Mar Lago

Acute respiratory distress syndrome after convalescent plasma use: treatment of a patient with Ebola virus disease contracted in Madrid, Spain

BACKGROUND In the current epidemic of Ebola virus disease, health-care workers have been transferred to Europe and the USA for optimised supportive care and experimental treatments. We describe the clinical course of the first case of Ebola virus disease contracted outside of Africa, in Madrid, Spain. METHODS Herein we report clinical, laboratory, and virological findings of the treatment of a female nurse assistant aged 44 years who was infected with Ebola virus around Sept 25-26, 2014, while caring for a Spanish missionary with confirmed Ebola virus disease who had been medically evacuated from Sierra Leone to La Paz-Carlos III University Hospital, Madrid. We also describe the use of experimental treatments for Ebola virus disease in this patient. FINDINGS The patient was symptomatic for 1 week before first hospital admission on Oct 6, 2014. We used supportive treatment with intravenous fluids, broad-spectrum antibiotics, and experimental treatments with convalescent plasma from two survivors of Ebola virus disease and high-dose favipiravir. On day 10 of illness, she had acute respiratory distress syndrome, possibly caused by transfusion-related acute lung injury, which was managed without mechanical ventilation. Discharge was delayed because of the detection of viral RNA in several bodily fluids despite clearance of viraemia. The patient was discharged on day 34 of illness. At the time of discharge, the patient had possible subacute post-viral thyroiditis. None of the people who had contact with the patient before and after admission became infected with Ebola virus. INTERPRETATION This report emphasises the uncertainties about the efficacy of experimental treatments for Ebola virus disease. Clinicians should be aware of the possibility of transfusion-related acute lung injury when using convalescent plasma for the treatment of Ebola virus disease. FUNDING La Paz-Carlos III University Hospital.

Hepatitis B, C, and D and HIV infections among immigrants from Equatorial Guinea living in Spain.

A total of 1,220 subjects from Equatorial Guinea living in Spain (median age = 41 years; 453 male and 767 female) was examined for antibodies to human immunodeficiency virus (HIV) and Hepatitis B (HBV), C (HCV), and D (HDV) viruses. Extracted RNA and DNA from the positive samples were used to quantify viral load. The prevalence of HIV antibodies, HCV RNA, and HBV surface antigen (HBsAg) was 10.8% (N = 132), 11.6% (N = 141), and 7.9% (N = 96), respectively. The most prevalent HIV variant was CRF02_AG (38.5%; N = 40). HCV genotype 4 (60%; N = 36) and HBV genotype A3 (32%; N = 8) were the hepatitis variants most frequently found. Superinfection with HDV was seen in 20.9% (N = 24) of HBsAg carriers. A control group of 276 immigrants from other sub-Saharan countries showed similar rates of HIV and HBsAg, although no HCV cases were found. Immigrants constitute a major source of HIV and hepatitis viruses in Spain; therefore, it is important that control measures are intensified.

