). The age-specific prevalences peaked, at 14.9%, in infants and children aged < or = 4 years. In a logistic regression analysis, the independent risk factors for current infestation or infestation in the preceding 6 months were identified as young age (odds ratio = 0.96; 95% confidence interval = 0.94-0.98), living in a house without a solid floor (odds ratio = 1.99; 95% confidence interval = 1.22-3.23), and walking barefoot (odds ratio = 1.77; 95% confidence interval = 1.12-2.80). In the study area, therefore, HrCLM is a common parasitic skin disease in children, is associated with behavioural and environmental risk factors, and shows marked seasonality in its prevalence. Local control of HrCLM should be based primarily on the health education of mothers and the elder girls who take care of their younger siblings.

Determinants of malaria prophylaxis among German travelers to Kenya, Senegal, and Thailand

BACKGROUND

Malaria chemoprophylaxis is a mainstay of malaria prevention in travelers. Adequate pretravel advice forms the basis for efficient malaria prophylaxis. This study assessed the determinants for seeking pretravel advice and evaluated the quality of advice from each source and its influence on the patterns and outcome of malaria prophylaxis intake.

METHODS

In March and April 2004, a self-administered questionnaire was distributed by cabin crews to passengers flying back to Germany from three popular tourist destinations: Kenya, Senegal, and Thailand. To evaluate the quality of advice and actual intake, figures were assessed against the official recommendations of the German Society of Travel Medicine and International Health (DTG).

RESULTS

A total of 1,001 passengers were included in the study (Kenya, 492; Senegal, 131; and Thailand, 378), of which 81% had sought any kind of pretravel health advice. Travelers' age and time of pretravel consultation were associated with the source of information consulted. Seventy-five percent of travelers from Senegal and Kenya received DTG compliant advice compared to only 17% of travelers from areas with low malaria risk in Thailand. Travelers returning from Kenya and Senegal had used correct chemoprophylaxis in only 65 and 47% of trips, respectively. In multivariate analysis, the factors determining correct intake among Senegal and Kenya travelers were receiving pretravel advice (from nonmedical professionals: OR 4.4, 95% CI 1.9-10.0 and from medical professionals: OR 15.4, 95% CI 7.3-32.4), a correct risk perception (OR 2.9, 95% CI 1.9-4.5), 2 to 3 weeks of travel abroad (vs a duration >3 wk: OR 2.2, 95% CI 1.3-3.8), and travel to Kenya (OR 1.9, 95% CI 1.1-3.1).

CONCLUSIONS

Malaria prevention among a large proportion of German travelers to tropical destinations is inadequate. Public health efforts should be made to raise awareness among travelers, travel agencies, and medical institutions in Germany.

Climate change and infectious diseases in North America: the road ahead

Global climate change is inevitable--the combustion of fossil fuels has resulted in a buildup of greenhouse gases within the atmosphere, causing unprecedented changes to the earth's climate. The Fourth Assessment Report of the Intergovernmental Panel on Climate Change suggests that North America will experience marked changes in weather patterns in coming decades, including warmer temperatures and increased rainfall, summertime droughts and extreme weather events (e.g., tornadoes and hurricanes). Although these events may have direct consequences for health (e.g., injuries and displacement of populations due to thermal stress), they are also likely to cause important changes in the incidence and distribution of infectious diseases, including vector-borne and zoonotic diseases, water-and food-borne diseases and diseases with environmental reservoirs (e.g., endemic fungal diseases). Changes in weather patterns and ecosystems, and health consequences of climate change will probably be most severe in far northern regions (e.g., the Arctic). We provide an overview of the expected nature and direction of such changes, which pose current and future challenges to health care providers and public health agencies.

Dermatologic conditions of the ill returned traveler: an analysis from the GeoSentinel Surveillance Network

BACKGROUND

Skin disorders are common in travelers. Knowledge of the relative frequency of post-travel-related skin disorders, including their geographic and demographic risk factors, will allow for effective pre-travel counseling, as well as improved post-travel diagnosis and therapeutic intervention.

METHODS

We performed a retrospective study using anonymous patient demographic, clinical, and travel-related data from the GeoSentinel Surveillance Network clinics from January 1997 through February 2006. The characteristics of these travelers and their itineraries were analyzed using SAS 9.0 statistical software.

