A longitudinal prospective study of active tuberculosis in a Western Europe setting: insights and findings

PURPOSE

This study investigates the potential of inflammatory parameters (IP), symptoms, and patient-related outcome measurements as biomarkers of severity and their ability to predict tuberculosis (TB) evolution.

METHODS

People with TB were included prospectively in the Stage-TB study conducted at five clinical sites in Barcelona (Spain) between April 2018 and December 2021. Data on demographics, epidemiology, clinical features, microbiology, and Sanit George Respiratory Questionnaire (SGRQ) and Kessler-10 as Health-Related Quality of Life (HRQoL) were collected at three time points during treatment. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), neutrophil/lymphocyte, and monocyte/lymphocyte ratios (NLR and MLR), complement factors C3, C4, and cH50, clinical and microbiological data, and HRQoL questionnaires were assessed at baseline, 2 months, and 6 months. Their ability to predict sputum culture conversion (SCC) and symptom presence after 2 months of treatment was also analysed.

RESULTS

The study included 81 adults and 13 children with TB. The CRP, ESR, NLR, and MLR values, as well as the presence of symptoms, decreased significantly over time in both groups. Higher IP levels at baseline were associated with greater bacillary load and persistent symptoms. Clinical severity at baseline predicted a delayed SCC. Kessler-10 improved during follow-up, but self-reported lung impairment (SGRQ) persisted in all individuals after 6 months.

CONCLUSIONS

IP levels may indicate disease severity, and sustained high levels are linked to lower treatment efficacy. Baseline clinical severity is the best predictor of SCC. Implementing health strategies to evaluate lung function and mental health throughout the disease process may be crucial for individuals with TB.

Male genitourinary schistosomiasis-related symptoms among long-term Western African migrants in Spain: a prospective population-based screening study

BACKGROUND

Schistosomiasis is highly endemic in sub-Saharan Africa and frequently imported to Europe. Male urogenital manifestations are often neglected. We aimed to ascertain the prevalence of genitourinary clinical signs and symptoms among long-term African migrants in a non-endemic European country using a serology test.

METHODS

We carried out a prospective, community-based cross-sectional study of adult male migrants from sub-Saharan Africa living in Spain. Schistosoma serology tests and microscopic urine examinations were carried out, and clinical data were obtained from an electronic medical record search and a structured questionnaire.

RESULTS

We included 388 adult males, mean age 43.5 years [Standard Deviation (SD) = 12.0, range: 18-76]. The median time since migration to the European Union was 17 [Interquartile range (IQR): 11-21] years. The most frequent country of origin was Senegal (N = 179, 46.1%). Of the 338, 147 (37.6%) tested positive for Schistosoma. Parasite eggs were present in the urine of only 1.3%. Nine genitourinary clinical items were significantly associated with positive Schistosoma serology results: pelvic pain (45.2%; OR = 1.57, 95% CI: 1.0-2.4), pain on ejaculation (14.5%; OR = 1.85, 95% CI: 1.0-3.5), dyspareunia (12.4%; OR = 2.45, 95% CI: 1.2-5.2), erectile dysfunction (9.5%; OR = 3.10, 95% CI: 1.3-7.6), self-reported episodes of infertility (32.1%; OR = 1.69, 95% CI: 1.0-2.8), haematuria (55.2%; OR = 2.37, 95% CI: 1.5-3.6), dysuria (52.1%; OR = 2.01, 95% CI: 1.3-3.1), undiagnosed syndromic STIs (5.4%), and orchitis (20.7%; OR = 1.81, 95% CI: 1.0-3.1). Clinical signs tended to cluster.

CONCLUSIONS

Urogenital clinical signs and symptoms are prevalent among male African long-term migrants with a positive Schistosoma serology results. Genital involvement can be frequent even among those with long periods of non-residence in their sub-Saharan African countries of origin. Further research is needed to develop diagnostic tools and validate therapeutic approaches to chronic schistosomiasis.

Corrigendum: Disseminated tuberculosis and diagnosis delay during the COVID-19 era in a Western European country: a case series analysis

[This corrects the article DOI: 10.3389/fpubh.2023.1175482.].

Disseminated tuberculosis and diagnosis delay during the COVID-19 era in a Western European country: a case series analysis

Background

Disseminated tuberculosis is frequently associated with delayed diagnosis and a poorer prognosis.

Objectives

To describe case series of disseminated TB and diagnosis delay in a low TB burden country during the COVID-19 period.

Methodology

We consecutively included all patients with of disseminated TB reported from 2019 to 2021 in the reference hospital of the Northern Crown of the Metropolitan Area of Barcelona. We collected socio-demographic information, clinical, laboratory and radiological findings.

Results

We included all 30 patients reported during the study period-5, 9, and 16 in 2019, 2020, and 2021 respectively-20 (66.7%) of whom were male and whose mean age was 41 years. Twenty-five (83.3%) were of non-EU origin. The most frequent system involvement was central nervous system (N = 8; 26.7%) followed by visceral (N = 7; 23.3%), gastro-intestinal (N = 6, 20.0%), musculoskeletal (N = 5; 16.7%), and pulmonary (N = 4; 13.3%). Hypoalbuminemia and anemia were highly prevalent (72 and 77%). The median of diagnostic delay was 6.5 months (IQR 1.8-30), which was higher among women (36.0 vs. 3.5 months; p = 0.002). Central nervous system involvement and pulmonary involvement were associated with diagnostic delay among women. We recorded 24 cured patients, two deaths, three patients with post-treatment sequelae, and one lost-to-follow up. We observed a clustering effect of patients in low-income neighborhoods (p < 0.001).

