Recent Travel History Research Articles

P32 A case of disseminated pneumococcal infection with musculoskeletal manifestations

Abstract Introduction Septic arthritis should be the first consideration in any patient presenting with a hot, swollen joint. Infection may affect one or more joints, and bacteria typically enter the joint through direct inoculation, haematogenous seeding, or spread from adjacent soft tissue or bone infection. Staphylococcus aureus is the most common causative organism. Streptococcus pneumoniae is an uncommon cause of septic arthritis, accounting for approximately 5% of cases. We present the case of a 78-year-old male with no significant medical history who presented with a polyarticular pattern of joint inflammation related to disseminated pneumococcal infection. Case description The patient presented with a one week history of gradual onset pain and swelling in the right knee and right wrist. He was previously well and remained physically active. He was a non-smoker, drank moderate alcohol and had no history of intravenous drug use. He had no current or preceding infective symptoms, including respiratory tract symptoms, nor history of trauma or recent foreign travel. Examination revealed a warm right knee effusion with restricted range of movement. There was swelling of both wrists (right more than left), both second metacarpophalangeal joints and the left ankle. There were no heart murmurs or peripheral stigmata of endocarditis. He was afebrile and haemodynamically stable. Admission blood tests showed WBC 21 x109/L, neutrophils 18 x109/L, CRP 369 mg/L, urate 452 µmol/L and procalcitonin 3.84 µg/L. Rheumatoid factor was 25.3 IU/mL with negative anti-CCP. Knee X-ray showed significant medial compartment osteoarthritis. Hand and wrist X-rays were unremarkable. Synovial fluid aspirate from the right knee grew Streptococcus pneumoniae and calcium pyrophosphate crystals were also seen on polarised light microscopy. Blood cultures were positive for the same organism. The patient underwent arthroscopic washout of the knee and was treated with colchicine and intravenous amoxicillin. He was taken to theatre for a right wrist washout, however the wrist was found to be clean and dry intraoperatively. He had two further washouts of the right knee and repeat intraoperative samples and blood cultures were negative. Additional screening for HIV, syphilis and myeloma was negative. Transthoracic echocardiogram showed no vegetations. CT chest showed basal atelectasis but no focal consolidation. Left hand and wrist MRI showed extensor compartment tenosynovitis and second metacarpophalangeal joint synovitis. His antibiotics were switched to intravenous ceftriaxone and oral doxycycline. He clinically improved and was discharged with a plan to complete a 6-week course with outpatient review. Discussion Streptococcus pneumoniae is an uncommon cause of septic arthritis, responsible for approximately 5% of all cases, but more often causes polyarticular infection than other organisms. This may be related to higher rates of bacteraemia in patients with pneumococcal septic arthritis. In one review of 190 cases of pneumococcal septic arthritis, polyarticular infection was present in 36% of patients and 72% had concomitant bacteraemia (compared with rates of approximately 20% polyarticular infection and 30-50% bacteraemia for septic arthritis overall). The joints most commonly affected are the knee, followed by the hip, shoulder, ankle and elbow. The original focus of infection is most commonly pneumonia or meningitis, but up to 50% of patients have no identifiable extra-articular source of infection. Pneumococcal septic arthritis more commonly affects patients with predisposing risk factors, such as rheumatoid arthritis, osteoarthritis, joint prosthesis, alcoholism, myeloma and other malignancies, diabetes and immunosuppression. Our patient had no specific predisposing medical conditions other than knee osteoarthritis, and his age was likely to be his main risk factor. It is also important to note that septic arthritis in the elderly can present atypically, with insidious onset and absence of fever or other signs of systemic infection. This was the case in our patient, who despite bacteraemia and markedly elevated inflammatory markers, did not otherwise appear floridly septic or unwell. Our patient presented with a polyarticular pattern of joint inflammation, although joint infection was only ultimately confirmed in the right knee. Also notable was the presence of calcium pyrophosphate crystals in the aspirate. One might theorise whether the infection might have triggered a reactive polyarthropathy or concurrent crystal arthritis. It is well recognised that septic arthritis and crystal arthritis can coexist in the same patient. The case also highlights the value in sampling multiple joints and taking blood cultures in such patients. Key learning points • Polyarthritis does not exclude the possibility of septic arthritis • Joint aspiration should be performed in all patients presenting with a hot, swollen joint • In cases of polyarthritis, consideration should be given to aspiration of all affected joints and taking blood cultures, particularly in the elderly and patients with predisposing risk factors for septic arthritis • Septic arthritis can present atypically in the elderly, with the absence of fever and other typical signs of systemic infection

