Presentation on theme: "Wes Van Voorhis Fellows Course 2010"— Presentation transcript:
1 Wes Van Voorhis Fellows Course 2010 Travelers’ and Tropical Medicine
2 28 yo female with fever Fevers began one day ago Hectic patternReturned 2 d ago from rural NigeriaNo food/water precautionsMosquito bitesNo malaria prophylaxis: “Did not need as a child” growing up in rural NigeriaMoved to US 9 yrs ago, first trip back to Nigeria6 mos pregnantPE: ill-appearing, alert, O x 3, T = 39.2, BP = 102/75, HR = 110
8 “Common” Binding types and Malaria During Pregnancy (CD36 binders)(CSA binders)Fried & Duffy. ScienceFried M. et al. NatureSince PfEMP1 proteins bind CD36, this suggests the parasite switches to non-CD36binding variants to ensure sequestration in placenta and not microvasculature.
9 Therapy of P. falciparum Malaria Quinine 650 po tid for 3-7 days (or i.v. quinidine) plus doxycycline for drug-resistant-falciparumArtemether (IND from CDC) Severe malariaAlternativesArtemisinin combo Rx [ACT: in US lumefantrine/artemether], Atovaquone 500 and proguanil 200 (Malarone) bid for 3 d (mild-moderate disease), Mefloquine (Larium), or Sulfadoxine and pyrimethamine (Fansidar) RESISTANCE!, Quinine and clindamycin,Consider exchange transfusion for parasitemia > 10% or cerebral malariaFollow smears for assessment of cure
10 21 year old Ecology student 6 weeks of enlarging facial lesionNo pain or pruritisNo feverWorked for a year in the rainforest in Belize studying the ecology of deforestation
16 Old World Cutaneous Leishmaniasis: “Wet type” rural, L Old World Cutaneous Leishmaniasis: “Wet type” rural, L. major (most common sp from Iraq US Troops)L. tropica: Urban leish., dry type, more common inAfghanistan, particularly in Kabul
18 Mucocutaneous Leishmaniasis: Late sequela of L. braziliensis spp Mucocutaneous Leishmaniasis: Late sequela of L. braziliensis spp. infection
19 Leishmaniasis Treatment: Prevention: Pentavalent antimonials (stibogluconate)Alternatives: Amphotericin B lipid formulation, pentamidine, miltefosine(visceral), paramomycin (visceral), (itraconazole, ketoconazole, posoconazole: maybe not as effective)Prevention:Vector (sandfly) controlInsect precautionsAnimal reservoir control
20 Cases from Tropical Medicine and ID Clinic 42 yo Male Ethiopian Refugee with fatigue, abdominal pain, and bloody stoolsBRBPR x 2mosFatigue and epigastric pain x 1 yrMay have lost weightNo fevers, chills, sweatsLeft Ethiopia 1 yr ago6 mos in refugee camps in SomaliaCame to Seattle 6 mos agoHx: Amebic dysentery, malariaPE: afebrile, thin, no HSM, rectal + occult bloodLabs: WBC = 7.1, Hct = 39, GOT = 78, GPT = 120, Alk Phos = 54, CXR = wnlWhat’s missing from his labs you’d like to see?Eosinophil count 1.6 K, Stool O&P – x 3, needed rectal bx to make dx of SchistoWes Van Voorhis
29 Schistosomiasis Treatment Prognosis Early and intermediate stages: Antihistamines, steroids + praziquantelLate stages: Treat active infections with praziquantelPrognosisGood in early casesPoor with cirrhosis or irreversible tissue damage
30 42 yo male with “worm in eye” Noted serpiginous movement of “worm” in eye in the evening while working at Children’s Hospital as a JanitorPresented to ER immediatelyHistory of transient migratory swellingsEmigrated from Benin, West Africa 1 yr agoPE: 3 cm undulating worm in subconjunctival space
31 Extraction of worm from eye and microscopic view
35 Loaisis Therapy Diethylcarbamazine Start with gradually increasing doses, advance to a level of 2 to 3 mg/kg tid [up to 600 mg/day] for 3 weeksAdjunctive therapy with antihistamines and steroidsCareful extraction of worm from subconjunctival space
36 Filaria (Thread-like Nematodes) Loaiasis:Transmitted by deer flies (Chrysops)Conjunctival or dermal migration (Calabar Swellings)
37 37 yo male with an itchy linear rash Presents one week after a beach vacation in JamaicaRash on thighappears to be moving at several cm/day
38 Linear Eruption on Skin After Beach Vacation in Jamaica
