Francesca Norman

Imported infectious diseases in mobile populations, Spain.

Health screening of immigrant populations is needed to ensure early diagnosis and treatment.

Neglected tropical diseases outside the tropics.

Background The neglected tropical diseases (NTDs) cause significant morbidity and mortality worldwide. Due to the growth in international travel and immigration, NTDs may be diagnosed in countries of the western world, but there has been no specific focus in the literature on imported NTDs. Methods Retrospective study of a cohort of immigrants and travelers diagnosed with one of the 13 core NTDs at a Tropical Medicine Referral Unit in Spain during the period April 1989-December 2007. Area of origin or travel was recorded and analyzed. Results There were 6168 patients (2634 immigrants, 3277 travelers and 257 VFR travelers) in the cohort. NTDs occurred more frequently in immigrants, followed by VFR travelers and then by other travelers (p<0.001 for trend). The main NTDs diagnosed in immigrants were onchocerciasis (n = 240, 9.1%) acquired mainly in sub-Saharan Africa, Chagas disease (n = 95, 3.6%) in immigrants from South America, and ascariasis (n = 86, 3.3%) found mainly in immigrants from sub-Saharan Africa. Most frequent NTDs in travelers were: schistosomiasis (n = 43, 1.3%), onchocerciasis (n = 17, 0.5%) and ascariasis (n = 16, 0.5%), and all were mainly acquired in sub-Saharan Africa. The main NTDs diagnosed in VFR travelers were onchocerciasis (n = 14, 5.4%), and schistosomiasis (n = 2, 0.8%). Conclusions The concept of imported NTDs is emerging as these infections acquire a more public profile. Specific issues such as the possibility of non-vectorial transmission outside endemic areas and how some eradication programmes in endemic countries may have an impact even in non-tropical western countries are addressed. Recognising NTDs even outside tropical settings would allow specific prevention and control measures to be implemented and may create unique opportunities for research in future.

Old and new challenges in Chagas disease

Chagas disease, caused by the parasite Trypanosoma cruzi, is a neglected disease, which can lead to cardiomyopathy, arrhythmias, megaviscera, and more rarely, polyneuropathy in up to 30-40% of patients around 20 to 30 years after acute infection. Although it is endemic in the Americas, global population movements mean that it can be located wherever migrants from endemic areas settle. The disease was first described 100 years ago and still challenges clinicians worldwide, since diagnostic, therapeutic, and prognostic methods remain insufficient. Furthermore, factors such as HIV co-infection, immunosuppressive drugs, transplantation, and neoplastic disease can alter the natural course of the infection. We present the case of a Bolivian woman with chronic T cruzi infection diagnosed at our clinic in Madrid, Spain, who subsequently developed non-Hodgkin lymphoma. Our report illustrates the challenges of an increasingly common infection seen in non-endemic countries, and highlights both daily management dilemmas and associated difficulties that arise.

Visceral leishmaniasis and HIV coinfection in the Mediterranean region.

Visceral leishmaniasis is hypoendemic in Mediterranean countries, where it is caused by the flagellate protozoan Leishmania infantum. VL cases in this area account for 5%–6% of the global burden. Cases of Leishmania/HIV coinfection have been reported in the Mediterranean region, mainly in France, Italy, Portugal, and Spain. Since highly active antiretroviral therapy was introduced in 1997, a marked decrease in the number of coinfected cases in this region has been reported. The development of new diagnostic methods to accurately identify level of parasitemia and the risk of relapse is one of the main challenges in improving the treatment of coinfected patients. Clinical trials in the Mediterranean region are needed to determine the most adequate therapeutic options for Leishmania/HIV patients as well as the indications and regimes for secondary prophylaxis. This article reviews the epidemiological, diagnostic, clinical, and therapeutic aspects of Leishmania/HIV coinfection in the Mediterranean region.

Chagasic Cardiomyopathy in Immigrants from Latin America to Spain

To the Editor: An estimated 8 million persons in 21 countries in the Western Hemisphere are infected by Trypanosoma cruzi, the cause of Chagas disease. The global infection rate is 1.4% (1) and varies by geographic area from 0.1% to 45.4% (2). After infection, organ involvement, predominantly cardiac disease, will develop in 20%–30% after 10–30 years (3).

Imported Leishmaniasis: A Heterogeneous Group of Diseases

BACKGROUND Leishmaniasis is endemic in many countries. The existence of different species combined with host factors may condition clinical presentation, treatment options, and disease outcome. In an endemic country, a predominance of certain species and presentations may be expected, whereas from the perspective of a tropical medicine referral unit a wider variety of cases from diverse geographical areas may be observed. METHODS Retrospective study of imported leishmaniasis cases diagnosed at a Tropical Medicine referral unit in Spain, during the period of January 1995 to June 2008. RESULTS In total, 18 cases were diagnosed: 12 cutaneous leishmaniasis (CL), 4 mucocutaneous leishmaniasis (ML), and 2 visceral leishmaniasis (VL) cases. Two patients were immunosuppressed. The majority of CL cases (9/12) occurring in travelers were acquired in New World countries and were treated with pentavalent antimonials. Three ML cases were acquired in the New World, two received initial treatment with pentavalent antimonials and two with liposomal amphotericin B (LAmB). For all four ML cases, a change in drug choice and multiple treatment courses were necessary, and one remained refractory to treatment. Both VL cases were acquired in Africa and responded well to LAmB treatment. CONCLUSION The management of leishmaniasis in non-endemic countries is still a challenge for physicians. With the variety of cases presented, both in immigrants and travelers from different geographical areas, this series illustrates the great diversity of imported leishmaniasis in terms of presentation, treatment options, and outcome. We consider this entity is becoming increasingly more frequent and clinicians should be aware of strategies for its correct management.