A picture speaks a thousand words: A case of ocular Loa loa

The ‘African eye worm’, also known as Loa loa, is filarial nematode that is commonly, transmitted by deer flies. A history of recent travel to endemic countries near western, Africa is common in patients with Loiasis. While a majority of patients infected with Loa, loa are asymptomatic, common presentations of Loiasis include localized areas of, edema, Calbar swellings, and ocular symptoms secondary to the migration of worms, through the spaces within the eye. This case illustrated presents a healthy 31-year-old, man with no history of recent travel who presented after his friend reported that a worm, was seen in his right eye., The patient had described symptoms of pain, redness, and excessive lacrimation in his, right eye for the past five days. Although the patient originally lived in Cameroon, he, had not travelled there or to any other country since arriving to the United Arab, Emirates two years ago. On physical examination, a worm was not visualized in his, eye. However, a personal photograph of the patient taken two days prior was provided, showcasing a long thin worm migrating in the lateral subconjunctival space of his right, eye. Laboratory investigations revealed eosinophilia in this patient. The personal, photograph along with these findings allowed for the diagnosis of Loiasis, and the, patient recovered completely following an extended 42-day course of oral albendazole., This case highlights the importance of a patient’s history and the physical evidence, they bring with them, especially in patients with ambiguous physical findings and, laboratory results

Serosurvey of canine leishmaniasis in five departments near an identified human clinical case in Marseille (France)

Leishmania infantum is a protozoan parasite of the family Trypanosomatidae, transmitted by the bite of phlebotomine sand flies (Diptera: Psychodidae). It is responsible for human and canine leishmaniasis in countries bordering the Mediterranean basin. Here we describe a clinical case of human cutaneous leishmaniasis in a 76-year-old female patient living in Marseille. Upon interrogation, the patient had no history of recent travel or contact with animals. The study involved clinical, serological, and molecular investigation of the occurrence of Leishmania infection in 718 dogs from five departments within a 130 km radius perimeter around Marseille. Five dogs showed signs of moderate leishmaniasis. Additionally, the serological survey of dogs revealed a global seroprevalence of 5.1%, with a significantly different prevalence in the Vaucluse department. Molecular analysis and phylogenetic studies highlighted the close relatedness of Leishmania strains between human and canine hosts with 99.6% of identity, indicating local transmission. The findings underscore the importance of serological surveillance in dogs and human. In a One Health approach, it is necessary to continue investigating Leishmania infection in all potential reservoirs, especially for zoonotic L. infantum in wildlife (red foxes, leporids, rodents, etc.) but also in dogs, cats, and equids.

Enhancing Diagnosis and Treatment Adjustments for Travelers Infected with Burkholderia pseudomallei: A Case Report - Beijing Municipality, China, June 2023.

Burkholderia pseudomallei (BP) infection leads to melioidosis, a tropical disease endemic to coastal provinces of southern China. Physicians in non-endemic areas, do not commonly consider this disease as a primary differential diagnosis for febrile patients. This article discusses a case of melioidosis in Northern China. The patient, who had recently visited a Southeast Asian region with high melioidosis prevalence, fell ill after exposure to contaminated water. The disease progressed quickly and with severity. Healthcare workers need to remain vigilant regarding travel-related diseases for accurate differential diagnosis and to provide timely and effective treatment, especially for patients with recent travel history or symptoms during travel.

