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Zika virus is an emerging flavivirus widely spreading through Latin America. Molecular diagnosis of the infection can be performed using serum, urine and saliva samples, although a well-defined diagnostic algorithm is not yet established. We describe a series of 24 cases of imported zika virus infection into Catalonia (northeastern Spain). Based on our findings, testing of paired serum and urine samples is recommended.

Traveller's diarrhoea (TD) is acquired primarily through ingestion of food and drinks contaminated with pathogens that cause diarrhoea. They can be bacteria, protozoa, helminths, and viruses. Globally, the most common causes of TD are two pathotypes of Escherichia coli (enterotoxigenic and enteroaggregative) and Campylobacter, although there are significant variations by geographic area visited. Most TD occurs in individuals traveling to low-middle income countries. The type of travel, length of stay, traveller's age, and the presence of certain underlying conditions are important risk factors to consider for the acquisition of TD. While TD is usually a mild and self-limiting disease, half of travellers with TD experience some limitation of activities during their trip, while up to 10% will experience persistent diarrhoea or other complications. The purpose of this article is to provide an updated microbiological, epidemiological, and clinical profile of traveller's diarrhoea, including known risk factors, as well as to make recommendations on the prevention and treatment of TD.

Benznidazole is recommended for treatment of Chagas infection. Effects of combination therapy with benznidazole and posaconazole have not been tested in Trypanosoma cruzi carriers.The purpose of this study was to determine whether posaconazole alone or combined with benznidazole were superior to benznidazole monotherapy in eliminating T. cruzi parasites measured by real time polymerase chain reaction (RT-PCR) in asymptomatic Chagas carriers.A prospective, multicenter randomized placebo-controlled study was conducted in 120 subjects from Latin America and Spain who were randomized to 4 groups: posaconazole 400 mg twice a day (b.i.d.); benznidazole 200 mg + placebo b.i.d.; benznidazole 200 mg b.i.d. + posaconazole 400 mg b.i.d.; or placebo 10 mg b.i.d. T. cruzi deoxyribonucleic acid was detected by RT-PCR at 30, 60, 90, 120, 150, 180, and 360 days. The primary efficacy outcome is the proportion of subjects with persistent negative RT-PCR by day 180; the secondary outcome was negative RT-PCR at 360 days.Only 13.3% of those receiving posaconazole and 10% receiving placebo achieved the primary outcome, compared with 80% receiving benznidazole + posaconazole and 86.7% receiving benznidazole monotherapy (p 0.0001 vs. posaconazole/placebo). Posaconazole monotherapy or posaconazole combined with benznidazole achieved high RT-PCR conversion rates during treatment (30 days; 93.3% and 88.9% and 60 days; 90%, and 92.3%) that were similar to benznidazole (89.7% and 89.3%); all were superior to placebo or posaconazole (10% and 16.7%, p 0.0001). This was not observed at 360 days; benznidazole + posaconazole and benznidazole monotherapy (both 96%) versus placebo (17%) and posaconazole (16%, p 0.0001). Serious adverse events were rare (6 patients) and were observed in the benznidazole-treated patients. Permanent discontinuation was reported in 19 patients (31.7%) receiving either benznidazole monotherapy or combined with posaconazole.Posaconazole demonstrated trypanostatic activity during treatment, but it is ineffective long-term in asymptomatic T. cruzi carriers. Benznidazole monotherapy is superior to posaconazole, with high RT-PCR conversion rates sustained at 1 year. Side effects lead to therapy discontinuation in 32%. No advantages were observed with combined therapy versus benznidazole monotherapy. (A Study of the Use of Oral Posaconazole [POS] in the Treatment of Asymptomatic Chronic Chagas Disease [P05267] [STOP CHAGAS]: NCT01377480).

Aims: This study sought to analyze the molecular mechanisms contributing to the development of rifaximin (Rfx) resistance in vitro in Escherichia coli. Twenty-eight Rfx-resistant mutants as well as four clinical isolates of E. coli were analyzed. The results obtained show that mutations in the rpoB gene and overexpression of Phe-Arg-β-naphthylamide (PAβN)-inhibitible efflux pump were implicated in Rfx resistance. Results: Amino acid substitutions at position 516 of the β-subunit of RNA polymerases were the most frequently obtained (53.6% of the mutants). The efflux pump inhibitor decreased the minimal inhibitory concentration (MIC) of 71.43% (20/28) of the mutant strains. Conclusions: Mutations studied in the rpoB gene and overexpression of PAβN-inhibitible efflux pumps contribute to Rfx resistance (together or not), whereas alterations in porin levels do not seem to have a relevant role in the acquisition of Rfx resistance.

Introduction and objectives The number of patients with Chagas disease in Spain has increased significantly. Chronic inflammation and endothelial dysfunction have been considered among the physiopathological mechanisms of Chagas heart disease. However, there have been conflicting data from clinical studies. Our purpose was to assess endothelial function and systemic levels of nitric oxide and high-sensitivity C-reactive protein in patients with the indeterminate form and with chronic Chagas cardiomyopathy living in a nonendemic area. Methods Flow-mediated endothelium-dependent vasodilatation and nitroglycerin-mediated vasodilatation were assessed with high-resolution ultrasound of the brachial artery in 98 subjects (32 with the indeterminate form, 22 with chronic Chagas cardiomyopathy and 44 controls). Nitric oxide and high-sensitivity C-reactive protein levels were measured in peripheral venous blood. Results Mean age was 37.6 ± 10.2 years and 60% were female. Nitroglycerin-mediated vasodilatation was significantly reduced in chronic Chagas cardiomyopathy compared to controls (median 16.8% vs 22.5%; P = .03). No significant differences were observed in flow-mediated vasodilatation and nitric oxide levels, although a trend towards lower flow-mediated vasodilatation after correction by baseline brachial artery diameter was observed in chronic Chagas cardiomyopathy. Levels of C-reactive protein were significantly higher in patients with the indeterminate form and with Chagas cardiomyopathy compared with controls ( P Conclusions Reduced nitroglycerin-mediated vasodilatation suggesting dysfunction of vascular smooth muscle cells was found in patients with chronic Chagas cardiomyopathy living in a nonendemic area. Higher C-reactive protein levels were observed in the indeterminate form and early stages of chronic Chagas cardiomyopathy, which could be related to the inflammatory response to the infection or early cardiovascular involvement.

