Difference between revisions of "Helminth infections"

(Proposed Diagnostic Criteria for Cysticercosis)
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*At-risk populations include impoverished, children, immigrants, tourists, HIV/AIDS patients, refugees  
 
*At-risk populations include impoverished, children, immigrants, tourists, HIV/AIDS patients, refugees  
 
*Most common in subtropical and tropical areas, moist climates, poor sanitation and hygiene  
 
*Most common in subtropical and tropical areas, moist climates, poor sanitation and hygiene  
 
===Types:===
 
*Roundworm (Ascaris lumbricoides, Toxocara canis)
 
*Whipworm (Trichuris trichiura)
 
*Hookworm (Necator americanus, Ancylostoma duodenale)
 
*Tapeworm (Diphyllobothrium latum, Echinococcus granulosus)
 
*Cysticercosis (Taenia solium, Taenia saginata)
 
*Lymphatic filariasis (aka Elephantiasis; Wuchereria bancrofti, Brugia malayi, and Brugia timori)
 
*Dracunculiasis (aka Guinea Worm disease; Dracunculus medinensis)
 
*[[Onchocerciasis]] (aka River Blindness; Onchocerca volvulus)
 
  
 
===Transmission:===  
 
===Transmission:===  
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**Dracunculiasis transmitted by ingestion of infected Cyclops water fleas in contaminated water (adult worm erodes through skin of leg, releases larvae in water when host wades in pond / open well, infecting the water fleas)
 
**Dracunculiasis transmitted by ingestion of infected Cyclops water fleas in contaminated water (adult worm erodes through skin of leg, releases larvae in water when host wades in pond / open well, infecting the water fleas)
  
==History==
+
==Differential Diagnosis==
 +
===Types:===
 +
*Roundworm
 +
**[[Ascaris lumbricoides]]
 +
**[[Toxocara canis]]
 +
*[[Whipworm]] ([[Trichuris trichiura]])
 +
*[[Hookworm]]
 +
**[[Necator americanus]]
 +
**[[Ancylostoma duodenale]]
 +
*Tapeworm
 +
**[[Diphyllobothrium latum]]
 +
**[[Echinococcus granulosus]]
 +
*[[Cysticercosis]]
 +
**[[Taenia solium]]
 +
**[[Taenia saginata]]
 +
*[[Lymphatic filariasis]] (aka Elephantiasis; Wuchereria bancrofti, Brugia malayi, and Brugia timori)
 +
*[[Dracunculiasis]] (aka Guinea Worm disease; Dracunculus medinensis)
 +
*[[Onchocerciasis]] (aka River Blindness; Onchocerca volvulus)
 +
 
 +
==Clinical Features==
 +
===History===
 
*Parasitic infections can be in the differential diagnosis for nearly every sign/symptom (GI, dermatologic, neurologic, pulmonary, ophthalmologic, hematologic)
 
*Parasitic infections can be in the differential diagnosis for nearly every sign/symptom (GI, dermatologic, neurologic, pulmonary, ophthalmologic, hematologic)
  
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**symptom chronology
 
**symptom chronology
  
 
==Clinical Features==
 
 
===Soil-transmitted helminths (Ascaris roundworm, whipworm, hookworm)===
 
===Soil-transmitted helminths (Ascaris roundworm, whipworm, hookworm)===
 
*Morbidity is related to number of worms harbored in intestines
 
*Morbidity is related to number of worms harbored in intestines
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**Do not aspirate cysts (risk of seeding disease or anaphylactoid reaction from spillage of hydatid sand which contains antigenic proteins)
 
**Do not aspirate cysts (risk of seeding disease or anaphylactoid reaction from spillage of hydatid sand which contains antigenic proteins)
 
**Surgical resection of cysts
 
**Surgical resection of cysts
 
===[[Cysticercosis]] (Taenia)===
 
*Neurocysticercosis
 
**Antiepileptic therapy is first-line treatment
 
**Treat active disease with caution. Antihelminthic therapy may cause increased inflammation, leading to further tissue damage especially with ocular or spinal involvement
 
**Ophthalmologic exam before treatment
 
**Steroids before antihelminthic therapy
 
**Albendazole 400 mg BID x 8-30 days
 
**Neurosurgery consult for symptomatic disease (acute obstructive hydrocephalus may occur)
 
 
*Intestinal stage
 
**Praziquantel 5-10 mg/kg x 1 dose
 
 
===[[Lymphatic filariasis]]===
 
*Diethylcarbamazine:
 