Comparative trends of brucellosis serological testing and confirmed brucellosis cases suggest inappropriate prescription habits

BackgroundBrucellosis is a zoonosis endemic to specific geographical regions. In first line laboratories, diagnosis is made by blood culture or Rose Bengal (RB) serology. MethodsWe compare brucellosis testing between 2012-2021 at two university hospitals in Brussels, Belgium with concomitant national confirmed cases and institutional cases. ResultsRB testing increased from 30 to 211 tests/year between 2012-2021. A total of fifty-two national brucellosis cases were notified during the study period, of which fifteen cases in Brussels. No trend was noted nationally or regionally. Epidemiological data indicated travel to endemic regions, confirmed by strain testing. Institutional cases all showed symptomatic presentations with positive travel histories. ConclusionsSerologic testing inappropriately increases yearly, while annual imported brucellosis cases remain rare, and have positive travel histories and are symptomatic. We therefore support current recommendations of limiting RB testing to symptomatic patients at risk of exposure, meaning predominantly positive recent travel history.

The emergence of Rocky Mountain spotted fever in the southwestern United States and northern Mexico requires a binational One Health approach.

Rocky Mountain spotted fever (RMSF) is an international and quintessential One Health problem. This paper synthesizes recent knowledge in One Health, binational RMSF concerns, and veterinary and human medical perspectives to this fatal, reemerging problem. RMSF, a life-threatening tick-borne disease caused by the bacterium Rickettsia rickettsii, emerged during the first decade of the 21st century in impoverished communities in the southwestern US and northern Mexico. Lack of an index of suspicion, delay in diagnosis, and delayed initiation of antibiotic treatment contribute to fatality. Campaigns targeting dog neutering, restraint to residents' properties, and on-dog and on-premises treatment with acaricides temporarily reduce prevalence but are often untenable economically. Contemporary Mexican RMSF is hyperendemic in small communities and cities, whereas epidemics occur in the western US primarily in small tribal communities. In in both locations, the epidemics are fueled by free-roaming dogs and massive brown dog tick populations. In the US, RMSF has a case fatality rate of 5% to 7%; among thousands of annual cases in Mexico, case fatality often exceeds 30%.1,2 Numerous case patients in US border states have recent travel histories to northern Mexico. Veterinarians and physicians should alert the public to RMSF risk, methods of prevention, and the importance of urgent treatment with doxycycline if symptomatic. One Health professionals contribute ideas to manage ticks and rickettsial disease and provide broad education for the public and medical professionals. Novel management approaches include vaccine development and deployment, acaricide resistance monitoring, and modeling to guide targeted dog population management and other interventions.

Maintaining the Region of the Americas free of polio: best practices for incident management support teams.

The Pan American Health Organization (PAHO) and its Member States have been leading the efforts to eradicate wild poliovirus in the Region of Americas since smallpox's successful elimination in 1971. The region became the first to be certified free of wild poliovirus in 1994. However, in July 2022, an unvaccinated patient with no recent travel history was diagnosed with poliomyelitis in the United States of America. In response to the emergence of a circulating vaccine-derived poliovirus in the United States, PAHO established the Polio Incident Management Support Team. This team has been coordinating response efforts, focusing on: coordination, planning, and monitoring; risk communication and community engagement; surveillance and case investigation; vaccination; and rapid response. In this paper, we identified and documented best practices observed following establishment of the Incident Management Support Team (September 2022-2023) through a comprehensive review and analysis of various data sources and country-specific data from the polio surveillance dashboard. The aim was to share these best practices, highlighting technical support and implementation of polio measures by Member States. Despite several challenges, the Americas region remains polio-free. Polio risk is declining, with a July 2023 assessment showing fewer countries at medium, high, and very high risk. This progress reflects improved immunization coverage, surveillance, containment, health determinants, and outbreak preparedness and response. The PAHO Polio Incident Management Support Team has played a key role in supporting these efforts.

Comparative genomics of an extensively drug resistant strain Klebsiella pneumoniae IITR008 with international high-risk clonal lineage ST147 isolated from river water.

