Clinicalparasitology 100410005437 Phpapp02 2

8/17/2019 Clinicalparasitology 100410005437 Phpapp02 2

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Parasitic Infections:Clinical Manifestations,

Diagnosis and Treatment

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The Reality

• 1.3 billion persons infected with1.3 billion persons infected with Ascaris (1: 4 persons on earth) Ascaris (1: 4 persons on earth)

• 300 million with schistosomiasis300 million with schistosomiasis

• 100 million new malaria cases/yr 100 million new malaria cases/yr

• At U!A" 3#$ of pediatric and At U!A" 3#$ of pediatric and

dental clinic children harboreddental clinic children harboredintestinal parasitesintestinal parasites



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ase1• 4%&yr&old pre'iosly healthy" U professor

• *&wee+ history of intermittent diarrhea" flatsand abdominal cramps

• ,iarrhea: -#/day pale no blood or mcs

• o tenesms• llness bean slowly drin campin trip to

olorado with loose stools

• 2pontaneosly remission for &* days at atime" then recr



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ase 1

• is #&yr&old son had had a mildcorse of watery diarrhea5ascribed

to 'iral astroenteritis by eneral

practitioner

• 2tool smear5no ps cells

• owe'er" wet preps showed6



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,ianosis7



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Giardiasis (G. lamblia)

• 2hold be sspected in proloned diarrhea• ontaminated water often implicated5otbrea+s

• ampers who fail to sterili8e montainstream water

• 9erson&person in day care centers

• 2• 2ymptoms sally resol'e spontaneosly in

4&* wee+s



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Giardiasis

Tests of choice

• ;-amination of concentrated stools forcysts (


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Case 2

• 40 y/o male 'icar retrned from % years ofmissionary wor+ in 2oth Africa

• ;-cellent health throhot stay there• 3 months after retrnin to U.2.

=2ddenly ill with abdominal distension =e'er =9erimbilical pain =@omitin =lood&tined diarrheal stools

• ,enied arthritis /+nown e-posre to parasites• amily history of Binflammatory bowel

diseaseC www.freelivedoctor.com


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Case 2

• 9hysical e-amination: = Actely ill =,istended abdomen

=o hepatomealy or splenomealy =,ecreased bowel sonds =2tool e-am

Dross blood presento ps cellseati'e for EF9" one neati'e F2



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Sigmoidoscoy re!ealed"

• ltiple pnctate bleedin sitesat ? to 1 cm with normal

appearin mcosa between sites• >his mcosa easily dendedwhen pressre applied to it"

lea'in lare areas of bleedinsbmcosa



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ase %

• ,ianosed with lcerati'e colitis

• 2tarted on corticosteroids

• >emperatre rose to 40G• Abdomen distension increased and

worsenin of symptoms

• ;merency laparotomy for to-icmeacolon



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,ianosis7



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Entamoeba histolytica

• Ene of ? amoebae commonly fond in hmans• Enly one that cases sinificant disease• ases intestinal (diarrhea and dysentery) and

e-traintestinal (li'er primarily) disease

• n U2 = nstittionali8ed patients =2

=>orists retrnin from de'elopin contries =9atients with depressed cell mediated

immnity



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Troho#oites $ith ingested R%C



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Troho#oites in colon tiss&e (' stain)



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Cyst ($et mo&nt)



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*moe+iasis: Clinical Manifestations

• 2ymptoms depend on deree of bowelin'asion

=2perficial: watery diarrhea and

nonspecific D complaints =n'asi'e: radal onset (1&3 wee+s) of

abdominal pain" bloody diarrhea"

tenesms

• e'er is seen in minority of patients



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*moe+iasis: Clinical Manifestations

• an be mista+en for lcerati'e colitis

• 2teroids can dramatically worsen andprecipitate to-ic meacolon

• Amebic li'er abscesses

=HUI pain" pain referred to riht sholder

=ih fe'er

=epatomealy (0$)



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*moe+ic a+scess

remem+er"

• an occr in ln" brain" spleen



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Amoebic Abscess

• !iJefaction of li'er cells

• ,o not contain ps

• Ancho'y paste sace

• ltre of contents sally sterile

•!i'er affected:

=3$&riht lobe

= #$&left lobe



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Remem+er"

• >hat stool is merely a con'enient'ehicle passin by

• Amoebae li'e the bowel wall• ,irect obser'ation preferable to mere

e-amination of stool

• >ropho8oites best seen in directscrapins of lcers



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*moe+iasis

Treatment

• ost respond to metronida8ole• Epen srical drainae shold bea'oided" if at all possible



