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The delayed appearance of a papule after returning from travelling hints towards the diagnosis cutaneous leishmaniasis. Histologically, a granulomatous inflammatory response is seen, and using Giemsa staining, intracellular parasites can be visualized within histiocytes. Polymer chain reaction (PCR) from the tissue or subsequent cultures not only aids in excluding other differential diagnoses, but also in the identification of the causing Leishmania subspecies. The latter is important for the choice of the optimal therapeutic regimen.

Since 2015 a significant increase in tuberculosis cases is notified in Germany, mostly due to rising numbers of migrants connected to the recent refugee crisis. Because of the low incidence in previous years, knowledge on tuberculosis is more and more limited to specialized centers. However, lung specialist and healthcare workers of other fields have contact to an increasing number of tuberculosis patients. In this situation, guidance for the management of standard therapy and especially for uncommon situations will be essential. This new guideline on tuberculosis in adults gives recommendations on diagnosis, treatment, prevention and prophylaxis. It provides a comprehensive overview over the current knowledge, adapted to the specific situation in Germany. The German Central Committee against Tuberculosis (DZK e. V.) realized this guideline on behalf of the German Respiratory Society (DGP). A specific guideline for tuberculosis in the pediatrics field will be published separately. Compared to the former recommendations of the year 2012, microbiological diagnostics and therapeutic drug management were given own sections. Chapters about the treatment of drug-resistant tuberculosis, tuberculosis in people living with HIV and pharmacological management were extended. This revised guideline aims to be a useful tool for practitioners and other health care providers to deal with the recent challenges of tuberculosis treatment in Germany., Competing Interests: Interessenkonflikt: Siehe Interessenkonflikterklärung auf www.awmf.org, (© Georg Thieme Verlag KG Stuttgart · New York.)

Hepatitis B and C virus infections are a leading cause of death in HIV-positive patients. Furthermore, the management of these infections is complicated. Psychosocial problems and comorbidities are frequent barriers to the optimal management of these patients. Furthermore, the rapid changes in treatment strategies particularly in Hepatitis C make it difficult to treat patients outside specialized centers. An improvement in treatment uptake and efficacy can only be achieved through coordinated efforts between private care physicians and specialized centers.

Antiretroviral therapy (ART) has improved quality of life and increased life expectancy of HIV-infected individuals. Opportunistic diseases are less common, and mortality has declined. Consequently, patterns of mortality and morbidity are changing among the HIV-positive population. The focus of care has shifted to ART-related problems and to various non-AIDS diseases. Such comorbidities, often occurring sequentially or concurrently, may be the consequences of long term ART toxicity, a state of chronic inflammation due to HIV infection, lifestyle-related risks for disease, and aging. The emergence of non-AIDS related conditions highlights the important role of primary care physicians, especially of those with extensive experience in HIV management.

Primary HIV-infection (PHI) encompasses the first 6 months after HIV infection. Phylogenetic analysis demonstrates that PHI accounts for approximately half of onward transmissions. Between 25 and 90 % of patients with PHI present with an acute retroviral syndrome, but asymptomatic or atypical manifestations of PHI are substantially underestimated and occur in up to one third. Signs and symptoms include fever, fatigue, sore throat, exanthema, lymphadenopathy and diarrhea. The unspecific nature of these signs and symptoms preclude a reliable clinical diagnosis. Therefore, an HIV test should be performed routinely amongst persons at risk. The 4th generation Combo test detects PHI in most cases within two to three weeks after infection and should be used for screening. A routine use of the HIV-specific PCR for screening purposes is discouraged. During the last decade early antiretroviral therapy has been recognized as beneficial for patients with PHI and therefore is recommended.

Current clinical aspects of genital ulcer diseases, urethritis and genital warts are reviewed. In the first part we focus on the commonest sexually transmitted pathogens associated with urethritis, including Chlamydia trachomatis and Neisseria gonorrhoea; and we provide an overview about human papilloma virus related genital infections. Diagnostic and treatment approaches are based on the most recent internationally published guidelines and should help practitioners managing their patients, preventing irreversible complications and further transmission.

Symptoms: A 40 year old, disoriented, HIV- and Hepatitis B positive male patient was admitted with 40.3 °C. Clinically he presented a sinustachycardia (160/min) and hypotension (70/60 mmHg)., Investigations/diagnosis: Laboratory analyses showed elevated infection parameters, azotemia, proteinuria and thrombopenia. CD(4+)T-helper cells: 320/µl (32 %), HIV RNA: <40 copies/ml, Hepatitis B DNA: 20800 copies/ml. Hantavirus serology (immunofluorescence antibody assay): 1:2048; serotype Puumala., Treatment/course: An early-goal-directed therapy and antibiotic treatment with Piperacillin and Tazobactam was initiated. The patient developed a bipulmonal infiltrate and an acute respiratory distress syndrome (ARDS ) requiring tracheal intubation, as well as a triad of fever, renal failure and profound hemorrhagic symptoms. This led to the diagnosis of the Puumala infection. Due to the parallel HIV- and Hepatits B infection an antiretroviral therapy was initiated., Conclusion: In summary the Puumala infection bears the potential for a severe multi-organ failure, which is not typical for this usually benign infection.

