Leishmaniasis in Germany. (Dispatches).In 2000, a reference center was created to systematically record leishmaniases in Germany. We analyzed 58 cases of leishmaniases imported during a 2-year period. These findings will serve as a baseline for the sandfly sandfly /sand·fly/ (sand´fli) any of various two-winged flies, especially of the genus Phlebotomus. sandfly Phlebotomus spp. Culicoides, Simulium and Austrosimulium spp. vector's anticipated northward move because of global warming global warming, the gradual increase of the temperature of the earth's lower atmosphere as a result of the increase in greenhouse gases since the Industrial Revolution. and as an advisory for immunocompromised immunocompromised /im·mu·no·com·pro·mised/ (-kom´pro-mizd) having the immune response attenuated by administration of immunosuppressive drugs, by irradiation, by malnutrition, or by certain disease processes (e.g., cancer). persons traveling to leishmaniasis-endemic areas. ********** Leishmaniases compose a spectrum of protozoal diseases protozoal diseases Diseases caused by protozoans. These organisms may remain in the human host for their entire life cycle, but many carry out part of their reproductive cycle in insects or other hosts. For example, mosquitoes are vectors of plasmodium, the cause of malaria. currently endemic in 88 countries in Asia, Africa, the Americas, and southern Europe Southern Europe or sometimes Mediterranean Europe is a region of the European continent. There is no clear definition of the term which can vary depending on whether geographic, cultural, linguistic or historical factors are taken into account. . The geographic distribution of leishmaniases has widened, and the disease is reported in areas in which leishmaniasis leishmaniasis (lēsh'mənī`əsĭs), any of a group of tropical diseases caused by parasitic protozoans of the genus Leishmania. was previously nonendemic (1). Apart from cutaneous cutaneous /cu·ta·ne·ous/ (ku-ta´ne-us) pertaining to the skin. cu·ta·ne·ous adj. Of, relating to, or affecting the skin. Cutaneous Pertaining to the skin. , mucocutaneous/mucosal, and visceral leishmaniases, HIV-1--associated leishmaniasis acquired in southern Europe and in other parts of the world have been observed in increasing numbers (1,2). Leishmaniasis is not notifiable notifiable /no·ti·fi·a·ble/ (no?ti-fi´ah-b'l) necessary to be reported to a government health agency. notifiable necessary to be reported to the relevant government authority. Said of individual diseases. in Germany. In September 2000, a national advice and reference center was created at the Institute of Tropical Medicine tropical medicine, study, diagnosis, treatment, and prevention of certain diseases prevalent in the tropics. The warmth and humidity of the tropics and the often unsanitary conditions under which so many people in those areas live contribute to the development and in Berlin; the aim of the center was to monitor the frequency, origin, and type of leishmaniases seen in Germany; to advise physicians; and to improve information for travelers to disease-endemic areas. The healthcare professionals were informed about the reference center by the Robert-Koch-Institute, the center for surveillance of infectious diseases infectious diseases: see communicable diseases. in Germany, as well as through the Journal of the German Medical Association, which is received by every registered physician (3). Leishmaniasis was diagnosed if parasites were detected in smears, culture, histologic sections, by polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is (PCR PCR polymerase chain reaction. PCR abbr. polymerase chain reaction Polymerase chain reaction (PCR) ) of lesion biopsy specimens, bone marrow, or peripheral blood peripheral blood Cardiology Blood circulating in the system/body . For detection of Leishmania-specific antigen the small subunit (ssu rRNA), the internal transcribed spacer ITS (for internal transcribed spacer) refers to a piece of non-functional RNA situated between structural ribosomal RNAs (rRNA) on a common precursor transcript. Read from 5' to 3', this polycistronic rRNA precursor transcript contains the 5' external transcribed sequence (5' ETS), (ITS-1) region of the ribosomal RNA ribosomal RNA n. See rRNA. ribosomal RNA (rī´bōsō´m genes, or both, were amplified by PCR (4). Leishmania Leishmania /Leish·ma·nia/ (lesh-ma´ne-ah) a genus of parasitic protozoa, including several species pathogenic for humans. In some classifications, organisms are placed in four complexes comprising species and subspecies: L. complexes and