Conclusion

There was a substantial delay in the diagnosis of disseminated TB in our study region, which might impacted the prognosis with women affected more negatively. Our results suggest that an increase in the occurrence of disseminated TB set in motion by diagnosis delay may have been a secondary effect of the COVID-19 pandemic.

Schistosomiasis screening in non-endemic countries from a cost perspective: Knowledge gaps and research priorities. The case of African long-term residents in a Metropolitan Area, Spain

BACKGROUND

Imported schistosomiasis is an emerging issue in European countries as a result of growing global migration from schistosomiasis-endemic countries, mainly in sub-Saharan Africa. Undetected infection may lead to serious long-term complications with an associated high cost for public healthcare systems especially among long-term migrants.

OBJECTIVE

To evaluate from a health economics perspective the introduction of schistosomiasis screening programs in non-endemic countries with high prevalence of long-term migrants.

METHODOLOGY

We calculated the costs associated with three approaches-presumptive treatment, test-and-treat and watchful waiting-under different scenarios of prevalence, treatment efficacy and the cost of care resulting from long-term morbidity. Costs were estimated for our study area, in which there are reported to reside 74,000 individuals who have been exposed to the infection. Additionally, we methodically reviewed the potential factors that could affect the cost/benefit ratio of a schistosomiasis screening program and need therefore to be ascertained.

RESULTS

Assuming a 24% prevalence of schistosomiasis in the exposed population and 100% treatment efficacy, the estimated associated cost per infected person of a watchful waiting strategy would be €2,424, that of a presumptive treatment strategy would be €970 and that of a test-and-treat strategy would be €360. The difference in averted costs between test-and-treat and watchful waiting strategies ranges from nearly €60 million in scenarios of high prevalence and treatment efficacy, to a neutral costs ratio when these parameters are halved. However, there are important gaps in our understanding of issues such as the efficacy of treatment in infected long-term residents, the natural history of schistosomiasis in long-term migrants and the feasibility of screening programs.

CONCLUSION

Our results support the roll-out of a schistosomiasis screening program based on a test-and-treat strategy from a health economics perspective under the most likely projected scenarios, but important knowledge gaps should be addressed for a more accurate estimations among long-term migrants.

SARS-CoV-2 Secondary Attack Rates in Vaccinated and Unvaccinated Household Contacts during Replacement of Delta with Omicron Variant, Spain

We performed a prospective, cross-sectional study of household contacts of symptomatic index case-patients with SARS-CoV-2 infection during the shift from Delta- to Omicron-dominant variants in Spain. We included 466 household contacts from 227 index cases. The secondary attack rate was 58.2% (95% CI 49.1%-62.6%) during the Delta-dominant period and 80.9% (95% CI 75.0%-86.9%) during the Omicron-dominant period. During the Delta-dominant period, unvaccinated contacts had higher probability of infection than vaccinated contacts (odds ratio 5.42, 95% CI 1.6-18.6), but this effect disappeared at ≈20 weeks after vaccination. Contacts showed a higher relative risk of infection (9.16, 95% CI 3.4-25.0) in the Omicron-dominant than Delta-dominant period when vaccinated within the previous 20 weeks. Our data suggest vaccine evasion might be a cause of rapid spread of the Omicron variant. We recommend a focus on developing vaccines with long-lasting protection against severe disease, rather than only against infectivity.

Schistosomiasis Among Female Migrants in Non-endemic Countries: Neglected Among the Neglected? A Pilot Study

Background

Schistosomiasis among migrant populations in Europe is an underdiagnosed infection, yet delayed treatment may have serious long-term consequences. In this study we aimed to characterize the clinical manifestations of Schistosoma infection among migrant women, and the degree of underdiagnosis.

Methods

We carried out a prospective cross-sectional study among a migrant population living in the North Metropolitan Barcelona area and coming from schistosomiasis-endemic countries. We obtained clinical, laboratory and socio-demographic data from electronic clinical records, as well as information about years of residence and previous attendance at health services. Blood sample was obtained and schistosomiasis exposure was assessed using a specific ELISA serological test.

Results

Four hundred and five patients from schistosomiasis-endemic regions were screened, of whom 51 (12.6%) were female. Seropositivity prevalence was 54.8%, but considering women alone we found a prevalence of 58.8% (30 out of 51). The median age of the 51 women was 41.0 years [IQR (35–48)] and the median period of residence in the European Union was 13 years [IQR (10–16)]. Schistosoma-positive women (N = 30) showed a higher prevalence of gynecological signs and symptoms compared to the seronegative women (96.4 vs. 66.6%, p = 0.005). Among seropositive women, the median number of visits to Sexual and Reproductive Health unit prior to diagnosis of schistosomiasis was 41 [IQR (18–65)].

