A study of Pneumocystis pneumonia in South Africa

An increased prevalence of Pneumocystis jirovecii with point mutations in the fas gene, coding for dihydropteroate synthase (DHPS), has been associated with sulfonamide use. The purpose of this research was to investigate the prevalence of P. jirovecii strains containing DHPS polymorphisms in South Africa, and to ascertain their clinical relevance in HIV-positive patients with Pneumocystis pneumonia (PCP). A pilot study confirmed the presence of DHPS polymorphisms in 42% of specimens. A subsequent prevalence study confirmed the high prevalence (56%) of mutant P. jirovecii in adult patients. A prospective clinical study found that 61% of PCP patients were infected with mutant P. jirovecii. The overall in-hospital mortality was 21%. Significantly more patients died in hospital of mutant P. jirovecii than those infected with wild-type strains (P = 0.04). Mortality at three months among the discharged patients was associated with the wild-type genotype. However, cause of death was unknown. There were no significant associations in patients infected with P. jirovecii containing single DHPS mutations versus those infected with the M3 genotype. There was an insignificant trend for patients infected with M3 strains to have lower median CD4+ cell counts versus patients harbouring single mutant strains (P = 0.06). Few patients were exposed to sulfonamides and 58% of patients diagnosed with HIV on admission harboured mutant P. jirovecii. P. jirovecii strains, in a subset of clinical study patients, were characterized by ITS typing. Eleven bona fide ITS haplotypes, six ITS1 and nine ITS2 types, were found. Almost half of the patients harboured more than one P. jirovecii strain. Eg occurred at a high frequency of 85%, and the presence of the local South African haplotype Eu was confirmed. Other ITS haplotypes detected were: Em, Ec, Eb, Bi, Gg, Ep, Fu4, Ne and Ai. Two novel ITS1 sequences SA1 and SA2 were detected. There were no obvious associations between ITS haplotype and a particular clinical characteristic or outcome. Eg haplotypes were more often associated with a wild-type DHPS genotype. Inter-human transmission of P. jirovecii carrying mutant DHPS genotypes could, at least in part, explain the high prevalence of DHPS mutations in adult HIV-positive South Africans

Comparison of Leishmania typing results obtained from 16 European clinical laboratories in 2014.

Leishmaniasis is endemic in southern Europe, and in other European countries cases are diagnosed in travellers who have visited affected areas both within the continent and beyond. Prompt and accurate diagnosis poses a challenge in clinical practice in Europe. Different methods exist for identification of the infecting Leishmania species. Sixteen clinical laboratories in 10 European countries, plus Israel and Turkey, conducted a study to assess their genotyping performance. DNA from 21 promastigote cultures of 13 species was analysed blindly by the routinely used typing method. Five different molecular targets were used, which were analysed with PCR-based methods. Different levels of identification were achieved, and either the Leishmania subgenus, species complex, or actual species were reported. The overall error rate of strains placed in the wrong complex or species was 8.5%. Various reasons for incorrect typing were identified. The study shows there is considerable room for improvement and standardisation of Leishmania typing. The use of well validated standard operating procedures is recommended, covering testing, interpretation, and reporting guidelines. Application of the internal transcribed spacer 1 of the rDNA array should be restricted to Old World samples, while the heat-shock protein 70 gene and the mini-exon can be applied globally