species were determined by digestion of the ribosomal ITS-1 PCR product with restriction enzymes (4). Within 2 years, 70 cases of leishmaniases (43 cutaneous or mucocutaneous/mucosal; 27 visceral) were reported. For 58 case-patients (35 cutaneous or mucocutaneous/ mucosal; 23 visceral), data were available on the age, sex, residence, travel destination, possible exposure location, reason for travel, duration of stay, duration and type of symptoms, concomitant diseases or therapies, type of diagnosis, and treatment received. Cutaneous and Mucosal Leishmaniasis Of the 35 patients with cutaneous or mucocutaneous/ mucosal leishmaniasis, 30 were German tourists (Table 1). The male-to-female ratio was 1.5:1. Ten had contracted cutaneous or mucocutaneous/mucosal leishmaniasis in Europe, 11 in Central and South America South America, fourth largest continent (1991 est. pop. 299,150,000), c.6,880,000 sq mi (17,819,000 sq km), the southern of the two continents of the Western Hemisphere. , 6 in Asia, and 3 in Africa. Two persons had been infected during work stays of 1 to 4 months in French Guyana, one each in Peru and Libya, and one patient had immigrated from Afghanistan. The median duration of lesions until the diagnosis of leishmaniasis was made was 4 months (range 3 weeks to 2 years). Sixteen patients had more than one lesion (median 2, range 1-6 lesions). Seventeen lesions were located in the face, including mouth and nose, 28 on the upper extremities and 21 on the lower extremities. Lesions were ulcerated Ulcerated Damaged so that the surface tissue is lost and/or necrotic (dead). Mentioned in: Adenoid Hyperplasia in 39 cases, papular-nodular in 24, and plaque-like in 3. Parasites were detected in 13 of 20 smears, in 9 of 10 cultures, and in 14 of 16 histologic sections; by using PCR, Leishmania-specific DNA DNA: see nucleic acid. DNA or deoxyribonucleic acid One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes. was detected in 16 of 16 biopsy specimens. Patient 1 had lesions in the mouth caused by L. infantum. She was under continuous immunosuppressive Immunosuppressive Any agent that suppresses the immune response of an individual. Mentioned in: Antirheumatic Drugs, Graft-vs.-Host Disease, Immunosuppressant Drugs immunosuppressive 1. pertaining to or inducing immunosuppression. 2. treatment for severe bronchial asthma bronchial asthma n. A condition of the lungs characterized by widespread narrowing of the airways due to spasm of the smooth muscle, edema of the mucosa, and the presence of mucus in the lumen of the bronchi and bronchioles. . Patient 2 had received methotrexate methotrexate, drug used in halting the growth of actively proliferating tissues. Introduced in the 1950s, it is used in the treatment of leukemia, psoriasis, and non-Hodgkin's lymphoma. and steroids for treatment of systemic collagenosis for several weeks. Both patients were tested for leishmanial infection in the blood; in both patients, the Leishmania-specific PCR of the buffy coat buf·fy coat n. The upper, lighter portion of the blood clot occurring when coagulation is delayed or when blood has been centrifuged. Buffy coat of the blood was positive. Patient 22 had mucocutaneous leishmaniasis mucocutaneous leishmaniasis n. A chronic variable disease caused by Leishmania braziliensis, endemic in Central and South America, and characterized by lesions of the skin and mucous membranes, which heal but are followed after months or years of the nasal septum nasal septum n. The wall dividing the nasal cavity into halves, composed of a central supporting skeleton covered by a mucous membrane. Nasal septum The cartilage which divides the nose in half. . She had been treated for a skin lesion Skin Lesions can include moles, cysts, warts or skin tags. Most are benign but are sometimes removed if they are painful, unsightly or restrict movement. Surgical removal is the most common treatment for most skin lesions. caused by L. braziliensis 3 years earlier. Visceral Leishmaniasis visceral leishmaniasis n. A chronic, often fatal disease occurring chiefly in Asia, caused by a protozoan parasite (Leishmania donovani) and characterized by irregular fever, enlargement of the spleen and liver, and emaciation. A total of 18 of the 23 visceral leishmaniasis patients were German tourists; 3 were immigrants from Angola, Iran, and Togo; and 2 were visitors from Italy and Portugal (Table 2). The male-to-female ratio was 6.7:1. The median time between symptom onset and the correct diagnosis was 4 months (range 1-16 months). All case-patients had fever, 17 (74%) had