Conclusion

The high prevalence of signs and symptoms among seropositive women and number of previous visits suggest a high rate of underdiagnosis and/or delayed diagnosis of Schistosoma infection, particularly female genital schistosomiasis, among migrant females.

Association of HLA-B*35 and moderate or severe cutaneous reactions secondary to benznidazole treatment in chronic Chagas disease patients

OBJECTIVES

Benznidazole is the first line treatment for Chagas disease. Adverse events appear in more than 50% of patients, leading to discontinuation in approximately 15%. Cutaneous reactions are one of the most frequent adverse events. HLA-genotyping previous studies identified an association between cutaneous reactions to benznidazole and carrying the specific allele HLA-B*35:05. We designed the present study to prospectively confirm this association.

METHODS

This is a prospective observational study including Chagas disease patients aged 18 years or more who accepted to receive benznidazole treatment following current guidelines. Allele genotyping of HLA-B was determined in all patients. Clinical and analytical follow-up was performed at days 0, 7, 14, 30 and 60 of treatment.

RESULTS

Two-hundred and seven patients were included. Seventy percent were female with a mean age of 45.1 (SD ±9.86) years mainly from Bolivia (92.8%). In 102 (49.3%) cases a cutaneous reaction was diagnosed. Forty-eight (46.6%) were classified as mild, 37 (35.9%) as moderate and 18 (17.5%) as severe. Thirty-two (15.4%) patients had to definitively interrupt the treatment due to a cutaneous reaction. Female sex (OR 4.49; 95%CI 1.62-12.47), new-onset eosinophilia prior to cutaneous symptoms (OR 2.55; 95%CI 1.2-5.43) and carrying the HLA-B*35 allelic group (OR 2.58; 95%CI 1.2-5.51) were all predictors of moderate to severe cutaneous reactions. No statistical significance was found when the specific allele HLA-B*35:05 was analyzed.

CONCLUSIONS

Patients carrying the HLA-B*35 allelic group are at higher risk of moderate to severe reactions when taking benznidazole treatment.

Drug exposure may have a substantial influence on COVID-19 prognosis among residents of long-term care facilities: an exploratory analysis

Objectives

To explore the association between drug exposure and SARS-CoV-2 prognosis among elderly people living in long-term care facilities (LTC)

Design

We carried out a cross-sectional study among old people living in LTC that had a proven SARS-CoV-2 infection, including socio-demographic data, comorbidities and drug intake at the moment of the diagnosis. The study was focused on ACE2 inhibitors, ARA-II blockers, inhaled bronchodilators, oral corticoids, platelet antiaggregants, oral anti-coagulants, statins and Vitamin D.

Results

1 306 individuals were included, with a mean age of 86.7 years, and 72.3% were females. The case fatality rate was 24.4%. Among the studied exposures platelet antiaggregants were the most prevalent (24.7%). After adjusting for propensity score, the intake of inhaled corticoids (OR 0.73; p=0.03) and statins (OR 0.65; p=0.03) were found to be protective factors of death, whereas ACE2 inhibitor showed an almost significant association (OR 0.73, p=0.07).

Conclusions

Considering the high prevalence of drug intake among elderly people, drug exposure may be an important Covid-19 disease modifier in LTC residents and should be considered when exploring prognostic risk factors associated to Covid-19.

SARS-CoV-2 contact tracing among disadvantaged populations during epidemic intervals should be a priority strategy: results from a pilot experiment in Barcelona

Objectives

The aim of this study was to trace contacts of coronavirus disease 2019 (COVID-19) hospitalised patients and determine the risk factors of infection in urban areas.

Study design

Longitudinal analysis of contacts identified from index cases.

Methods

A contact tracing study was carried out in the Northern Metropolitan area of Barcelona, Spain, during the inter-epidemic lapse of May to July 2020, a period of low SARS-CoV-2 incidence. Index cases were notified from the referral hospital. Contacts were traced and followed up for 14 days. Reverse transcription polymerase chain reaction was performed on day 0 and day 14 for contacts.

Results

In total, 368 contacts were identified from 81 index cases (median of seven contacts per index case), from which 308 were traced successfully. The median age of contacts was 28 years, 62% (223 of 368) were men. During the follow-up period, 100 contacts tested positive for COVID-19 (32.5% [95% confidence interval {CI} = 27.3–38.0]), with a secondary infection rate of 48.3% (95% CI = 40.8–55.9) among housemates. Clusters of index and respective contacts tended to aggregate within disadvantaged neighbourhoods (P < 0.001), and non-national index cases (N = 28, 34.1%) resulted in higher secondary infection rates compared with nationals (51.0% [95% CI = 41.0–60.9] vs 22.3% [95% CI = 16.8–28.8]; P < 0.001).

Conclusions

Disadvantaged communities experience a disproportionate burden of COVID-19 and may act as infection reservoirs. Contact tracing with a cross-cutting approach among these communities is required, especially during inter-epidemic periods.

Approach to amoebic colitis: Epidemiological, clinical and diagnostic considerations in a non-endemic context (Barcelona, 2007-2017)

Background

Amoebic colitis is the most frequent clinical manifestation of invasive intestinal infection due to Entamoeba histolytica and a common cause of diarrhoea worldwide. Since higher transmission rates are usually related to poor health and exposure to unhygienic conditions, cases reported in Europe usually involve immigrants and international travellers. The goal of this study was to characterise both the clinical and the epidemiological features of a European population diagnosed with amoebic colitis and then to evaluate the diagnostic tools and therapeutic options applied.

