A patient transferred from South Africa to Israel acquired a Candida auris infection. Phylogenetic analysis showed resemblance of C. auris to isolates from South Africa but not Israel, suggesting travel-associated infection. C. auris infection occurred weeks later in another patient at the same hospital, suggesting prolonged environmental persistence.

Background Persistent abdominal symptoms (PAS) are the leading cause of post-travel morbidity although there is a paucity of evidence concerning the etiology of this condition. Recently molecular methods for protozoa detection in stool have been introduced. Herein we describe the clinical aspects and the prevalence of gastrointestinal protozoa in returning travelers with PAS. Methods From 2017–2019, clinical information and stool specimens from returning travelers with PAS were analyzed for the presence of parasites using the Allplex-GI-Parasite-assay. Stool findings from symptomatic patients without a travel history were used as a comparator. Results During the two-year study, 203 stool specimens from of travelers were analyzed. The median duration of symptoms before seeking care was 6 months, the most common symptoms were fatigue (79.2%), abdominal pain (75.7%) and loose stool (70.8%). Most of travelers had returned from Asia (57.6%), mainly from the Indian-subcontinent and only 52.6% were backpackers. Altogether, 36.9% samples were positive for protozoa, with Blastocystis hominis being the most common (26.6%) in samples, followed by D. fragilis (18.7%), Giardia lamblia (3.0%) and Cryptosporidium spp (0.5%). The former two were dominant in all regions. All cases of G. lamblia, but one. Were acquired in the Indian subcontinent (OR 16.9; 95% CI: 1.9 to 148.3). Entamoeba histolytica was not detected. The demographic characterization of the 1359 non-travelers was comparable to the travelers. Among them D. fragilis was the most common followed by B. hominis, which was significantly less frequent compared to in the travelers (16.7% vs 26.6%, P < 0.001). Average Ct values for each stool parasites were comparable between the two groups. Conclusion Among returning travelers with PAS, more than one third were positive for gastrointestinal protozoa. A low rate of giardia was found and no E.histolytica while B. hominis followed by D. fragilis were the dominant findings Further studies are required to better understand the role of these protozoa in PAS.

Highlights A 65-year-old Israeli working in Welkait, Ethiopia, not using malaria prophylaxis, developed fever. Malaria RDT was consistent with non-falciparum malaria (plasmodium LDH+/HRP-) but microscopy showed typical P. falciparum. HRP2/3 were negative by PCR. The patient suffered two recrudescence episodes following artemether-lumefantrine and atovaquone-proguanil treatments, and responded to mefloquine treatment.