Diagnosis of Malaria Infection with or without Disease

The revised W.H.O. guidelines for malaria management in endemic countries recommend that treatment should be reserved to laboratory confirmed cases, both for adults and children. Currently the most widely used tools are rapid diagnostic tests (RDTs), that are accurate and reliable in diagnosing malaria infection. However, an infection is not necessarily a clinical malaria, and RDTs may give positive results in febrile patients who have another cause of fever. Excessive reliance on RDTs may cause overlooking potentially severe non malarial febrile illnesses (NMFI) in these cases. In countries or areas where transmission intensity remains very high, fever management in children (especially in the rainy season) should probably remain presumptive, as a test-based management may not be safe, nor cost effective. In contrast, in countries with low transmission, including those targeted for malaria elimination, RDTs are a key resource to limit unnecessary antimalarial prescription and to identify pockets of infected individuals. Research should focus on very sensitive tools for infection on one side, and on improved tools for clinical management on the other, including biomarkers of clinical malaria and/or of alternative causes of fever

Strategies for management of strongyloidiasis in migrants from Sub-Saharan Africa recently arrived in Italy: A cost-effectiveness analysis

Abstract Background The Italian and the European Centre for Disease Control and Prevention guidelines both recommend a systematic serological screening for strongyloidiasis in sub-Saharan migrants (SSA), however, studies on clinical and economic impact of this strategy in the Italian and European settings are lacking. Methods A population of 100,000 migrants from SSA to Italy was considered and a Markov decision tree model was developed to assess the clinical and economic impact of two interventions for strongyloidiasis compared with the current practice (passive diagnosis of symptomatic cases): a) universal serological screening and treatment with ivermectin in case of positive test b) universal presumptive treatment with ivermectin. One and 10-year time horizon in the health-care perspective were considered. Results In the one and 10-year time horizon respectively the costs for passive diagnosis was €1,164,169 and €9,735,908, those for screening option was € 2,856,011 and € 4,959,638 and those for presumptive treatment was €3,538,474 and € 4,883,272. Considering the cost per cured subject in the one-year time horizon, screening appears more favorable (€209.53), than the other two options (€232.55 per presumptive treatment and €10,197.29 per current strategy). Incremental cost-effectiveness ratio (ICERs) of screening strategy and presumptive treatment were respectively 265.27 and 333.19. The sensitivity analysis identified strongyloidiasis' prevalence as the main driver of ICER. Conclusions Compared to the current practice (passive diagnosis) both screening and presumptive treatment strategies are more favorable from a cost-effectiveness point of view, with a slight advantage of the screening strategy in a one-year time horizon

Current pharmacotherapeutic strategies for Strongyloidiasis and the complications in its treatment

Introduction: Strongyloidiasis, an infection caused by the soil-transmitted helminth Strongyloides stercoralis, can lead immunocompromised people to a life-threatening syndrome. We highlight here current and emerging pharmacotherapeutic strategies for strongyloidiasis and discuss treatment protocols according to patient cohort. We searched PubMed and Embase for papers published on this topic between 1990 and May 2022. Areas covered: Ivermectin is the first-line drug, with an estimated efficacy of about 86% and excellent tolerability. Albendazole has a lower efficacy, with usage advised when ivermectin is not available or not recommended. Moxidectin might be a valid alternative to ivermectin, with the advantage of being a dose-independent formulation. Expert opinion: The standard dose of ivermectin is 200 mu g/kg single dose orally, but multiple doses might be needed in immunosuppressed patients. In the case of hyperinfection, repeated doses are recommended up to 2 weeks after clearance of larvae from biological fluids, with close monitoring and further dosing based on review. Subcutaneous ivermectin is used where there is impaired intestinal absorption/paralytic ileus. In pregnant or lactating women, studies have not identified increased risk with ivermectin use. However, with limited available data, a risk-benefit assessment should be considered for each case

Ultrasound and intestinal lesions in Schistosoma mansoni infection: A case-control pilot study outside endemic areas

Infection with Schistosoma mansoni is a major cause of morbidity and mortality in endemic areas, and is increasingly diagnosed in migrants and travellers outside transmission areas. Markers for the assessment of morbidity and impact of control programs in endemic areas and for the clinical management of patients in the clinical setting are scant, especially for intestinal involvement. Ultrasonography is well established to evaluate hepatosplenic pathology; on the contrary, ultrasound evaluation of intestinal schistosomiasis is virtually unexplored. In this pilot study, we aimed to describe and evaluate the accuracy of unenhanced intestinal ultrasound for morbidity due to intestinal S. mansoni infection

Evidence-Based Guidelines for Screening and Management of Strongyloidiasis in Non-Endemic Countries

