Dokument: Malaria bei Reiserückkehrern in einem tropenmedizinischen Zentrum in Deutschland

Titel:	Malaria bei Reiserückkehrern in einem tropenmedizinischen Zentrum in Deutschland
Weiterer Titel:	Travellers' Malaria in a Center of tropical medicine in Germany
URL für Lesezeichen:	https://docserv.uni-duesseldorf.de/servlets/DocumentServlet?id=47757
URN (NBN):	urn:nbn:de:hbz:061-20181119-112502-0
Kollektion:	Dissertationen
Sprache:	Deutsch
Dokumententyp:	Wissenschaftliche Abschlussarbeiten » Dissertation
Medientyp:	Text
Autor:	Breuer, Ronja [Autor]
Dateien:	[Dateien anzeigen] Adobe PDF [Details] 1,55 MB in einer Datei [ZIP-Datei erzeugen] Dateien vom 06.11.2018 / geändert 06.11.2018
Beitragende:	Priv.-Doz. Dr. Richter Joachim [Gutachter] Prof. Dr. Höhn, Thomas [Gutachter]
Dewey Dezimal-Klassifikation:	600 Technik, Medizin, angewandte Wissenschaften » 610 Medizin und Gesundheit
Beschreibungen:	Während die Malaria insbesondere im subsaharischen Afrika eine häufige Erkrankung darstellt, ist sie hierzulande eher selten. Mögliche Probleme die hierdurch entstehen können, sind zum einen die Gefahr vermehrter falsch-positiver Diagnosen und einer Übertherapie der Erkrankung in Ländern, in denen die Malaria sehr häufig vorkommt und zum anderen unzureichende Kenntnisse über die Erkrankung beim medizinischen Personal in Ländern wie Deutschland. Die Arbeit verfolgt zwei wesentliche Ziele. Erstens soll die Patientenpopulation in Deutschland am Beispiel von Patienten einer tropenmedizinischen Abteilung einer Deutschen Universitätsklinik beschrieben werden um potenzielle Verbesserungsmöglichkeiten in der Versorgung herauszuarbeiten. Zweitens soll der Frage nachgegangen werden, ob in Afrika, dem Kontinent mit den meisten Erkrankten, tatsächlich gehäuft falsch-positive Diagnosen der Malaria stattfinden. Retrospektiv wurden aus dem Untersuchungszeitraum vom 01.01.1999 bis zum 31.12.2013 289 Patienten bzw. deren Akten analysiert, die in der Tropenmedizinischen Ambulanz Düsseldorf mit einer Malaria mitbetreut wurden. Hier wurden u.a. Alter, Geschlecht, Herkunfts- und Infektionsland, diverse Laborparameter, das Prophylaxeverhalten, sowie der Zeitraum zwischen Fieberbeginn und der Diagnosestellung untersucht. Diese Daten wurden teilweise auf einen Zusammenhang mit der Entwicklung einer komplizierten Malaria überprüft. Weiterhin wurden aus demselben Untersuchungszeitraum 226 Fälle retrospektiv analysiert, die in Afrika eine Malariadiagnose erhielten und sich anschließend zur Nachuntersuchung in der tropenmedizinischen Ambulanz vorstellten. Von den 289 Patienten, die in Düsseldorf im Untersuchungszeitraum mit einer Malaria behandelt wurden, hatten 16,3% einen komplizierten Verlauf. Die Letalität betrug 1%. 82% der Patienten hatten eine Einfachinfektion mit P. falciparum, 9% mit P. vivax, und jeweils 3% mit P. ovale bzw. malariae. Zudem gab es vereinzelt Mehrfachinfektionen und Patienten bei denen keine eindeutige Speziesidentifikation möglich war. Bei einem Patient wurde P. knowlesi gefunden. Insgesamt war ein leichter Anstieg der Fallzahlen gegen Ende des Untersuchungszeitraums zu verzeichnen. Weiterhin wurden im Spätsommer und Herbst die meisten Patienten diagnostiziert. Ein Großteil der Patienten (72%) war zwischen 25 und 55 Jahre alt, wobei ein weiterer, wenn auch kleinerer Häufungsgipfel bei den Kindern zu beobachten war. Komplizierte Verläufe traten signifikant häufiger bei Patienten unter 10 sowie über 60 Lebensjahren auf. 65% der Patienten waren männlich. Die meisten Infektionen wurden in Afrika erworben (89%). Hiervon infizierten sich wiederum die meisten Patienten in Ghana, gefolgt von Nigeria und Kamerun. Auch die Herkunft war bei einem Großteil der Patienten Afrika (53,6%). Bei 51% der Patienten war das Herkunftsland gleichzeitig auch das Infektionsland. Eine korrekte medikamentöse Malariaprophylaxe wurde nur von 10,6% der Patienten durchgeführt. Die Zeitspanne von Symptombeginn bis zur Diagnosestellung war im Mittelwert 5,27 Tage. Nur 37 Patienten erhielten schon am ersten Tag der Symptome die korrekte Diagnose. Um bei Patienten, bei denen in Afrika eine Malaria diagnostiziert worden war, diese Diagnose a posteriori zu verifizieren wurden meist Antikörper bestimmt (89,8%). Zusätzlich kamen Schnelltests und mikroskopische Untersuchungen zur Anwendung. Nur in 31,9% der Fälle konnte eine Malaria im Nachhinein bestätigt werden. Insgesamt bestätigte sich die Erkenntnis, dass die Malaria meist bei Reisenden auftritt, weil keine oder eine unzureichende medikamentöse Malariaprophylaxe durchgeführt worden war. Der Nachweis von histidinreichem Protein 2 als Marker für eine Malaria tropica bestätigte sich als zuverlässig, sowie der