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Wes Van Voorhis Fellows Course 2010

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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 pattern Returned 2 d ago from rural Nigeria No food/water precautions Mosquito bites No malaria prophylaxis: “Did not need as a child” growing up in rural Nigeria Moved to US 9 yrs ago, first trip back to Nigeria 6 mos pregnant PE: ill-appearing, alert, O x 3, T = 39.2, BP = 102/75, HR = 110

3 Blood (thin) smear

4 Temperature Chart of Benign Tertian Malaria

5 Fever Curve of P. falciparum

6 Malaria: Complications
Anemia Pernicious Syndromes ARDS/Pulmonary Edema Shock Cerebral malaria Severe Anemia Renal failure, Blackwater fever Hypoglycemia Malaria more severe in pregnancy, fetal loss


8 “Common” Binding types and Malaria During Pregnancy
(CD36 binders) (CSA binders) Fried & Duffy. Science Fried M. et al. Nature Since PfEMP1 proteins bind CD36, this suggests the parasite switches to non-CD36 binding 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-falciparum Artemether (IND from CDC) Severe malaria Alternatives Artemisinin 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 malaria Follow smears for assessment of cure

10 21 year old Ecology student
6 weeks of enlarging facial lesion No pain or pruritis No fever Worked for a year in the rainforest in Belize studying the ecology of deforestation


12 Lutzomyia Phlebotomine Fly (Sandfly)


14 Leishmaniasis Clinical Syndrome Leishmania species
Visceral (Kala azar) Old World Cutaneous New World Cutaneous Mucocutaneous L. donovani complex L. tropica complex L. major complex L. mexicana complex L. braziliensis complex

15 Visceral Leishmaniasis or Kala Azar

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 in Afghanistan, particularly in Kabul

17 Cutaneous Leishmaniasis: Brazil

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) control Insect precautions Animal reservoir control

20 Cases from Tropical Medicine and ID Clinic
42 yo Male Ethiopian Refugee with fatigue, abdominal pain, and bloody stools BRBPR x 2mos Fatigue and epigastric pain x 1 yr May have lost weight No fevers, chills, sweats Left Ethiopia 1 yr ago 6 mos in refugee camps in Somalia Came to Seattle 6 mos ago Hx: Amebic dysentery, malaria PE: afebrile, thin, no HSM, rectal + occult blood Labs: WBC = 7.1, Hct = 39, GOT = 78, GPT = 120, Alk Phos = 54, CXR = wnl What’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 Schisto Wes Van Voorhis

21 Rectal Biopsy

22 Rectal Biopsy

23 Schistosomiasis: Distribution

24 Cercaria Penetrating Skin

25 Schistosome Dermatitis

26 Schistosome Dermatitis: Lifecycle

27 Adult Schistosomes in copulo: Female is smaller

28 Schistosomiasis: Lifecycle

29 Schistosomiasis Treatment Prognosis
Early and intermediate stages: Antihistamines, steroids + praziquantel Late stages: Treat active infections with praziquantel Prognosis Good in early cases Poor 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 Janitor Presented to ER immediately History of transient migratory swellings Emigrated from Benin, West Africa 1 yr ago PE: 3 cm undulating worm in subconjunctival space

31 Extraction of worm from eye and microscopic view

32 Loa loa distribution

33 Loa loa Vector: Deerfly

34 Loa loa: Lifecycle

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 weeks Adjunctive therapy with antihistamines and steroids Careful 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 Jamaica Rash on thigh appears to be moving at several cm/day

38 Linear Eruption on Skin After Beach Vacation in Jamaica

39 Cutaneous Larva Migrans

40 CUTANEOUS LARVA MIGRANS: Etiology, Epidemiology, and Clinical
Etiology Ancylostoma braziliense 1. Reaches adulthood only in cats and dogs 2. Life cycle similar to human hookworm 3. In humans, filariform larvae penetrate skin 4. Remains in skin, does not reach maturity Epidemiology 1. Eggs and larvae require warm moist temperatures 2. Beaches and areas under houses contaminated 3. In USA southern Atlantic and Gulf states Clinical Manifestations 1. Severe itching 2. Red linear skin lesions (15 to 20 cm) 3. Secondary bacterial infections

41 CUTANEOUS LARVA MIGRANS: Lab, Rx, Prognosis, Prevention
Laboratory 1. Eosinophilia rare 2. Larvae rarely found in skin biopsy Treatment 1. Ivermectin or albendazole p.o. 2. Thiabendazole applied topically 3. Treat bacterial infections Prognosis 1. Untreated lesion may persist for weeks or months 2. Therapy usually successful Prevention Pet control

42 3 yo male Buttock rash Linear Itchy Moved from SE USA in last month

43 3 y.o. with Buttock Rash

44 Strongyloidiasis: Larva currens in a Photographer who traveled widely and had eosinophilia

45 Strongyloidiasis: Distribution

46 Strongyloidiasis: Life Cycle
Cases from Tropical Medicine and ID Clinic Strongyloidiasis: Life Cycle Direct: 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

47 Chest X Ray: Strongyloidiasis hyperinfection

48 Strongyloidiasis: Laboratory Diagnosis
Rhabditiform larvae in stools Number in stools small, variable Several specimens should be checked Concentration and culture techniques should be used Rhabditiform larvae in duodenal aspirates or jejunal biopsies With pulmonary involvement, filariform larvae in sputum Eosinophilia common Serology can be helpful

49 Strongyloidiasis Treatment and Prevention
Ivermectin Albendazole (Thiabendazole-no more) Prognosis and Prevention Prognosis is poor in hyperinfection syndrome Control measures similar to that of Hookworm Treat patients PRIOR to immunosuppression.

50 25 yo male with fever One week ago had a fever
After a couple of days, lysed in a sweat Two nights ago, fever returned Denies other Sxs except mild abd discomfort, back ache, headache Temp last night was 101.5 Peace Corps volunteer for 2 yrs in W. Africa Returned 6 mos ago PE: T = 38.7, spleen tip palpable 5 cm below left costal margin



53 P. vivax Lifecycle in Man

54 (Tanzania, Oceania) (Fansidar or Malarone for vivax?) (P. malariae ChloroR is now reported)

55 47 yo male with hemoptysis
3 mo hx of hemoptysis Denies fevers, chills, weight loss Emigrated from Vietnam 1 yr ago 30 yr pack smoking history PPD negative No previous CXR

56 Gross Pathology: Nodule

57 Paragonimiasis Nodule Showing Flukes

58 Paragonimus Adults Removed from Lung

59 Paragonimiasis: Lifecycle

60 Paragonimiasis Laboratory Treatment and prevention
Eosinophilia, abnormal CSF (Eosinophils, protein) Radiographic: CXR can resemble TB or tumor Definitive diagnosis by egg demonstration in sputum or feces Sputum often negative first 3 months Later, 75-85% positive repeated exams and concentration techniques needed Eggs will not show up in AFB stain Serology helpful in correct clinical circumstance Treatment and prevention Praziquantel (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 earlier Posterior right thigh 3wks ago noted to have pin-point hole that enlarged 2wks ago movement noted, erythema expanded to 1 cm No pain, no pruritis Pt fishing in central Panama 6 wks 1500 ft elevation on a lake Bitten by many flies and mosquitoes Exam: 2.5 cm indurated nodule White organism extended 0.5 mm from hole with pressure Wes Van Voorhis

62 Papule 43 y.o. male after visiting Panama,
Lake fishing at 1,500 ft altitude


64 Dermatobium hominis

65 Dermatobium hominis Adult

66 Maggots That Cause Myiasis

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.

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