Imported leishmaniasis in Sweden 1993-2016

In Sweden, leishmaniasis is an imported disease and its epidemiology and incidence were not known until now. We conducted a retrospective, nationwide, epidemiological study from 1993 to 2016. Probable cases were patients with leishmaniasis diagnoses reported to the Swedish Patient registry, collecting data on admitted patients in Swedish healthcare since 1993 and out-patient visits since 2001. Confirmed cases were those with a laboratory test positive for leishmaniasis during 1993-2016. 299 probable cases and 182 confirmed cases were identified. Annual incidence ranged from 0.023 to 0.35 per 100 000 with a rapid increase in the last 4 years. Of 182 laboratory-verified cases, 96 were diagnosed from 2013 to 2016, and in this group, almost half of the patients were children under 18 years. Patients presented in different healthcare settings in all regions of Sweden. Cutaneous leishmaniasis was the most common clinical manifestation and the majority of infections were acquired in Asia including the Middle East, specifically Syria and Afghanistan. Leishmania tropica was responsible for the majority of cases (42%). A combination of laboratory methods increased the sensitivity of diagnosis among confirmed cases. In 2016, one-tenth of the Swedish population were born in Leishmania-endemic countries and many Swedes travel to these countries for work or vacation. Swedish residents who have spent time in Leishmania-endemic areas, could be at risk of developing disease some time during their lives. Increased awareness and knowledge are needed for correct diagnosis and management of leishmaniasis in Sweden

Clinical presentation and diagnosis of imported strongyloidiasis at a tertiary hospital, Stockholm, Sweden

Background: Since Strongyloides can persist in its host for decades, and cause life threatening infections data on prevalence, the burden and risk factors for infection is crucial in migrant populations. Methods: In this observational retrospective cohort study, we describe the epidemiological, clinical, and microbiological characteristics of imported strongyloidiasis diagnosed at the Karolinska University Hospital, Stockholm, Sweden, during 2010–2021. Results: We identified 98 individuals with strongyloidiasis, 89 (90.8%) born in endemic and 9 (9.2%) in non-endemic countries. Sub-Saharan Africa was the most common origin among the group born in endemic countries (62, 69.7%), (p < 0.005). There were 22 individuals with an underlying immunosuppressive condition.Gastrointestinal symptoms (53/98, 54.1%) were the symptoms most frequently described, and were more frequent in adults (57.0%) vs children (0%) (p = 0.013). Eosinophilia was detected in 74 (75.5%), being more frequent in the endemic-borne group (79.8% vs 33.3%, p = 0.002). Eight persons developed complications of strongyloidiasis because of either hyperinfection or disseminated disease. No people living with HIV with CD4 <500/mm3 (n = 6) developed severe strongyloidiasis. Conclusion: A limited number of strongyloidiasis cases was identified, with few complicated cases in immunosuppressed patients. Further studies focusing on identifying and exploring the risk of complicated strongyloidiasis in immunosuppressed patients are needed

Surveillance of leishmaniasis cases from 15 European centres, 2014 to 2019: a retrospective analysis

International audienceBackgroundSurveillance of human leishmaniasis in Europe is mostly limited to country-specific information from autochthonous infections in the southern part. As at the end of 2021, no integrated analysis has been performed for cases seen across centres in different European countries.AimTo provide a broad perspective on autochthonous and imported leishmaniasis cases in endemic and non-endemic countries in Europe.MethodsWe retrospectively collected records from cutaneous, mucosal and visceral leishmaniasis cases diagnosed in 15 centres between 2014 and 2019. Centres were located in 11 countries: Belgium, France, Germany, Italy, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and the United Kingdom. Data on country of infection, reason for travelling, infecting species, age and sex were analysed.ResultsWe obtained diagnostic files from 1,142 cases, of which 76%, 21% and 3% had cutaneous, visceral, and mucosal disease, respectively. Of these, 68% were men, and 32% women, with the median age of 37 years (range: 0-90) at diagnosis. Visceral leishmaniasis was mainly acquired in Europe (88%; 167/190), while cutaneous leishmaniasis was primarily imported from outside Europe (77%; 575/749). Sixty-two percent of cutaneous leishmaniasis cases from outside Europe were from the Old World, and 38% from the New World. Geographic species distribution largely confirmed known epidemiology, with notable exceptions.ConclusionsOur study confirms previous reports regarding geographic origin, species, and traveller subgroups importing leishmaniasis into Europe. We demonstrate the importance of pooling species typing data from many centres, even from areas where the aetiology is presumably known, to monitor changing epidemiology