Resumen Introduccion y objetivos El numero de pacientes con enfermedad de Chagas ha aumentado de manera significativa en Espana. La inflamacion cronica y la disfuncion endotelial han sido consideradas mecanismos fisiopatologicos de la cardiopatia chagasica. Sin embargo, en los estudios clinicos se han obtenido datos contradictorios. Nuestro objetivo fue evaluar la funcion endotelial y las concentraciones sistemicas de oxido nitrico y proteina C reactiva de alta sensibilidad en pacientes con la forma indeterminada de la enfermedad y con miocardiopatia chagasica cronica que vivian en un area no endemica. Metodos Se determino la vasodilatacion mediada por flujo, dependiente del endotelio, y la vasodilatacion mediada por nitroglicerina mediante ecografia de alta resolucion de la arteria humeral en 98 individuos (32 con la forma indeterminada de la enfermedad, 22 con miocardiopatia chagasica cronica y 44 controles). Se efectuaron determinaciones de las concentraciones de oxido nitrico y proteina C reactiva de alta sensibilidad en sangre venosa periferica. Resultados La media de edad fue 37,6 ± 10,2 anos; el 60% eran mujeres. La vasodilatacion mediada por nitroglicerina estaba significativamente reducida en la miocardiopatia chagasica cronica en comparacion con los controles (mediana, 16,8 frente a 22,5%; p = 0,03). No se observaron diferencias significativas en la vasodilatacion mediada por flujo ni en los valores de oxido nitrico, aunque se vio una tendencia a una menor vasodilatacion mediada por flujo tras la correccion segun el diametro basal de la arteria humeral en la miocardiopatia chagasica cronica. Las cifras de proteina C reactiva fueron significativamente mayores en los pacientes con la forma indeterminada de la enfermedad y con miocardiopatia chagasica que en los controles (p Conclusiones Se observo una reduccion de la vasodilatacion mediada por nitroglicerina que sugiere una disfuncion de las celulas de musculo liso vascular en pacientes con miocardiopatia chagasica cronica residentes en un area no endemica. Se observaron cifras superiores de proteina C reactiva en la forma indeterminada de la enfermedad y en las fases iniciales de la miocardiopatia chagasica cronica, lo que podria estar relacionado con la respuesta inflamatoria a la infeccion o la afeccion cardiovascular temprana.

The substantial immigration into Spain from endemic areas of Chagas disease such as Latin America has increased the number of potential donors of organs and tissues. In addition, an increasing number of patients with advanced Chagas heart disease may eventually be eligible to receive a heart transplant, a universally accepted therapeutic strategy for the advanced stages of this disease. Therefore, it is necessary to establish protocols for disease management. This document is intended to establish the guidelines to be followed when a potential donor or a tissue or organ recipient is potentially affected by Chagas disease and summarizes the action criteria against the possibility of Chagas disease transmission through the donation of organs, tissues, or hematopoietic stem cells and aims to help professionals working in this field. A single registry of transplants in Trypanosoma cruzi infected donors and/or recipients will provide and disseminate experience in this area, which has shown a low recorded incidence to date.

Due to international migration, Chagas disease, endemic in Latin America, has become more common in non-endemic areas. Chronic Chagas disease can cause damage to the digestive system leading to constipation. However, a range of factors influences constipation and a better understanding of the role of non-Chagas related factors is required to improve management of Chagas-related digestive problems. This study explores perceptions of constipation and changes in food and exercise habits amongst Bolivians in Barcelona, Spain. Bolivian migrants attending the Tropical Medicine Unit (Hospital Clínic, Barcelona) were interviewed about their food habits in Spain and Bolivia, migratory experience, work and leisure activities. Chagas seropositive participants also received radiological examinations. Bolivian migrants experienced dietary changes, influenced by work-related factors, which included reductions in quantities of food and liquid consumed. Almost half the participants reported changes in digestive rhythm since arriving in Spain. Constipation, which was common, in some cases was only recounted during interviews. Bolivian migrants’ constipation may be associated with chronic Chagas disease or migration-related dietary changes. Careful questioning using the Rome III criteria is however required to ensure its diagnosis. Radiological studies are also required to confirm the role of Chagas disease and identify potentially serious intestinal damage.

Strongyloides stercoralis has a unique ability to replicate in the human host and lead to chronic infection that can persist for several decades. Thirty-three patients (10 travellers and 23 immigrants) with imported S. stercoralis infection were studied and clinical and epidemiological characteristics described. Only 16 patients (48.5%) reported symptoms, mainly of the gastrointestinal tract. Eosinophilia was present in 21 (63.6%) patients. Seven patients (21.2%) had an immunocompromising condition. Patients were classified into chronic asymptomatic infection (17/33, 51.5%), chronic symptomatic infection (11/33, 33.3%) and hyperinfection (5/33, 15.2%). Four of the latter (80%) had an immunocompromising condition. Strongyloides stercoralis infection should be considered in immigrants and travellers with eosinophilia or compatible symptoms coming from endemic areas. Diagnosis should always be sought in immunocompromised hosts.

Due to recent trends in migration, there are millions of people from Chagas disease-endemic countries now living in North America, Europe, Australia and Japan, including thousands of people with Trypanosoma cruzi infection. Most infected individuals are not aware of their status. Congenital, transfusion- and/or transplant-associated transmission has been documented in the United States, Spain, Canada and Switzerland; most instances likely go undetected. High priorities include the implementation of appropriate screening, evaluation and clinical management, and better assessment of the true burden associated with this disease.

Chagas disease is a neglected infectious disease in the tropics and an emerging health problem in Europe and the USA. In the past decade, a link has been recorded between ischaemic stroke and Trypanosoma cruzi infection in several epidemiological studies, and an increase in stroke prevalence is expected with the ageing of the population infected with T cruzi in Latin America. Heart failure, mural thrombus, left ventricular apical aneurysm, and several types of cardiac arrhythmias are associated with stroke in Chagas disease. Stroke could also be the first sign of Chagas disease in asymptomatic patients and those with mild systolic dysfunction, so patients with stroke who are from endemic regions should be screened for T cruzi infection. The most frequent stroke syndrome seen in patients with Chagas disease is partial anterior circulation infarction. Stroke recurrence has been estimated to occur in 20% of patients, and secondary prevention measures include chronic anticoagulation in cardioembolic chagasic stroke. So far, no studies have been done to assess the effect of chagasic stroke on vascular dementia.