History and Admission Findings: A 19-year-old HIV-positive man was admitted with fever of unknown origin and poor general condition. Antiretroviral therapy had been stopped by the patient eight months prior to admission., Investigations: Laboratory tests revealed pancytopenia, high viral load and low count of T-helper cells (13/µl). Computer tomography of the thorax showed small patchy infiltrations. Extensive examinations (microbiology, laboratory tests, multiple investigations) revealed no pathogen. Liver biopsy proved disseminated histoplasmosis., Treatment and Course: Liposomal amphotericin B was started and switched to oral itraconazole after 14 days with itraconazole. With this treatment the patient condition improved and fever stopped. T-helper cells increased and the patient was discharged., Conclusion: Disseminated histoplasmosis as an AIDS-defining opportunistic infection is uncommon (particularly as the patient had not been abroad in the last four years) and can be a life-threatening complication. Diagnosis must be confirmed by invasive methods especially in patients with compromised immune status and rapid clinical progression., (© Georg Thieme Verlag KG Stuttgart · New York.)

A 65 year old HIV-infected patient (CDC A2, diagnosed in 07/2008) presented with facial, erythematous infiltrated papular lesions. Consistent with progressive immunodeficiency a low CD4+ T-cell count and an increase of the viral load was seen simultaneously and an eosinophilic pustular folliculitis (EPF) was assumed. Though, the lesional biopsy revealed a follicular eosinophilic infiltration and endotrichial hyphae, proving for an infiltrating dermatophytosis. This shows how an infiltrating Tinea faciei is mimicking clinically and histologically an HIV-associated EPF of the face.

Tuberculosis (TB) continues to be one of the infectious diseases with the world's highest rates of avoidable morbidity and mortality. A continuing downward trend has only been observed in highly industrialized countries, including Germany with 4,400 cases in the year 2009 representing an incidence of 5.5 per 100,000 persons. At the same time, the exposure to this patient group and the clinical experience are decreasing. Tuberculosis may affect any organ. The lung was the manifestation site in 80% of cases, and extrapulmonary manifestations were recorded in 20% of cases in Germany in the year 2008. Lymph node involvement is most common with a rate of approximately 50% of all extrapulmonary cases followed by the pleura in 18% of cases, genitourinary tract in 13% of cases, bones and joints in 6% of cases, gastrointestinal tract in 6% of cases, the central nervous system in 3% of cases and the spine in 3% of cases. Symptoms like fever, night sweats and weight loss are non-specific and may be absent. The aim of the review is to raise awareness of this disease, which is increasingly falling into oblivion, with its various radiological manifestations and to point out clinical-epidemiological and demographic factors that raise suspicion of tuberculosis., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Investigations concerning the outcome for patients suffering from neuro-AIDS treated on a neurological intensive care unit and specific predictors indicating "dead" were analyzed., Material and Methods: A total of 56 patients with a mean age of 39 ± 0.7 years, a mean CD4+ cell count of 130 ± 166 CD4+ cells/µl and viral load of 146,520 ± 198,059 copies/ml were treated on a neurological intensive care unit due to different forms of neuro-AIDS., Results: Of the patients, 34% were immigrants of whom 74% came from sub-Saharan regions. In 57% of the patients the diagnosis of HIV infection was made during therapy on the neurological intensive care unit. The median for the time between diagnosis of HIV infection and the treatment on the neurological intensive care unit was 8 days for immigrants and 10 years for residents. The most common manifestations of neuro-AIDS were cerebral toxoplasmosis, cryptococcosis and progressive multifocal leukoencephalopathy (PML). Fifty per cent of the patients (n=28) died during treatment on the neurological intensive care unit. Negative predictors for the outcome "dead" were (a) artificial ventilation, (b) antiretroviral naïve immigrant, (c) primary cerebral lymphoma and (d) missing antiretroviral therapy as a result of admission to the intensive care unit., Discussion: The rate of death during treatment of neuro-AIDS on a neurological intensive care unit is much higher than during treatment of internal medicine problems of HIV infection. Antiretroviral naïve immigrants show a much higher rate of death compared to residents in Germany. A lot of research and effort is necessary to improve the availability of the Highly Active Anti-Retroviral Therapy (HAART) worldwide in order to improve the outcome especially for immigrants with neuro-AIDS treated on a neurological intensive care unit.