Methods and results

This was a retrospective observational study in which data from all patients diagnosed with amoebic colitis attending at the International Health Units of two tertiary referral hospitals, Germans Trias i Pujol University Hospital (Badalona, North Barcelona Metropolitan Area) and Vall d’Hebron University Hospital (Barcelona city) between 2007 and 2017 were analysed. During the study period 50 patients were diagnosed with amoebic colitis. Thirty-six (72%) were men, and immigrants accounted for 46% of all cases. Antecedents of any international travel were reported for 28 (56%), the most frequent destinations having been the Indian subcontinent, South and Central America and sub-Saharan Africa. Preexisting pathological conditions or any kind of immunosuppression were identified in 29 (58%) patients; of these, 13 (26%) had HIV infection—all of them men who have sex with men—and 5 (10%) had inflammatory bowel disease. Diarrhoea, abdominal pain and dysentery were the most frequently recorded symptoms of invasive amoebae. Diagnosis was made through microbiological study in 45 (90%) and/or histological identification of amoebae in colon biopsies in 10 (20%). After treatment with metronidazole (82%) or tinidazole (8%), all patients had good outcomes. Post-acute intraluminal treatment was indicated in 28 (56%).

Conclusions

Amoebic colitis should be suspected in patients with diarrhoea and compatible epidemiological risk factors (immigration, travelling abroad or men who have sex with men), especially if some degree of immunosuppression concurs. These risk factors must be taken into account in any diagnostic approach to inflammatory bowel disease (IBD), and active searches for stool parasites should be performed in such cases to rule out misdiagnosis or simultaneous amoebic infection. Treatment should include intraluminal anti-amoebic treatment in order to avoid relapse and prevent further spread of the disease.

Epidemiological, clinical, diagnostic and economic features of an immigrant population of chronic schistosomiasis sufferers with long-term residence in a non-endemic country (North Metropolitan area of Barcelona, 2002-2016)

Background

Schistosomiasis, one of the neglected tropical diseases (NTD) listed by the WHO, is an acute and chronic parasitic disease caused by blood flukes (trematode worms) of the genus Schistosoma. Complications of long-term infestation include liver cirrhosis, bladder tumors and kidney failure. The objective of this study was to carry out a clinical and epidemiological characterization of a schistosomiasis-diagnosed immigrant population with long-term residencein the EU as well as to evaluate the diagnostic methods available to date.

Methods and results

A total of 61 individuals with Schistosoma infection who received medical attention between June 2002 and June 2016 at the North Metropolitan International Health Unit in Barcelona (Catalonia, Spain), were included in the study. All patients were sub-Saharan African immigrants. The majority were male (91.8%) with a median age of 34 years. Symptoms attributable to infection such as haematuria, abdominal pain and dysuria were recorded in up to 90% of patients. The percentage of eosinophils decreased amongst older patients (p = 0.002) and those with symptoms associated with urinary tract infections (p = 0.017). Serology was used for diagnosis in 80.3% of the cases, with microscopic examination showing the remaining 9.8% positive for parasite eggs. Direct microbiological diagnosis was more useful in patients with less than 5 years of residence in the EU (p = 0.05). Chronic complications were present in 22 (36%) of the patients, with renal failure affecting 20 (33%). Of these 20, 6(10%) developed terminal renal failure and required hemodialysis, while 3 (5%) received a renal transplantation.

Conclusion

Morbidity associated with chronic long-term schistosomiasis is frequent among African immigrants in non-endemic countries. Better diagnostic tools and appropriate early treatment would prevent the development of visceral damage. Thorough screening in selected patients would also be useful to avoid chronic complications.

Epidemiological and clinical assessment of a shared territorial malaria guideline in the 10 years of its implementation (Barcelona, North Metropolitan Area, Catalonia, Spain, 2007-2016)

BACKGROUND

Malaria remains a major source of morbi-mortality among travellers. In 2007, a consensual multicenter Primary Care-Hospital shared guideline on travel-prior chemoprophylaxis, diagnosis and clinical management of imported malaria was set up in the Barcelona North Metropolitan area. The aim of the study is to assess the evolution of malaria cases in the area as well as its clinical management over the 10 years of its implementation.

RESULTS

A total of 190 malaria cases, all them imported, have been recorded. The overall estimated malaria crude incidence was of 0.47 cases per 10,000 population/year (95% CI 0.34-0.59) with a slight significant positive slope especially at the expense of an increase in Indian sub-continent Plasmodium vivax cases. The number of patients who attended the pre-travel consultation was low (13.7%) as well as those with prescribed chemoprophylaxis (10%). Severe malaria was diagnosed in 34 (17.9%) patients and ICU admittance was required in 2.6% of them. Organ sequelae (two renal failures and one post-acute distress respiratory syndrome) were recorded in 3 patients at hospital discharge, although all three were recovered at 30 days. None of the patients died. Patients complying with severity criteria were significantly males (p = 0.04), came from Africa (p = 0.02), were mainly non-immigrant travellers (p = 0.01) and were attended in a hospital setting (p < 0.001). The most frequently identified species was Plasmodium falciparum (64.2%), P. vivax (23.2%), Plasmodium malariae (1.6%) and Plasmodium ovale (1.1%). Those patients diagnosed with P. falciparum malaria came more often from sub-Saharan Africa (p < 0.001) and those with P. vivax came largely from the Indian sub-continent (p = 0.003). Among the 126 patients in whom an immunochromatographic antigenic test was performed, the result was interpreted as falsely negative in 12.1% of them. False negative results can be related to cases with <1% parasitaemia.