Severe imported malaria is an important problem in many countries in which this disease is not endemic. This retrospective study describes the characteristics of 20 adults with severe imported malaria admitted to our intensive care unit from 1991 through 2007. All episodes were caused by Plasmodium falciparum and all patients had returned from sub-Saharan Africa, except for one transfusion recipient. All persons were considered non-immune, and none had taken appropriate chemoprophylaxis. The median time between the initiation of symptoms and the diagnosis was seven days. Five patients died (mortality rate = 25%). A higher frequency of unrousable coma and acidosis and a higher median Apache II score at admission was noted in the persons who died. Mortality by severe malaria remains high despite high quality management, which highlights the importance of chemoprophylaxis and early diagnosis and treatment.

Objectives: Enteroaggregative Escherichia coli (EAEC) and enterotoxigenic E. coli (ETEC) are among the most frequent microorganisms causing traveller’s diarrhoea. The aim of this study was to investigate the evolution of antimicrobial resistance in EAEC and ETEC causing diarrhoea in patients who had travelled to different developing countries, comparing two periods of time, 1994–97 and 2001–04. Methods: Overall, 134 EAEC and 190 ETEC clinical isolates were studied. The MICs of ampicillin, chloramphenicol, nalidixic acid, tetracycline, trimethoprim/sulfamethoxazole, ciprofloxacin and amoxicillin/ clavulanic acid were determined by the Etest method. Detection of mutations in the quinolone-resistance determining region of the gyrA and parC genes was performed by PCR and DNA sequencing. Results: When antimicrobial resistance in EAEC and ETEC isolates was compared between the two periods of time, a statistically significant increase in resistance (P

Fundamento y objetivo >El dengue es la arbovirosis importada mas frecuente en nuestro medio. El aumento de los viajes internacionales y la creciente incidencia de esta enfermedad en paises del tropico ha hecho que se considere una enfermedad emergente. En este estudio se describen las caracteristicas clinicas y epidemiologicas de los casos de dengue importado en un periodo de 3 anos. Pacientes y metodo >Estudio prospectivo en el que se incluyo a pacientes diagnosticados de dengue importado en un periodo de 3 anos (2002-2005). Se recogieron datos clinicos y epidemiologicos, asi como muestras de sangre apareadas para el estudio serologico y de biologia molecular. Los datos se analizaron con el paquete estadistico Stata 9.2. Resultados >Se diagnosticaron 61 casos, la mayoria turistas europeos que habian viajado a America Central. El 98,4% de los pacientes presento fiebre y el 80,3%, erupcion cutanea. Cinco pacientes presentaron criterios de gravedad. Un 18% de los casos se consideraron dengue secundario, aunque ningun paciente cumplio criterios de la Organizacion Mundial de la Salud (OMS) de dengue hemorragico. La confirmacion de la infeccion se realizo en 26 casos a traves de la deteccion del genoma viral, y en 35 casos por serologia. De los 61 pacientes se consideraron 4 como dengue probable y 57 como dengue confirmado. Conclusiones >El dengue es un diagnostico frecuente en los pacientes con fiebre importada de un viaje a zonas del tropico y puede presentar complicaciones. Hay un porcentaje importante de dengue secundario, aunque el paciente no presente historia de dengue previo, por lo que hay riesgo de dengue hemorragico en Espana.

Objectives: To select rifaximin-resistant mutants of Escherichia coli and to establish the frequency of mutation, cross-resistance with other antimicrobial agents and the stability of the mutants obtained. Methods: Four E. coli isolates [two enteroaggregative E. coli (EAEC) and two enterotoxigenic E. coli (ETEC)] were used to obtain rifaximin-resistant mutants. The frequency of mutation in the presence of rifaximin, rifampicin and ciprofloxacin was established by growth on plates containing serial dilutions of antibiotic above the bacterial MIC. To determine the stability of rifaximin resistance, 28 selected resistant mutants were grown for 20 consecutive cultures on antibiotic-free plates. Every 10 days, the MICs of rifaximin, chloramphenicol, nalidixic acid and ciprofloxacin were established. Results: The frequency of mutation in the presence of rifaximin ranged between 5.7 x 10 -7 and 1.6 x 10 -6 in the case of the ETEC isolates, and between 2.0 x 10 -8 and 9.3 × 10 -8 in the case of the EAEC isolates; the frequency of mutation in the presence of rifampicin was in the order of 10 -8 and no mutant in the presence of ciprofloxacin was obtained. Twenty-six out of 28 selected mutants exhibited resistance levels around or higher than 256 mg/L. In all cases, the resistance was stable, and no reversion towards the original parental MIC was observed. In no case was the MIC of chloramphenicol, nalidixic acid or ciprofloxacin affected. Conclusions: Rifaximin has a low level of resistance selection, although it may select stable highly resistant mutants in a single step. Periodical surveillance of the levels of rifaximin resistance is required to detect the possible appearance of rifaximin-resistant clinical isolates. Further studies to characterize in-depth the mechanisms of stable resistance to rifaximin are necessary.

Chagas' disease, or American trypanosomiasis, is a parasitic zoonosis found only in the Americas. Under natural conditions, Trypanosoma cruzi is transmitted by insects belonging to different species of Triatoma. However, several routes of transmission that do not involve insect vectors have also been described, such as transmission via blood products or transplantation of infected organs, and vertical transmission. At present, the number of people infected with Chagas' disease worldwide is estimated to be about 10-12 million. The process of urbanization in Latin America and migratory population movements from endemic countries have led to the disease being diagnosed in non-endemic areas. It is estimated that 20-30% of individuals infected with T. cruzi will develop symptomatic heart disease at some point during their lives. The specific differential characteristics of chronic chagasic cardiopathy, lack of knowledge of the disease among many healthcare workers, and the fact that arrhythmia or sudden death is frequently the first manifestation of disease all make it essential that diagnostic and therapeutic protocols for the disease are developed and disseminated. The aim should be to improve patient care by increasing understanding of the condition by physicians and other healthcare professionals who may be involved in its detection and treatment.