splenomegaly splenomegaly /sple·no·meg·a·ly/ (-meg´ah-le) enlargement of the spleen. congestive splenomegaly Banti's disease; splenomegaly secondary to portal hypertension. , 11 (48%) hepatomegaly hepatomegaly /hep·a·to·meg·a·ly/ (hep?ah-to-meg´ah-le) enlargement of the liver. hep·a·to·meg·a·ly n. The abnormal enlargement of the liver. Also called megalohepatia. , 20 (87%) anemia, 17 (74%) leukopenia leukopenia /leu·ko·pe·nia/ (-pe´ne-ah) reduction of the number of leukocytes in the blood below about 5000 per cubic mm.leukope´nic basophilic leukopenia basophilopenia. , and 8 (35%) thrombocytopenia Thrombocytopenia Definition Thrombocytopenia is an abnormal drop in the number of blood cells involved in forming blood clots. These cells are called platelets. . Bone marrow smears indicated Leishmania in 18 of 20, bone marrow culture in 6 of 7, bone marrow histologic sections in 7 of 8, PCR of the bone marrow in 8 of 9, and PCR of the buffy coat of the blood in 7 of 7 cases. Additionally, antibodies were detected in medium to high concentration by an immunofluorescence Immunofluorescence A technique that uses a fluorochrome to indicate the occurrence of a specific antigen-antibody reaction. The fluorochrome labels either an antigen or an antibody. test, enzyme-linked immunosorbent assay enzyme-linked immunosorbent assay n. ELISA. Enzyme-linked immunosorbent assay (ELISA) A diagnostic blood test used to screen patients for AIDS or other viruses. (ELISA ELISA (e-li´sah) Enzyme-Linked Immuno-Sorbent Assay; any enzyme immunoassay using an enzyme-labeled immunoreactant and an immunosorbent. ELISA n. ), or both, in 14 of 15 cases. Species was identified in 7 of 18 visceral cases contracted in southern Europe and indicated Leishmania belonging to the L. donovani complex, which implicated im·pli·cate tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates 1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot. 2. infection with L. infantum. Six cases of visceral leishmaniasis occurred in children 2 months of age to 11 years of age. Four German tourists and two immigrants had long-known HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. infection (median duration 3 years, range 8 months-6 years). All HIV-coinfected patients had CD4-cell counts below 200/[micro]L (median 108, range 23-185 CD4 cells/[micro]L) when the diagnosis of visceral leishmaniasis was made. Of the remaining 11 patients, 1 had a thymoma Thymoma Definition Thymomas are the most common tumor of the thymus. Description The thymus is located in the upper chest just below the neck. with impaired T-helper-1 cell function, 2 had received intermittent immunosuppressive therapy Immunosuppressive therapy Medical treatment in which the immune system is purposefully thwarted. Such treatment is necessary, for example, to prevent organ rejection in transplant cases. (methotrexate and steroids) for rheumatologic disease, and 2 patients had their spleens removed. Three patients were in an impaired general condition because of combinations of diabetes, hypertonus, hypercholesterolemia Hypercholesterolemia Definition Hypercholesterolemia refers to levels of cholesterol in the blood that are higher than normal. Description Cholesterol circulates in the blood stream. It is an essential molecule for the human body. , and emphysema emphysema (ĕmfĭsē`mə), pathological or physiological enlargement or overdistention of the air sacs of the lungs. A major cause of pulmonary insufficiency in chronic cigarette smokers, emphysema is a progressive disease that commonly . In the remaining three patients (53-68 years of age), apart from hypertonus in one, no impairing condition was detected. Discussion Information on single cases and a small case series of imported leishmaniases in Germany is available, but systematic reporting on frequency, type, and origin of leishmanial infections in Germany did not exist until 2000 (5-7). Our recent surveillance is dependent on passive consultation and reporting and therefore may have selection bias because if visceral leishmaniasis, a potentially fatal disease that requires hospitalization, is suspected, advice on diagnosis and treatment is sought more often than for the skin infection. We assume that our system captures approximately half of the visceral leishmaniasis cases and approximately one third of the classical cutaneous cases imported to Germany. A total of 47% of all cases, but 78% of the visceral cases were contracted in the European Mediterranean area and Portugal, and most of the infections indicated a species of the L. donovani