Carbapenem resistant Klebsiella pneumoniae causing severe infection resulting in morbidity and mortality have become a global health concern. K. pneumoniae with sequence type ST147 is an international high-risk clonal lineage, genomic studies have been done on K. pneumoniae ST147 isolated from clinical origin but genomic data for environmental K. pneumoniae ST147 is very scarce. Herein, K. pneumoniae IITR008, an extensively drug resistant and potentially hypervirulent bacterium, was isolated from Triveni Sangam, the confluence of three rivers where religious congregations are organized. Phenotypic, genomic and comparative genomic analysis of strain IITR008 was performed. Antibiotic susceptibility profiling revealed resistance to 9 different classes of antibiotics including ß-lactams, ß-lactam combination agents, carbapenem, aminoglycoside, macrolide, quinolones, cephams, phenicol, and folate pathway antagonists and was found to be susceptible to only tetracycline. The strain IITR008 possesses hypervirulence genes namely, iutA and iroN in addition to numerous virulence factors coding for adherence, regulation, iron uptake, secretion system and toxin. Both the IITR008 chromosome and plasmid pIITR008_75 possess a plethora of clinically relevant antibiotic-resistant genes (ARGs) including blaCTX-M-15, blaTEM-1, and blaSHV-11, corroborating the phenotypic resistance. Comparative genomic analysis with other ST147 K. pneumoniae provided insights on the phylogenetic clustering of IITR008 with a clinical strain isolated from a patient in Czech with recent travel history in India and other clinical strains isolated from India and Pakistan. According to the 'One Health' perspective, surveillance of antibiotic resistance in the environment is crucial to impede its accelerated development in diverse ecological niches.

Predictors of later COVID-19 test seeking.

Delays in COVID-19 testing may increase the risk of secondary household and community transmission. Little is known about what patient characteristics and symptom profiles are associated with delays in test seeking. We conducted a retrospective cohort study of all symptomatic patients diagnosed with COVID-19 and assessed in a COVID Expansion to Outpatients (COVIDEO) virtual care program between March 2020 and June 2021. The primary outcome was later test seeking more than 3 days from symptom onset. Multivariable logistic regression was used to examine predictors of later testing including patient characteristics and symptoms (30 individual symptoms or 7 symptom clusters). Of 5,363 COVIDEO patients, 4,607 were eligible and 2,155/4,607 (46.8%) underwent later testing. Older age was associated with increased odds of late testing (adjusted odds ratio [aOR] 1.007/year; 95% CI 1.00 to 1.01), as was history of recent travel (aOR 1.4; 95% CI 1.01 to 1.95). Health care workers had lower odds of late testing (aOR 0.50; 95% CI 0.39 to 0.62). Late testing was associated with symptoms in the cardiorespiratory (aOR 1.2; 95% CI 1.05, 1.36), gastrointestinal (aOR = 1.2; 95% CI 1.04, 1.4), neurological (aOR 1.1; 95% CI 1.003, 1.3) and psychiatric (aOR 1.3; 95% CI 1.1, 1.5) symptom clusters. Among individual symptoms, dyspnea, anosmia, dysgeusia, sputum, and anorexia were associated with late testing; pharyngitis, myalgia, and headache were associated with early testing. Certain patient characteristics and symptoms are associated with later testing, and warrant further efforts to encourage earlier testing to minimize transmission.

January 2024 Medical Image of the Month: Polyangiitis Overlap Syndrome (POS) Mimicking Fungal Pneumonia

No abstract available. Manuscript truncated after 150 words. A 32-year-old woman with a history including hypertension, end-stage renal disease requiring dialysis, asthma, nonischemic cardiomyopathy, and migraines, was directly transferred to our hospital in November 2023 for the evaluation of hemoptysis. The patient reported a two-week history of a nonproductive cough, runny nose, muscle aches, subjective fevers, chills, fatigue, nausea, and decreased appetite. Within the past 2 days the patient had also developed hemoptysis, with 5-6 episodes per day. Initial investigations, including chest X-ray and CT chest, revealed large biapical pulmonary consolidations with cavitation. Multiple nodular densities were observed throughout both lungs (Figures 1 and 2). The patient denied any recent sick contacts, travel history, and prior tuberculosis infection. She did, however, disclose a period of incarceration from 2011 to 2019. Upon arrival at our hospital, the patient recounted a relatively normal state of health until January 2023 when she underwent a two-month hospitalization, culminating in the diagnosis of …