Fifty million people are estimated to travel from industrial countries to the tropics annually. In spite of exhaustive studies and widely different diagnosis among returned patients, some cases of febrile illnesses remain without an etiological diagnosis, suggesting that these cases could be due to viral respiratory tract infections. From August 2005 to October 2006, 118 febrile patients without a specific diagnosis in their first visit at the Center for International Health of the Hospital Clínic of Barcelona were included. In all of them, in order to study respiratory viruses, a nasopharyngeal swab was collected. Clinical and radiological features and epidemiological data, as well as other samples for microbiologic studies, were also collected during consultation. Based on the physician's judgment at the time of consultation, patients were classified into four groups: respiratory symptoms (62%), febrile syndrome with nonspecific symptoms (24%), digestive symptoms (10%), and patients presenting both respiratory and digestive symptoms (4%). A pathogen microorganism was detected in 61 patients (52%). Respiratory viruses were detected in 44 out of 118 (37%) travelers included in the study, representing 56% of the patients with respiratory symptoms. The most frequently viruses detected were influenza virus (38%), rhinovirus (23%), adenovirus (9%), and respiratory syncytial virus (9%). Respiratory viruses have been shown to play an important role in imported fever. In light of the fact that international tourism is an increasing phenomenon, new strategies to prevent the spread of respiratory viruses should be considered, specially for influenza when a vaccine is available. J. Med. Virol. 80:711–715, 2008. © 2008 Wiley‐Liss, Inc.

Thromboembolic events were described in patients with Chagas disease without cardiomyopathy. We aim to confirm if there is a hypercoagulable state in these patients and to determine if there is an early normalization of hemostasis factors after antiparasitic treatment. Ninety-nine individuals from Chagas disease-endemic areas were classified in two groups: G1, with T.cruzi infection (n = 56); G2, healthy individuals (n = 43). Twenty-four hemostasis factors were measured at baseline. G1 patients treated with benznidazole were followed for 36 months, recording clinical parameters and performance of conventional serology, chemiluminescent enzyme-linked immunosorbent assay (trypomastigote-derived glycosylphosphatidylinositol-anchored mucins), quantitative polymerase chain reaction, and hemostasis tests every 6-month visits. Prothrombin fragment 1+2 (F1+2) and endogenous thrombin potential (ETP) were abnormally expressed in 77% and 50% of infected patients at baseline but returned to and remained at normal levels shortly after treatment in 76% and 96% of cases, respectively. Plasmin-antiplasmin complexes (PAP) were altered before treatment in 32% of G1 patients but normalized in 94% of cases several months after treatment. None of the patients with normal F1+2 values during follow-up had a positive qRT-PCR result, but 3/24 patients (13%) with normal ETP values did. In a percentage of chronic T. cruzi infected patients treated with benznidazole, altered coagulation markers returned into normal levels. F1+2, ETP and PAP could be useful markers for assessing sustained response to benznidazole., Author Summary The manuscript describes the results of a study whose aim was to assess the tendency to coagulate in people suffering from a parasitic infection frequent in Latin America named T. cruzi infection or Chagas disease, by the study of several coagulation factors. According to the state of the art in this topic, specific treatment for Chagas disease is recommended in recent (acute) and late (chronic) stages of the infection. The effectiveness of current available drugs in the chronic stage of infection is still a topic of debate due to inconsistent results across studies and a lack of early measurable parameters of response to specific treatment. Another aim of this study was to determine if the presence of an upregulated procoagulative activity in plasma in people suffering T. cruzi infection could be used as potential marker that indicates therapeutic response in people at chronic stage of the disease. The results of this study suggest that measurements of alterations of procoagulative activity may be useful to indicate specific treatment for T. cruzi chronically infected patients and new data concerning early response to treatment biomarkers.

Histoplasmosis is an infection that occurs when conidia of the dimorphic fungus Histoplasma capsulatum var capsulatum are inhaled into the lungs. It is the most common systemic mycosis diagnosed among European travelers returning from endemic areas of Central and South America, 1–3 and in recent years, a growing number of cases, both isolated and in clusters, have been detected in nonendemic areas such as Europe. 4–7 This rise in apparent cases of histoplasmosis is thought to be a result of increased international travel, especially tourism, cooperation, and trade. However, heightened awareness of the clinical manifestations and epidemiology of histoplasmosis by health care practitioners in these countries may have also played a part in increasing diagnosis. Published data have undoubtedly underestimated the true magnitude of this travel‐related mycosis (as well as other geographically restricted endemic mycoses such as coccidiomycosis, paracoccidioidomycosis, and penicilliosis), and many cases, especially those asymptomatic or presenting as a mild nondescript febrile illness, often go undiagnosed. Most cases of imported histoplasmosis are known to occur in small clusters with a common source of infection. Usually, the individuals affected in these outbreaks have a history of participation in leisure and work activities, which involve heavy exposure to bat or bird droppings (mostly cavers and volunteers with recent involvement in cleaning tasks or rehabilitation of old buildings). 8–12 More than 95% of immunocompetent people remain asymptomatic following low‐inoculum infection with H capsulatum . 2 In the few symptomatic cases which occur, clinical presentation includes a self‐limited benign pulmonary illness with fever, malaise, dry cough, and chest pain. Disseminated severe disease is only observed in those individuals with a high degree of prior exposure to guano or impaired cellular immunity. 6,13,14 Here, we describe an outbreak of acute histoplasmosis with unusual clinical manifestations among four previously healthy Spanish travelers who had …

BACKGROUND: Dengue fever is the most common arboviral disease in travelers. In countries where dengue virus is endemic, sequential (secondary) infections with different dengue virus serotypes are associated with disease severity. Data on severity and secondary infection rates in a population of travelers are lacking. METHODS: Intensified surveillance of dengue fever in travelers was performed within the European Network on Surveillance of Imported Infectious Diseases. Data were collected at 14 European clinical referral centers between 2003 and 2005. RESULTS: A total of 219 dengue virus infections imported from various regions of endemicity were reported. Serological analysis revealed a secondary immune response in 17%. Spontaneous bleeding was observed in 17 (8%) patients and was associated with increased serum alanine and aspartate aminotransferase levels and lower median platelet counts. Two (0.9%) patients fulfilled the World Health Organization (WHO) case definition for dengue hemorrhagic fever. However, 23 (11%) travelers had severe clinical manifestations (internal hemorrhage, plasma leakage, shock, or marked thrombocytopenia). A secondary immune response was significantly associated with both spontaneous bleeding and other severe clinical manifestations. CONCLUSIONS: In travelers, severe dengue virus infections are not uncommon but may be missed if the WHO classification is strictly applied. High liver enzyme levels and low platelet counts could serve as indicators of disease severity.