complex, most probably L. infantum, as the probable causative agent. Thirteen infections (22%) were acquired on the Mediterranean islands of Ibiza, Ischia Ischia (ēs`kyä), volcanic island (1991 pop. 16,013), 18 sq mi (47 sq km), Campania, S Italy, in the Tyrrhenian Sea between the Gulf of Gaeta and the Bay of Naples. , Majorca, Malta, Korfu, or Sicily. This distribution reflects the fact, that the Mediterranean countries, Spain, Italy, and the Mediterranean islands, in particular, are the favorite vacation areas for Germans. Annually, Germans take 18 million vacations to the European Mediterranean area (including 8 million to Spain and 6 million to Italy) with a median duration of 2 weeks. Sixty percent of travel to Italy and 90% of travel to Spain are to Leishmania-endemic areas. While leishmaniasis has always been endemic in the Mediterranean countries, the maximum northern latitude for sandfly survival is speculated to move further to the North, beyond Germany (1) because of global warming. If this scenario is correct, the imported cases may serve as a potential substrate for the sandfly vector. Dogs that are imported as pets from the disease-endemic areas of southwestern Europe or that contract the infection when accompanying their owners for vacation are another potential substrate (8). Infections with L. infantum in a child, as well as in a horse who had never left Germany, have recently been described and have led to speculations about an autochthonous autochthonous /au·toch·tho·nous/ (aw-tok´thah-nus) 1. originating in the same area in which it is found. 2. denoting a tissue graft to a new site on the same individual. focus (9,10). Also recently, the first sandfly species, Phlebotomus mascittii Grassi, 1908, was detected in southern Germany, although its potential as a vector of Leishmania remains to be demonstrated (11). As expected, visceral leishmaniasis is often manifested in persons with impaired immunocompetence immunocompetence /im·mu·no·com·pe·tence/ (-kom´pe-tens) immunoresponsiveness; the capacity to develop an immune response after exposure to antigen. because of young age, HIV infection, immunosuppressive therapy and, in our analysis, in older persons with concomitant diseases. Notably, 12 (67%) of 18 of the visceral cases contracted in the European Mediterranean area were in adults, thus confirming a change in age groups affected. Formerly, visceral leishmaniasis was known mainly as a disease of children (1,2). This change may partly be explained by the increased proportion of Leishmania and HIV--co-infected persons and partly by increased travel activities of otherwise immunocompromised persons, including elderly persons. Furthermore, even in patients with cutaneous leishmaniasis cutaneous leishmaniasis n. An endemic disease in northern Africa and western and central Asia, caused by infection with promastigotes of Leishmania tropica and transmitted by the bite of a sandfly of the genus Phlebotomus. , dissemination of parasites has to be excluded in case of impaired immunocompetence (e.g., immunosuppressive treatment). In these cases, Leishmania-specific PCR of the buffy coat of the peripheral blood is a sensitive method for detecting parasite spread beyond the skin. Parents of small children and persons with reduced immunocompetence should be informed about their increased susceptibility to infection with Leishmania when traveling to disease-endemic areas. Measures to reduce the exposure to sandflies, such as clothes, repellents, and mosquito nets as well as collars impregnated im·preg·nate tr.v. im·preg·nat·ed, im·preg·nat·ing, im·preg·nates 1. To make pregnant; inseminate. 2. To fertilize (an ovum, for example). 3. with repellents for accompanying dogs, should be recommended.
Table 1. Characteristics of patients with cutaneous and mucosal
leishmaniasis, Germany
No. Exposure Status Sex Age (y)
Europe
1 France Tourist F 64
2 Italy Tourist F 24
3 Malta Tourist M 22
4 Malta Tourist M 39
5 Malta Tourist F 57
6 Malta Tourist M 62
7 Spain (Majorca) Tourist F 5
8 Spain (Majorca) Tourist M 13
9 Spain Tourist F 31
10 Spain Tourist M 33
Americas
11 Belize Tourist M 36
12 Belize Tourist F 32
13 Bolivia Tourist M 35
14 Brazil Tourist M 25
15 Brazil Tourist M 39
16 Brazil Tourist M 33
17 Ecuador Tourist F 29
18 Ecuador Tourist M 36
19 French Guyana Work stay M 28
20 French Guyana Work stay M 22
21 Guatemala Tourist M 31
22 Peru Work stay F 25
23 Peru Tourist F 33
24 Peru Tourist M 35
Asia
25 Afghanistan Immigrant M 21
26 Afghanistan Tourist F 12
27 United Arab Emirates Tourist F 44
28 Syria Tourist M 5
29 Syria Tourist F 3