Best practices for flexible endoscope high-level disinfection-an integrative review

Background: Flexible endoscopes have a complicated design which includes several small lumen channels intended to facilitate the flow of fluids, tissue, and tools through the length of the device. This complex design leads to reprocessing challenges for high-level disinfection (HLD) to ensure endoscopes are free from contaminants that could lead to hospital-acquired infections. The aim of this project was to identify optimal strategies and obstacles for each stage of flexible endoscope HLD through an integrative review with the goal of achieving reprocessing excellence. Methods: A literature search was conducted using PubMed/Medline and CINAHL databases. A total of 32 articles and six guidelines were included in the review. Results: Ten elements with best-practice recommendations of flexible endoscope HLD have been identified. The HLD elements that received the most literature support include quality assurance/process monitoring and manual cleaning/decontamination. Several barriers to the adequate performance of HLD elements were also identified. Conclusion: This integrative review applied varying levels of rigour to identify and synthesize best practices for the following HLD elements: point-of-use treatment, transport, leak testing, manual cleaning/decontamination, visual inspection, manual or automated HLD, rinsing/drying, storage/hang time, record keeping, and quality assurance/process monitoring.

Clinical characteristics of Mpox at a single center in Saudi Arabia: a retrospective study

Objectives: Mpox (formerly known as monkeypox) is a viral infection that has been linked to a global outbreak as recent as in the year 2022. Mpox outbreaks have been increasingly reported in non-endemic regions since 2017 with over 23,000 cases reported in 80 countries as of August 1, 2022. Objective of study was describe the clinical characteristics, treatment and outcomes of Mpox disease as experienced in a tertiary care center in Riyadh, Saudi Arabia from May 2022 till the study date. Methodology: This retrospective chart review study was conducted in a large academic tertiary care hospital in Riyadh, Saudi Arabia. Data were obtained from administrative and electronic medical records and analyzed. Results: Of 33 patients suspected to have Mpox since May 2022, 16 tested positive. In total, 18.8% of patients with Mpox (3/16) had a personal history of recent travel, and 62.5% (10/16) reported some form of recent sexual contact. All the patients presented with rash, and most of them (93.8%) had anogenital rash. The mean number of skin lesions was 6.69, and no one reported coexisting sexually transmitted diseases. In addition, 31.25% (5/16) received antivirals, and no mortality was recorded. Conclusions: Mpox infection demonstrated a variety of signs and symptoms, with all patients presenting with dermatological manifestations. The spread of this disease in our region exhibited some dissimilarities in the clinical presentation and coexisting infections. This highlights the importance of maintaining a high index of suspicion and a low threshold for testing in order to halt further spread.

Risk Factors and Spatial Distribution of Cutaneous Leishmaniasis in District Chitral, Pakistan

Background: Cutaneous leishmaniasis (CL) is a parasitic disease endemic to many regions, including Pakistan's Khyber Pakhtunkhwa (KPK) province. Chitral District, with its unique environmental conditions, presents a significant hotspot for CL transmission, driven by various socio-economic and environmental factors. Methods: This study was conducted between June and October 2023 in four tehsils of Chitral District. A total of 3,748 confirmed CL patients were surveyed for demographic information (figure 14), risk factors, and clinical data. Factors such as housing conditions, proximity to livestock, travel history, and environmental attributes were analyzed. Data were processed using SPSS (version 25.0), with significance determined at p < 0.05. Results: Key findings revealed that 76.94% of patients had recent travel history to endemic areas. Rural residency (58.65%), close proximity to livestock (88.76%), and inadequate housing conditions contributed significantly to CL prevalence. Poor waste management (66.04%) and vegetation near homes (52.14%) were identified as environmental risk factors. A majority (68.45%) of individuals did not use protective measures like mosquito nets, further increasing exposure to vector habitats. Conclusion: The study highlights the multifactorial nature of CL transmission in Chitral District. Socio-economic challenges, environmental factors, and travel history are major contributors. Effective public health strategies should focus on improving housing infrastructure, enhancing healthcare access, and promoting personal protection measures to reduce the burden of CL in high-risk areas.