The aim of this study was to analyze the evolution of the levels of resistance to nine antimicrobial agents in clinical isolates of Campylobacter spp. causing traveler's diarrhea during the period from 1993 to 2003. The antimicrobial resistance levels to ampicillin, amoxicillin plus clavulanic acid, chloramphenicol, tetracycline, erythromycin, gentamicin, clindamicin, nalidixic acid and ciprofloxacin were established by the method of Kirby-Bauer. Two subperiods (1993-1998 and 1999-2003) were chosen to compare the evolution of the levels of antimicrobial resistance. Mantel-Haenszel or Fisher's exact test was performed to determine statistical significance. High levels of resistance to four out of nine antimicrobial agents tested were detected: ampicillin (66.3%), nalidixic acid (52.2%), ciprofloxacin (46.7%), and tetracycline (42.4%). In addition, resistance levels of 20.6%) to amoxicillin plus clavulanic acid were detected. An increase in the resistance levels between the two subperiods analyzed for those five antimicrobial agents was observed. This increase was statistically significant for ampicillin, nalidixic acid, and ciprofloxacin. Two cases of therapeutic failure during treatment with ciprofloxacin were detected. The level of resistance to the most commonly used antibacterial agents in the developing world is increasing in Campylobacter spp., the increase in the resistance to quinolones being of special concern.

Chagas' disease, or American trypanosomiasis, is a parasitic zoonosis found only in the Americas. Under natural conditions, Trypanosoma cruzi is transmitted by insects belonging to different species of Triatoma. However, several routes of transmission that do not involve insect vectors have also been described, such as transmission via blood products or transplantation of infected organs, and vertical transmission. At present, the number of people infected with Chagas' disease worldwide is estimated to be about 10-12 million. The process of urbanization in Latin America and migratory population movements from endemic countries have led to the disease being diagnosed in non-endemic areas. It is estimated that 20-30% of individuals infected with T. cruzi will develop symptomatic heart disease at some point during their lives. The specific differential characteristics of chronic chagasic cardiopathy, lack of knowledge of the disease among many healthcare workers, and the fact that arrhythmia or sudden death is frequently the first manifestation of disease all make it essential that diagnostic and therapeutic protocols for the disease are developed and disseminated. The aim should be to improve patient care by increasing understanding of the condition by physicians and other healthcare professionals who may be involved in its detection and treatment.

INTRODUCTION: Delayed haemolytic anaemia is one of the more frequent events after treatment with intravenous artesunate in patients with severe malaria. Little is known about its frequency and the outcomes of patients with this condition. METHODS: A retrospective study was conducted to describe the incidence of delayed haemolysis in a cohort of patients with severe malaria by Plasmodium falciparum treated with artesunate between August 2013 and July 2015. RESULTS: The study included 52 patients with malaria due to Plasmodium falciparum, with 21 having severe malaria. The majority were male (66.7%), and the median age was 43 years. Four patients (19%) presented post-artesunate delayed haemolysis 11-13 days from the initiation of treatment. Two patients required hospital admission and red blood cell transfusion. CONCLUSION: Post-artesunate delayed haemolysis is frequent in patients with severe malaria treated with intravenous artemisinins. These patients should be monitored for 4 weeks after treatment is started.

Schistosomiasis is a parasitic disease reported in 78 countries, with an additional recent outbreak in Corsica [1,2]. Generally, Schistosoma haematobium causes urogenital problems, whereas S. mansoni, S. japonicum, S. mekongi, S. guineensis, and S. intercalatum generate intestinal symptoms. Occasionally, ectopic tissue tropisms [3] and infections by parasites resulting from hybridization occur [4,5]. Geographical distribution and transmission of Schistosoma species depend on the presence of suitable intermediate snail hosts to complete the life cycle. Here we report on an unusual case of urogenital schistosomiasis in a Dominican adult male, living in Spain, with no history of visiting a known endemic area.

Background Few studies have assessed the burden of Chagas disease in non-endemic countries and most of them are based on prevalence estimates from Latin American (LA) countries that likely differ from the prevalence in migrants living in Europe. The aim of this study was to systematically review the existing data informing current understanding of the prevalence of Chagas disease in LA migrants living in European countries. Methods We conducted a systematic review and meta-analysis of studies reporting prevalence of Chagas disease in European countries belonging to the European Union (EU) before 2004 in accordance with the MOOSE guidelines and based on the database sources MEDLINE and Global Health. No restrictions were placed on study date, study design or language of publication. The pooled prevalence was estimated using random effect models based on DerSimonian & Laird method. Results We identified 18 studies conducted in five European countries. The random effect pooled prevalence was 4.2% (95%CI:2.2-6.7%); and the heterogeneity of Chagas disease prevalence among studies was high (I2 = 97%,p, Author Summary Chagas disease is emerging in European countries due to the migration flows from Latin-American endemic countries to Europe, particularly to southern countries. Some studies have evaluated the prevalence of this disease in several European countries although these estimates are based on national population prevalence rates from countries of origin and the estimated size of the corresponding migrant population. The objective of this study is to review the studies about the prevalence of Chagas disease in Latin American migrants living in European countries. Our meta-analysis provides prevalence estimates of Chagas disease that should be used to estimate the burden of disease in European countries. This accurate data about country specific prevalence of Chagas disease could be used to evaluate the cost-effectiveness of screening programmes and also could help policy makers to design health interventions concerning Chagas disease.

