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Havana Syndrome is used to describe the array of deficits seen in diplomats stationed in Cuba from August 2016 to September 2017.1 Patients from this cohort were clinically studied, investigating their symptoms, audition and vestibular deficits, and imaging abnormalities seen on MRI.1-3 The primary studies were retrospective, looking at how these symptoms could be classified or fit into diagnostic criteria. The cohort had many similarities: a sound at the onset of symptoms, a mix of neurologic and otologic symptoms, and persistent symptoms that lasted for months.1-3 Theories of the cause of Havana Syndrome have led to no conclusive answer. Potential viral etiologies, mass psychogenic illness, and head trauma were examined as causes.1-5 Diseases with established diagnostic criteria were used to compare the patients' symptoms to try to find a disease that fits Havana Syndrome.3 Recent information from the Office of the Director of National Intelligence suggested the most likely cause to be mass psychogenic illness. With the cause of Havana Syndrome still unknown, a review of reported cases and reports helps otolaryngologists understand Havana Syndrome so they diagnose it only when appropriate and do not miss other conditions that may present with similar symptoms and that might respond well to targeted treatment.

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BACKGROUND: ST-elevation myocardial infarction (STEMI) systems of care have reduced inter-hospital transfer times and facilitated timely reperfusion goals. Helicopters may be an option when land transportation is not feasible; however, the safety of air transport in patients with acute coronary syndrome (ACS) is a factor to consider. OBJETIVES: The aim of this study was to evaluate the safety of helicopter transport for patients with ACS. METHODS: Prospective, observational, and descriptive study including patients diagnosed with ACS within the STEMI network of a metropolitan city transferred by helicopter to a large cardiovascular center to undergo percutaneous coronary intervention. The primary outcome of the study was the incidence of air-travel-related complications defined as IV dislodgement, hypoxia, arrhythmia, angina, anxiety, bleeding, and hypothermia. Secondary outcomes included the individual components of the primary outcome. RESULTS: A total of 106 patients were included in the study; the mean age was 54 years and 84.9% were male. The most frequent diagnosis was STEMI after successful fibrinolysis (51.8%), followed by STEMI with failed fibrinolysis (23.7%) and non-reperfused STEMI (9.4%). Five patients (4.7%) developed at least one complication: IV dislodgement (1.8%) and hypoxemia (1.8%) in two patients and an episode of angina during flight (0.9%). A flight altitude of > 10,000 ft was not associated with complications. CONCLUSIONS: The results of this study suggest that helicopter transportation is safe in patients undergoing acute coronary syndrome, despite the altitude of a metropolitan area.

ANTECEDENTES: Los sistemas de atención de IAMCEST han reducido los tiempos de transferencia interhospitalaria y han facilitado las metas de reperfusión oportuna. Los helicópteros pueden ser una opción cuando el transporte terrestre no es factible; sin embargo, la seguridad del transporte aéreo en pacientes con síndrome coronario agudo (SICA) es un factor a considerar. OBJETIVOS: Evaluar la seguridad del transporte en helicóptero para pacientes con SICA. MÉTODOS: Estudio prospectivo, observacional, descriptivo. Se incluyeron pacientes con diagnóstico de SICA dentro de la red IAMCEST en metrópolis extensa, trasladados en helicóptero a un centro cardiovascular. El resultado primario del estudio fue la incidencia de complicaciones relacionadas con los viajes aéreos definidas cómo desalojo de catéter intravenoso, hipoxia, arritmia, angina, ansiedad, sangrado e hipotermia. RESULTADOS: Total de 106 pacientes; la edad media fue de 54 años y 84,9% eran hombres. La altitud media de vuelo fue de 10,100 pies y la distancia media de vuelo fue de 50,0 km. El diagnóstico más frecuente fue IAMCEST tras fibrinolisis exitosa (51,8%), seguido de IAMCEST con fibrinolisis fallida (23,7%). Cinco pacientes (4,7%) desarrollaron una complicación: desalojo IV (1,8%) e hipoxemia (1,8%) en dos pacientes y un episodio de angina durante el vuelo (0,9%). Una altitud de vuelo mayor de 10,000 pies no se asoció a complicaciones. CONCLUSIONES: Los resultados de este estudio sugieren que el transporte en helicóptero es seguro en pacientes con SICA, incluso en altitudes > 10,000 pies.