CONCLUSIONS

After 10 years of surveillance, a moderate increase in malaria incidence was observed, mostly P. vivax cases imported from the Indian sub-continent. Although severe malaria cases have been frequently reported, none of the patients died and organ sequelae were rare. Conceivably, the participation of the Primary Care and the District and Third Level Hospital professionals defining surveillance, diagnostic tests, referral criteria and clinical management can be considered a useful tool to minimize malaria morbi-mortality.

Risk of Active Tuberculosis among Index Case of Householders-A Long-Term Assessment after the Conventional Contacts Study

OBJECTIVES

The aim of this study was to determine the incidence of active tuberculosis (TB) among household contacts of TB-index cases diagnosed during a 7-year period in a public Primary Care Center located in a high-incidence area.

DESIGN AND SAMPLE

A retrospective cohort study was performed. Data collection was based on the capture-recapture method; the two main sources crossed information from TB-index and contact cases from the El Fondo Primary Care Center (Santa Coloma de Gramenet, Spain) and their reports to the National Epidemiologic Surveillance Service.

MEASURES

Variables were divided into demographic and health data (result of the Mantoux test, chest X-ray, presence of risk factors, and indication for chemoprophylaxis).

RESULTS

Community nurses identified 103 household contacts that underwent the conventional contact study. Overall, 60.19% were male; the mean age was 29.08 years. Only one case of secondary active TB was found, representing an incidence of 0.56% per TB-index case and year.

CONCLUSION

The incidence of new secondary TB among household contacts with TB-index cases was of a case. Nevertheless, a long-term follow-up of these householders beyond the conventional contacts study should be considered in areas with higher incidences of TB or among specific high-risk populations.

Chagas Cardiomyopathy: Usefulness of EKG and Echocardiogram in a Non-Endemic Country

BACKGROUND

Chagas disease (CD) is a major cause of cardiomyopathy in Latin America, and migration movements have now spread the disease worldwide. However, data regarding Chagas cardiomyopathy (CC) and the usefulness of echocardiography in non endemic countries are still scarce.

METHODS AND RESULTS

We selected 485 patients in the chronic phase of CD from two Spanish settings. Data from physical examination, electrocardiogram (EKG), x-ray, and two dimensional transthoracic echocardiogram were recorded. Trypanosoma cruzi DNA was assessed by PCR in peripheral blood. Patients were stratified according to the Kuschnir classification and a combination of echocardiogram and electrocardiogram findings. Patients mainly came from Bolivia (459; 94.6%). One hundred and forty three patients (31.5%) had at least one electrocardiogram abnormality. Twenty seven patients (5.3%) had an abnormal echocardiography. Patients with abnormal echocardiography were older (47 (IQR 38-57) years vs 41 (IQR 38-57) years); p = 0.019) and there was a greater proportion of males (66.7% vs 29.7%); p<0.001). Among echocardiographic variables, diastolic dysfunction was associated with poor cardiac status. In the multivariate analysis, abnormal EKG and gender were associated with abnormal echocardiography. Echocardiography may be spared for males under 30 and females under 45 years old with normal EKG as the likelihood of having an abnormal echocardiography is minimal. Association between T. cruzi DNA in the peripheral blood and cardiac involvement was not observed.

CONCLUSION

CC rates in the studied population are low. Age and sex are important determinants for the development of CC, and with the EKG should guide echocardiogram performance.

Oesophageal motility disorders in infected immigrants with Chagas disease in a non-endemic European area

BACKGROUND

Immigration-related new diseases pose a growing challenge for healthcare services in receptor countries. Following Latin American migration, Chagas disease has inevitably appeared in Europe.

AIM

To determine the prevalence and characteristics of oesophageal motility disorders in immigrants infected with Trypanosoma cruzi, using high resolution oesophageal manometry (HREM).

METHODS

In all newly-diagnosed cases with chronic Chagas infection referring upper digestive symptoms, a protocolized clinical evaluation and complementary tests including barium oesophagogram and HREM were carried out. As control group, 14 healthy subjects from the same endemic areas were studied with HREM.

RESULTS

We included 61 patients (46 female, 15 male; age range 26-63 years). Only seven patients (11%) had a minor alteration on barium oesophagogram. By contrast, 23 (37%) patients showed an alteration in oesophageal manometry, mainly minor motility disorders (34%). Only one healthy control (7%) had a minor motility disorder at HREM (p = 0.029 vs. patients).