The molecular epidemiology, antimicrobial susceptibility, and mechanisms of resistance of 34 Salmonella spp. strains causing acute gastroenteritis, isolated from different provinces in Cuba, were determined. Sixty-four percent of the strains showed multiresistance. Salmonella typhimurium was the most frequent with 15 strains (44%), 13 of which belonged to phagotype 104 and presented similar genetic profiles of pulsed field gel electrophoresis. High levels of resistance to tetracycline (53%), spectinomycin (50%), ampicillin (44%), and chloramphenicol (41%) were found. Resistance to tetracycline was associated with the tet G and tet A genes. Resistance to ampicillin was caused by the presence of beta-lactamases, mainly the CARB type. The floR gene was the main mechanism of resistance to chloramphenicol. Our results showed an antimicrobial susceptible clone of Salmonella enterica serotype Agona in two separate regions. This is the first report of the widespread dissemination of a multiresistant clone of S. enterica serotype Typhimurium definitive phage type 104 in Cuba.

Traveler’s diarrhea (TD) is the most frequent health problem in travelers to developing countries. Several personal and environmental risk factors are at the basis of TD acquisition and are discussed in this paper. TD is caused by a wide range of infectious organisms, ETEC and EAEC bacteria strains being the main enteropathogens incriminated in TD. Other causative bacteria are: Shigella spp., Campylobacter spp., Vibrio spp., Aeromonas spp., Salmonella spp., and Plesiomonas spp. Parasite species are also included: Cyclospora cayetanensis, Giardia lamblia, Crystosporidium, Entamoeba histolytica, as well as viruses: rotavirus, adenovirus, Norwalk virus. Due to the great diversity of pathogens incriminated, several pathophysiological mechanisms have been described and some of them are still poorly understood. The clinical symptoms present are also quite variable, although inflammatory and non-inflammatory diarrhea have been established as a classical and basic classification of diarrhea.

Fundamento y objetivo Se han descrito correlaciones convincentes entre mutaciones en determinados genes de Plasmodium falciparum y la resistencia contra antimalaricos. Con la intencion de aplicar las tecnicas moleculares en los mecanismos de vigilancia epidemiologica en el Hospital Clinic de Barcelona, y para mapear grados potenciales de resistencia, investigamos la presencia de mutaciones en los codones relevantes de genes asociados a resistencias en aislados de P. falciparum importados por viajeros. Pacientes y metodo Se analizo mediante reaccion en cadena de la polimerasa (PCR) y restriccion con enzimas el genotipo de los genes pfctr, pfmdr1, dhfr, dhps y citocromo B en cepas de P. falciparum aisladas de 53 pacientes diagnosticados en el Servicio de Medicina Tropical con sintomas de malaria despues de haber realizado un viaje a zonas endemicas de malaria. Resultados El 63% de los pacientes presento un aislado de P. falciparum con la mutacion K76T en pfctr. En el 54% de los aislados se encontro Tyr86 en pfmdr1. Las mutaciones en los codones 51, 59 y 108 de dhfr se encontraron en el 33, el 49 y el 44% de los aislados, respectivamente. Las mutaciones en los codones 436, 437 y 540 de dhps se encontraron en el 35, el 35 y el 8,5% de los aislados. El 30% de los viajeros estaba infectado por parasitos que presentaban 3 o mas mutaciones en alguno de los codones de dhps y dhfr. Ninguno de los pacientes presento mutado el codon Tyr268 en el gen del citocromo B. Conclusiones La alta prevalencia de mutaciones en los aislados importados sugiere el rapido desarrollo y la expansion de resistencias a la mayoria de los antimalaricos comunmente usados. La concurrencia de mas de una mutacion en localizaciones diferentes sugiere la expansion de resistencias multiples, lo que pone asi de manifiesto la ineficacia de la monoterapia con los antipaludicos mas comunes.

This study aims to characterize the presence of virulence factors of enterotoxigenic Escherichia coli (ETEC) causing traveler's diarrhea. Among 52 ETEC isolates, the most common toxin type was STh, and the most frequent colonization factors (CFs) were CS21, CS6, and CS3. On the other hand, the nonclassical virulence factors EAST1 and EatA were frequently present.

The evolution of antimicrobial resistance in Salmonella isolates causing traveler's diarrhea (TD) and their mechanisms of resistance to several antimicrobial agents were analyzed. From 1995 to 2002, a total of 62 Salmonella strains were isolated from stools of patients with TD. The antimicrobial susceptibility to 12 antibiotics was determined, and the molecular mechanisms of resistance to several of them were detected as well. The highest levels of resistance were found against tetracycline and ampicillin (21 and 19%, respectively), followed by resistance to nalidixic acid (16%), which was mainly detected from 2000 onward. Molecular mechanisms of resistance were analyzed in 16 isolates. In these isolates, which were resistant to ampicillin, two genes encoding β-lactamases were detected: oxa-1 (one isolate) and tem -like (seven isolates [in one strain concomitantly with a carb-2 ]). Resistance to tetracycline was mainly related to tetA (five cases) and to tetB and tetG (one case each). Resistance to chloramphenicol was related to the presence of the floR and cmlA genes and to chloramphenicol acetyltransferase activity in one case each. Different genes encoding dihydrofolate-reductases ( dfrA1 , dfrA12 , dfrA14 , and dfrA17 ) were detected in trimethoprim-resistant isolates. Resistance to nalidixic acid was related to the presence of mutations in the amino acid codons 83 or 87 of the gyrA gene. Further surveillance of the Salmonella spp. causing TD is needed to detect trends in their resistance to antimicrobial agents, as we have shown in our study with nalidixic acid. Moreover, such studies will lead to better treatment and strategies to prevent and limit their spread.

