Wes Van Voorhis Fellows Course 2010

1. Wes Van VoorhisFellows 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. (CD36 binders) (CSA binders) “Common” Binding types and Malaria During Pregnancy Fried & Duffy. Science. 1996. Fried M. et al. Nature. 1998. 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 potid 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. LutzomyiaPhlebotomineFly(Sandfly)

14. 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 L. braziliensis complex LeishmaniasisClinical SyndromeLeishmania species

15. Visceral Leishmaniasis or Kala Azar

16. 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. CutaneousLeishmaniasis: Brazil

18. MucocutaneousLeishmaniasis:Late sequela of L. braziliensis spp. infection

19. Leishmaniasis • Treatment: • 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. 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?

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 • 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 EtiologyAncylostoma 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

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 • Treatment • 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