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ase 3

• 9re'iosly healthy 3&year&old irl

• Attends day&care center

• ? day history of watery diarrhea

• asea

•@omitin

• Abdominal cramps

• !ow&rade fe'erwww.freelivedoctor.com


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ase 4

• 34 year&old A,2 patient

• ,ebilitatin" cholera&li+e diarrhea

• 2e'ere abdominal cramps• alaise

• !ow&rade fe'er

• Keiht loss• Anore-ia



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http://www.emedicine.com/med/images/Large/1070Med00484-01.jpg


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,ianosis7

ase 3 F 4



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>hree cysts stained pale red are seen in the center

with this acid fast stain




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odified acid&fast stain of stool showin red oocysts of

Cryptosporidium parvum aainst the ble bac+rond of

coliforms and debris www.freelivedoctor.com



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Cryptosporidium parvum

• ases secretory diarrhea: 10 liter/day

• 2inificant case of death in @/A,2

• Animal reser'oirs

• ncbation period: &10 days


C idi


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Cryptosporidium parvum

• nfants F yon children in day&care

• Unfiltered or ntreated drin+in water• armin practices: lambin" cal'in" and

mc+&spreadin

•2e-al practices: oral contact with stool of aninfected indi'idal

• osocomial settin with other infectedpatients or health&care employees

• @eterinarians: contact with farm animals• >ra'elers to areas with ntreated water• !i'in in densely poplated rban areas• Ewners of infected hosehold pets (rare)



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,ianosis and >reatment

• est dianosed by stool e-am

•o +nown effecti'e treatment

• ita8o-amide shortens dration ofdiarrhea



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Case -

• r. F rs. H. were sailin with their 3children in Lamaica

• !i'in primarily on the boat with se'eral daytrips to a small coastal island

• En island" ate se'eral types of tropical frit

• oth became sddenly ill with fe'ers" chills"mscle aches" and loss of appetite.

• 2oht treatment locally" and weredianosed with hepatitis" li+ely de to

inestion of to-ic frit



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Case -

• >wo days later" r. H. became Mandiced and passed dar+ rine

• e proressi'ely worsened" becamecomatose and died

• n the meantime" rs. H. wastransferred to 2U for li'er transplant



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Case -

• one of the children were sic+ despiteha'in eaten the same frits and other

foods.

• >he family had ta+en chloroJineprophyla-is aainst malaria" bt the

parents stopped the medicine % wee+s

prior to becomin ill becase of side

effects.



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.alciar&m !s/ 0i!a1

• !ocation: alciparm confined totropics and sbtropics 'i'a- more

temperate• alciparm infects H of any ae

others li+e reticlocytes

• alciparm&infected Hs stic+ to'asclar endothelim casin

capillary bloc+aewww.freelivedoctor.com


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Malaria: Genetic s&sceti+ility

• >wo enetic traits associated withdecreased ssceptibility to malaria

• Absence of ,ffy blood rop antienbloc+s in'asion of Plasmodium vivax

=2inificant nmber of Africans

• 9ersons with sic+le cell hemolobin areresistant to P. falciparum

• 2ic+le cell disease and trait



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Malaria: Clinical manifestations• on&specific" fl&li+e illness

• ncbation = P. falciparum:


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Malaria: Clinical manifestations

• ebrile paro-ysms ha'e 3 classic staes = old stae9t feels cold and has sha+in chills1&*0 mins. prior to fe'er

= ot stae

3achycardia" hypotension" coh" A" bac+ pain"

/@" diarrhea" abdo pain" altered consciosness

= 2weatin stae

ar+ed diaphoresis followed by resoltion offe'er" profond fatie" and sleepiness%&* hors after onset of hot stae



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• Ether symptoms depend on malaria strain• P. vivax, ovale and malariae: few other s-s• P. falciparum:

= ,ependent pon host immne stats

= o prior immnity/splenectomy hih le'elsof parasitemia profond hemolysis

= @asclar obstrction and hypo-iaNidneys: renal failre

rain: (2) O hypo-ia" coma" sei8res

!ns: plmonary edema

= Landice F hemolobinria (blac+water fe'er)



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• Always sspect malaria in tra'elersfrom de'elopin contries who

present with:

=nflen8a&li+e illness

=Landice

=onfsion or obtndation



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,ianosis

• Diemsa&stained blood smear

=>hic+ and thin smears

• P. falciparum: =est Mst after fe'er pea+

• Ethers:

=2mears can be performed at any time

• ;-amine blood on 3&4 sccessi'e days



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Differences in strains

• P. falciparum

=o dormant phase in li'er

=ltiple sinet rin trophs per cell =ih percentae (P$) parasiti8ed

Hs considered se'ere



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• P. vivax and ovale

=,ormant li'er phase

=2inle sinet rin trophs per cell =2chffnerQs dots in cytoplasm

=!ow percent (R $) of parasiti8edHs



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• P. malariae =o dormant stae

=2inle sinet rin trophs per cell =@ery low parasitemia



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Treatment

• P. falciparum malaria can be fatal if notpromptly dianosed and treated

• on& P. falciparum malaria rarelyreJires hospitali8ation

• Kidespread dr resistance dictatesreimen (www.cdc.o'/tra'el ,

malaria hot line: ??0&4##&??##).www.freelivedoctor.com

>reatment

http://www.cdc.gov/travelhttp://www.cdc.gov/travel


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>reatment

Uncomplicated malaria

• P. vivax, ovale, malariae, chloroJine&ssceptible falciparum

=hloroJine =9rimaJine for dormant li'er forms

• hloroJine&resistant falciparum =Iinine pls do-ycycline

=efloJine = Ato'aJone pls proanil (A9) = Artemisins (common in 2; Asia de to

mlti&dr resistance)www.freelivedoctor.com


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>reatment

2e'ere malaria• ,r options

=Iinidine lconate5onlyappro'ed parenteral aent in U2

= Artemisin



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Pre!ention

• efloJine• ,o-ycycline• ets

• 30&3$ ,;;>

• 9ermethrin spray for clothin and nets



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And donQt foret baae

malariaS



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ase

• rs. H. was treated with @ Jinidineand impro'ed rapidly.

• n retrospect" r. H. had died fromntreated blac+water fe'er

=ew parasites in peripheral blood

= Acte renal failre


ase *


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ase *

• A %4&year&old white male army officer

• Heferred to the @A , clinic with a 3&monthhistory of a lesion on his riht le"

de'elopin appro-imately % wee+s after

retrnin from raJ

• Hecent tra'el history: 1 month in Nwait and% months tra'elin between Nwait and raJ

• Hecalled bein bitten nmeros times bysmall flyin insects and other nasty BbsC



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ase *

9hysical e-amination essentially normal

e-cept for:

• on&tender (%0 T 1 mm) scalyerythematos plaJe with a moist

central erosion of the left popliteal area.

• >here was no lymphadenopathy and nomcosal lesions were noted



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,ianosis7



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* i t t h ti ll fill d ith


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*n intact macrohage ractically filled $ith

amastigotes (arro$s),


! i h i i


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!eishmaniasis

• >ropical areas where phlebotominesandfly is common: 2oth America"

ndia" anladesh" iddle ;ast" ;ast

Africa

• 2andfly introdces flaellatedpromastiote into hman inested

by macrophaes de'elops into

nonflaellated amastiote


eishmaniasis


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eishmaniasis

• taneos

=ost common amon farmers" settlers"troops and torists in id ;ast (L. major

and tropica), entral and 2oth America

(L. mexicana, brailiensis, amaonensis,and panamensis)

=L. mexicana reported in >e-as

• @isceral (+ala a8ar) = Anemia" le+openia" thrombocytopenia"hyperammaloblinemia common



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eishmaniasis: Diagnosis

• iopsy and Diemsa stain with amastiotes

• 2pecies most pre'alent in different places• L. donovani = ndia• L. infantum = id ;ast• L. c!a"asi = !atin America

• L. amaonensis && ra8il


0i l i h i i


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0isceral eishmaniasis

• ,issemination of amastiotesthrohot the reticlendothelial systemof the body

=2pleen

=one marrow

=!ymph nodes

• Epportnistic infection in A,2 patients• neffecti'e hmeral response



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epatosplenomealy



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Slenic asirate

• ost satisfactory method• 2pleen mst be at least 3cm below

!

• Aspirate stained with Diemsa


i h i i t t t


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eishmaniasis: treatment

• Enly dr appro'ed in U2 is Amphotericin

• >reatment of ctaneos disease

depends on anatomic location• any spontaneosly heal and do not

reJire treatment



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Hemember..