Strongyloidiasis is an intestinal parasitic infection becoming increasingly important outside endemic areas, not only because of the high prevalence found in migrant populations, but also because immunosuppressed patients may suffer a potentially fatal disseminated disease. The aim of these guidelines is to provide evidence-based guidance for screening and treatment of strongyloidiasis in non-endemic areas. A panel of experts focused on three main clinical questions (who should be screened and how, how to treat), and reviewed pertinent literature available in international databases of medical literature and in documents released by relevant organizations/societies. A consensus of the experts' opinion was sought when specific issues were not covered by evidence. In particular, six systematic reviews were retrieved and constituted the main support for this work. The evidence and consensus gathered led to recommendations addressing various aspects of the main questions. Grading of evidence and strength of recommendation were attributed to assess the quality of supporting evidence. The screening of individuals at risk of the infection should be performed before they develop any clinical complication. Moreover, in immunosuppressed patients, the screening should be mandatory. The screening is based on a simple and widely accessible technology and there is now a universally accepted treatment with a high efficacy rate. Therefore, the screening could be implemented as part of a screening program for migrants although further cost-effectiveness studies are required to better evaluate this strategy from a public health point of view

Diagnostic study on an immunochromatographic rapid test for schistosomiasis: comparison between use on serum and on blood spot from fingerprick

An immunochromatographic rapid test (ICT; Schistosoma ICT IgG-IgM, LDBIO Diagnostics) demonstrated high sensitivity (96%) in the diagnosis ofSchistosoma mansoniandS. haematobium. To date, the test has been validated for use on serum only, but in the absence of lab equipment, blood drop from fingerprick could be a useful option. This method is acquiring more interest because of the high flow of migrants rapidly moving across Italy and other European countries

Radiographic and HRCT imaging findings of chronic pulmonary schistosomiasis: review of 10 consecutive cases

Objective: To describe the chest radiography (CR) and the high resolution CT (HRCT) imaging findings of chronic pulmonary schistosomiasis (CPS)Methods and materials: This retrospective study included 10 patients suffering from CPS, studied between September 2013 and October 2016 by using CR and HRCT. Images were reviewed by two experienced radiologists in consensus, blinded to clinical data. A p value < 0.05 was considered significantResults: All the patients enrolled showed some abnormalities at HRCT, including lung consolidations, solid nodules, nodules with pen-nodular halo, ground-glass opacities, enlarged hilar lymph-nodes. Only seven patients showed findings at CR (p = 0.001). At CT, none of the patients had significant pleural, vascular (pulmonary arteries) or cardiac findings. Post-therapy studies (mean interval 35 days) demonstrated the absence of residual disease in all patients.Conclusion: The imaging findings of CPS varied widely in our study population. HRCT may show signs which are occult on plain radiograph. All lesions disappeared after appropriate therapy at imaging follow-up studie

Extended screening for infectious diseases among newly-arrived asylum seekers from Africa and Asia, Verona province, Italy, April 2014 to June 2015

Background and aimManagement of health issues presented by newly-arrived migrants is often limited to communicable diseases even though other health issues may be more prevalent. We report the results of infectious disease screening proposed to 462 recently-arrived asylum seekers over 14 years of age in Verona province between April 2014 and June 2015. Methods: Screening for latent tuberculosis (TB) was performed via tuberculin skin test (TST) and/or QuantiFERON-TB Gold in-tube assay and/or chest X-ray. An ELISA was used to screen for syphilis. Stool microscopy was used to screen for helminthic infections, and serology was also used for strongyloidiasis and schistosomiasis. Screening for the latter also included urine filtration and microscopy. Results: Most individuals came from sub-Saharan Africa (77.5%), with others coming from Asia (21.0%) and North Africa (1.5%). The prevalence of viral diseases/markers of human immunodeficiency virus (HIV) infection was 1.3%, HCV infection was 0.85% and hepatitis B virus surface antigen was 11.6%. Serological tests for syphilis were positive in 3.7% of individuals. Of 125 individuals screened for TB via the TST, 44.8% were positive and of 118 screened via the assay, 44.0% were positive. Of 458 individuals tested for strongyloidiasis, 91 (19.9%) were positive, and 76 of 358 (21.2%) individuals from sub-Saharan Africa were positive for schistosomiasis. Conclusions: The screening of viral diseases is questionable because of low prevalence and/or long-term, expensive treatments. For opposing reasons, helminthic infections are probably worth to be targeted by screening strategies in asylum seekers of selected countries of origin

Blackwater Fever Treated with Steroids in Nonimmune Patient, Italy

: Causes of blackwater fever, a complication of malaria treatment, are not completely clear, and immune mechanisms might be involved. Clinical management is not standardized. We describe an episode of blackwater fever in a nonimmune 12-year-old girl in Italy who was treated with steroids, resulting in a rapid clinical resolution