**Day 1: 50 mg PO
 
**Day 2: 50 mg TID
 
**Day 3: 100 mg TID
 
**Days 4-21: 6 mg/kg/day divided TID
 
*Combined treatment with diethylcarbamazine/albendazole or ivermectin/albendazole may be more effective
 
*Meticulous skin care to prevent superinfection/cellulitis
 
*Surgical management of scrotal elephantiasis and chronic lymphatic obstruction
 
 
===[[Dracunculiasis]]===
 
*Metronidazole 750 mg TID x 5-10 days OR thiabendazole 50-75 mg/day divided BID x 3 days
 
*Must also extract adult worm from skin
 
*Patients with active skin lesions should stay out of potable water
 
  
 
==See Also==
 
==See Also==

Revision as of 20:16, 6 September 2014

Background

  • Approximately 2 billion people infected worldwide
  • Many are WHO-designated Neglected Tropical Diseases
  • At-risk populations include impoverished, children, immigrants, tourists, HIV/AIDS patients, refugees
  • Most common in subtropical and tropical areas, moist climates, poor sanitation and hygiene

Transmission:

  • No direct person-to-person transmission
  • Fecal-oral transmission (ingestion of eggs in contaminated soil / vegetables / water)
    • Ascaris and whipworm from human feces
    • Toxocara from dog / cat feces
    • Echinococcus from sheep / cattle feces
    • Taenia eggs from human feces
  • Cutaneous transmission
    • Hookworm eggs hatch in the soil, mature larvae penetrate skin
    • Lymphatic filariasis transmitted via bite from infected mosquito (Anopheles, Aedes, and Culex)
    • Onchocerciasis transmitted via bite from blackflies (Simulium species)
  • Food or waterborne transmission
    • Taenia also transmitted by ingestion of larval cysts in undercooked pork or beef
    • Diphyllobothrium tapeworm transmitted by contaminated freshwater fish
    • Dracunculiasis transmitted by ingestion of infected Cyclops water fleas in contaminated water (adult worm erodes through skin of leg, releases larvae in water when host wades in pond / open well, infecting the water fleas)

Differential Diagnosis

Types:

Clinical Features

History

  • Parasitic infections can be in the differential diagnosis for nearly every sign/symptom (GI, dermatologic, neurologic, pulmonary, ophthalmologic, hematologic)
  • Obtain a travel history in every patient
    • countries of travel
    • duration of stay
    • activities while traveling (adventure travel, tourism, working, swimming)
    • living arrangements – city / village / hotel / tent
    • drinking water source
    • symptom chronology

Soil-transmitted helminths (Ascaris roundworm, whipworm, hookworm)

  • Morbidity is related to number of worms harbored in intestines
  • Light infections often asymptomatic
  • Heavier infections with variety of manifestations including GI symptoms (abdominal pain, diarrhea, blood in stool, rectal prolapse), malaise, weakness, impaired cognitive / physical development, malnutrition
  • Hookworm and whipworm infestations also cause iron-deficiency anemia
    • Adult worms attach to intestinal wall to feed, causing ongoing luminal blood loss
  • Löffler’s syndrome
    • Result of Ascaris or hookworm larval transit through the lungs
    • Characterized by persistent non-productive cough, chest pain, wheezing, rales, pulmonary infiltrates on CXR and marked eosinophilia

Toxocara canis

  • Visceral toxocariasis (visceral larva migrans)
    • Larvae travel through liver / lungs / CNS causing fever, cough, enlarged liver, pneumonia
  • Ocular toxocariasis (ocular larva migrans)
    • Larvae travel to the eye causing inflammation and scarring of retina, usually only one eye, irreversible vision loss

Tapeworm

  • Taenia (intestinal)
    • Ingestion of eggs results in intestinal infection
    • Usually asymptomatic, but heavier infections may result in GI upset, anemia, anorexia, diarrhea
  • Diphyllobothrium
    • Usually asymptomatic, may have GI symptoms
    • Rarely, migrating proglottids can cause cholangitis, cholecystitis, or intestinal obstruction
    • Competes for absorption of vitamin B12, causes pernicious anemia

Echinococcosis

  • Larvae travel from small intestine via bloodstream to multiple sites
  • Liver is target organ in ⅔ of cases
  • Less than 10% of patients have brain involvement (seizures, focal neurologic signs)
  • Pulmonary involvement also possible (cough, expectoration of sand-like material, hemoptysis, chest pain, anaphylactoid reaction from leaking cyst, mass effect from expanding cyst)