RESULTS

A skin-related diagnosis was reported for 4594 patients (18% of all patients seen in a GeoSentinel clinic after travel). The most common skin-related diagnoses were cutaneous larva migrans (CLM), insect bites including superinfected bites, skin abscess, and allergic reaction (38% of all diagnoses). Arthropod-related skin diseases accounted for 31% of all skin diagnoses. Ill travelers who visited countries in the Caribbean experienced the highest proportionate morbidity due to dermatologic conditions. Pediatric travelers had significantly more dog bites and CLM and fewer insect bites compared with their adult counterparts; geriatric travelers had proportionately more spotted fever and cellulitis.

CONCLUSIONS

Clinicians seeing patients post-travel should be alert to classic travel-related skin diseases such as CLM as well as more mundane entities such as pyodermas and allergic reactions. To prevent and manage skin-related morbidity during travel, international travelers should avoid direct contact with sand, soil, and animals and carry a travel kit including insect repellent, topical antifungals, and corticosteroids and, in the case of extended and/or remote travel, an oral antibiotic with ample coverage for pyogenic organisms.

Tuberculosis risk in US Peace Corps Volunteers, 1996 to 2005

BACKGROUND

With the popularity of international travel increasing, more travelers in endemic areas may increase their risk of tuberculosis (TB). We analyzed Peace Corps data to assess the risk of TB in long-term travelers from the United States.

METHODS

We analyzed purified protein derivative (PPD) conversion and acute TB case data from the Peace Corps Epidemiological Surveillance System as well as postservice claims data. We calculated the risk of PPD conversion and active TB in all countries with Peace Corps Volunteers between 1996 and 2005 and compared these risks with other published data.

RESULTS

The overall incidence rates for positive PPD conversions and active TB cases are 1.283 and 0.057 per 1,000 Volunteer-months, respectively. The Africa region had the highest PPD conversion rate of 1.467 conversions per 1,000 Volunteer-months as well as the highest active TB rate of 0.089 cases per 1,000 Volunteer-months. Per-country incidence rates for PPD conversions and active TB cases ranged widely from 0.000 to 5.514 cases and 0.000 to 2.126 cases per 1,000 Volunteer-months, respectively. In countries identified as "high risk," there were 1.436 cases of PPD conversions and 0.084 cases of active TB per 1,000 Volunteer-months.

CONCLUSIONS

Peace Corps Volunteers have significantly higher rates of TB when compared to the average US population but much lower than those reported for travelers to highly endemic countries. Volunteers assigned to highly endemic countries still have a lower risk compared to other travelers to those same countries. Keeping in mind that Peace Corps Volunteers are a unique population, these data may be useful in providing medical advice to long-term travelers.

Fever of unknown origin in the returning traveler

The returning traveler with fever presents a diagnostic challenge for the health care provider. When evaluating such a patient, the highest priority should be given to diseases that are potentially fatal or may represent public health threats. A good history is paramount and needs to include destination, time and duration of travel, type of activity, onset of fever in relation to travel, associated comorbidities, and any associated symptoms. Pretravel immunizations and chemoprophylaxis may alter the natural course of disease and should be inquired about specifically. The fever pattern, presence of a rash or eschar, organomegaly, or neurologic findings are helpful physical findings. Laboratory abnormalities are nonspecific but when corroborated with clinical and epidemiologic data may offer a clue to diagnosis.

Amebic colitis: new insights into pathogenesis and treatment

Amebiasis, caused by the protozoan parasite Entamoeba histolytica, affects more than 50 million people worldwide, with over 100,000 deaths annually. The majority of cases are asymptomatic; however, significant morbidity and mortality are associated with illness in the remaining 10% of cases. Recent advances in the understanding of the mechanism of infection by E. histolytica, the role of the innate immune system, and the role of genetic disposition to infection will allow the development of novel detection and treatment methods. The disease mechanisms, clinical findings, therapeutic strategies, and important developments regarding amebiasis are discussed here.

The exanthem of dengue fever: Clinical features of two US tourists traveling abroad

BACKGROUND

Dengue fever is the most common identifiable cause of acute febrile illness among travelers returning from South America, South Central Asia, Southeast Asia, and the Caribbean. Although the characteristic exanthem of dengue fever occurs in up to 50% of patients, few descriptions of it are found in the dermatology literature, and discussions of how to distinguish the dengue exanthem from other infectious disease entities are rare. Chikungunya fever is an emerging infectious disease now seen in returning US tourists and should be considered in the differential diagnosis of dengue fever in the appropriate patient.

OBJECTIVE

The purpose of our study was to report two cases of dengue fever among returning US tourists, provide a review of dengue fever, offer an extensive differential diagnosis of dengue fever, and raise awareness among dermatologists of chikungunya fever.

