Executive summary consensus statement of imported diseases group (GEPI) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SETMSI), on the diagnostic and treatment of imported schistosomiasis

Schistosomiasis is a highly prevalent disease, especially in immigrant populations, and is associated with significant morbidity and diagnostic delays outside endemic areas. For these reasons, the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SEMTSI) have developed a joint consensus document to serve as a guide for the screening, diagnosis and treatment of this disease outside endemic areas. A panel of experts from both societies identified the main questions to be answered and developed recommendations based on the scientific evidence available at the time. The document was reviewed by the members from both societies for final approval.

Epidemiological assessment of 5598 brucellosis inpatients in Spain (1997-2015)

Brucellosis remains one of the main zoonoses worldwide. Epidemiological data on human brucellosis in Spain are scarce. The objective of this study was to assess the epidemiological characteristics of inpatient brucellosis in Spain between 1997 and 2015. A retrospective longitudinal descriptive study was performed. Data were requested from the Health Information Institute of the Ministry of Health and Equality, which provided us with the Minimum Basic Data Set of patients admitted to the National Health System. We also obtained data published in the System of Obligatory Notifiable Diseases. A total of 5598 cases were registered. The period incidence rate was 0.67 (95% CI 0.65-0.68) cases per 100 000 person-years. We observed a progressive decrease in the number of cases and annual incidence rates. A total of 3187 cases (56.9%) came from urban areas. The group most at risk comprised men around the fifth decade of life. The average (±s.d.) hospital stay was 12.6 days (±13.1). The overall lethality rate of the cohort was 1.5%. The number of inpatients diagnosed with brucellosis decreased exponentially. The group of patients with the highest risk of brucellosis in our study was males under 45 years of age and of urban origin. The lethality rate has reduced to minimum values. It is probable that hospital discharge records could be a good database for the epidemiological analysis of the hospital management of brucellosis and offer a better information collection system than the notifiable diseases system (EDO in Spanish).

Fake imported tropical diseases: A retrospective study

OBJECTIVE

When we evaluate a patient with a suspected imported disease we cannot forget to include any autochthonous causes that may mimic imported pathologies to avoid misdiagnosis and therapeutic delay.

METHODS

A descriptive longitudinal retrospective study was designed with patients in whom an imported disease was suspected but who were finally diagnosed with autochthonous processes. The patients were selected from two internal medicine practices specializing in tropical diseases between 2008-2017 in Spain.

RESULTS

We report 16 patients, 11 (68.7%) were males, and the mean age was 43.4 ± 13.7 years old. Thirteen patients (81.2%) were travellers. Half of the patients were from Latin America, 7 (43.5%) were from Africa, and 1 (6.2%) was from Asia. The time from trip to evaluation ranged between 1 week and 20 years (median, 4 weeks), and the mean time from evaluation to diagnosis was 58.4 ± 100.9 days. There were 5 (31.2%) cases of autochthonous infection, 5 (31.2%) cases of cancer, 2 (12.5%) cases of inflammatory disease, and 2 (12.5%) cases of vascular disease.

CONCLUSIONS

Travel or migration by a patient can sometimes be a confusing factor if an imported disease is suspected and may cause delays in the diagnosis and treatment of an autochthonous disease. We highlight that 1/3 of the patients with autochthonous diseases in this study had cancer. The evaluation of imported diseases requires a comprehensive approach by the internist, especially if he specializes in infectious and/or tropical diseases and is, therefore, the best qualified to make an accurate diagnosis.

Study of the influencing factors of the blood levels of toxic elements in Africans from 16 countries

Africa's economy is growing faster than any other continent and it has been estimated that the middle class in Africa now exceeds 350 million people. This has meant a parallel increase in the importation of consumer goods and in the implementation of communication and information technologies (ICT), but also in the generation of large quantities of e-waste. However, inadequate infrastructure development remains a major constraint to the continent's economic growth and these highly toxic residues are not always adequately managed. Few studies have been conducted to date assessing the possible association between socioeconomic development factors, including e-waste generation, and blood levels of inorganic elements in African population. To disclose the role of geographical, anthropogenic, and socioeconomic development determinants on the blood levels of Ag, Al, As, Be, Cd, Co, Cr, Hg, Ni, Pb, Sb, and V -all of them frequently found in e-waste-, an immigrant population-based study was made including a total of 245 subjects from 16 countries recently arrived to the Canary Islands (Spain). Women presented higher levels of blood elements than men, and Northern Africans (Moroccans) were the most contaminated. People from low-income countries exhibited significantly lower blood levels of inorganic elements than those from middle-income countries. We found a significant association between the use of motor vehicles and the implementation of information and communication technologies (ICT) and the level of contamination. Immigrants from the countries with a high volume of imports of second-hand electronic equipment, telephone and internet use had higher levels of inorganic elements. In general terms, the higher level of economic development the higher the blood levels of inorganic pollutants, suggesting that the economic development of Africa, in parallel to e-waste generation and the existence of informal recycling sites, have directly affected the level of contamination of the population of the continent.