CONCLUSIONS

Oesophageal motor disorders in infected immigrants with Chagas disease are common, and mainly characterized by a minor motility disorder that is not detected by barium oesophagogram. Hence, as well as barium oesophagogram examination, HREM should be considered, to assess oesophageal damage in this specific group of patients.

Has the economic crisis led to a new risk profile for international travellers?

INTRODUCTION

The economic world crisis has led to the migration of European workers to developing countries with a high incidence of infectious diseases. The objective of this study was to assess whether this context has produced an increase in the risks to international travellers for work reasons (TWR).

METHODS

Observational, retrospective study. The study population included TWR who were attended before travelling at an International Health Unit in the year 2007 (the year before the initiation of the European crisis) and in the year 2012 (when the structural crisis was established). A comparative socioeconomic analysis was performed as well as an analysis of the risk factors present in both groups.

RESULTS

In 2007 and 2012 a total of 9,197 travellers were attended. Of these, there were 344 TWR (3.4%); 101 TWR (2.8%) in 2007 and 243 TWR (4.5%) in 2012 (p<0.001). The average age of the travellers was 38.1 years (SD: 10.57). The most common destination was Sub-Saharan Africa, in 164 (47.6%) of the cases. Malaria chemoprophylaxis was prescribed to 152 travellers (44%) and 80 presented comorbidity (23.25%). The TWR from 2012 presented a significantly greater age (p=0.05), more comorbidity (p=0.018) and a greater proportion of stays in rural areas (p=0.0009) for longer time periods (p=0.001).

CONCLUSIONS

At 5 years from the start of the economic crisis, there was a change in the profile of TWR. Their number has increased significantly, as has the proportion who present risk factors for contracting imported diseases. The International Health Units should adapt to these new circumstances and adopt preventive measures for this population.

Arboviral infections diagnosed in a European area colonized by Aedes albopictus (2009-2013, Catalonia, Spain)

BACKGROUND

The invasive mosquito Aedes albopictus, with proven vectorial ability to transmit European autochthonous cycles of dengue and chikungunya virus, has currently colonized every coastal department of Eastern Spain. The main objective of the study was to define the epidemiological and clinical characteristics as well as the trends of these two arboviral diseases in a European area heavily colonized by Ae. albopictus.

METHOD

A voluntarily-based, prospective and multicenter surveillance study was performed in all medical units of the North Metropolitan area of Barcelona (406,000 inhabitants, Catalonia; Spain) with diagnostic capability from 2009 to 2013. Since any possible increase in arboviral cases could be justified by changes in traveling behaviors along the study period (especially longer trips) the trend showed by these two arboviral diseases was compared with that displayed by malaria cases during the same period.

RESULTS

38 out of 52 (73.1%) suspected cases could be serologically confirmed (IgM+): dengue 34/38 (89.5%) and chikungunya 4/38 (11.5%). No autochthonous cases were identified. The overall incidence of both arboviruses was 0.19 cases/10,000 inhabitants-year (95% CI: 0.07-0.3); dengue = 0.17 cases/10,000 inhabitants-year (95% CI: 0.05-0.3), and chikungunya = 0.02 cases/10,000 inhabitants-year (95% CI: 0.001-0.03). The Incidence Relative Risk of arboviral disease between 2009 and 2013 shown a significant trend (IRR = 1.27. IC 95%: 1.01-1.59; p = 0.043) when compared with that displayed by malaria (IRR = 1.04. IC 95%: 0.924-1.192). If no unexpected circumstances concur, the arboviral disease incidence tax would equal that of malaria about 2021-2022.

CONCLUSIONS

The incidence of dengue and chikungunya is steadily increasing in the North Metropolitan area of Barcelona, a region densely colonized by Ae. albopictus, at the entire expense of imported cases (especially Visiting Friends and Relatives travelers). To date, no secondary autochthonous cases have been identified and, thus, they have not taken part in this rise.

Immunosuppression and Chagas disease; experience from a non-endemic country

Reactivation of Chagas disease in the chronic phase may occur when immunosuppression is established, sometimes resulting in high parasitaemia and severe clinical manifestations such as meningitis and meningoencephalitis. Although this situation is being increasingly described, there is still scarce information. This retrospective observational study was performed in three Tropical Medicine Units of Barcelona (Spain) included in the International Health Programme of the Catalan Health Institute (PROSICS). The objective of the study was to describe epidemiological, clinical, microbiological, prognostic and therapeutic data from patients with Chagas disease and any kind of immunosuppressive condition attended in these three institutions from January 2007 to October 2014. From 1823 patients with Chagas disease attending these three centres during the study period, 38 (2%) had some kind of immunosuppressive condition: 12 patients had human immunodeficiency virus infection, 8 patients had neoplasia, 4 patients underwent organ transplantation and 14 patients had an autoimmune disease. Eight (21.1%) patients had cardiac involvement, and six (15.8%) patients had gastrointestinal involvement. Acute Trypanosoma cruzi infection was detected in two Spanish patients. Thirty-one (81.6%) patients received treatment with benznidazole, of whom 17 (54.8%) had some kind of adverse event. No patient had a severe manifestation or reactivation of Chagas disease. Patients with Chagas disease under immunosuppressive conditions are being increasingly described, especially in non-endemic countries. More information about this topic is required and international consensus in the diagnosis, treatment and follow up of these patients must be established to reduce the morbidity and mortality.