30 Turkey Tourist F 33
31 Turkey Tourist M 37
Africa
32 Egypt Tourist M 25
33 Egypt Tourist F 27
34 Kenya Tourist M 50
35 Lybia Work stay M 34
No. Leishmania species Treatment Outcome
Europe
1 L. donovani complex No treatment No cure
2 L. donovani complex Liposomal Improved
amphotericin B
3 L. donovani complex Perilesional Cured
pentavalent
antimonials
4 L. donovani complex Perilesional Cured
pentavalent
antimonials
5 n.d. Perilesional Cured
pentavalent
antimonials
6 n.d. Perilesional Cured
pentavalent
antimonials
7 n.d. Pentamidine Cured
isethionate
8 L. donovani complex Perilesional Cured
pentavalent
antimonials
9 L. donovani complex No treatment Unknown
10 L. donovani complex Antibiotic Cured
Americas
11 L. braziliensis complex Liposomal Unknown
amphotericin B
12 n.d. IFN-gamma Cured
13 L. braziliensis complex Liposomal Unknown
amphotericin B
14 n.d. Systemic Cured
pentavalent
antimonials
15 L. braziliensis complex Liposomal Unknown
amphotericin B
16 L. braziliensis complex Liposomal Cured
amphotericin B
17 L. braziliensis complex Liposomal Cured
amphotericin B
18 n.d. Liposomal Cured
amphotericin B
19 L. braziliensis complex Liposomal Cured
amphotericin B
20 L. braziliensis complex Liposomal Cured
amphotericin B
21 L. mexicana Ketoconazole Cured
22 L. braziliensis complex Liposomal Cured
amphotericin B
23 L. braziliensis complex Liposomal Cured
amphotericin B
24 L. braziliensis complex Liposomal Cured
amphotericin B
Asia
25 L. tropica Aminosidine ointment No cure
26 n.d. Aminosidine ointment Cured
27 n.d. Perilesional Cured
pentavalent
antimonials
28 n.d. Perilesional Unknown
pentavalent
antimonials
29 n.d. Perilesional Unknown
pentavalent
antimonials
30 n.d. Antibiotic Cured
31 L. donovani complex Liposomal Improved
amphotericin B
Africa
32 L. tropica Aminosidine ointment No cure
33 L. tropica Aminosidine ointment Cured
34 n.d. Perilesional Cured
pentavalent
antimonials
35 n.d. Aminosidine ointment Cured
(a) n.d., not done; IFN, interferon.
Table 2. Characteristics of patients with visceral leishmaniasis,
Germany
No. Exposure Status Sex Age Risk factor
1 Italy Tourist M 2 y Child
2 Italy Tourist F 5 y Child
3 Italy Tourist M 11 y Child
4 Spain Tourist F 8 mo Child
5 Spain Tourist M 9 mo Child
6 Iran Immigrant M 7 y Child
7 Spain Tourist M 43 y HIV
8 Spain (Ibiza) Tourist M 48 y HIV
9 Portugal Visitor M 29 y HIV
10 France Tourist M 31 y HIV
11 Angola Immigrant M 40 y HIV
12 Togo Immigrant M 37 y HIV
13 Italy (Sicily) Visitor M 31 y Thymoma
14 Italy (Ischia) Tourist M 67 y Methotrexate/steroids
15 Italy (Sicily) Tourist M 68 y Methotrexate
16 Italy (Ischia) Tourist M 70 y Splenectomy
17 Spain Tourist M 51 y Splenectomy
18 Greece Tourist M 66 y Diabetes mellitus
(Korfu) Hypertonus
19 Spain Tourist M 52 y Hypertonus
Hypercholesterolemia
20 Greece Tourist M 45 y Diabetes mellitus
(Korfu) Emphysema
21 Tunisia Tourist M 53 y Hypertonus
22 Malta Tourist F 55 y --
23 China Tourist M 67 y --
Leishmania
No. species Treatment Outcome
1 n.d. Liposomal amphotericin B Cured
2 n.d. Liposomal amphotericin B Cured
3 n.d. Liposomal amphotericin B Cured
4 n.d. Liposomal amphotericin B Cured
5 L. donovani Liposomal amphotericin B Cured
complex
6 L. donovani Liposomal amphotericin B Cured
complex
7 L. donovani Liposomal amphotericin B; No relapse for 6
complex maintenance therapy: months
HAART plus liposomal
amphotericin B once monthly
8 L. donovani Liposomal amphotericin B; No relapse for 8
complex maintenance therapy: months
HAART plus liposomal
amphotericin B once monthly
9 n.d. Liposomal amphotericin B; unknown
maintenance therapy:
HAART plus liposomal
amphotericin B once monthly
10 L. donovani Liposomal amphotericin B; Relapse after 4
complex maintenance therapy: months;
HAART plus liposomal retreatment with
amphotericin B once monthly liposomal
amphotericin B; No
relapse for 3
months
11 L. donovani Systemic pentavalent unknown
complex antimonials; maintenance
therapy: HAART
plus pentavalent antimonials
once monthly
12 L. donovani Liposomal amphotericin B Cured
complex
13 n.d. Liposomal amphotericin B Cured
14 L. donovani Liposomal amphotericin B Cured
complex
15 n.d. Liposomal amphotericin B Cured
16 n.d. Liposomal amphotericin B Cured
17 L. donovani Liposomal amphotericin B Cured
complex
18 n.d. Liposomal amphotericin B Cured
19 n.d. Liposomal amphotericin B Cured
20 L. donovani Systemic pentavalent Cured
complex antimonials
21 L. donovani Liposomal amphotericin B Cured
complex
22 n.d. Liposomal amphotericin B Cured
23 n.d. Liposomal amphotericin B Cured
(a) n.d., not done; HAART, highly active anti-retroviral therapy.