There are currently two major factors that have modified the epidemiology of Chagas disease in the last decades: climate change and migration flows. In this new scenario, there are new challenges to control and prevent Trypanosoma cruzi infection in endemic countries, such as the control of a wider distribution of triatomine vectors or the reinforcement of vertical transmission programs. In non-endemic areas, few countries are aware of the emergence of this new disease and have established changes in their health systems. To address this new public health challenge, the priorities should be control programs to avoid new cases of T. cruzi infection acquired through vertical transmission, blood transfusion or organ transplant. In both, endemic and non-endemic areas, the international community and all the actors involved in Chagas disease must join efforts mainly in two directions: better management of the infection in affected individuals and more research to cover the knowledge gap mainly in physiopathology, diagnosis and treatment.

Chagas disease is a parasitic infection that leads to a significant public health problem in countries where the disease is endemic and where it is nonendemic. Benznidazole is the most commonly used drug for the etiological treatment of Chagas disease. Patients treated with benznidazole suffer frequent adverse drug reactions. Although arthralgia is common, arthritis has been reported as a very rare side effect. The objective of this study was to describe arthritis in a cohort of Trypanosoma cruzi -infected patients treated with benznidazole.

Chagas disease has a unique history where the confluence of rural and marginalized populations affected, the deeply rooted attitudes, clinical practices and an underfunded research area has resulted in one of the most current neglected health issues. Globalization has changed the epidemiology of the disease, which is now found throughout the Americas but also in Europe and Japan. Thus, Chagas disease is a global public health problem. In this new paradigm, a strong partnership aimed to coordinate actions to scale up diagnostics and treatments, to engage communities and health practitioners in implementation and advocating for sustained funding for the development of improved tools, can play a critical role to leave behind this story of neglect. Even with the imperfect tools currently available, still much can be done.

BACKGROUND: Recent decades have seen a rise in population movements and, therefore, the spread of tropical diseases and changes in the epidemiology of global disease patterns. Only 50% of travelers to tropical areas receive pre-travel advice and most of them present risk behaviors for acquiring infections. The aim of this study was to describe the clinical and epidemiological characteristics of travelers and identify factors associated with risk behaviors. METHODS: We made a retrospective, descriptive and analytical study of 772 travelers consulting a tropical medicine clinic in Barcelona in 2010. Data on demographic and clinical variables, travel characteristics and risk behaviors were collected. RESULTS: Among all travelers studied, 65.8% (466/708) received pre-travel advice and 30.7% (209/680) took malaria prophylaxis. At least one risk behavior was reported by 82.6% (587/711) of travelers. People travelling for 1-6 months had a 3-fold higher likelihood of experiencing risk behaviors than people travelling for 6 months had a 13-fold higher likelihood (95% CI 3.11-56.14, p

Fundamento Conocer las caracteristicas clinicas y epidemiologicas de la enteritis por Cyclospora cayetanenesis Pacientes Y Metodo Protocolo clinico, epidemiologico y microbiologico de estudio en viajeros a paises de renta baja Resultados Se diagnostico ciclosporiasis a 55 pacientes. El 96% consultaron por diarrea del viajero (DV). Las caracteristicas mas llamativas de la DV eran la persistencia de la diarrea (mas de 2 semanas de evolucion), que afectaba a 38 pacientes (69%), y una perdida igual o superior a 3 kg de peso en el 38% de pacientes de la serie. En el 36% de los casos la DV se inicio despues del viaje. Aunque cosmopolita, C. cayetanensis se aislo con mas frecuencia en viajeros a America Latina, el subcontinente indio y el sudeste asiatico. Solo en 5 viajeros se detecto algun factor de riesgo potencialmente especifico: frambuesas en tres casos, leche de bufalo en uno y ceviche en uno. Conclusiones C. cayetanensis es un enteropatogeno emergente, que se aisla en un 2 a un 4% de los pacientes afectados de DV y debe formar parte del diagnostico diferencial en esta enfermedad.

Introduction: Chagas disease is a common condition among Latin American immigrants living in Spain. Material and methods: An immunochromatographic test was used for Chagas disease screening in 148 patients from Latin America and the results were compared with those of 2 ELISA techniques. Results: The test had a sensitivity of 92.5%, a specificity of 96.8%, and a coefficient of agreement with the 2 ELISA techniques of 0.9. Conclusions: The specificity of the test assayed suffices for Chagas disease screening, but the sensitivity needs to be improved before it can be used for this purpose.

Enteroaggregative Escherichia coli (EAEC) is associated with diarrhea in Spanish travelers to developing countries. In this study, the polymerase chain reaction was used to test EAEC isolates for genes encoding putative virulence factors, including EAEC adhesins, the plasmid-encoded toxin (Pet), a heat-stable enterotoxin (EAST), and Shigella enterotoxins 1 and 2 (ShET1 and ShET2). Findings included a low prevalence of genes for Pet (4.3%), ShET2 (4.3%), and the adherence factor AAF/II (8.7%). The overlapping genes encoding the ShET1 and the Pic mucinase were present in most EAEC strains tested (56.5%); however, some strains that carried this locus did not produce both proteins, as determined by Western immunoblot. Surprisingly, ShET1 and ShET2 genes were also found in other E. coli pathotypes, as was the EAST toxin locus. These findings underscore the heterogeneity of EAEC strains and suggest that the ShET1 may be an important virulence factor in traveler's diarrhea.

Eighty-six strains of Shigella spp. were isolated during the dry season from stool samples of children under 5 years of age in Ifakara, Tanzania. The epidemiological relationship as well as the antimicrobial susceptibility and mechanisms of resistance to ampicillin, chloramphenicol, and co-trimoxazole were investigated. Four different epidemiological tools, pulsed-field gel electrophoresis (PFGE), repetitive extragenic palindromic (REP)-PCR, plasmid analysis, and antibiogram, were compared for typing Shigella strains. Seventy-eight (90%) strains were Shigella flexneri and were distributed into four groups, by either PFGE or REP-PCR, with 51, 17, 7, and 3 strains. The four strains of Shigella dysenteriae belonged to the same group, and the four strains of Shigella sonnei were distributed in two groups with three and one strain each. Plasmid analysis showed a high level of heterogeneity among strains belonging to the same PFGE group, while the antibiogram was less discriminative. REP-PCR provided an alternative, rapid, powerful genotyping method for Shigella spp. Overall, antimicrobial susceptibility testing showed a high level of resistance to ampicillin (81.8%), chloramphenicol (72.7%), tetracycline (96.9%), and co-trimoxazole (87.9%). Ampicillin resistance was related to an integron-borne OXA-1-type β-lactamase in 85.1% of the cases and to a TEM-1-type β-lactamase in the remaining 14.8%. Resistance to co-trimoxazole was due to the presence of a dhfr Ia gene in all groups except one of S. flexneri , where a dhfr VII gene was found within an integron. Chloramphenicol resistance was associated in every case with positive chloramphenicol acetyltransferase activity. All strains were susceptible to nalidixic acid, ciprofloxacin, ceftazidime, cefotaxime, and cefoxitin. Therefore, these antimicrobial agents may be good alternatives for the treatment of diarrhea caused by Shigella in Tanzania.