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BACKGROUND: Chikungunya is an important travel-related disease because of its rapid geographical expansion and potential for prolonged morbidity. Improved understanding of the epidemiology of travel-related chikungunya infections may influence prevention strategies including education and vaccination. METHODS: We analysed data from travellers with confirmed or probable chikungunya reported to GeoSentinel sites from 2005 to 2020. Confirmed chikungunya was defined as a compatible clinical history plus either virus isolation, positive nucleic acid test or seroconversion/rising titre in paired sera. Probable chikungunya was defined as a compatible clinical history with a single positive serology result. RESULTS: 1202 travellers (896 confirmed and 306 probable) with chikungunya were included. The median age was 43 years (range 0-91; interquartile range [IQR]: 31-55); 707 (58.8%) travellers were female. Most infections were acquired in the Caribbean (28.8%), Southeast Asia (22.8%), South Central Asia (14.2%) and South America (14.2%). The highest numbers of chikungunya cases reported to GeoSentinel were in 2014 (28.3%), 2015 (14.3%) and 2019 (11.9%). The most frequent reasons for travel were tourism (n = 592; 49.3%) and visiting friends or relatives (n = 334; 27.7%). The median time to presentation to a GeoSentinel site was 23 days (IQR: 7-52) after symptom onset. In travellers with confirmed chikungunya and no other reported illnesses, the most frequently reported symptoms included musculoskeletal symptoms (98.8%), fever/chills/sweats (68.7%) and dermatologic symptoms (35.5%). Among 917 travellers with information available, 296 (32.3%) had a pretravel consultation. CONCLUSIONS: Chikungunya was acquired by international travellers in almost 100 destinations globally. Vector precautions and vaccination where recommended should be integrated into pretravel visits for travellers going to areas with chikungunya or areas with the potential for transmission. Continued surveillance of travel-related chikungunya may help public health officials and clinicians limit the transmission of this potentially debilitating disease by defining regions where protective measures (e.g. pretravel vaccination) should be strongly considered.

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Currently, mal de débarquement syndrome (MdDS) has been reported only among adults. This case series describes 3 pediatric patients with MdDS. MdDS presentation in children is similar to that of adults, although the frequency of comorbid conditions is greater. Diagnostic delays are common and likely due to under-recognition of MdDS among children.

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INTRODUCTION: Acute febrile illnesses (AFI) are a frequent chief complaint in outpatients. Because the capacity to investigate the causative pathogen of AFIs is limited in low- and middle-income countries, patient management may be suboptimal. Understanding the distribution of causes of AFI can improve patient outcomes. This study aims to describe the most common etiologies diagnosed over a 16-years period in a national reference center for tropical diseases in a large urban center in Rio de Janeiro, Brazil. METHODS: From August 2004-December 2019, 3591 patients > 12 years old, with AFI and/or rash were eligible. Complementary exams for etiological investigation were requested using syndromic classification as a decision guide. Results. Among the 3591 patients included, endemic arboviruses such as chikungunya (21%), dengue (15%) and zika (6%) were the most common laboratory-confirmed diagnosis, together with travel-related malaria (11%). Clinical presumptive diagnosis lacked sensitivity for emerging diseases such as zika (31%). Rickettsia disease and leptospirosis were rarely investigated and an infrequent finding when based purely on clinical features. Respiratory symptoms increased the odds for the diagnostic remaining inconclusive. CONCLUSIONS: Numerous patients did not have a conclusive etiologic diagnosis. Since syndromic classification used for standardization of etiological investigation and presumptive clinical diagnosis had moderate accuracy, it is necessary to incorporate new diagnostic technologies to improve diagnostic accuracy and surveillance capacity.

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Travelers to Chagas disease endemic regions of Latin America may be at risk for Trypanosoma cruzi infection. We report a 67-year-old woman who screened positive for T. cruzi infection while donating blood. The patient had a history of an unusual febrile illness and marked swelling of the face sustained at age 10 after camping in northern Mexico that led to a 3-week hospitalization without a diagnosis. More than 4 decades later, rapid diagnostic tests and commercial and confirmatory serology for Chagas disease were all positive for T. cruzi infection. On evaluation, the patient described a progressive chronic cough, gastroesophageal reflux, and dysphagia for > 10 years. There was no evidence of any cardiac complications. However, esophageal manometry demonstrated significant dysmotility, with 90% of swallows being ineffective with evidence of esophageal pressurization and retrograde peristalsis in several swallows, suggesting early autonomic disruption due to Chagas disease esophagopathy. In this report, we highlight the importance of travel-related Chagas disease among travelers to endemic regions and the need to further identify potential risks of transmission among this at-risk population.

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Increasing numbers of travellers returning from Cuba with dengue virus infection were reported to the GeoSentinel Network from June to September 2022, reflecting an ongoing local outbreak. This report demonstrates the importance of travellers as sentinels of arboviral outbreaks and highlights the need for early identification of travel-related dengue.

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Bed bugs are hematophagous ectoparasites usually found in bedsteads mattresses, and sheets. The bed bug infestations have been increasing dramatically, but only a few cases have been reported in Brazil. We presented a case of a 49-year-old woman with diffuse, extremely itchy skin lesions, after she returned from an international travel.