METHODS

This study includes clinical findings of two returning travelers, one who traveled to Mexico and the other to Thailand, complemented by a discussion of both dengue fever and its differential diagnosis.

LIMITATIONS

Limited to 2 case reports.

CONCLUSION

Dengue fever should be considered in the differential diagnosis of fever and rash in the returning traveler. Dermatologists should be aware of the distinctive exanthem of dengue fever. Recognition of the dengue fever rash permits a rapid and early diagnosis, which is critical, as dengue fever can progress to life-threatening dengue hemorrhagic fever or dengue shock syndrome.

Antimicrobial prevention and therapy for travelers' infection

International journeys are increasing and more than 70 million people from industrialized countries cross the borders of tropical countries every year. More than 50% of them will suffer from some form of infectious illness, ranging from mild travelers' diarrhea to severe dengue fever to fatal malaria, with a wide spectrum of microbiological entities. Travel-related respiratory infections, including TB, and sexually transmitted infections are also increasingly reported. Awareness of travel-related risk is not always adequate among international travelers. Specific training on travel medicine-related issues, as well as better diagnostic facilities for imported diseases, is crucial for physicians and nurses in industrialized countries.

Rabies postexposure prophylaxis in returned injured travelers from France, Australia, and New Zealand: a retrospective study

BACKGROUND

There is little published information available describing rabies pre- and postexposure prophylaxis (PEP) in tourists returning to their home country and seeking care for animal-associated injuries, especially those associated with a rabies risk.

METHOD

We analyzed 261 travelers seeking care on returning to their home country following an animal-related injury acquired abroad. Information on individual cases of rabies (PEP) including preexposure status, type of contact with a potentially rabid animal, type of animal, and the nature of rabies PEP was collected by retrospectively analyzing records from May 1997 to May 2005.

RESULTS

The majority of injuries were acquired in South-east Asia and North Africa. Only 6.8% of injured patients were previously vaccinated against rabies, while 75.4% of the cohort experienced a severe injurious contact with animals (World Health Organization category III). Of travelers who sustained a high-risk injury, only 24% received both vaccination and rabies immune globulin,(RIG) while 76% received vaccination only. Of the travelers who did not receive RIG, 43% had received a first dose of vaccine more than 7 days after return and before presenting to a clinic in their home country.

CONCLUSIONS

This study highlights important deficiencies in rabies PEP for travelers who acquire high-risk, animal-associated injuries in rabies-endemic countries, with the majority not receiving adequate PEP or experiencing a substantial delay before receiving rabies vaccination.

Imported tropical infectious ulcers in travelers

Skin ulcers are a commonly encountered problem at departments of tropical dermatology in the Western world. Furthermore, the general dermatologist is likely to be consulted more often for imported chronic skin ulcers because of the ever-increasing travel to and from tropical countries. The most common cause of chronic ulceration throughout the world is probably pyoderma. However, in some parts of the world, cutaneous leishmaniasis is one of the most prevalent causes. Mycobacterium ulcerans is an important cause of chronic ulcers in West Africa. Bacterial infections include pyoderma, mycobacterial infections, diphtheria, and anthrax. Pyoderma is caused by Staphylococcus aureus and/or beta-hemolytic streptococci group A. This condition is a common cause of ulcerative skin lesions in tropical countries and is often encountered as a secondary infection in travelers. The diagnosis is often made on clinical grounds. Antibacterial treatment for pyoderma should preferably be based on culture outcome. Floxacillin is generally active against S. aureus and beta-hemolytic streptococci. Infection with Mycobacterium ulcerans, M. marinum, and M. tuberculosis may cause ulcers. Buruli ulcers, which are caused by M. ulcerans, are endemic in foci in West Africa and have been reported as an imported disease in the Western world. Treatment is generally surgical, although a combination of rifampin (rifampicin) and streptomycin may be effective in the early stage. M. marinum causes occasional ulcerating lesions in humans. Treatment regimens consist of combinations containing clarithromycin, rifampin, or ethambutol. Cutaneous tuberculosis is rare in travelers but may be encountered in immigrants from developing countries. Treatment is with multiple drug regimens consisting of isoniazid, ethambutol, pyrazinamide, and rifampin. Cutaneous diphtheria is still endemic in many tropical countries. Cutaneous diphtheria ulcers are nonspecific and erythromycin and penicillin are both effective antibacterials. Antitoxin should be administered intramuscularly in suspected cases. Anthrax is caused by spore-forming Bacillus anthracis. This infection is still endemic in many tropical countries. Eschar formation, which sloughs and leaves behind a shallow ulcer at the site of inoculation, characterizes cutaneous anthrax. Penicillin and doxycycline are effective antibacterials. Cutaneous leishmaniasis is caused by different species belonging to the genus Leishmania. The disorder is one of the ten most frequent causes of skin diseases in travelers returning from (sub)tropical countries. The clinical picture is diverse, ranging from a painless papule or nodule to an ulcer with or without a scab. Treatment depends on the clinical manifestations and the species involved.Sporotrichosis, chromo(blasto)mycosis, and mycetoma are the most common mycoses that may be accompanied by ulceration. Infections are restricted to certain regions and often result from direct penetration of the fungus into the skin. Anti-mycotic treatment depends on the microorganism involved. The most common causes of infectious skin ulceration encountered in patients from tropical countries who present at a department of tropical dermatology are reviewed in this article.