Necrotizing and sarcoidal granulomas in the skin and synovial membrane, associated with common variable immunodeficiency

Common variable immunodeficiency (CVID) is a primary immunodeficiency characterized by hypogammaglobulinaemia, T-cell abnormalities and recurrent bacterial infections. Patients with CVID can present granulomatous lesions on both the skin and other organs. When these lesions are the first sign of the disease, the diagnosis can be very challenging. We report the case of a patient with undiagnosed CVID, who presented with necrotizing and sarcoidal granulomas on the skin and synovial membrane as the first appearance of immunodeficiency.

Randomized trial of posaconazole and benznidazole for chronic Chagas' disease

BACKGROUND

Current therapeutic options for Chagas' disease are limited to benznidazole and nifurtimox, which have been associated with low cure rates in the chronic stage of the disease and which have considerable toxicity. Posaconazole has shown trypanocidal activity in murine models.

METHODS

We performed a prospective, randomized clinical trial to assess the efficacy and safety of posaconazole as compared with the efficacy and safety of benznidazole in adults with chronic Trypanosoma cruzi infection. We randomly assigned patients to receive posaconazole at a dose of 400 mg twice daily (high-dose posaconazole), posaconazole at a dose of 100 mg twice daily (low-dose posaconazole), or benznidazole at a dose of 150 mg twice daily; all the study drugs were administered for 60 days. We assessed antiparasitic activity by testing for the presence of T. cruzi DNA, using real-time polymerase-chain-reaction (rt-PCR) assays, during the treatment period and 10 months after the end of treatment. Posaconazole absorption was assessed on day 14.

RESULTS

The intention-to-treat population included 78 patients. During the treatment period, all the patients tested negative for T. cruzi DNA on rt-PCR assay beyond day 14, except for 2 patients in the low-dose posaconazole group who tested positive on day 60. During the follow-up period, in the intention-to-treat analysis, 92% of the patients receiving low-dose posaconazole and 81% receiving high-dose posaconazole, as compared with 38% receiving benznidazole, tested positive for T. cruzi DNA on rt-PCR assay (P<0.01 for the comparison of the benznidazole group with either posaconazole group); in the per-protocol analysis, 90% of the patients receiving low-dose posaconazole and 80% of those receiving high-dose posaconazole, as compared with 6% receiving benznidazole, tested positive on rt-PCR assay (P<0.001 for the comparison of the benznidazole group with either posaconazole group). In the benznidazole group, treatment was discontinued in 5 patients because of severe cutaneous reactions; in the posaconazole groups, 4 patients had aminotransferase levels that were more than 3 times the upper limit of the normal range, but there were no discontinuations of treatment.

CONCLUSIONS

Posaconazole showed antitrypanosomal activity in patients with chronic Chagas' disease. However, significantly more patients in the posaconazole groups than in the benznidazole group had treatment failure during follow-up. (Funded by the Ministry of Health, Spain; CHAGASAZOL ClinicalTrials.gov number, NCT01162967.).

Strongyloides stercoralis, the hidden worm. Epidemiological and clinical characteristics of 70 cases diagnosed in the North Metropolitan Area of Barcelona, Spain, 2003-2012

BACKGROUND

The nematode Strongyloides stercoralis has a very particular autoinfection life-cycle which leads to chronic infections remaining undetected for decades. However, hyperinfection can occur in patients receiving immunotherapy resulting in high mortality rates. The main objective of this study was to assess the results of a 10-year multicenter surveillance program performed in an area with dense immigration in Barcelona, Spain.

METHODS

From January 2003 to December 2012, all individuals with Strongyloides stercoralis infection attending the four centers with diagnostic capability in the North Metropolitan area of Barcelona were recorded.

RESULTS

The annual detection rate was 0.2 new diagnosed cases x10 000 inhabitants/year and 1 case x10 000 immigrants/year. Many patients were immigrants (63; 90.0%), asymptomatic (45; 64.3%) and with a high eosinophil count (63; 90.0%). Immunosuppression was present in 11 (15.7%) patients, among whom two (2.8%) cases of disseminated hyperinfection were recorded. Ivermectin was prescribed in 45 (76.3%) and albendazole in 14 (23.7%). Following treatment seven patients (11.9%) receiving albendazole presented relapse, that is, albendazole failed to clear the parasite in 50% of these drug-treated patients (p < 0.001).

CONCLUSIONS

During the study period, 90% of the cases of Strongyloides stercoralis diagnosed could be considered as imported by immigrants, most being asymptomatic and with eosinophilia. The infection is probably largely underestimated and population-based studies are needed to determine its true prevalence. Meanwhile, diagnosis must be based on active investigation of the helminth (serology and feces culture), especially in immunocompromised patients. The implementation of pre-immunosuppression protocols with the aim of identifying Strongyloides stercoralis is encouraged with empirical treatment with ivermectin being recommended in sites without diagnostic facilities.

[A clinical and epidemiological study of the Trypanosoma cruzi infected population in the north metropolitan area of Barcelona]

BACKGROUND

As an inevitable consequence of Latin American immigration to Europe, Spain and other European countries, it is necessary to confront the approach to cases of Chagas infection/disease for which, epidemiologically, there are more questions than answers. This study has aimed to describe all the Chagas-infected population in the north metropolitan area of Barcelona (406,000 inhabitants).