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Introduction: An increase in interprovincial travel has been registered annually during the last decade on the north and northeast coast of Peru, resulting in the spread of vector-borne diseases such as malaria. Therefore, travelers using interprovincial transport should be informed about the impact of infectious diseases in endemic regions and be aware of the risk of acquiring a travel-related condition. Objective: Examine travelers' malaria-related knowledge, attitudes, and practices. Methods: A cross-sectional study was conducted from January to March 2019 of a random sample of individuals who attended bus stations classed as areas with a higher risk of malaria selected at random in Chiclayo, Peru. The study was conducted reliably through a survey consisting of 29 questions: 18 about knowledge and 11 about attitudes. Results: Of the 250 participants in the study, knowledge was found to be good in 29.13 percent, practices in 14.74 percent, and attitudes in 18.33 percent. People with a higher education degree had a better level of knowledge and attitudes. Also, 60 people were asked about their self-perception of knowledge about malaria and said their knowledge about the subject was adequate. Of the 190 who reported not having enough knowledge about malaria, 49.47 percent were interested in learning about malaria practices and 25.26 percent were interested in learning about treatment. Conclusions: Most of the knowledge, attitudes, and practices of people who travel to endemic areas are not adequate(AU)

Introducción: En la última década se ha registrado un incremento anual de los viajes interprovinciales en la costa norte y noreste de Perú, lo que ha provocado la propagación de enfermedades transmitidas por vectores, como es el caso de la malaria. Es por eso que los usuarios del transporte interprovincial deben estar informados sobre el impacto de las enfermedades infecciosas en las regiones endémicas y sobre el riesgo de adquirir una enfermedad relacionada con los viajes. Objetivo: Examinar los conocimientos, actitudes y prácticas de los viajeros en relación con la malaria. Métodos: En el período comprendido de enero a marzo de 2019, se realizó un estudio transversal de una muestra aleatoria de personas que visitaban estaciones de ómnibus clasificadas como áreas de alto riesgo de malaria, seleccionadas aleatoriamente en Chiclayo, Perú. El estudio se llevó a cabo mediante un procedimiento confiable basado en una encuesta de 29 preguntas: 18 sobre conocimientos y 11 sobre actitudes. Resultados: De los 250 participantes en el estudio, 29,13 por ciento mostraron buen dominio de los conocimientos, 14,74 por ciento de las prácticas y 18,33 por ciento de las actitudes. Los graduados de la educación superior tenían un mejor nivel de conocimientos y actitudes. Además, a 60 personas se les preguntó sobre la percepción que tenían acerca de sus propios conocimientos sobre la malaria, y respondieron que estos eran apropiados. De los 190 que declararon no tener suficientes conocimientos sobre la malaria, 49,47 por ciento mostraron interés en aprender sobre prácticas relacionadas con la enfermedad y 25,26 por ciento sobre el tratamiento de la misma. Conclusiones: La mayor parte de los conocimientos, actitudes y prácticas de las personas que viajan en regiones endémicas no es adecuada(AU)

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La diarrea del viajero (DV) es la complejidad más común y su repercusión varía en función de muchas variables: edad, lugar de destino, estación del año, tipo de residencia, origen del viajero y, por supuesto, la dieta durante el viaje, en definición es la emisión de heces sueltas tres o más veces al día, se adquiere mayormente al consumir alimentos y bebidas contaminados con patógenos que ocasionen diarrea. A nivel mundial, las causas más comunes de DV son dos patotipos de Escherichia coli (enterotoxigénica y enteroagregativa) y Campylobacter, aunque existen variaciones significativas según el área geográfica visitada. Algunos autores han detectado la presencia de diarrea en más de la mitad de los viajeros a países en vías de desarrollo. Se realizó un estudio descriptivo de corte transversal en 15 hospitales centinelas de la zona 9 del Sistema de Vigilancia de la resistencia antimicrobiana, en la provincia de Pichincha Quito, Ecuador entre enero 2019 a enero 2020, con el objeto de caracterizar los eventos de DV. 517 registros, solo en 298 se asento la procedencia, pudiendo atribuirse a ese 42,34% la procedencia por nacionalidad, se estimó que 108 casos presentaron infección mixta de al menos una bacteria y otro tipo de agresor, lo que representa 36,24%, siendo el agente causal principalmente involucrado ETEC, seguida de E. coli H7:O157 (N=60)(AU)

Traveler's diarrhea (DV) is the most common complexity and its impact varies depending on many variables: age, place of destination, season of the year, type of residence, origin of the traveler and, of course, the diet during the trip, In definition, it is the emission of loose stools three or more times a day, it is acquired mostly by consuming food and beverages contaminated with pathogens that cause diarrhea. Worldwide, the most common causes of DV are two Escherichia coli pathotypes (enterotoxigenic and enteroaggregative) and Campylobacter, although there are significant variations depending on the geographic area visited. Some authors have detected the presence of diarrhea in more than half of the travelers to developing countries. A descriptive cross-sectional study was carried out in 15 sentinel hospitals in zone 9 of the Antimicrobial Resistance Surveillance System, in the province of Pichincha Quito, Ecuador between January 2019 and January 2020, in order to characterize VD events. 517 records, only in 298 the origin was established, and that 42.34% can be attributed the origin by nationality, it was estimated that 108 cases presented mixed infection of at least one bacterium and another type of aggressor, which represents 36.24% , the causative agent being mainly involved ETEC, followed by E. coli H7: O157 (N = 60). Likewise, ETEC is responsible for the greatest severity in clinical pictures, being responsible for 50.00% of the cases in this category(AU)

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