Influenza infections have important socio-economic consequences. Risk groups identified so far include small children and elderly adults with comorbidities. In recent years in addition to seasonal influenza an outbreak of avian influenza occurred in 2005 and the new H1N1 pandemic occurred in 2009. For the latter other at risk groups were affected and a different clinical course has been documented. The focus of this article is to give an overview on the epidemiology, clinical characteristics, diagnosis and therapy of influenza infections.

Endemic deep or systemic mycoses are common in specific geographical areas of the world. Coccidioidomycosis is present in semi-desert areas, histoplasmosis and paracoccidioidomycosis in tropical regions and blastomycosis belongs to temperate climates. The two former are widely distributed in the American continent and some tropical regions of the world; the third is limited to Central and South America, and the last to North America and Central and East Africa. These mycoses all have a similar pathogenesis, as the inoculum enters the host through the respiratory tract. Cutaneous manifestations are secondary to lymphatic and hematogenous dissemination. These deep mycoses are exceptional in Europe. Most cases are observed in returning travelers from endemic areas, aid workers, archaeologists, speleologist and immigrants. However, there have been some autochthonous cases of histoplasmosis due to Histoplasma capsulatum var. capsulatum reported in European countries such as Italy and Germany. In this article, we provide up-to-date epidemiological, clinical, diagnostic and therapeutic data on the four most important imported systemic mycoses in Europe., (© The Authors • Journal compilation © Blackwell Verlag GmbH, Berlin.)

Presented here are two cases of patients with unclear visual loss. A diagnostic assessment with spectral domain optical coherence tomography (Sd-OCT), fluorescein angiography (FLA) and blood analyses was performed due to vitreous clouding. Characteristic FLA findings for papillitis and vasculitis and as yet undescribed morphological Sd-OCT changes in the photoreceptor layer and in the pigment epithelium were found. During the treatment of the diagnosed lues these changes were resolved. The Sd-OCT technique seems to be a useful and effective diagnostic tool for uveitis diagnostics.

Unexplained cough for more than 2 - 3 weeks or patients considered to be at high risk for tuberculosis (TB) should be investigated in a timely manner: Chest radiography and 3 sputum examinations for detection acid-fast bacilli and TB cultures are essential first diagnostic steps. Pending sputum results an antibiotic trial (avoiding fluorochinolones) is warranted and if symptoms do not resolve and the diagnosis remains unclear then additional investigations are required to confirm or rule out pulmonary tuberculosis: sputum provocation by inhalation of hypertonic saline or alternatively bronchoscopy may provide samples to confirm TB or lead to an alternative diagnosis. Immunologic and molecular tests are useful in specific situations to identify previous contact with specific mycobacteria or identify drug-resistant strains. Prompt diagnosis and treatment are important epidemiologic measures to prevent transmission of mycobacteria to contacts including the medical personnel. Isolation measures take into account the transmission by aerosol and the viability of the mycobacteria and specific criteria need to be met before these precautions can be abandoned.

The human immunodeficiency virus (HIV) epidemic has allowed the incidence of tuberculosis to rise globally and particularly in sub-Saharan Africa. Diagnosis and treatment of tuberculosis is more complex in patients with HIV/AIDS. Sputum smear microscopy is performing poorly in HIV-infected individuals, who are often started on antituberculosis treatment on clinical grounds. The treatment of coinfected patients requires antituberculosis and antiretroviral drugs to be administered concomittantly; challenges include pill burden and patient compliance, drug interactions, overlapping toxic effects, and immune reconstitution inflammatory syndrome. Current guidelines recommend starting antiretroviral treatment within a few weeks of antituberculosis therapy for patients with CD4 cell counts < 350 cells/ul.

Tuberculosis control activities focus on identification and treatment of sputum smear positive tuberculosis patients. As soon as these patients can be treated, they not only have an optimal chance for cure, they also no longer spread Mycobacterium tuberculosis (M.tb) in the community. Screening is a systematic search for tuberculosis disease, often performed by radiological or by sputum smear examinations. On the other hand, Screening for Infection with M.tb is with immunological tests. Persons infected with M.tb have an increased risk to develop active tuberculosis in the future. Screening for infection is recommended in tuberculosis contact tracing and in several risk groups for the progression to tuberculosis disease, specifically before the start of immunosuppressive therapy with tumor necrosis factor antagonists or in transplant recipients. Several immunological tests are available. If compared to the traditional in vivo Mantoux tuberculin skin test, in vitro blood tests called Interferon Gamma Release Assays (IGRA) are more specific because the cell wall antigens used for the tests are not present in the wall of Bacille Calmitte Guerin BCG and most atypical mycobacteria. Another advantage of IGRA is the mitogen positive control, which detects unreliable tests in immunodeficiency. Persons found to be infected with M.tb are treated with prophylactic isoniacid for 9 months.