Enteroaggregative Escherichia coli in mid-Norway: A prospective, case control study.

The use of molecular methods has led to increased detection of Enteroaggregative Escherichia coli (EAEC) in faecal samples. Studies have yielded conflicting results regarding the clinical relevance of this finding. The objective of this study was to investigate the prevalence of EAEC in faecal samples from patients with diarrhoea and healthy controls and describe characteristics of EAEC positive persons. From March 1st, 2017 to February 28th, 2019, we investigated all consecutive faecal samples from patients with diarrhoea received at the laboratory and collected faecal samples from randomly invited healthy controls from mid-Norway. Real-time multiplex PCR was used for detection of bacterial, viral, and parasitic pathogens. We registered sex, age, urban versus non-urban residency, and travel history for all participants. Statistical analyses were performed with Pearson chi-squared test, Kruskal-Wallis test, and Mann-Whitney U test. We identified EAEC in 440 of 9487 (4.6%) patients with diarrhoea and 8 of 375 (2.2%) healthy controls. The EAEC prevalence was 19.1% among those with diarrhoea and recent foreign travel and 2.2% in those without travel history independent of diarrhoea. Concomitant pathogens were detected in 64.3% of EAEC-positive patients with diarrhoea. The median age was 28.5 in those with EAEC-positive diarrhoea and 38 in those with EAEC-negative diarrhoea (p <0.01). In patients with diarrhoea, travel was reported in 72% of those with EAEC and concomitant pathogens, and 54% and 12% in those with only EAEC and no EAEC, respectively (p <0.01). EAEC was a common detection, particularly in patients with diarrhoea and recent international travel, and was found together with other intestinal pathogens in the majority of cases. Our results suggest that domestically acquired EAEC is not associated with diarrhoea. Patients with EAEC-positive diarrhoea and concomitant pathogens were young and often reported recent travel history compared to other patients with diarrhoea.

Multiple species of canine Rhipicephalus complex detected in Canada

Multiple species of brown dog ticks have been described in the United States and the Caribbean: Rhipicephalus sanguineus sensu stricto (s.s.), also referred to as temperate lineage; R. linnaei (=tropical lineage); and R. rutilus (=southeastern Europe lineage) However, Rhipicephalus spp. are rarely recovered from dogs in Canada. To identify canine Rhipicephalus spp. in Canada and determine the influence of travel history on infestation, ticks morphologically identified as brown dog ticks (n = 93) collected from dogs (n = 13) in British Columbia, Ontario, and Québec, Canada were submitted with information regarding each dog's geographic location and travel history. Nucleic acid was extracted from available individual ticks (n = 86) and PCR was used to amplify sequences of a 12S rRNA mitochondrial gene fragment. Sequences were compared to published reference sequences of known species and a phylogenetic tree constructed. Twenty-three ticks (26.7%) consistent with R. linnaei were identified on seven dogs, including dogs from British Columbia and Ontario, with a median infestation intensity of 2 ticks/dog (mean = 3.3 ticks/dog). Sixty-one ticks (70.9%) consistent with R. sanguineus s.s. were found on two dogs from Québec and Ontario (median = 30.5 ticks/dog; mean = 30.5 ticks/dog). One dog from Ontario was infested with R. rutilus (n = 2) (2.3%). Species could not be determined for ticks from three dogs from Ontario and Québec. Most infested dogs (10/13; 76.9%) had a recent (< 1 month) international travel history. These data confirm that multiple species of canine Rhipicephalus are occasionally found in Canada and suggest introduction following travel is likely responsible for these infestations. Further analysis will allow for greater understanding of the range and diversity of canine Rhipicephalus spp. in North America and may reveal risk factors for infestation.

Case 324.