Introduccion La malaria por Plasmodium falciparum es la forma mas agresiva de esta enfermedad, que se registra en el 90% en Africa. Solo adquieren cierto grado de inmunidad los originarios de zonas endemicas. Es incierto si la inmunidad se pierde al perder el contacto con el parasito. Pacientes y metodos Estudio retrospectivo de los pacientes con malaria importada de Africa por P. falciparum en el Hospital Clinic de Barcelona, en el periodo 1999-2005. Comparamos caracteristicas epidemiologicas, clinicas y de laboratorio entre inmigrantes y viajeros. Resultados De 187 pacientes, 85 eran inmigrantes de zona endemica, la mayoria de los cuales residian desde hacia mas de 5 anos en zona no endemica y presentaron menos complicaciones. Discusion Estos datos podrian apuntar a cierta persistencia de la inmunidad cuando personas previamente semiinmunes migran a zonas no endemicas.

Among 200 isolates of Shigella from patients with travellers’ diarrhoea, 12 isolates (four isolated in 1995–2000 and eight in 2001–2004) exhibited quinolone resistance. Nine of these isolates originated from India. These resistant isolates had at least one amino-acid substitution in GyrA. Quinolone resistance is increasing in Shigella spp. causing travellers’ diarrhoea, and particularly among isolates causing diarrhoea in travellers returning from India.

The in vitro activity of rifaximin against 84 diarrheagenic Escherichia coli and 11 Shigella sonnei causing traveler's diarrhea was evaluated. The MIC of rifaximin ranged between0.007 and 32 mg/L; other agents tested had an MIC of256 mg/L in most cases. The results showed the potential use of rifaximin to treat these infections.

Background Some data indicate that obstructive sleep apnoea syndrome (OSAS), a disorder characterized by recurrent episodes of cessation of respiratory airflow during sleep, is highly prevalent in the general population but no such data exist in southern Europe. Methods In the Zaragoza metropolitan area (northeast of Spain) a representative sample of 1360 subjects aged > 18 years and selected by quota methods according to age, sex and geographical distribution agreed to participate. Trained interviewers visited selected residents to administer a sleep questionnaire in the presence of a bedmate or another closely-related person who lived in the subject's home; anthropometric data and arterial blood pressure were also recorded. All participants were invited to record nocturnal home oximetry (NHO). The NHO results were classified as 'abnormal' (or consistent with OSAS) in the presence of repetitive, short-duration arterial oxyhaemoglobin saturation (SaO2) fluctuations. Results The diagnosis of OSAS was established in subjects with loud (severe) snoring + excessive daytime sleepiness + abnormal oximetry In the group of 1222 subjects (597 males, 625 females) who agreed to have NHO, 63.7% of men and 36.3% of women snored 'usually' or 'always' (severe snorers): daytime sleepiness in active situations occurred in 12.1% and 14.4% respectively. The association of severe snoring plus daytime sleepiness plus abnormal NHO was found in 18 subjects (13 males, 5 females). Conclusions We estimated that among Spanish adults, 0.8% of women and 2.2% of men meet the minimal criteria to diagnose sleep apnoea syndrome.

The aim of the study presented here was to assess the incidence of histoplasma infection in a cohort of 342 individuals in Spain who had traveled to Latin America for the first time. The histoplasmin skin test was positive in 20% of the travelers, and Central America posed a higher risk for infection than South America (p=0.013). Sleeping outdoors (p=0.031) and the duration of travel (p=0.016) were also identified as significant risk factors. Serological testing demonstrated poor overall sensitivity for detecting infection in the travelers, but for the symptomatic acute cases the results were improved. Histoplasmosis must be considered in patients presenting with fever (odds ratio=3.51 [1.52-8.12]) or cough (odds ratio=4.24 [1.32-13.58]) after visiting Latin America. The results of this study have public health implications and indicate the risks of acquiring histoplasmosis should be included in pre-travel counseling.

Fundamento y objetivo Senegal es uno de los paises que esta despertando un creciente interes como destino turistico. En el ano 2000 hubo un mayor numero de casos de paludismo en pacientes procedentes de dicho pais. El objetivo del presente trabajo es constatar dicho aumento, describir las caracteristicas de los pacientes e identificar los motivos de este incremento. Pacientes y metodo Durante los anos 1999-2002 se recogieron de forma prospectiva los datos clinicos y epidemiologicos de todos los casos de paludismo atendidos de forma consecutiva en el servicio de Medicina Tropical del Hospital Clinico de Barcelona. Resultados Se atendio a un total de 276 pacientes, 74 durante el ano 2000; de ellos, 17 habian viajado a Senegal y Gambia. Su edad media era de 36,58 (6,9) anos, y el 12% eran mujeres. El 59% eran espanoles, un 35% senegaleses y un 6% gambianos. El motivo del viaje fue turismo en 9 (53%) casos, y visita a familiares en 7 (41%). La duracion media de la visita fue de 31 (20,6) dias y solo el 17,6% de los viajeros realizo profilaxis correcta. Plasmodium falciparum fue la especie mas frecuente (88%). El porcentaje de pacientes con paludismo que habian visitado Senegal vario desde un 6,6% en el ano 1996 a un 20% en el ano 2000 y un 6,3% el ano 2002 (p Conclusiones En el ano 2000 hubo un aumento no esperado de paludismo importado de Senegal en nuestra unidad. Los cambios en la dinamica de transmision del paludismo y de las ofertas turisticas podrian ser causas de un aumento insospechado de los casos de esta enfermedad.