• >he factors determinin the form ofleishmaniasis:

=!eishmanial species =Deoraphic location

=mmne response of the host


Case 3


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Case 3

• 3#&year&old bsinessman

• 9re'iosly fit

• %&wee+ history of fe'er since retrnin fromra8il bsiness trip

• l&li+e symptoms and myalia• ad consmed stea+ tartare in ra8il

• Heslts all nremar+able&&&normal K and;2H neati'e smears H and rine EN

• ontined to ha'e fe'er" tachycardia andmyalia



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ase #

• A %


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ases ? F #

Khat parasite cold

case this pictre7


*IDS Patient


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*IDS Patient


*IDS Patient


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*IDS Patient


Toxoplasma gondii cyst in +rain


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Toxoplasma gondii cyst in +rain

tiss&e $ith ' stain (4551)



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or the bsinessman6

• #oxoplasma seroloy was positi'e ata 'ery hih titer

• Hesponded to treatment withslphonamide W pyrimethamine

• o relapse



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>ransmission

• ;atin oocysts e-creted by catsharborin se-al staes of parasite

• Etbrea+s traced to inadeJatelycoo+ed meat of herbi'ores (raw beef)

• tton


# l dii


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#oxoplasma "ondii • Korldwide distribtion• man infection

= nestion of cysts in ndercoo+ed meat ofherbi'ores

= Kater/food contaminated with oocysts = onenitally = nfected orans" blood (less common)

• 9re'alence of latent infection in U2 abot 10$

rance abot ?$ = Denerally hiher in less&de'eloped world = 0$ in A,2 patients p to


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p g

Imm&nocometent hosts

• !atent infection (persistence of cysts)is enerally asymptomatic

• er'ical lymphadenopathy (10&%0$)• ono&li+e presentation (R1$ of all

mono&li+e illnesses)

• horioretinitis• @ery rare: myocarditis" myositis


Toxoplasma gondii:


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g

Imm&nocomromised hosts

• Eften life&threatenin• Almost always reacti'ation of latent infection• A,2

= ;ncephalitis most common manifestation = Usally sbacte onset/focal (if ,4R %00) = ental stats chanes" sei8res" wea+ness"

cranial ner'e abnormalities" cerebellar sins"

= an present as acte hemiparesis/lanaedeficit

= Usally mltiple rin&enhancin lesions on>/H• 9nemonitis• horioretinitis


# l dii


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#oxoplasma "ondii:

linical manifestations• mmnocompromised hosts

=on&A,2 (transplants" hematoloic

malinancies)2 ?$

yocardial 40$

9lmonary %$


Toxoplasma gondii:


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Toxoplasma gondii:

Clinical manifestations

• onenital• Acte infection asymptomatic in mother • linical manifestations rane: no seJelae to

seJelae that de'elop at 'arios times after

birth =horioretinitis =2trabisms

=lindness =;pilepsy" mental retardation" pnemonitis"microcephaly" hydrocephals" spontaneosabortion" stillbirth


Toxoplasma gondii: diagnosis


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Toxoplasma gondii: diagnosis

• linical sspicion crcial• 2eroloy is primary method of dianosis

=" D

• istopatholoy =>achy8oites in tisse sections or body

flid (difficlt to stain)

=ltiple cysts near necrotic"inflammatory lesions



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#oxoplasma "ondii: >reatment

• mmnocompetent adlts are sallynot treated nless 'isceral disease is

o'ert or symptoms are se'ere and

persistent• mmnodeficient patients

=!atent disease: not treated

= Acti'e disease: pyrimethamine Wslfadia8one W folinic acid



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#oxoplasma "ondii: >reatment

• onenital: =>reatment of acte infected prenant

women decreases bt does not eliminate

transmission2piramycin

=f fetal infection is docmented" treat with

pyrimethamine W slfadia8one W folinic acid =9ostnatal treatment: pyrimethamine W

slfadia8one W folinic acid



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ase %%

• %&year&old acasian woman presentedwith 1&wee+ history of fe'er" chills" sweatin"

myalias" fatie

• o tra'el abroad• ad one cranberry pic+in inassachsetts appro- 3 wee+s earlier

• 9;: anemic" hepatosplenomealy

• lood wor+p: hemolytic anemia" redcedplatelets



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>hic+ smear


>hi


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>hin smear

Maltese cross



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,ianosis77



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abesiosis

• abesiosis cased byhemoproto8oan parasites of the

ens $abesia• %100 species reported

• ew actally case hmaninfection


abesiosis


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abesiosis

• $abesia microti

• !ife cycle in'ol'es two hosts:

=,eer tic+" &xodes dammini, (definiti'ehost) introdces sporo8oites into

white&footed mose

• Ence inested by an appropriate tic+ametes nite and ndero a sporoonic

cycle resltin in sporo8oites• mans enter cycle when bitten by

infected tic+swww.freelivedoctor.com


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abesiosis

,eer are the hosts pon which the

adlt tic+s feed and are indirectly part

of the $abesia cycle as they inflencethe tic+ poplation



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abesiosis

• lindamycinX pls Jinine

• Ato'aJoneX pls a8ithromycinX

• ;-chane transfsion in se'erely illpatients with hih parasitemia

X Appro'ed by ,A


Case 6


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Case 6• *&year&old son of seasonal farm

wor+er

• 9resents with coh and fe'er"whee8e

• H re'eals a lobar pnemonia• Admitted for initial therapy• After % days of antibiotics" with ood

defer'escence" a worm is fond in hisbed

• 2tool e-am re'eals 6www.freelivedoctor.com


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,ianosis7


Ascaris lumbricoides


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• n D tract" few symptoms in liht infections =asea =@omitin

=Ebstrction of small bowel or commonbile dct.• 9lmonary: symptoms de to miration

= Al'eoli ('erminos pnemonia)5coh"fe'er whee8e" dyspnea" &ray chanes"eosinophilia


ff t f *d lt A i 7


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ffects of *d&lt Ascaris 7orms

• ,epends on worm load• ;ffects

=echanical: obstrction" 'ol'ls"

intsssception" appendicitis"obstrcti'e Mandice" li'erabscesses" pancreatitis" asphy-ia

• >o-ic and etabolic =alntrition (comple-)



Di i


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Diagnosis

• haracteristic es on direct smeare-amination

• f treatin mi-ed infections" treat Ascaris first

=ebenda8ole

=9yrantel• ontrol:

=9eriodic mass treatment of children"health edcation" en'ironmentalsanitation



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ase 10

• 11&year&old female• ,oin poorly in school

• ot sleepin well• Anorectic• omplains of itchin in rectal reion

throhot the day• A 2cotch&tape test re'eals6



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,ianosis7


ntero+i&s (Pin$orm)


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• 1# million infections in U.2.

• ncidence hiher in whites• 9reschool and elementary school most often• ostly asymptomatic• octrnal anal prritis cardinal featre de to

miration and es

• ay ha'e insomnia" possible emotionalsymptoms

•,2&es or adlts on perinem Yscotch tapeZ

• ebenda8ole 100 m. Hepeat in % wee+s.9yrantel pamoate 11 m/+ repeat % wee+s


Case 44


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• *


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8n the day of admission"

• e'er" confsion" and not able to et otof bed&&&transported to the hospital

• nitial blood wor+:

=;le'ated K =Haised eosinophil cont 4 times

normal

• Underwent UD endoscopy• ,odenal biopsy obtained



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,ianosis


Strongyloides: Cr&cial *sects


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of ife Cycle

• nfection acJired throh penetrationof intact s+in

• nfection may persist for many years 'iaatoinfection

• n immnocompromised patients" thereis ris+ of dissemination or hyperinfection

=yperinfection syndrome



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Disseminated Strongyloidiasis

• ih mortality?$

• 9enetration of t wall by infecti'e lar'ae

• Dt oranisms carried on the srface oflar'ae reslts in polymicrobial sepsis"

meninitis

• !ar'ae disseminate into all parts of body:2" lns" bladder" peritonem


S&mmaryClinical .indings


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S&mmary Clinical .indings

• ,efecti'e cell&meditated immnity:steroids" brns" lymphomas" A,2 (7)

• Dl symptoms in abot two&thirds:

= Abdominal pain

=loatin

=,iarrhea =onstipation

• Khee8in" 2E" hemoptysiswww.freelivedoctor.com

S&mmaryClinical .indings


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S&mmary Clinical .indings• 2+in rash or prritis in [ one&third

=!ar'a crrens (racin lar'a)

=ntensely prritic

=!inear or serpiinos rticariawith flare that mo'es &1 cm/hr

=Usally bttoc+s" roin" and trn+

=n dissemination" diffsepetechiae and prpra


S Cli i l .i di


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S&mmary9Clinical .indings

• ;osinophilia *0&


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ase 1%

• ? year old farmer from ,i-ie onty

• 9resents with profond 2E

• 9hysical e-amination: anemic otherwisenremar+able

• !aboratory e-amination re'eals a profondanemia (hct %4) with aniso and poi+ilocytosis

• Hemainder of laboratory e-amination normal.