Executive summary: Prevention and treatment of opportunistic infections and other coinfections in HIV-infected patients: May 2015

Opportunistic infections continue to be a cause of morbidity and mortality in HIV-infected patients. They often arise because of severe immunosuppression resulting from poor adherence to antiretroviral therapy, failure of antiretroviral therapy, or unawareness of HIV infection by patients whose first clinical manifestation of AIDS is an opportunistic infection. The present article is an executive summary of the document that updates the previous recommendations on the prevention and treatment of opportunistic infections in HIV-infected patients, namely, infections by parasites, fungi, viruses, mycobacteria, and bacteria, as well as imported infections. The article also addresses immune reconstitution inflammatory syndrome. This document is intended for all professionals who work in clinical practice in the field of HIV infection.

Prevention and treatment of opportunistic infections and other coinfections in HIV-infected patients: May 2015

Despite the huge advance that antiretroviral therapy represents for the prognosis of infection by the human immunodeficiency virus (HIV), opportunistic infections (OIs) continue to be a cause of morbidity and mortality in HIV-infected patients. OIs often arise because of severe immunosuppression resulting from poor adherence to antiretroviral therapy, failure of antiretroviral therapy, or unawareness of HIV infection by patients whose first clinical manifestation of AIDS is an OI. The present article updates our previous guidelines on the prevention and treatment of various OIs in HIV-infected patients, namely, infections by parasites, fungi, viruses, mycobacteria, and bacteria, as well as imported infections. The article also addresses immune reconstitution inflammatory syndrome.

Different pattern of contamination by legacy POPs in two populations from the same geographical area but with completely different lifestyles: Canary Islands (Spain) vs. Morocco

The archipelago of the Canary Islands is one of the so-called ultra-peripheral territories of the European Union due to its geographical location away from the continent. Although the level of socioeconomic development and lifestyle of this region is comparable to that of any other of the European Union, it is just 100 km off the coast of Morocco, in the African continent. The population of the Canaries has been extensively studied with respect to their levels of POPs, and it has been described that their levels are relatively high compared to other European regions. It has been speculated with that the proximity to Africa may be associated with this level of contamination, but so far this theory has not been verified. This paper describes for the first time the levels of organochlorine pesticides (OCPs) and polychlorinated biphenyls (PCBs) in a sample of the population of Morocco (n = 131), which were compared with those of a similar sample of the population of permanent residents in the Canary Islands (n = 100) in order to check this hypothesis. Our results showed that Moroccans have higher median values of OCPs than the residents in the Canaries (∑ OCP = 150.2 ng/g lw vs. 83.4 ng/g lw, p = 0.0001). Regarding the PCBs, although recent studies have reported that new environmental sources of PCBs exist in several African countries (including Morocco), the plasma levels of most congeners were significantly higher in Canarians than in Moroccans, especially for the dioxin-like PCBs (median = 7.3 ng/g lw vs. 0.0 ng/g lw, p = 0.0001). The detailed analysis of our results suggests that the levels of these pollutants in the Canarian people are more influenced by their lifestyle and the previous use of these chemicals in the archipelago than by its geographical vicinity with Morocco.

Socioeconomic development as a determinant of the levels of organochlorine pesticides and PCBs in the inhabitants of Western and Central African countries

Several studies of environmental samples indicate that the levels of many persistent organic pollutants (POPs) are increasing in Africa, but few studies have been conducted in humans. Simultaneously, many African countries are experiencing a rapid economic growth and implementing information and communication technologies (ICT). These changes have generated high amounts of electronic waste (e-waste) that have not been adequately managed. We tested the hypothesis that the current levels of two main classes of POPs in Western and Central African countries are affected by the degree of socioeconomic development. We measured the levels of 36 POPs in the serum of recent immigrants (N=575) who came from 19 Sub-Saharan countries to the Canary Islands (Spain). We performed statistical analyses on their anthropometric and socioeconomic data. High median levels of POPs were found in the overall sample, with differences among the countries. Organochlorine pesticide (OCP) and polychlorinated biphenyl (PCB) levels increased with age. People from low-income countries had significantly higher OCP levels and much lower PCB levels than those from high-income countries. We found a significant association between the implementation of ICT and PCB contamination. Immigrants from the countries with a high volume of imports of second-hand electronic equipment had higher PCB levels. The economic development of Africa and the e-waste generation have directly affected the levels of POPs. The POP legacies of these African populations most likely are due to the inappropriate management of the POPs' residues.