Acknowledgments We thank colleagues at German hospitals and health institutions who discussed their patients with us or kindly contributed to the data collected on leishmaniases. References (1.) Desjeux P. The increase in risk factors for leishmaniasis worldwide. Trans R Soc Trop Med Hyg 2001;95:239-43. (2.) World Health Organization. Leishmania/HIV co-infection: southwestern Europe, 1990-1998 (WHO/LEISH/2000.42). Geneva Geneva, canton and city, Switzerland Geneva (jənē`və), Fr. Genève, canton (1990 pop. 373,019), 109 sq mi (282 sq km), SW Switzerland, surrounding the southwest tip of the Lake of Geneva. : The Organization; 2000. (3.) Harms G, Bienzle U. Leishmaniosen-importierte Krankheiten. Dtsch Arztebl 2000;31/32:1589-92. (4.) Schonian G, Schnur L, Fahri M. Genetic heterogeneity in the species Leishmania tropica Leishmania trop·i·ca n. The protozoan that includes subspecies that cause anthroponotic cutaneous leishmaniasis. revealed by different PCR-based methods. Trans R Soc Trop Med Hyg 2001;95:217-24. (5.) Hohenschild S, Feldmeier H. Imported kala azar in children and adults--comparison of medical history, clinical and diagnostic findings. J Trop Pediatr 1995;41:378-9. (6.) Harms G, Zenk J, Martin S, Kokozidou M, Puschel W, Bienzle U, et al. Localized lymphadenopathy lymphadenopathy /lym·phad·e·nop·a·thy/ (-op´ah-the) disease of the lymph nodes. angioimmunoblastic lymphadenopathy , angioimmunoblastic lymphadenopathy with dysproteinemia due to leishmanial infection. Infection 2001 ;29:355-6. (7.) Holzer E, Kupferschmidt HG. Cutaneous leishmaniasis in East German citizens. Z Arztl Fortbild (Jena) 1986;80:381-3. (8.) Gothe R, Nolte I, Kraft W. Leishmaniasis in dogs in Germany: epidemiological case analysis and alternatives to conventional causal therapy. Tierarztl Prax 1997;25:68-73. (9.) Bogdan C, Schonian G, Banuls AL, Hide M, Pratlong F, Lorenz E, et al. Visceral leishmaniasis in a German child who had never entered a known endemic area Endemic area A geographical region where a particular disease is prevalent. Mentioned in: Leprosy, Scrub Typhus : case report and review of the literature. Clin Infect Dis 2001;32:302-6. (10.) Koehler K, Stechele M, Hetzel U, Domingo M, Schonian G, Zahner H, et al. Cutaneous leishmaniasis in a horse in southern Germany caused by Leishmania infantum. Vet Parasitol 2002;109:9-17. (11.) Naucke TJ, Pesson B. Presence of Phlebotomus (Transphlebotomus) mascittii Grassi, 1908 (Diptera: Psychodidae) in Germany. Parasitol Res 2000;86:3356. Address for correspondence: Gundel Harms, Institute of Tropical Medicine Berlin, Spandauer Damm 130, 14050 Berlin, Germany; fax: +49-30-30116-888; email: gundel.harms@charite.de Gundel Harms, * Gabriele Schonian, * and Hermann Feldmeier ([dagger]) * Charite, Humboldt University Berlin, Berlin, Germany; and ([dagger]) Free University of Berlin, Berlin, Germany Dr. Harms is a senior lecturer and researcher in tropical medicine and international health at the Institute of Tropical Medicine and at the Medical Faculty Charite, Humboldt University Berlin, Germany. Her primary research interests are the interaction of HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome and parasitic infections, leishmaniasis in particular. |
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