434
Correspondence
Response to Letter: We would like to thank Dr Soentjens and colleagues for commenting on our paper “Failure of repeated treatment with praziquantel and arthemeter in four patients with acute schistosomiasis.” We understand that Soentjens and colleagues primarily addressed the following: 1. The use of arthemeter after 3 months. 2. The use of praziquantel versus steroids in patients whose serological titers fail to decrease after treatment. 3. Reason for not treating the other two patients who bathed in Lake Victoria. Our point-by-point reply is the following: First, we did not administer arthemeter after 3 months, but rather used only praziquantel. Second, we agree with Soentjens and colleagues that a rise in antibody titers could be triggered by immune activation. However, immunity itself must be activated by something not present before, as serotiters and eosinophils in our patients were markedly decreasing in the previous months. Our idea is that praziquantel had not been able to kill1 adult worms, which started laying new eggs, thus triggering the new inflammatory and immune response with the resultant rise of eosinophil and antibody titers observed. Indeed, we detected a significant fall of antibodies and eosinophil levels after each course of praziquantel. We interpret this as the result of a direct action of the drug on renewed antigen production. If this is not the case, the question of what triggered the immuno-inflammatory reaction itself remains in our opinion unanswered, given that other parasitic infections such as strongyloidiasis were reasonably excluded through specific tests. Third, the other two patients were not treated as they had no symptoms, and no serologic and laboratory evidence of schistosomiasis was seen. J Travel Med 2014; 21: 433–435
435
Correspondence
Regarding the other points, follow-up of treatment of our patients was guided not only by the serological response but also by symptoms and raised eosinophil counts as pointed out in table 1 and in the figure of our article. Rectal biopsies were not performed because symptoms were quite mild, and we felt that invasive procedures were unnecessary. PCR could indeed be very useful for diagnosis and follow-up of schistosomiasis in travelers, but it is not available in all laboratories, and more experience is needed to assess any real advantage of its routine use. Finally, we are aware that further studies are needed to redesign the therapeutic options for acute schistosomiasis. Until then, we maintain that praziquantel is a much better option than steroids when antibodies and eosinophils rebound after dropping following a first course of praziquantel plus arthemeter.
In summary, our aim was to draw attention to the need for prolonged follow-up after a first course of praziquantel combined with arthemeter in the case of acute schistosomiasis in international travelers.
Liliana Praticò,∗ Bianca Mariani,∗ Enrico Brunetti,∗ Roberta Maserati,† Antonella Bruno,† Stefano Novati,∗ and Guido Chichino‡ ∗ Infectious
Disease Department, San Matteo Hospital, University of Pavia, Pavia, Italy; † Microbiology and Virology Department, San Matteo Hospital, University of Pavia, Pavia, Italy; ‡ Division of Infectious and Tropical Diseases, ASL, Casale Monferrato, Italy Reference 1. Chai JY. Praziquantel treatment in trematode and cestode infections: an update. Infect Chemother 2013; 45:32–43.
J Travel Med 2014; 21: 433–435
Copyright of Journal of Travel Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Correspondence
Response to Letter: We would like to thank Dr Soentjens and colleagues for commenting on our paper “Failure of repeated treatment with praziquantel and arthemeter in four patients with acute schistosomiasis.” We understand that Soentjens and colleagues primarily addressed the following: 1. The use of arthemeter after 3 months. 2. The use of praziquantel versus steroids in patients whose serological titers fail to decrease after treatment. 3. Reason for not treating the other two patients who bathed in Lake Victoria. Our point-by-point reply is the following: First, we did not administer arthemeter after 3 months, but rather used only praziquantel. Second, we agree with Soentjens and colleagues that a rise in antibody titers could be triggered by immune activation. However, immunity itself must be activated by something not present before, as serotiters and eosinophils in our patients were markedly decreasing in the previous months. Our idea is that praziquantel had not been able to kill1 adult worms, which started laying new eggs, thus triggering the new inflammatory and immune response with the resultant rise of eosinophil and antibody titers observed. Indeed, we detected a significant fall of antibodies and eosinophil levels after each course of praziquantel. We interpret this as the result of a direct action of the drug on renewed antigen production. If this is not the case, the question of what triggered the immuno-inflammatory reaction itself remains in our opinion unanswered, given that other parasitic infections such as strongyloidiasis were reasonably excluded through specific tests. Third, the other two patients were not treated as they had no symptoms, and no serologic and laboratory evidence of schistosomiasis was seen. J Travel Med 2014; 21: 433–435
435
Correspondence
Regarding the other points, follow-up of treatment of our patients was guided not only by the serological response but also by symptoms and raised eosinophil counts as pointed out in table 1 and in the figure of our article. Rectal biopsies were not performed because symptoms were quite mild, and we felt that invasive procedures were unnecessary. PCR could indeed be very useful for diagnosis and follow-up of schistosomiasis in travelers, but it is not available in all laboratories, and more experience is needed to assess any real advantage of its routine use. Finally, we are aware that further studies are needed to redesign the therapeutic options for acute schistosomiasis. Until then, we maintain that praziquantel is a much better option than steroids when antibodies and eosinophils rebound after dropping following a first course of praziquantel plus arthemeter.
In summary, our aim was to draw attention to the need for prolonged follow-up after a first course of praziquantel combined with arthemeter in the case of acute schistosomiasis in international travelers.
Liliana Praticò,∗ Bianca Mariani,∗ Enrico Brunetti,∗ Roberta Maserati,† Antonella Bruno,† Stefano Novati,∗ and Guido Chichino‡ ∗ Infectious
Disease Department, San Matteo Hospital, University of Pavia, Pavia, Italy; † Microbiology and Virology Department, San Matteo Hospital, University of Pavia, Pavia, Italy; ‡ Division of Infectious and Tropical Diseases, ASL, Casale Monferrato, Italy Reference 1. Chai JY. Praziquantel treatment in trematode and cestode infections: an update. Infect Chemother 2013; 45:32–43.
J Travel Med 2014; 21: 433–435
Copyright of Journal of Travel Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