A 69-year-old right-handed man with a history of substance use disorder, hypertension, and diabetes presented to the emergency department in an unresponsive state. Upon examination, apart from tachycardia (heart rate, 108 beats per minute), vital signs were within normal ranges (blood pressure, 134/102 mm Hg; temperature, 97.9°F [36.6°C]; respiratory rate, 16 breaths per minute; oxygen saturation, 96%). He had a Glasgow coma scale score of 8. Otherwise, the physical examination revealed no abnormalities. His prior psychiatric and surgical histories were unremarkable. There was no history of recent travel, camping, hiking, or vaccination. No family history could be obtained. Laboratory work-up revealed an elevated creatine kinase level (49 006 U/L [818.4 μkat/L]; normal reference range, 10-205 U/L [0.17-3.42 μkat/L]). An electrocardiogram showed sinus tachycardia without evidence of cardiac ischemia. An echocardiogram was unremarkable. Alanine aminotransferase (126 U/L [2.10 μkat/L]; normal reference range, 0-40 U/L [0-0.67 μkat/L]) and aspartate aminotransferase (488 U/L [8.15 μkat/L]; normal reference range, 3-44 U/L [0.05-0.74 μkat/L]) levels were elevated. Polymerase chain reaction results were negative for HIV-1, HIV-2, syphilis treponemal, and COVID-19 antibodies. The rest of the routine laboratory work-up findings were within normal limits. Urine drug screening was positive for cocaine, marijuana, fentanyl, and benzodiazepines. Naloxone was administered, but the patient remained unresponsive. Intubation was performed for airway protection. Noncontrast and contrast-enhanced CT of the head (Fig 1) and CT angiography were performed in the emergency department to rule out an acute intracranial abnormality. Multisequence MRI of the brain with administration of intravenous contrast material was ordered for further assessment (Figs 2-4). CT of the abdomen and pelvis was unremarkable (images not shown).

Hepatic Schistosomiasis with Abnormal Ultrasound Findings

Schistosomiasis is an endemic disease in many countries in Africa and the Middle East, and affects millions of individuals. When schistosome eggs are deposited in the liver, an inflammatory response occurs, and if this response becomes chronic, it can lead to non-cirrhotic portal hypertension. A 46-year-old female patient who was diagnosed with hepatic schistosomiasis who recently traveled to the Philippines presented to our hospital with a one-week history of abdominal pain and diarrhea. On transabdominal ultrasound, a reticular echogenic pattern and periportal wall thickening were noted. If the patient has a recent history of travel and characteristic findings on abdominal ultrasound, hepatic schistosomiasis should be suspected and can be diagnosed by detecting ova on liver biopsy.

Case Report: Disseminated hydatid cyst: Unusual presentation and therapeutic challenges

Introduction: Cystic echinococcosis (CE), caused by Echinococcus granulosus sensu lato, is a parasitic disease prevalent in endemic regions. CE frequently leads to the formation of hydatid cysts in various organs, with the liver being the most commonly affected site. Involvement of the spleen has been rarely reported in the literature. Managing disseminated hydatid cyst disease presents significant diagnostic and therapeutic challenges. Case presentation: A 40-year-old female with a past medical history of hypothyroidism presented with sudden onset shortness of breath, dry cough, and chest pain for 3 days. She had a recent travel history to Egypt. Physical examination revealed mild right upper quadrant tenderness. Laboratory findings showed elevated white blood cell count with eosinophilia and increased inflammatory markers. Chest X-ray and pan-computed tomography (Pan-CT) scans identified multiple cystic lesions in the lung, liver and spleen. Serological tests confirmed the presence of anti-Echinococcus antibodies, leading to a diagnosis of disseminated hydatid cyst disease. The patient was managed medically and surgically by a multidisciplinary team. Conclusion: Disseminated hydatid cyst disease, though rare, presents complex diagnostic and management challenges. Timely recognition, supported by clinical, radiological, and serological assessments, is essential. Surgical intervention should be considered in a patient when multiple extrahepatic cysts are present, and rupture is evident, as this approach can significantly reduce patient morbidity and mitigate life-threatening complications.