Screening of Imported Infectious Diseases Among Asymptomatic Sub-Saharan African and Latin American Immigrants: A Public Health Challenge

Migrants from developing countries are usually young and healthy but several studies report they may harbor asymptomatic infections for prolonged periods. Prevalence of infections were determined for asymptomatic immigrants from Latin America and sub-Saharan Africa who ettended to a European Tropical Medicine Referral Center from 2000 to 2009. A systematic screening protocol for selected infections was used. Data from 317 sub-Saharan Africans and 383 Latin Americans were analyzed. Patients were mostly young (mean age 29 years); there were significantly more males among sub-Saharan Africans (83% versus 31.6%) and pre-consultation period was longer for Latin Americans (5 versus 42 months). Diagnoses of human immunodeficiency virus (HIV), chronic hepatitis B and C virus infection, and latent tuberculosis were significantly more frequent in sub-Saharan Africans (2.3% versus 0.3%; 14% versus 1.6%; 1.3 versus 0%; 71% versus 32.1%). There were no significant differences in prevalence for syphilis and intestinal parasites. Malaria and schistosomiasis prevalence in sub-Saharan Africans was 4.6% and 5.9%, respectively, and prevalence of Chagas disease in Latin Americans was 48.5%. Identifying and treating asymptomatic imported infectious diseases may have an impact both for the individual concerned and for public health. Based on these results, a systematic screening protocol for asymptomatic immigrants is proposed.

Travelers visiting friends and relatives (VFR) and imported infectious disease: Travelers, immigrants or both? A comparative analysis

INTRODUCTION Immigrants are increasingly traveling back to their countries of origin to visit friends and relatives (VFRs). They account for an important proportion of all international travelers and have a high risk for certain travel-related infectious diseases. METHODS We describe the spectrum of infectious diseases diagnosed in a cohort of 351 VFRs and compare them with two previously published cohorts: of immigrants and travelers attended at our centre. RESULTS The most frequent diagnoses observed among VFRs were typical travel-associated infections such as malaria (75 [21.4%]), travelers diarrhea 17 [4.8%]), intestinal parasites (16 [4.6%]) and dengue (11 [3.1%]). Asymptomatic chronic infectious diseases, such as latent tuberculosis (56 [16%]), chronic viral hepatitis (18 [5.1%]) and filariasis (18 [5.1%]), probably acquired before migration, were also observed. CONCLUSIONS VFRs should thus be approached from two perspectives as concerns imported infectious diseases: as travelers and as immigrants. Etiological studies focusing on the presenting complaint as well as systematic screening for other latent infectious diseases should be performed.

Imported Histoplasmosis: Two Distinct Profiles in Travelers and Immigrants

BACKGROUND Histoplasmosis is acquiring importance in nonendemic areas due to the increase in travel and immigration, being the most common systemic mycosis acquired by European travelers. Epidemiological studies show that the incidence of Histoplasma infection in these patients may be higher than previously believed and a wide clinical spectrum of disease may be observed. METHODS Cases of histoplasmosis diagnosed at a Tropical Medicine Referral Unit in Madrid, Spain, during the period January 1996 to December 2006 were reviewed. RESULTS Ten cases of histoplasmosis in travelers and immigrants are described. Five HIV-positive patients (four immigrants and one expatriate) all presented with progressive disseminated disease. Five HIV-negative patients (travelers) all presented with pulmonary disease: four with an acute pulmonary form (one with pleural involvement) and one patient was found to have residual pulmonary disease (lung nodule). Three of the travelers also had rheumatologic manifestations (arthromyalgias or arthritis). CONCLUSIONS Clinicians in nonendemic areas may be faced with patients with a diagnosis of histoplasmosis and although Histoplasma infection can have a varied and nonspecific clinical presentation, imported histoplasmosis may have two distinct profiles. Previously, healthy travelers may be exposed in endemic areas and mainly develop acute forms of the disease with a favorable outcome. Immigrants or expatriates from endemic areas who may be immunosuppressed due to HIV infection may experience reactivation of latent disease developing disseminated forms with high mortality rates. This infection should be considered in the differential diagnosis of diseases affecting travelers and immigrants.

Chagas Disease and Breast-feeding

Mothers with this disease should continue breast-feeding unless they are experiencing the acute phase, reactivated disease, or bleeding nipples.