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Ross, M. Richard Olds, M. Cripps, Ph. Farrar, M. McManus, Ph. I n , approximately million people traveled internationally. Address reprint requests to Dr. Ross at a. A recent study analyzed data from the GeoSentinel Surveillance Network which consists of 42 specialized travel or tropical-medicine sites located around the world on 25, returned travelers over a 9-year period from to For personal use only.

No other uses without permission. All rights reserved. Data are from Swaminathan et al. Table 1 lists the major entero- weight loss. Conse- are the mobile flagellate trophozoites, which are quently, parasites such as giardia, entamoeba, responsible for the clinical symptoms of the dis- strongyloides, and schistosoma are often neglect- ease, and the cyst forms, the infective stage, in ed or insufficiently covered.

However, person- This close association between the trophozoites to-person transmission is possible. Downloaded from nejm. Table 1. From atrophy, crypt hyperplasia, intestinal hyperper- there, they migrate upward through the trachea, meability, and damage to the brush border of the are swallowed, and finally reach the small intes- enterocyte.

These hatch in the gut lumen, and the first-stage rhabditiform lar- Entamoeba vae either are passed out in the feces and develop Three entamoeba species E. The parasite is ac- Autoinfection can result in persistent infec- quired through the ingestion of food or water tion for decades.

After it has been with a chronic infection are asymptomatic. Susceptibility in male patients has been self-limiting. The three most impor- struction and the formation of microabscesses tant species in humans are Schistosoma hematobi- that gradually coalesce.

Schistosome larvae cercariae emerge Strongyloides from the snails and penetrate human skin, there- There are more than 50 species of strongyloides, by instigating infection.

Patients with acute schistosomi- human host, reach the lungs by way of the blood asis, or the Katayama syndrome, which usually n engl j med ;19 nejm. Schistosomiasis odontitis. Salmonella se- much as a week later. In cases of infection with rovar Typhi, which has no animal reservoir, is S. However, in der cancer. The majority of cases of C. A rapid increase tecture, membrane trafficking, signal transduc- in resistance to fluoroquinolones by C.

Shigella has no natural reser- invasion into host cells. The organism invades the the differential diagnosis, microscopical exami- intestinal epithelial cells of the colon through nation of the stool or specialized laboratory tests M cells from the basolateral side and spreads will be required. Light microscopy has tradition- laterally. Al- principal T3SS and other virulence factors for in- though microscopy can be performed cheaply, its vasion.

A physician should also know the dia and strongyloides, given the difficulties in incubation periods of potential infections. Acute morphologic identification of the parasites. Polymerase- enteric protozoan or helminthic infection. Con- chain-reaction analysis can detect most parasitic sideration of these factors, in combination with infections and is more sensitive than antibody careful assessment of the timing of clinical signs detection, but it is not performed routinely in pa- and symptoms, should help the physician deter- thology clinics.

Routine blood persistent diarrhea. Changes in villous morpho- tests should consist of a full blood count e. A stool sample should be obtained, performed because of advances in antigen-detec- cultured, and examined for bacteria, cysts, eggs, tion techniques. Duodenal fluid can be aspirated n engl j med ;19 nejm. Multidrug-resistant involvement in patients infected with entamoeba Salmonella enterica Typhi and S. For pa- Africa, and to date we know of no intervention tients with more severe diarrhea, isotonic intra- studies about the best antimicrobial regimen to venous fluids e.

In infants, breast-feed- Knowledge of global resistance patterns can ing should be maintained, along with an oral help inform the choice of empirical antibiotics rehydration solution plus a zinc supplement. A diet in returning travelers. Glucocorticoids are con- of easily digestible food soups, toast, crackers, traindicated in immunosuppressed persons who mashed potatoes, rice, and bananas is often rec- are infected with strongyloides.

A short course ommended for those with acute watery diarrhea. For nontyphoid cluding sexually transmitted infections, in order salmonella diarrhea, the objective of therapy is to to better inform travelers of the health risks in treat or prevent the occurrence of bacteremic dis- the country of their destination.

Physicians need ease. Rifaxi- choice. If the diarrhea persists, the organism bacterial pathogens. Cripps reports receiving through his institution consult- ing fees from Probiotec, grant support from Danisco and Glaxo- killed whole-cell vaccine. He also has a pending patent applica- ment.

Promising candidates include Vi-conjugate tion through Danisco regarding probiotics. No other potential conflict of interest relevant to this article was reported. References 1. United Nations. UNWTO tourism high- fectious diseases at home and abroad? Scott KG. Giardia lamblia disrupts tight lights.

Illness in travelers returning from the tinal epithelial monolayers: effects of epi- 2. Cartwright R. Gastrointestinal illness tropics: a prospective study of pa- dermal growth factor. Parasitology ; in tourists: whose responsibility? Euro tients. J Travel Med ; Surveill ;9 3 Role of 3. Gorbach SL. Ann Intern elers reported to the GeoSentinel Surveil- mucosal injury during murine giardiasis. Med ; Diagnosis and treatment of acute and Marano C, Freedman DO.

Global Giardia duodenalis: the double-edge sword persistent diarrhea. Exp Curr Opin Infect Dis ; Parasitol ; Giardia Mortimer L, Chadee K. The immuno- et al.

Spectrum of disease and relation to intestinalis: new insights on an old patho- pathogenesis of Entamoeba histolytica. Exp place of exposure among ill returned gen.

Med Microbiol ; N Engl J Med ; New insights Clin Proc ; Navaneethan U, Giannella RA. Infec- Microbes Infect ; Entamoeba tious colitis. Curr Opin Gastroenterol Is human giardiasis caused by two with men.

Lancet Infect Dis ; 7. DuPont HL. Bacterial diarrhea. N Engl different Giardia species? Gut Microbes


Enteropathogens and chronic illness in returning travelers.









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