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,ianosis7



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'oo$orm


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'oo$orm

• ased by two different species (orth American and Eld Korld)• @ery similar to stronyloides in life cycle• Attaches to dodenm" feeds on blood• ;laborates anticoalant" attaches and

reattaches many times

• !oss of arond 0.1 ml/d of blood perworm



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• ebanda8ol

• 9yrantel pamoate


ase 13


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• #&yr&old schoolirl 'isitin the U.2. fromalaysia

• 1 wee+ history of epiastric pain"flatlence" anore-ia" bloody diarrhea

• o eosinophilia noted• linical dianosis of amoebic dysentery

made

• owe'er" microscopy of stool prep6



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,ianosis7


Trichuris trichiura (7hi$orm)


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• ommon in 2otheast U.2.• reJently coe-ists with ascaris• ;ntirely intralminal life cycle5es are

inested

• reJently asymptomatic• 2e'ere infections: diarrhea" abdominal

pain and tenesms

• Hectal prolapse in children• ,2&es in stool• ebenda8ole 100 m bid - 3 days



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ase 14


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• 1#&year&old trailer par+ handyman seenin ;H

• Kor+ed nder trailers wearin shorts

and no shirt• ,e'eloped intensely prritic s+in rash• Unable to sleep

• K 1#"000• *$ eosinophils.



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ase 1


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ase 1

• An # year old boy• 9resents with s+in lesions and itchin

after spendin the smmer at a beach

condo in 2t. Astine with his family(mother" father" yoner sister" do andcat).

• !es show se'eral raised" reddened"serpiinos lesions that are intenselyprritic.



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,ianosis 7


taneos !ar'a irans


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• ased by filariform lar'ae of do or cat

hoo+worm ( 'ncylostoma brailiense or 'ncylostoma duodenale

• ommon in 2otheast U.2.• Hed paple at entry with serpiinos tnnel

• ntense prritis• 2elf limitin condition• ,ianosis clinical• >opical or oral thiabenda8ole % m/+ bid for 3&

days• ay se ethyl chloride topically


C&taneo&s lar!a migrans

(creeing er&tion)


144/200

(creeing er&tion)

• ore common in children =!ar'ae penetrate s+in and case

tinlin followed by intense itchin.

• ;s shed from do and cat bowelsde'elop into infectios lar'ae otside the

body in places protected from desiccation

and e-tremes of temperatre

• 2hady" sandy areas nder hoses" atbeach" etc.


taneos lar'a mirans


145/200

(creepin erption)

Usally not associated with

systemic symptoms


taneos lar'a mirans

(creepin erption)


146/200

(creepin erption)

• ,ianosis and treatment• 2+in lesions are readily reconi8ed

• Usally dianosed clinically

• Denerally do not reJire biopsy =He'eal eosinophilia inflammatory infiltrate

=iratin parasite is enerally not seen

•2tool smear will re'eal es



147/200



148/200


0isceral ar!a Migrans


149/200

• nfection with do or cat rond worms• #oxocara canis #oxocara catis• Underdianosed based on seropre'alence

sr'eys

• ea'y infections associated with fe'er" coh"nasea" 'omitin" hepatomealy" andeosinophilia

• Uncommon in adlts

• Eclar type more common in adlts• ,ianosis&;!2A• >hiabenda8ole: % m/+ bid days


ase 1?

• A 34 yr old woman from 2adi Arabia


150/200

• A 34 yr&old woman from 2adi Arabia

• Hadiation and cyclophosphamide" adriamycin"'incristine and prednisone for diffse lare celllymphoma of the nec+.

• ild eosinophilia (A;V00) at the time of

dianosis• 4 months after initiation of chemo" c/o intermittent

diffse abdominal pain" bloatin" constipation and

occasional rectal bleedin.

• Absolte eosinophil cont: 1000


ase 1?


151/200

ase 1?

• o e'idence of lymphoma fond on re&stain

• ompleted chemo" was deemed to be in

complete remission" bt had persistence ofD complaints.

• Upper endoscopy was nre'ealin.

• olonoscopy and biopsy re'ealedranlomatos inflammation" prominent

eosinophilic infiltrate" srrondin a collection

of es.www.freelivedoctor.com


152/200



153/200

Chronic intestinal schistosomiasiswww.freelivedoctor.com

ase 1?


154/200

ase 1?

• >he patient was treated withpra8iJantel and did not ha'e

relapse of symptoms at %&yearfollow&p

• A;V%0


2chistosomiasis: ;pidemioloy

f


155/200

and life cycle

• ercariae in fresh water penetrate hmans+in.

• ercariae matre to schistosomlae" whichenter the bloodstream" li'er and ln.

• atre worms mirate to the 'enossystem of the small intestine (. japonicum)" lare intestine (. mansoni ) orbladder 'enos ple-s (. !aematobium).


2chistosomiasis: ;pidemioloy

d lif l


156/200

and life cycle

• Korms release es for many years into stool orrine" resltin in fresh water contamination.

