Johannes Schäfer

Skin and soft tissue infections in intercontinental travellers and the import of multi-resistant Staphylococcus aureus to Europe

Staphylococcus aureus is emerging globally. Treatment of infections is complicated by increasing antibiotic resistance. We collected clinical data and swabs of returnees with skin and soft tissue infections (SSTI) at 13 travel-clinics in Europe (www.staphtrav.eu). Sixty-two percent (196/318) SSTI patients had S. aureus-positive lesions, of which almost two-thirds (122/196) were Panton-Valentine leukocidin (PVL) positive. PVL was associated with disease severity, including hospitalization for SSTI (OR 5.2, 95% CI 1.5-18.2). In returnees with SSTI, longer travel and more intense population contact were risk factors for nasal colonization with PVL-positive S. aureus. Imported S. aureus frequently proved resistant to trimethoprim-sulfamethoxazole (21%), erythromycin (21%), tetracycline (20%), ciprofloxacin (13%), methicillin (12%) and clindamycin (8%). Place of exposure was significantly (p < 0.05) associated with predominant resistance phenotypes and spa genotypes: Latin America (methicillin; t008/CC24/304), Africa (tetracycline, trimethoprim-sulfamethoxazole; t084/CC84, t314/singleton, t355/CC355), South Asia (trimethoprim-sulfamethoxazole, ciprofloxacin; t021/CC21/318), South-East Asia (clindamycin; t159/CC272). USA300-like isolates accounted for 30% of all methicillin-resistant S. aureus imported to Europe and were predominantly (71%) acquired in Latin America. Multi-resistance to non-β-lactams were present in 24% of imports and associated with travel to South Asia (ORcrude 5.3, 95% CI 2.4-11.8), even after adjusting for confounding by genotype (ORadjusted 3.8, 95% 1.5-9.5). Choosing randomly from compounds recommended for the empiric treatment of severe S. aureus SSTI, 15% of cases would have received ineffective antimicrobial therapy. These findings call for the development of regionally stratified guidance on the antibiotic management of severe imported S. aureus disease and put the infected and colonized traveller at the centre of interventions against the global spread of multi-resistant S. aureus.

Suspected new wave of muscular sarcocystosis in travellers returning from Tioman Island, Malaysia, May 2014

In May 2014, six patients presented in Germany with a Sarcocystis-associated febrile myositis syndrome after returning from Tioman Island, Malaysia. During two earlier waves of infections, in 2011 and 2012, about 100 travellers returning to various European countries from the island were affected. While the first two waves were associated with travel to Tioman Island mostly during the summer months, this current series of infections is associated with travel in early spring, possibly indicating an upcoming new epidemic.

Prolonged Clinical Course of Muscular Sarcocystosis and Effectiveness of Cotrimoxazole Among Travelers to Tioman Island, Malaysia, 2011–2014

To the Editor—In expansion to the international investigation of acute muscular sarcocystosis (AMS) among travelers to Tioman Island, Malaysia, 2011–2012, by Esposito et al [1], we would like to add some very recent clinical observations that we believe are important. Together with locally involved colleagues from several medical institutions in Germany, we have been diagnosing and following 39 travelers with muscular sarcocystosis since 2011 [2–4]. The disease described as AMS [1] should not be misunderstood by clinicians as being only a short-term infection. This parasitic zoonosis is characterized by a chronic infection of muscular tissue by Sarcocystis species [5], causing longer lasting and even chronic signs and symptoms in at least a subset of the infected travelers, following the acute initial episode. From repeated follow-up visits and continuing patient contact also by telephone and e-mail following this international investigation [1], we can meanwhile specify the duration of symptoms and intensity of myalgia in the majority of our patients in more detail. Mean duration from onset of first symptoms to complete recovery was 4.2 months (median, 2.2 months; min 0, max 23 months; n = 35). Six of these patients had symptoms for >6 months; 2 are still experiencing recurrent episodes of weakness/fatigue and characteristic myalgia after 13 and 23 months, respectively, although in decreasing intensity. Maximum severity of myalgia on a scale from 0 to 10 (0 = no pain, 10 = maximum pain) [3, 6] was reported to be 5.7 (median, 6.0; min 0, max 10; n = 36). Trimethoprim and pyrimethamine have shown antiparasitic effects in cell and animal studies [7, 8]. Our later patients whom we had therefore offered treatment with cotrimoxazole (mostly 2 × 960 mg/day, for 10–20 days [3, 4]) reported a shorter duration of symptoms compared to previously treated patients (mean, 1.1 month; median, 0.7; min 0.25, max 2.2 months; n = 9, vs mean, 5.3; median, 3.0; min 0, max 23 months; n = 26; P = .032). The earlier cotrimoxazole treatment was initiated, the shorter the duration of symptoms tended to be (median of 0.6, 1.0, and 2.0 months if cotrimoxazole treatment was started during the initial acute phase, asymptomatic interval period, and later myositic stage of the disease, respectively; each n = 3). Considering these follow-up data, we understand the clinical course of muscular sarcocystosis in humans due to Sarcocystis nesbitti [1–4] as an initial acute infection with unspecific febrile symptoms, leading to a chronic muscular parasitic infestation later, with the formation of sarcocysts. The latter stage is associated with prolonged and often relapsing myositic signs and symptoms, and elevated creatine kinase levels and eosinophilia. Duration and severity of symptoms with chronic muscular infection evidently show a wide interindividual variability. Further studies will need to investigate determinants for severity of disease, noninvasive diagnostic tests, and effective therapy.

Human Invasive Muscular Sarcocystosis Induces Th2 Cytokine Polarization and Biphasic Cytokine Changes, Based on an Investigation among Travelers Returning from Tioman Island, Malaysia

ABSTRACT Sarcocystis nesbitti is a parasite responsible for a biphasic eosinophilic febrile myositis syndrome in two recent outbreaks in Malaysia. We demonstrate Th2 cytokine polarization in infected travelers, an overall cytokine production decrease in the early phase of the disease suggestive of initial immunosuppression, and elevated levels of proinflammatory and chemotactic cytokines in the later myositic phase.

Imported cholera with acute renal failure after a short business-trip to the Philippines, Germany, October 2015

A German businessman developed acute watery diarrhoea after a three-day trip to the Philippines. He was admitted with severe hypotension and acute renal failure, but recovered with rapid rehydration. Vibrio cholerae O1 serotype Ogawa was isolated. Physicians need to be aware of endemic cholera in Asia including the Philippines and consider this in their pre-travel advice.

Typhus Group Rickettsiosis, Germany, 2010–20171

Typhus group rickettsiosis is caused by the vectorborne bacteria Rickettsia typhi and R. prowazekii. R. typhi, which causes murine typhus, the less severe endemic form of typhus, is transmitted by fleas; R. prowazekii, which causes the severe epidemic form of typhus, is transmitted by body lice. To examine the immunology of human infection with typhus group rickettsiae, we retrospectively reviewed clinical signs and symptoms, laboratory changes, and travel destinations of 28 patients who had typhus group rickettsiosis diagnosed by the German Reference Center for Tropical Pathogens, Hamburg, Germany, during 2010–2017. Immunofluorescence assays of follow-up serum samples indicated simultaneous seroconversion of IgM, IgA, and IgG or concurrence in the first serum sample. Cytokine levels peaked during the second week of infection, coinciding with organ dysfunction and seroconversion. For 3 patients, R. typhi was detected by species-specific nested quantitative PCR. For all 28 patients, R. typhi was the most likely causative pathogen.