In 2007, the German Central Committee against Tuberculosis (DZK) published recommendations for contact tracing that introduced the new interferon gamma release assays (IGRAs). Meanwhile, substantial progress has been made in documenting the utility of IGRAs. Because IGRAs are usually superior to the tuberculin skin test (TST) in detecting latent TB infection (LTBI) with respect to sensitivity and specificity in adult contact populations that are at least partially BCG vaccinated, it is now recommended that instead of two-step testing only IGRAs be used.[nl]As the literature does not yet provide sufficient data on the accuracy of IGRAs in children younger than 5 years, the TST remains the method of choice in that age group. To date, also, no clear body of data exists to substantiate better performance for IGRAs than for the TST in older children, thus in this age group using of either test is recommended. The new recommendations also underscore the importance of a diligent preselection of close contacts in order to achieve a high probability that positive test results represent recent infection and to thus increase the benefit of chemopreventive treatment for those identified as requiring it. In a third point of update, it is noted that re-testing of contacts individuals found positive for LTBI may produce a considerable number of false-negative results and should thus be avoided in case of documented exposure., (© Georg Thieme Verlag KG Stuttgart · New York.)

A 37-year-old homosexual man was admitted because of oropharyngeal pain, fever, diarrhea, loss of weight and lymphadenopathy since one week. Acute retroviral syndrome (ARS) in primary HIV type 1 infection was diagnosed, associated with Giardia lamblia infection. Antiinfective and combined antiretroviral treatment was established, and the general condition of the patient rapidly improved. The presented report demonstrates that in case of acute HIV-infection with diarrhea other infections should be considered, particularly with regard to enteropathogens like Giardia lamblia.

History and Admission Findings: A 39-year-old man complained about a slightly reddish non-itching rash evolving on his body during the last few weeks without any general symptoms. Physical examination revealed trunk-dominated roseola, papules, a few nodules with haemorrhagic crust on top, and round hyperkeratotic clavus-like lesion on the left plantar foot. In his mouth, he had a few up to 1.5 cm large erosions, and on his capillitium a diffuse alopecia., Investigations: Serologic testing for syphilis was positive with Treponema-pallidum-particle-agglutination test at 1:163840, VDRL 1:64, positive IgG-FTA-ABS and 19S-IgM-FTA-ABS tests, and a pleocytosis of the liquor. In addition, there were a co-infection with mycoplasma hominis and first diagnosis of HIV infection (CDC-stadium A1)., Treatment and Course: The patient was diagnosed as having secondary syphilis with suspicion of neurologic involvement and was therefore treated with 6x5 Mio. I.E. Penicillin G i.v. per day for 14 days after the initial application of 40 mg methylprednisolone. Under this regimen complete resolution of the skin lesions was noted over a 4 week period as well as slow re-growth of the hair. HIV infection at stadium A1 did not require antiretroviral treatment., Conclusion: A non-pruritic rash should always point to the differential diagnosis of syphilis. If syphilis is diagnosed, any other sexually transmitted disease including HIV should be excluded as possible co-infection. In case of HIV, neurosyphilis can develop at an earlier stage of common syphilis., (Copyright (c) Georg Thieme Verlag KG Stuttgart--New York.)

Infections with non-tuberculous mycobacteria (NTM) belong to the AIDS-defining illnesses of HIV infection. Severe immunosuppression with CD4+ lymphocyte counts lower than 50 cells/microl is a risk factor for the acquaintance of NTM infections. More than 90% of NTM infections in HIV-seropositive individuals are caused by bacteria of the M. avium complex. The manifestations of the disease are heterogeneous and not specific for the causative mycobacterial species. Furthermore, the differentiation between infection and colonisation can be challenging, especially when NTM are isolated from respiratory specimen. Diagnosis and therapy are recommended according to the guidelines of the American Thoracic Society and the Infectious Diseases Society of America (ATS/IDSA). The treatment success relies on the effects of antiretroviral therapy and a combination of 2 - 4 antimycobacterial antibiotics tailored to the NTM species. In vitro resistance testing often does not predict the clinical response. Interactions with antiretroviral medications are common. The complexity of HIV/NTM co-infection is discussed from an epidemiological, microbiological and clinical perspective., (Georg Thieme Verlag KG Stuttgart, New York.)