• reshwater snails are infected by miracidia and arenecessary for the prodction of cercariae and

hman infection.• . mansoni

= 2oth America" aribbean" Africa" id ;ast• . japonicum

= hina and 9hilippines• . !aematobium

= Africa" id ;ast


2chistosomiasis: linical manifestations


157/200

• >hree staes of disease" correspondin to life

cycle within hman hosts• 2wimmerQs itch

= Kithin %4 hors of cercariae penetration• 2erm sic+ness syndrome (Natayama fe'er)

= 4 to # wee+s later when worms matre andrelease es

e'er" headache" coh" chills" sweatin"lymphadenopathy" hepatosplenomealy

sally resol'es spontaneosly;le'ated ; and eosinophils

ost common with . japonicumwww.freelivedoctor.com

hronic 2chistosomiasis

• Dranlomatos reaction to e deposition in


158/200

Dranlomatos reaction to e deposition in

intestine" li'er" bladder" lns

• . mansoni, japonicum

= hronic diarrhea" abdominal pain" blood loss"portal hypertension" hepatosplenomealy"

plmonary hypertension

= ;osinophilia is common

= !i'er fnction tests are sally normal

• . *aematobium

= ematria" bladder obstrction" hydronephrosis"recrrent U>s" bladder cancer


2chistosomiasis:

,i i d > t t


159/200

,ianosis and >reatment

• ,etection of characteristic es in stool" rineor tisse biopsy is dianostic

=Urine is best between 1% and %9m"passed throh 10 \m filter to concentratees

• Antibody tests are a'ailable" bt limited by

sensiti'ity" specificity• 9ra8iJantel is the dr of choice



160/200



161/200

S. mansoni

Stool

S. haematobium

;rine

S. japonicum


Case 4<

• 1&yr&old irl


162/200

• e'er" rash" swellin arond the eye and hands"se'ere headaches

• atie" achin mscles and Moints• 2wollen lymph nodes on the bac+ of nec+• Keiht loss

• 9roressi'e confsion" personality chanes• 2leepin for lon periods of the day• nsomnia• ad been on a safari with parents to Kest Africa

• ,s+y red lesion de'eloped within 1 wee+• @aely remembered bein bitten by a fly



163/200

,ianosis7


n'estiations


164/200

n'estiations

• lood films

• !mbar pnctre


lood smear


165/200



166/200

African trypanosomiasis

#rypanosoma brucei "ambiense


>setse fly


167/200


>reatment


168/200

• 2ramin

• elasoprol


ase 1<

* ld b tl i d f il


169/200

• *&yr&old boy recently arri'ed from ra8il

• 2wellin arond the eye

• onMncti'itis

•e'er

• ;nlared lymph nodes

• epatosplenomealy

• ad stayed in a hotel5adobe style withthatched roof



170/200



171/200

,ianosis7


lood smear


172/200


Hed'iid b

(assassin b)


173/200

(assassin b)


Chagas disease:



174/200


• !ocal edema is followed by fe'er" malaise"anore-ia

=ore rarely: myocarditis" encephalitis

• ]ears later: chronic haas ,isease (10&30$) =eart: primary taret

ardiomyopathy associated with "

emboli" arrythmias =D tract: mea&esophas" meacolon


haas disease: ,ianosis

and treatment


175/200

and treatment

• Acte disease is dianosed by seeintrypomastiotes on peripheral bloodsmear

• hronic disease is dianosed by;!2A detectin D antibody to #.crui

• >reatment slows the proression ofheart disease


haas ,isease

• 9blic health implications in the U2


176/200

• 9blic health implications in the U2

• hronic =ardiomyopathy =eaesophas

=eacolon• lood transfsion• >ransplant

=2olid oran =sclos+eletal alloraft tisse


ase %0


177/200

• %0&yr&old male• Abdominal pain and nasea for se'eral months• ore common in the mornin

• Helie'ed by eatin small amonts of food• 2ome diarrhea and irritability• Keiht loss

• 9rrits ani• 9assae of white BbitsC



178/200



179/200

,ianosis7


#aenia sa"inata


180/200

• nestion of raw or poorly coo+ed beef • ows infected 'ia the inestion of hmanwaste containin the es of the parasite

• ows contain 'iable cysticercs lar'ae in

the mscle• mans act as the host only to the adlt

tapeworms

• Up to % meters in the lmen of intestine• ond all o'er the world" incldin the U.2.