Cysticercosis (Taenia larval cysts)

  • Adult worm matures in intestine, may end up anywhere in body (CNS, muscle, soft tissue, eye, heart, liver)
  • Cluster of larvae in the brain forms expanding cyst
  • Neurologic symptoms including seizures, AMS, focal neurologic deficit, or hydrocephalus

Lymphatic filariasis

  • Larvae migrate to lymphatic vessels and mature into adults
  • Massive peripheral edema with thickening of overlying skin particularly in lower extremities and genitalia
  • Recurrent cellulitis is common

Dracunculiasis

  • Adult worm migrates through subcutaneous tissues of the leg and erodes through skin
  • Rash, intense pruritus, nausea, vomiting, dyspnea, and diarrhea prior to eruption

Diagnosis

General

  • Stool studies (ova and parasites)
  • CBC to identify peripheral eosinophilia or anemia (not sensitive or specific)
  • Peripheral blood smear to identify microfilariae (e.g. lymphatic filariasis)

Disease/Symptom Specific

  • Pulmonary symptoms: CXR and sputum smear (e.g. Löffler’s syndrome)
  • CNS symptoms
    • Neuroimaging (CT with contrast or MR brain) may reveal ring-enhancing lesions, calcifications, or focal enhancing lesions in neurocysticercosis
    • CSF serologies/ELISA for echinococcus, cysticercosis
  • Ultrasound or CT can localize cyst of echinococcus
  • ELISA or biopsy of affected tissue to diagnosis toxocariasis, cysticercosis
  • Identification of adult worm or microscopic larvae in cutaneous ulcer fluid can confirm dracunculiasis

Clinical Management

Soil-transmitted helminthes

  • Ascaris: albendazole 400 mg x 1 dose OR mebendazole 100 mg BID x 3 days (both high efficacy)
  • Whipworm (Trichuris): albendazole 400 mg x 1 dose
    • Historically treated with albendazole or mebendazole, but monotherapy has low efficacy against Trichuris especially in heavy infections; higher cure rate achieved with oxantel pamoate-albendazole combination compared to any monotherapy in recent RCT (Speich, et al. NEJM 2014; 370:610-620)
  • Hookworm: albendazole 400 mg x 1 dose (high efficacy) OR mebendazole 500 mg x 1 dose (low to moderate efficacy)
  • Iron supplements in anemia

Toxocariasis (visceral larva migrans)

  • Diethylcarbamazine 6 mg/kg/day divided TID x 7-10 days OR mebendazole 100-200 mg BID x 5 days OR albendazole 400 mg BID x 3-5 days

Tapeworm

  • Diphyllobothrium
    • Praziquantel 5-10 mg/kg x 1 dose
    • Replete vitamin B12 if patient has megaloblastic anemia
  • Echinococcus:
    • Tissue stage/hydatid disease: albendazole 400 mg BID x 28 days, repeat as needed every 2 weeks x 3 cycles
    • Do not aspirate cysts (risk of seeding disease or anaphylactoid reaction from spillage of hydatid sand which contains antigenic proteins)
    • Surgical resection of cysts

See Also

External Links

Sources

  1. "Chapter 133 - Parasitic Infections." Rosen's Emergency Medicine: Concepts and Clinical Practice. Ed. John A. Marx, Robert S. Hockberger, and Ron M. Walls. Philadelphia, PA: Mosby Elsevier, 2014. 1768-784.
  2. "The 17 Neglected Tropical Diseases." World Health Organization. http://www.who.int/neglected_diseases/diseases/en/. Web. 11 Aug. 2014.
  3. "Parasites." Centers for Disease Control and Prevention. http://www.cdc.gov/parasites/. Web. 11 Aug. 2014.
  4. Wilcox S, Thomas S, Brown D, Nadel E. “Gastrointestinal Parasite.” The Journal of Emergency Medicine, 2007; 33(3):277-280
  5. Del Brutto OH, Rajshekhar V, White A, et al. “Proposed diagnostic criteria for neurocysticercosis.” Neurology, 2001; 57:177-183.
  6. Del Brutto OH. “Diagnostic criteria for neurocysticercosis, revisited.” Pathogens and Global Health, 2012; 106(5):299-304.
  7. Speich B, Ame S, et al. "Oxantel Pamoate–Albendazole for Trichuris Trichiura Infection." New England Journal of Medicine, 2014; 370: 610-620.