Filariasis in travelers presenting to the GeoSentinel Surveillance Network

BACKGROUND

As international travel increases, there is rising exposure to many pathogens not traditionally encountered in the resource-rich countries of the world. Filarial infections, a great problem throughout the tropics and subtropics, are relatively rare among travelers even to filaria-endemic regions of the world. The GeoSentinel Surveillance Network, a global network of medicine/travel clinics, was established in 1995 to detect morbidity trends among travelers.

PRINCIPAL FINDINGS

We examined data from the GeoSentinel database to determine demographic and travel characteristics associated with filaria acquisition and to understand the differences in clinical presentation between nonendemic visitors and those born in filaria-endemic regions of the world. Filarial infections comprised 0.62% (n = 271) of all medical conditions reported to the GeoSentinel Network from travelers; 37% of patients were diagnosed with Onchocerca volvulus, 25% were infected with Loa loa, and another 25% were diagnosed with Wuchereria bancrofti. Most infections were reported from immigrants and from those immigrants returning to their county of origin (those visiting friends and relatives); the majority of filarial infections were acquired in sub-Saharan Africa. Among the patients who were natives of filaria-nonendemic regions, 70.6% acquired their filarial infection with exposure greater than 1 month. Moreover, nonendemic visitors to filaria-endemic regions were more likely to present to GeoSentinel sites with clinically symptomatic conditions compared with those who had lifelong exposure.

SIGNIFICANCE

Codifying the filarial infections presenting to the GeoSentinel Surveillance Network has provided insights into the clinical differences seen among filaria-infected expatriates and those from endemic regions and demonstrated that O. volvulus infection can be acquired with short-term travel.

Etiology of travel-related fever

PURPOSE OF REVIEW

Many potentially life-threatening infections cause fever. Several recent large studies help to define causes of fever in returned travelers.

RECENT FINDINGS

The destination of travel determines the relative likelihood of the different major causes of fever. Systemic febrile illness occurs disproportionately among ill travelers returning from sub-Saharan Africa. Malaria remains the most important overall cause of systemic febrile illness in travelers to tropical regions; dengue fever is now the most prominent cause of fever in travelers to certain regions, most notably Asia. Chikungunya fever has emerged as a major cause of fever in travelers to Indian Ocean islands off Africa and to India itself. Causes of fever vary by the time of presentation after travel. Vivax malaria is an important cause of fever with onset more than a month after return; recently studies have shown that parasites causing relapse are genetically distinct from those causing primary infection. At expert referral centers up to 25% of febrile patients have no specific cause of fever determined.

SUMMARY

Knowledge of predominant causes of febrile infections by geographic region, traveler characteristics, and time of presentation can assist the clinician in guiding posttravel diagnosis and empiric therapy of ill returned travelers and is also valuable in pretravel preparation.

[Travelling epidemics]

OBJECTIVES

We have to become aware of the current development of international travels which has contributed to amplify circulation of all sorts of infectious agents. We will describe the current situation.

OBSERVATIONS

Infectious agents are carried by means of travellers, immigrants, as well as by animals, goods and merchandise. The distribution of infections potentially responsible for epidemics tends to become worldwide and some of them are emergent diseases.

SOLUTIONS

Such a situation imposes enhancement of international surveillance and development of resources for control and response to alerts. Developed countries possess most advanced equipments and interventional structures: they are those which may intervene predominantly in the fight against epidemics. The necessary contribution of these industrialized countries is increasing in developing countries in which infectious epidemics are spreading and such intervention must be sustained. The content of the article is a review of major threatening infectious epidemic diseases with the contribution of personal experiences.