Influence of Online Reviews on Hotel Reservation Intentions: Insights from Bangladeshi Travellers

The primary objective of this research is to undertake an empirical investigation of the overall influence of online reviews on hotel booking intentions within the context of Bangladesh. The study involved the execution of semi-structured interviews with a sample of 25 individuals with a recent history of frequent travel and hotel stays. Subsequently, a thematic analysis of the responses was conducted with the goal of elucidating the outcomes and ascertaining the influence of online reviews on individuals' predispositions towards booking a hotel for their accommodation facility. The findings of the study revealed that positive reviews wield the most substantial influence among the various dimensions of tourists' reviews. Notably, the idea of "trust" appeared within the identified indicators as a mediating variable in the association between reviews and the intention to book a hotel. Moreover, this empirical study also showed that unfavorable online reviews significantly influence individuals ‘intents to reserve hotels, whereas positive reviews do not yield an equivalent impact. Considering these outcomes, the authors draw a series of management implications, including the need to use this information to promote stakeholder engagement and collaboration, to use these indicators for the management of hotels to adopt a more holistic approach to address the service gap in the hospitality industry, and to focus on resilient planning for sustainable smart tourism development.

Abstract 087: Cocaine‐Induced Acute Spinal Cord Ischemia Syndrome

Introduction Acute spinal cord ischemia syndrome (ASCIS) is a rare disease that is thought to comprise roughly only 1.2% of all strokes [1, 2]. These strokes primarily occur in the anterior spinal cord artery (ASA) and/or the posterior spinal cord artery (PCA) territory and can have widely variable clinical presentation. The use of recreational cocaine in young adults is well known to be responsible for acute ischemic and hemorrhagic strokes in individuals who lack other vascular risk factors. What is significantly rarer with few reported cases, however, is cocaine‐related ASCIS as the etiology of non‐traumatic acute spinal cord myelopathy [3‐7]. Methods N/A Results A 40‐year‐old female with a history of type I Diabetes mellitus, bipolar disorder, and polysubstance abuse presented with acute‐onset bilateral lower limb weakness, sensory loss, neck pain, and bladder incontinence. On admission, she reported using intravenous crack cocaine in the evening before admission and experiencing a fall in the bathroom a few hours after. She was unable to move her lower limbs following this fall. On examination, there was flaccid weakness in both lower extremities with decreased pinprick sensation below the T4 level and absent sensation below the thighs on both sides. She had no trauma preceding her symptoms and denied any recent vaccinations or travel history. An urgent CT (computed tomography) scan of the cervical, thoracic, and lumbar spine ruled out any obvious traumatic injury. Her urine drug screen was positive for cocaine, opiate, cannabinoid, and benzodiazepine. MRI (Magnetic Resonance Imaging) of the brain without contrast was unremarkable. MRI of the spine with contrast demonstrated two areas of T2 hyperintensities from C5‐C6 and T4 to the conus with cord expansion. The lesion in the thoracic spinal cord showed contrast enhancement and spared the dorsal column. Lumbar puncture was traumatic and showed elevated protein (&gt;300 mg/dl) as well as elevated glucose (186 mg/dl). CSF studies, including meningitis/encephalitis panel, gram stain and culture, flow cytometry, cytology, and oligoclonal bands were negative. Serum autoimmune myelopathy panel, serum Aquaporin‐4 antibodies and MOG (Myelin Oligodendrocyte Glycoprotein) antibodies were negative. The other etiologies of non‐traumatic myelopathy, including HIV, Treponema pallidum, and HTLV‐I/II antibodies, were negative. A diagnostic spinal angiogram was completed with no evidence of arteriovenous fistula or aortic dissection. She completed five days of plasma exchange without any improvement and was transferred to an acute rehabilitation facility. At four months follow‐up, she continues to be flaccid in her lower limbs and requires a urinary catheter leading to frequent urinary tract infections. Conclusion While cocaine‐related cerebrovascular events are well documented, very few cases of cocaine‐related ASCIS have been described. The mechanism is thought to be multifactorial due vasospasm, cerebral vasculitis, vascular thrombosis, cardioembolism from cocaine‐induced myocardial infarction or cardiomyopathy, and hypertensive surges [9]. Due to the scarcity of these events, the patient outcomes are unclear. Other studies on outcomes of spinal cord ischemia have shown that ASIA Impairment Scale (AIS) score, lesion level, and patient age were the strongest predictors of neurologic and functional outcomes, whereas etiology of the ischemia had no effect on outcomes [10].