Nachweis von pan-plasmodialer Aldolase als unzuverlässig. Es zeigen sich hier Hinweise darauf, dass in Deutschland die Diagnose der Malaria nicht selten zu spät gestellt wird, und dass dies zu einer Gefährdung der Patienten führt. Andererseits konnte gezeigt werden, dass in Afrika eine Malaria häufig fälschlicherweise diagnostiziert wird, was zum falschen Schluss von Reisenden führen kann, eine medikamentöse Prophylaxe sei nicht mehr effektiv. Whereas malaria is a common infection in sub-Saharan Africa, this infection is, since its eradication in Germany, limited to rare imported cases. Limited knowledge on this disease may lead to a delayed diagnosis and therapy of this acute potentially lethal infection. On the other hand it is conceivable that in highly endemic regions the knowledge on its lethal potential might lead to over-diagnosis of febrile diseases misinterpreted as malaria. This might cause travelers with a febrile diseases treated as malaria to believe that antimalarial chemoprophylaxis has not been effective. This work pursues two objectives: firstly, to describe a population presenting in a tropical diseases section of a German University Hospital in order to elaborate potential improvement possibilities; secondly, it is attempted to clarify whether or not in Africa, the continent with the highest number of malaria infections, false-positive malaria diagnoses occur and if so, how frequently. 289 malaria patients, who were attended in the University Hospital of Düsseldorf between 01.01.1999 and 31.12.2013 were analysed retrospectively. Age, sex, countries of patients' origin and of infection, relevant laboratory parameters, the behavior regarding the prophylactic use of antimalarials, as well as the time elapsed between first fever attack and diagnosis were recorded. The data were analysed with respect to a complicated clinical course of malaria. Further 226 subjects were analysed retrospectively, who had presented during the same period and who had been diagnosed in Africa as having malaria before. In order to verify their diagnosis a posteriori specific antibody tests (89.8%) and malaria-point of-care rapid tests were used. The latter enable a short-termed a posteriori diagnosis of past falciparum malaria via the detection of histidine-rich protein 2. Yearly, in Düsseldorf malaria patients presented most frequently during late summer and autumn. Overall, there was an increase of cases over the last years. 72% of patients were 25 to 55 years old, whilst there was a minor peak of incidence among children. Most infections were acquired in Africa (89%), most frequently in Ghana, Nigeria and Cameroon. Similarly, the country of origin of most patients was Africa (53.6%). In 51% of patients the originary country corresponded to the country of origin. 82% of 289 patients suffered from falciparum malaria, 9% from a tertian malaria due to P. vivax, 3% to P. ovale and 3% from a quartan malaria due to P. malariae. P. knowlesi was diagnosed in one case. The other few cases were either mixed infections or the Plasmodium species could not be doubtlessly identified. 16,3% of infections took a complicated course: lethality was 1%. Complications were significantly more frequent in patients under 10 or over 60 years of age. 65% of these patients were male. A correct antimalarial chemoprophylaxis had been reported by only 10,6% of all patients. The time elapsed between first symptoms and diagnosis was 5.27 days on average. Only 37 patients were correctly diagnosed already on the first day. Of the other 226 subjects who had been diagnosed as having had malaria in Africa, only 31.9% were confirmed a posteriori. Concluding it was confirmed that malaria most frequently occurs in travelers who do not take a correct antimalarial chemoprophylaxis. The detection of histidine-rich protein 2 as marker for a falciparum malaria proved reliable, which was not the case for the detection of pan-plasmodial aldolase equally displayed on many rapid tests. It is probable that in Germany malaria not unfrequently is diagnosed too late and that this delay endangers malaria patients. On the other hand we could show that in Africa travellers and expatriates who suffer from a fever are diagnosed too frequently as having malaria and that this might make them conclude that antimalarial chemoprophylaxis is not effective.
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Lizenz:	Urheberrechtsschutz
Bezug:	Düsseldorf 01.01.1999 - 31.12.2013
Fachbereich / Einrichtung:	Medizinische Fakultät » Institute » Tropenmedizin
Dokument erstellt am:	19.11.2018
Dateien geändert am:	19.11.2018
Promotionsantrag am:	28.02.2018
Datum der Promotion:	02.10.2018