Imported submicroscopic malaria in Madrid

BackgroundSubmicroscopic malaria (SMM) can be defined as low-density infections of Plasmodium that are unlikely to be detected by conventional microscopy. Such submicroscopic infections only occasionally cause acute disease, but they are capable of infecting mosquitoes and contributing to transmission. This entity is frequent in endemic countries; however, little is known about imported SMM.The goals of this study were two-fold: a) to know the frequency of imported SMM, and b) to describe epidemiological, laboratorial and clinical features of imported SMM.MethodsA retrospective study based on review of medical records was performed. The study population consisted of patients older than 15 years attended at the Tropical Medicine Unit of Hospital Carlos III, between January 1, 2002 and December 31, 2007. Routinely detection techniques for Plasmodium included Field staining and microscopic examination through thick and thin blood smear. A semi-nested multiplex malaria PCR was used to diagnose or to confirm cases with low parasitaemia.ResultsSMM was diagnosed in 104 cases, representing 35.5% of all malaria cases. Mean age (IC95%) was 40.38 years (37.41-43.34), and sex distribution was similar. Most cases were in immigrants, but some cases were found in travellers. Equatorial Guinea was the main country where infection was acquired (81.7%). Symptoms were present only in 28.8% of all SMM cases, mainly asthenia (73.3% of symptomatic patients), fever (60%) and arthromialgias (53.3%). The associated laboratory abnormalities were anaemia (27.9%), leukopaenia (15.4%) and thrombopaenia (15.4%). Co-morbidity was described in 75 cases (72.1%).ConclusionsResults from this study suggest that imported SMM should be considered in some patients attended at Tropical Medicine Units. Although it is usually asymptomatic, it may be responsible of fever, or laboratory abnormalities in patients coming from endemic areas. The possibility of transmission in SMM has been previously described in endemic zones, and presence of vector in Europe has also been reported. Implementation of molecular tests in all asymptomatic individuals coming from endemic area is not economically feasible. So re-emergence of malaria (Plasmodium vivax) in Europe may be speculated.Abstract in SpanishIntroducciónLa malaria submicroscópica (MSM) puede ser definida como una infección por Plasmodium de baja densidad, no detectable mediante microscopía convencional. Ocasionalmente produce enfermedad aguda, pero es capaz de producir infección el mosquito y ser transmitida. Es frecuente en regiones endémicas; sin embargo, existe poca información sobre la MSM importada.El objetivo de este estudio es doble: a) Conocer la frecuencia de MSM importada; b) Describir las caracetrísitcas epidemiológicas, analíticas y clínicas de la MSM importada.MétodosEstudio retrospectivo mediante revisión de historias clínicas. La población de estudio estaba formada por mayores de 15 años atendidos en la Unidad de Medicina Tropical del Hospital Carlos III, entre el 1 de enero de 2002 y el 31 de diciembre de 2007. Las técnicas rutinarias de detección de Plasmodium incluyen tinción de Field, gota gruesa y extensión. Una técnica de PCR (seminested multiplex) fue utilizada para el diagnostico o para confirmar casos con baja parasitemias.ResultadosLa MSM fue diagnosticada en 104 casos, representando el 35.5% de los casos de malaria. La edad media (IC95%) fue 40.38 años (37.41-43.34), y la distribución por sexos fue similar. La mayoría de los casos eran en inmigrantes, describiéndose también casos en viajeros. Guinea Ecuatorial fue el principal país de adquisición de la infección (81.7%). Los síntomas estaban presentes en el 28.8% de todos los casos de MSM, principalmente astenia (73.3% de los pacientes sintomáticos), fiebre (60%) y artromialgias (53.3%). Las anomalías analíticas asociadas fueron anemia (27.9%), leucopenia (15.4%) y trombopenia (15.4%). Había comorbilidad en 75 casos (72.1%).DiscusiónEstos resultados sugieren que debería considerarse la MSM importada en algunos pacientes atendidos en las Unidades de Medicina Tropical. Aunque suele ser asintomática, puede ser responsable de fiebre o alteraciones analíticas en provenientes de regiones endémicas. La posibilidad de transmisión de la MSM ha sido previamente demostrada, así como la presencia en Europa del vector. La implementación de tests moleculares a todos los individuos asintomáticos que provienen de regiones endémicas no es económicamente factible. Por tanto, se puede especular con la idea de la re-emergencia de malaria en Europa (al menos de P. vivax).

The use of PCR in the diagnosis of hyper-reactive malarial splenomegaly (HMS).

Between August 1997 and September 1998, 14 cases of hyper-reactive malarial splenomegaly (HMS) were diagnosed in the Instituto de Salud Carlos III in Madrid, Spain. These cases, from Equatorial Guinea and Cameroon, were identified using the diagnostic criteria established by Y. M. Fakunle in 1981: gross splenomegaly; high levels of anti-malarial antibodies; IgM in serum at least two standard deviations above the local mean; and clinical and immunological response to antimalarial treatment. Although malarial parasites were only detected in the Giemsa-stained blood films of four of the cases, these four and four others were found to have the DNA of such parasites in their blood when tested using a method based on a semi-nested, multiplex PCR. These result indicate that malarial parasitaemias may be more prevalent in HMS than is usually recognized.

Lung nodules, fever, and eosinophilia in a traveler returning from Madagascar.

A 44-year-old Spanish man presented with a 2-month history of fever after an 8-day trip to Madagascar. During his journey, he bathed once in the Lily waterfall near Ampefy, a village about 100 km west of Antananarivo (Figure 1). He did not recall any other freshwater exposures. Six days after the bath, he reported a 2-day febrile episode, with a maximum temperature of 40°C. Thereafter, he began experiencing malaise, low-grade fever, night sweats, and mild diarrhea. He denied any respiratory symptoms or urticaria. Physical examination was unremarkable. He had a total leukocyte count of 7,600 cells/μL (26% eosinophils). Chest x-ray and computed tomography scan showed multiple nodules in both lungs (Figures 2 and ​and3).3). Urine and stool tests for parasites and serology for Strongyloides spp., Toxocara spp., and Wuchereria spp. were negative. The result of a serologic enzyme-linked immunosorbent assay for Schistosoma spp. (NovaLisa, NovaTec Immundiagnostica GmbH, Dietzenbach, Germany) was strongly positive. With the suspicion of acute schistosomiasis the patient was treated with prednisone and two courses of praziquantel with full recovery. Figure 1. Lily waterfall of Ampefy in Madagascar. Picture taken by the patient presumably the day of the infection. Figure 2. Chest radiograph showing ill-defined nodular opacities in both lungs. Figure 3. Computed tomography of the lung showing multiple round lesions of different sizes in both lungs. Acute schistosomiasis (also called Katayama fever or syndrome) is typically seen in nonimmune travelers. Diagnosis might be challenging as the three major clinical features (fever, rash, and respiratory symptoms) are non-specific and occur in combination in only a small percentage of patients.1 In addition, serum antibodies and egg excretion might be negative at the time of the clinical presentation.2 The chest radiograph may show different abnormalities, including multiple nodular lesions.1,3 Optimal treatment regimen for Katayama syndrome is not known. Praziquantel is considered the drug of choice for schistosomiasis but is relatively ineffective against the migrating larvae that are the cause of the acute symptoms. A course of praziquantel is required after 2–3 months of the exposure, when the infection is established and adult worms have developed. Concurrent administration of glucocorticoids is recommended to ameliorate symptoms related to the immunological reaction.2 Katayama syndrome should be considered in patients returning from endemic areas with fever, eosinophilia, and a nodular pulmonary pattern on imaging.