40 CUTANEOUS LARVA MIGRANS: Etiology, Epidemiology, and Clinical Etiology Ancylostoma braziliense1. Reaches adulthood only in cats and dogs2. Life cycle similar to human hookworm3. In humans, filariform larvae penetrate skin4. Remains in skin, does not reach maturityEpidemiology1. Eggs and larvae require warm moist temperatures2. Beaches and areas under houses contaminated3. In USA southern Atlantic and Gulf statesClinical Manifestations1. Severe itching2. Red linear skin lesions (15 to 20 cm)3. Secondary bacterial infections
41 CUTANEOUS LARVA MIGRANS: Lab, Rx, Prognosis, Prevention Laboratory1. Eosinophilia rare2. Larvae rarely found in skin biopsyTreatment1. Ivermectin or albendazole p.o.2. Thiabendazole applied topically3. Treat bacterial infectionsPrognosis1. Untreated lesion may persist for weeks or months2. Therapy usually successfulPreventionPet control
42 3 yo maleButtock rashLinearItchyMoved from SE USA in last month
46 Strongyloidiasis: Life Cycle Cases from Tropical Medicine and ID ClinicStrongyloidiasis: Life CycleDirect: Rhabditiforms reach soil, develop into filariform larvae, these penetrate skin, reach venous system, lungs, intestine, mature and begin oviposition in days.Indirect: Rhabditiforms reach soil, develop into free living adults, mate and produce new generations of rhabditiforms indefinately, with appropriate climatic conditions, filariform larvae develop which can invade humans. Autoinfection: develop into filariform larvae before passing into feces (constipation, debilitation, immunosuppression may enhance this process) and filariforms penetrate intestinal wall or perianal skin, may result in prolonged (20-30 yr infections).Wes Van Voorhis
48 Strongyloidiasis: Laboratory Diagnosis Rhabditiform larvae in stoolsNumber in stools small, variableSeveral specimens should be checkedConcentration and culture techniques should be usedRhabditiform larvae in duodenal aspirates or jejunal biopsiesWith pulmonary involvement, filariform larvae in sputumEosinophilia commonSerology can be helpful
49 Strongyloidiasis Treatment and Prevention IvermectinAlbendazole(Thiabendazole-no more)Prognosis and PreventionPrognosis is poor in hyperinfection syndromeControl measures similar to that of HookwormTreat patients PRIOR to immunosuppression.
50 25 yo male with fever One week ago had a fever After a couple of days, lysed in a sweatTwo nights ago, fever returnedDenies other Sxs except mild abd discomfort, back ache, headacheTemp last night was 101.5Peace Corps volunteer for 2 yrs in W. AfricaReturned 6 mos agoPE: T = 38.7, spleen tip palpable 5 cm below left costal margin
60 Paragonimiasis Laboratory Treatment and prevention Eosinophilia, abnormal CSF (Eosinophils, protein)Radiographic: CXR can resemble TB or tumorDefinitive diagnosis by egg demonstration in sputum or fecesSputum often negative first 3 monthsLater, 75-85% positiverepeated exams and concentration techniques neededEggs will not show up in AFB stainSerology helpful in correct clinical circumstanceTreatment and preventionPraziquantel (or bithionol or triclabendazole)Adequate cooking of shellfish
61 Cases from Tropical Medicine and ID Clinic 43 yo male presents with “a worm in leg”2 mm papule noted 5 wks earlierPosterior right thigh3wks ago noted to have pin-point hole that enlarged2wks ago movement noted, erythema expanded to 1 cmNo pain, no pruritisPt fishing in central Panama 6 wks 1500 ft elevation on a lakeBitten by many flies and mosquitoesExam: 2.5 cm indurated noduleWhite organism extended 0.5 mm from hole with pressureWes Van Voorhis
62 Papule 43 y.o. male after visiting Panama, Lake fishing at 1,500 ft altitude
67 Third instar larva of Cordylobia anthropophaga, the Tumbu fly Third instar larva of Cordylobia anthropophaga, the Tumbu fly. The powerful mouth hooks, with which the larva feeds, are seen as long, dark bars.
68 Extracting a larva of Cordylobia anthropophaga after covering it with paraffin. The pair of black spiracles can just be seen in the centre of the posterior tip of the larva.