title: Is imported onchocerciasis a truly rare entity? Case report and review of the literature.
abstract: BACKGROUND
  Onchocerciasis is endemic in a number of tropical countries in Africa and South America, and it is occasionally diagnosed as an imported disease in non-endemic areas.
  
  
  METHODS
  We describe the case of an African migrant with long-lasting pruritus and a cutaneous nodule who was diagnosed with onchocerciasis after nodulectomy, and review the medical literature regarding imported cases of onchocerciasis in the period 1994-2014.
  
  
  RESULTS
  Twenty-nine cases of onchocerciasis diagnosed in migrants from endemic countries, and in expatriates and travellers from non-endemic areas were retrieved. They were predominantly males (73.3%), had a median age of 37 years (two were aged <15 years), and acquired the diseases in sub-Saharan Africa, most frequently in Cameroon (43.3%). Diagnosis of onchocercosis was proven in 73.3% of patients. The most frequent clinical manifestations in these and our own patient were pruritus (23/30, 76.7%), unilateral leg or forearm swelling (13/30, 43.3%) and rash (12/30, 40.0%), whereas only two (6.9%) complained of eye symptoms. Eosinophilia was observed in almost all of the patients (92.0%), with median counts of 2915/μL among migrants and 1960/μL among travellers/expatriates. Eighteen patients underwent a skin snip biopsy, which was positive in 10 cases (55.5%); in the other 13 patients the parasite was directly demonstrated by means of a skin or nodule biopsy (n = 5), nodulectomy (n = 5) or slit lamp examination (n = 3). Eighteen received ivermectin, alone, and seven ivermectin combined with diethylcarbamazine or doxycycline. Outcome details were available for only 14 patients, all of whom were asymptomatic after a median follow-up of 10 months (range 1-48).
  
  
  CONCLUSIONS
  Onchocerciasis is a neglected tropical disease whose subtle and non-specific features may lead to under-diagnosis or underreporting in non-endemic areas. Physicians should consider this tropical disease when caring for migrants and travellers/expatriates with pruritus, skin lesions and eosinophilia.
authors.affiliation: Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milano, Italy; III Division of Infectious Diseases, Luigi Sacco Hospital, Fatebenefratelli Sacco ASST, Milano, Italy. Electronic address: spinello.antinori@unimi.it.
authors.forename: Spinello
authors.initials: S
authors.lastname: Antinori
authors.affiliation: Pathology Unit, Luigi Sacco Hospital, Fatebenefratelli Sacco ASST, Milano, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Parravicini
authors.affiliation: III Division of Infectious Diseases, Luigi Sacco Hospital, Fatebenefratelli Sacco ASST, Milano, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Galimberti
authors.affiliation: Pathology Unit, Luigi Sacco Hospital, Fatebenefratelli Sacco ASST, Milano, Italy.
authors.forename: Antonella
authors.initials: A
authors.lastname: Tosoni
authors.affiliation: Pathology Unit, Melegnano and Martesana ASST, Vizzolo Predabissi, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Giunta
authors.affiliation: Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milano, Italy; III Division of Infectious Diseases, Luigi Sacco Hospital, Fatebenefratelli Sacco ASST, Milano, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Galli
authors.affiliation: III Division of Infectious Diseases, Luigi Sacco Hospital, Fatebenefratelli Sacco ASST, Milano, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Corbellino
authors.affiliation: III Division of Infectious Diseases, Luigi Sacco Hospital, Fatebenefratelli Sacco ASST, Milano, Italy.
authors.forename: Anna Lisa
authors.initials: AL
authors.lastname: Ridolfo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D054242:Emigrants and Immigrants; D005260:Female; D005869:Ghana; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D009855:Onchocerciasis; D055815:Young Adult
keywords: Immigrants; Imported infections; Onchocerciasis; Pruritus; River blindness; Travellers