Chikungunya virus infections among travellers returning to Spain, 2008 to 2014.

Since the first documented autochthonous transmission of chikungunya virus in the Caribbean island of Saint Martin in 2013, the infection has been reported within the Caribbean region as well as North, Central and South America. The risk of autochthonous transmission of chikungunya virus becoming established in Spain may be elevated due to the large numbers of travellers returning to Spain from countries affected by the 2013 epidemic in the Caribbean and South America, as well as the existence of the Aedes albopictus vector in certain parts of Spain. We retrospectively analysed the laboratory diagnostic database of the National Centre for Microbiology, Institute of Health Carlos III (CNM-ISCIII) from 2008 to 2014. During the study period, 264 confirmed cases, of 1,371 suspected cases, were diagnosed at the CNM-ISCIII. In 2014 alone, there were 234 confirmed cases. The highest number of confirmed cases were reported from the Dominican Republic (n = 136), Venezuela (n = 30) and Haiti (n = 11). Six cases were viraemic in areas of Spain where the vector is present. This report highlights the need for integrated active case and vector surveillance in Spain and other parts of Europe where chikungunya virus may be introduced by returning travellers.

Zika Virus Screening among Spanish Team Members After 2016 Rio de Janeiro, Brazil, Olympic Games

We evaluated the risk for the Spanish Olympic Team acquiring Zika virus in Rio de Janeiro, Brazil, during 2016. We recruited 117 team members, and all tested negative for Zika virus. Lack of cases in this cohort supports the minimum risk estimates made before the Games.

Abnormal depolarizing patterns in three patients with filarial infection

Several authors have described a particular potential of automated depolarization analysis in detecting malaria infection as part of the routine full blood count (FBC) performed by the Cell-Dyn 4000 analyzer. In these cases, abnormal depolarizing patterns are due to the presence of leukocyte-associated malaria hemozoin, a pigment which depolarizes the laser light. In this report we describe samples from three individual patients who did not have malaria infection but showed abnormal depolarizing events. Further investigation determined that these samples were from patients infected by the nematode Mansonella perstans. The observed depolarizing pattern consisted of a normal depolarizing eosinophil population and in addition an abnormal depolarizing population that showed a close “linear” relationship between “granularity” (90° depolarization) and “lobularity” (90° polarization). This atypical population was smaller than normal leukocytes and thus clearly different from the patterns associated with malaria infection. Abnormal depolarization patterns of M. perstans clearly do not reflect leukocyte-associated malaria hemozoin. It is possible however that the erythrocyte-lysing agent used to facilitate leukocyte analysis by the instrument may have caused microfilaria fragmentation and thus the distinctive “straight-line” features of the abnormal scatter plots

Dermatological manifestations in onchocerciasis: A retrospective study of 400 imported cases

INTRODUCTION Onchocerciasis is caused by Onchocerca volvulus and mainly leads to pruritus and skin and visual disorders, including blindness. Seventeen million people are infected in 38 countries; 31 of these are in sub-Saharan Africa, six in Latin America and one on the Arabian Peninsula. More than 99% of cases occur in sub-Saharan Africa where 120 million people are at risk of infection. Eye disorders have been well-documented; however, skin disorders have not been described accurately. The objective of our study was to describe the epidemiology, main skin manifestations and treatment of imported onchocerciasis. MATERIAL AND METHODS A retrospective study was thus conducted by analysing the main demographic, clinical and treatment data regarding a cohort of 400 patients attending a reference clinical unit over a 17-year period. RESULTS Most patients were female (55%) with mean age 37.5±16.7 years. All the migrants came from sub-Saharan countries. The most frequently occurring dermatological symptom was pruritus. Ivermectin had been used as first-line therapy and adverse reactions had been described in 11 patients (3.2%). CONCLUSIONS The results indicate the fact that there should be a clinical suspicion of onchocerciasis regarding immigrants from endemic areas having skin lesions compatible with the diseases profile or asymptomatic patients having eosinophilia or unexplained high IgE. Moreover, skin snips from the buttocks region were very fruitful and treatment with ivermectin was seen to be safe. This is the largest case series regarding imported onchocerciasis described up to the present time.