%eef Tae$orm


181/200


>reatment


182/200

• 9ra8iJantel

• Albenda8ole

• iclosamide


>apeworms (estodes)

• Adlt worms inhabit D tract of definiti'e 'ertebrate host


183/200

Adlt worms inhabit D tract of definiti'e 'ertebrate host

• !ar'ae inhabit tisses of intermediate host• mans

= ,efiniti'e for #. sa"inata

= ntermediate for +c!inococcus "ranulosus (hydatid)

= oth definiti'e and intermediate for #. solium• Adlt worms shed e&containin sements in stool

inested by intermediate host lar'al form in tisses


ase %1

• A 33 year old ndian man was admitted


184/200

• A 33 year&old ndian man was admittedwith a rand mal sei8re

• % yrs 9>A" he had 'ertio and > re'ealedan enhancin calcified lesion in left

temporal&parietal reion• -: rother had rand mal sei8re

se'eral years earlier

• >hrohot his life" he has eaten a diethea'y in por+


ase %1


185/200

• ,ifficlty spea+in and loss of consciosnesswhile on the phone

• o&wor+ers noticed enerali8ed tonic&clonicsei8res lastin 10 mintes.

• > re'ealed new locali8ed edema arond thepre'iosly identified lesion and a second

contios rin enhancin lesion.

• e recei'ed phenytoin (,ilantin" an antisei8remed) and days of corticosteroids.


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186/200


ase %1

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187/200

• ;!2A titer was positi'e for antibodiesaainst #aenia solium.

• >he nerosreons tell yo thatresection is impossible becase of thee-tent and location of the lesion


ystercercosis

i f t d ith th l l t f # i


188/200

• man infected with the lar'al stae of #aeniasolium

• mans can ser'e as definiti'e or intermediatehost

• ;s are inested" or possibly et to stomach byre'erse peristalsis

• 9robably mch more common than is reported"since most infections are asymptomatic


ystercercosis


189/200

• 2ymptoms depend on location of cysts" btfreJently inclde motor spasms" sei8res"

confsion" irritability" and personality chane

• n the eye" often sbretinal or in 'itreos.o'ement may be seen by the patient. 9ain"

amarosis" and loss of 'ision may occr.


ysticercosis• linical manifestations


190/200

= Adlt worms rarely case s-s = !ar'ae penetrate intestine" enter blood" ande'entally encyst in the brain.

erebral 'entircles hydrocephals

2pinal cord

compression" parapleia2barachnoid space chronic meninitis

erebral corte- sei8res

= ysts may remain asymptomatic for years" andbecome clinically apparent when lar'ae die

= !ar'ae may encyst in other orans" bt are rarelysymptomatic


ysticercosis

• ,ianosis


191/200

• ,ianosis

= > and H preferred stdies,iscrete cysts that may enhance

Usally mltiple lesions

=2inle lesions especially common in cases

from ndiaElder lesions may calcify

= 2!ymphs or eos" low lcose" ele'ated protein

= 2eroloy;specially in cases with mltiple cysts


ysticercosis


192/200

• >reatment =omple- and contro'ersial

=9ra8iJantel and albenda8ole may +ill cysts"bt death of lar'ae can increase inflammation"edema and e-acerbate s-s

=Khen possible" srical resection ofsymptomatic cyst is preferred

=orticosteroids 's. edema and inflammationantisei8re meds


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193/200


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194/200


ase %1


195/200

• e was not treated with pra8iJantel oralbenda8ole

• e contined to recei'e dilantin forsei8res and was treated withcorticosteroids for edema


Classification of Parasitic Diseases

• 9roto8oa: amoeba flaellates ciliates


196/200

• eta8oa (two phyla)1) elminths (worms)ematodes

= ntestinal = ;-tra&intestinallatworms (platyhelminths)

= estodes (tapeworms)

= >rematodes (fl+es)%) Arthopods (ectoparasites): scabies" lice" fly

lar'aewww.freelivedoctor.com

General r&les of treatment


197/200

• 9roto8oa: reJire species&specifictreatment

•eto8oa: species&specific


Deneral rles of treatment of meta8oa


198/200

ematodes ntestinal ebenda8ole or Albenda8ole

>isse Albenda8ole

iliariae 'ermectin" do-ycycline

estodes 9ra8iJantel" Albenda8ole"iclosamide

>rematode 9ra8iJantel

;ctoparasites 9ermethrin" 'ermectin



199/200

>his is Mst the beinnin of a reat

ad'entre in infectios diseases

ine ua non:

history and physical e-amination



200/200

>han+ yo

!enno- N. Archibald" ," 9h," H9

l+a1^fl.ed

Documents

Clinicalparasitology 100410005437 Phpapp02 2