Microbiology and outcome of iliopsoas abscess in 124 patients

To describe the microbiology and outcome of iliopsoas abscess (IPA) in a large case series, we analyzed 124 cases of IPA collected from 1990 through 2004 in 11 hospitals in Spain. Twenty-seven (21.8%) patients had primary and 97 (78.2%) had secondary IPA. The main sources of infection were bone (50.5%), gastrointestinal tract (24.7%), and urinary tract (17.5%). A definitive microbial diagnosis was achieved in 93 (75%) cases. Abscess culture was the most frequent procedure leading to microbial diagnosis, followed by blood cultures. Staphylococcus aureus, Escherichia coli, and Bacteroides species were the most frequent microbial causes: S. aureus was the most common organism in patients with primary abscesses (42.9%) and with abscesses of skeletal origin (35.2%), whereas E. coli was the leading organism in those with abscesses of urinary (61.5%) and gastrointestinal (42.1%) tracts. Mycobacterium tuberculosis was found in 15 patients, 4 of them associated with human immunodeficiency virus (HIV) infection. Twenty (21.5%) cases had polymicrobial infections; these were more common among patients with abscesses of gastrointestinal origin. Information on clinical outcome was available for 120 patients; 19 (15.8%) had a relapse and 6 (5%) died due to complications related to the IPA. Patients who died were older and more likely to have bacteremia and E. coli isolated from cultures. In conclusion, secondary IPA is more prevalent than primary IPA. Among those with secondary IPA, most abscesses are secondary to a skeletal source. A bacterial etiology can be identified in most cases. The overall prognosis of patients with this condition is good.

[Bacterial, mycobacterial and fungal opportunistic infections in HIV-infected immigrants: diagnosis and treatment]

The number of HIV infected immigrants has increased sharply in Spain. These patients are prone to contracting several different types of opportunistic infections, including bacterial, mycobacterial, fungal and parasitic infections. The present article provides an in-depth review of bacterial and fungal infections, with particular emphasis on those not endemic in our country.

Increased rat alveolar macrophage expression of functional iNOS induced by a Dirofilaria immitis immunoglobulin superfamily protein

Dirofilaria immitis is a worldwide filarial nematode causing heartworm disease in dogs and cats. Several mosquito species, which are able to feed both on humans and animals, can transmit this parasite. Inflammatory progression of host tissues induced by parasites are mediated by several molecules, including nitric oxide (NO), which usually exerts deleterious effects on parasites and occasionally on the host. We analyze the in vitro effect of total D. immitis adult worm somatic antigens on naïve rat alveolar macrophage NO production and further separation of parasite proteins to define specific D. immitis somatic molecules influencing host cell NO secretion. Additionally, we address the possible influence of Wolbachia spp. on the in vitro production of NO by macrophages. Our results demonstrate that D. immitis adult worm soluble antigens are able to specifically induce NO production from host macrophages. Furthermore, we demonstrated that this effect is due to nematode antigens rather than to defined components (LPS and metabolic molecules) derived from its endosymbiont, Wolbachia spp. In addition, we were able to isolate and identify one of the parasite specific components from the DiSo extract, denominated DiID35.3 and putatively belonging to the Immunoglobulin Superfamily Protein (ISP) group, triggering NO release from macrophages in a dose-dependent and specific manner.

Echinococcus multilocularis laminated-layer components and the E14t 14-3-3 recombinant protein decrease NO production by activated rat macrophages in vitro

Echinococcus multilocularis and Echinococcus granulosus cause alveolar and cystic (unilocular) echinococcosis, respectively, in humans and animals. It is known that these parasites can affect, among other molecules, nitric oxide (NO) production by periparasitic host cells. Nevertheless, detailed dissection of parasite components specifically affecting cell NO production has not been done to date. We compare the effect of E. granulosus and E. multilocularis defined metacestode structural (laminated-layer associated) and metabolic (14-3-3 protein, potentially related with E. multilocularis metacestode tumor-like growth) components on the NO production by rat alveolar macrophages in vitro. Our results showed that none of these antigens could stimulate macrophage NO production in vitro. However, a reversed effect of some Echinococcus antigens on NO in vitro production was found when cells were previously exposed to LPS stimulation. This inhibitory effect was found when E. multilocularis laminated-layer (LL) or cyst wall (CW) soluble components from both species were used. Pre-stimulation of cells with LPS also resulted in a strong, dose-dependent reduction of NO and iNOS mRNA production after incubation of cells with the E14t protein. Thus, the E. multilocularis 14-3-3 protein appears to be one of the components accounting for the suppressive effect of the CW and LL metacestode extracts.

[Pulmonary embolism: analysis of cases without initial suspicion and sensitivity of three clinical models]

BACKGROUND AND OBJECTIVE

Pulmonary embolism (PE) is a frequent and severe condition. Although clinical models do exist, many patients are wrongly diagnosed. Our objective was to evaluate the clinical characteristics of patients with PE who are admitted at a hospital without initial clinical suspicion of it. We also evaluated the sensitivity of three clinical models in order to categorize the pre-test probability of PE.

PATIENTS AND METHOD

Retrospective review of clinical cases of PE diagnosed in a teaching hospital during one year. We compared the clinical features of patients whose PE was not initially suspected with those of patients in whom PE was a first diagnosis. The three clinical models were applied in all cases.

RESULTS

58 patients were identified. In 15 out of them (26%), PE was not an initial diagnosis. Patients without an initial PE suspicion were older, and previous surgery was less frequent among them. The clinical models exhibited sensitivities (60, 85, 89%) which were lower than those previously reported but higher than the doctor's initial clinical suspicion (74%). The models showed bad agreement between them (kappa = 0.06-0.1).

CONCLUSIONS

An initial misdiagnosis of PE is not justified by atypical clinical characteristics. The use of clinical models would improve the clinical suspicion.