PATIENTS AND METHODS

A prospective and multicentric study was performed in 3 hospitals and 1 International Health Unit. It included all patients with Trypanosoma cruzi positive serology, regardless of the requesting reason.Results The 139 diagnosed cases represent an annual incidence of: a) 0.68/10,000 inhabitants and, b) 73.2/10,000 immigrants coming from endemic zones. Of the patients, 80 (57.6%) had alterations in some complementary tests: cardiologic 62 (44.6%), digestive 38 (27.3%) and 20 (14.4%) both. According to the Brazilian Consensus of Chagas cardiomyopathy, they were classified as: 0=84 (60.4%); a=40 (28.7%); b1=4 (2.9%), b2=10 (7.2%) and c/d=1 (0.7%). Treatment with benznidazole (5mg/kg/24h for 60 days) was prescribed in 116 (83.4%) patients, 89 (76.7%) of whom completed it. Secondary effects were recorded in 56 (50.9%), which made it necessary to withdraw it in 21 (19.1%).

CONCLUSIONS

Fewer cases of Chagas infection/disease than expected have been diagnosed in the North Metropolitan area of Barcelona. The series contains a high number of patients and there may be an elevated number of immigrants from endemic zones who have the asymptomatic chronic stages of the infection and who were unaware of their condition.

Clinical, electrocardiographic and echocardiographic abnormalities in Latin American migrants with newly diagnosed Chagas disease 2005-2009, Barcelona, Spain

Following Latin American migration, Chagas disease has inevitably appeared in non-endemic countries in Europe and elsewhere. New policies are necessary to prevent transmission in those countries but the long, often undetected chronic period of the early stages of the disease also renders epidemiological studies important. The main objective of our study was to determine the presence of clinical, electrocardiogram (ECG) and echocardiographic abnormalities in a population of Latin American migrants infected with Trypanosoma cruzi at the moment of diagnosis. We performed a hospital-based observational study of 100 adult patients with newly diagnosed Chagas infection between January 2005 and December 2009. Thirty-seven patients were classified within the Brazilian Consensus on Chagas cardiomyopathy early cardiac stages (A or B1) and 49 presented pathological findings (stage B2) according to the Panamerican Health Organization Classification. Overall, 49 patients showed ECG and/or echocardiographic alterations. The presence of ECG and ecocardiographic alterations were significantly associated (p=0.038). The most frequent ECG and echocardiographic findings were right bundle branch block (12 cases) and impaired left ventricular wall relaxation (24 cases), respectively. In conclusion, ECG and echocardiographic alterations coherent with Chagas cardiomyopathy were found in a large proportion of newly diagnosed Latin American migrants infected with T. cruzi. In the mid-term, Chagas disease might become an important cause of chronic cadiomyopathy in our attendance area.

Epidemiologic and biogeographic analysis of 542 VFR traveling children in Catalonia (Spain). A rising new population with specific needs

BACKGROUND

Imported diseases recorded in the European Union (EU) increasingly involve traveling immigrants returning from visits to their relatives and friends (VFR). Children of these immigrant families can represent a population of extreme vulnerability.

METHODS

A randomized cross-sectional study of 698 traveling children under the age of 15 was performed. VFR traveling children and non-VFR (or tourist) children groups were compared.

RESULTS

A total of 698 individuals were analyzed: 354 males (50.7%) and 344 females (49.3%), with a median age (interquartile range) of 4 (2-9) years. Of these, 578 (82.8%) had been born in the EU with 542 (77.7%) being considered as VFR, whereas 156 (22.3%) were considered tourists. VFR children were younger (4.7 vs 8.2 yr; p < 0.001), they had more frequently been born in the EU (62.8% vs 20.1%; p < 0.01) and were more frequently lodged in private homes (76.6% vs 3.2%: p < 0.001) and rural areas (23.2% vs 1.6%; p < 0.001). Furthermore, VFR remained abroad longer (51.6 vs 16.6 d; p < 0.001), the visit/travel time interval was shorter (21.8 vs 32.2 d; p < 0.001) than tourists, and consultation was within 10 days prior to the departure (26.4% vs 2.7%; p < 0.001). The risk factor most differentiating VFR children from tourists was accommodation in a rural setting [odds ratio(OR) = 5.26;95%CI = 2.704-10.262;p < 0.001].

CONCLUSIONS

VFR traveling children showed a greater risk of exposure to infectious diseases compared with tourists. Immigrant families may represent a target group to prioritize international preventive activities.

Automatic image analysis methods for the determination of stereological parameters - application to the analysis of densification during solid state sintering of WC-Co compacts

Automatic image analysis methods which were used to determine microstructural parameters of sintered materials are presented. Estimation of stereological parameters at interfaces, when the system contains more than two phases, is particularly detailed. It is shown that the specific surface areas and mean curvatures of the various interfaces can be estimated in the numerical space of the images. The methods are applied to the analysis of densification during solid state sintering of WC-Co compacts. The microstructural evolution is commented on. Application of microstructural measurements to the analysis of densification kinetics is also discussed.