Helminth infections: Difference between revisions
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==Background== | ==Background== | ||
*Approximately 2 billion people infected worldwide | *Approximately 2 billion people infected worldwide | ||
*Many are WHO-designated Neglected Tropical Diseases | *Many are WHO-designated Neglected Tropical Diseases<ref>The 17 Neglected Tropical Diseases." World Health Organization. http://www.who.int/neglected_diseases/diseases/en/. Web. 11 Aug. 2014.</ref> | ||
*At-risk populations include impoverished, children, immigrants, tourists, HIV/AIDS patients, refugees | *At-risk populations include impoverished, children, immigrants, tourists, HIV/AIDS patients, refugees <ref name="CDC">"Parasites." Centers for Disease Control and Prevention. http://www.cdc.gov/parasites/. Web. 11 Aug. 2014.</ref> | ||
*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 <ref name="rosens">"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.</ref> | ||
===Transmission:=== | ===Transmission:=== | ||
*No direct person-to-person transmission | *No direct person-to-person transmission | ||
*Fecal-oral transmission (ingestion of eggs in contaminated soil / vegetables / water) | *Fecal-oral transmission (ingestion of eggs in contaminated soil / vegetables / water)<ref name="rosens"></ref> | ||
**Ascaris and whipworm from human feces | **Ascaris and whipworm from human feces | ||
**Toxocara from dog / cat feces | **Toxocara from dog / cat feces | ||
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*Morbidity is related to number of worms harbored in intestines | *Morbidity is related to number of worms harbored in intestines | ||
*Light infections often asymptomatic | *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 | *Heavier infections with variety of manifestations including GI symptoms (abdominal pain, diarrhea, blood in stool, rectal prolapse), malaise, weakness, impaired cognitive / physical development, malnutrition<ref>Wilcox S, Thomas S, Brown D, Nadel E. “Gastrointestinal Parasite.” The Journal of Emergency Medicine, 2007; 33(3):277-280</ref></ref> | ||
*Hookworm and whipworm infestations also cause iron-deficiency anemia | *Hookworm and whipworm infestations also cause iron-deficiency anemia | ||
**Adult worms attach to intestinal wall to feed, causing ongoing luminal blood loss | **Adult worms attach to intestinal wall to feed, causing ongoing luminal blood loss | ||
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===[[Tapeworm]]=== | ===[[Tapeworm]]=== | ||
*Taenia (intestinal) | *Taenia (intestinal)<ref name="CDC"></ref> | ||
**Ingestion of eggs results in intestinal infection | **Ingestion of eggs results in intestinal infection | ||
**Usually asymptomatic, but heavier infections may result in GI upset, anemia, anorexia, diarrhea | **Usually asymptomatic, but heavier infections may result in GI upset, anemia, anorexia, diarrhea | ||
*[[Diphyllobothrium]] | *[[Diphyllobothrium]] | ||
**Usually asymptomatic, may have GI symptoms | **Usually asymptomatic, may have GI symptoms<ref name="CDC"></ref> | ||
**Rarely, migrating proglottids can cause cholangitis, cholecystitis, or intestinal obstruction | **Rarely, migrating proglottids can cause cholangitis, cholecystitis, or intestinal obstruction | ||
**Competes for absorption of vitamin B12, causes pernicious anemia | **Competes for absorption of vitamin B12, causes pernicious anemia | ||
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*Pulmonary symptoms: CXR and sputum smear (e.g. Löffler’s syndrome) | *Pulmonary symptoms: CXR and sputum smear (e.g. Löffler’s syndrome) | ||
*CNS symptoms | *CNS symptoms | ||
**Neuroimaging (CT with contrast or MR brain) may reveal ring-enhancing lesions, calcifications, or focal enhancing lesions in neurocysticercosis | **Neuroimaging (CT with contrast or MR brain) may reveal ring-enhancing lesions, calcifications, or focal enhancing lesions in neurocysticercosis<ref>Del Brutto OH, Rajshekhar V, White A, et al. “Proposed diagnostic criteria for neurocysticercosis.” Neurology, 2001; 57:177-183.</ref><ref>Del Brutto OH. “Diagnostic criteria for neurocysticercosis, revisited.” Pathogens and Global Health, 2012; 106(5):299-304.</ref> | ||
**CSF serologies/ELISA for echinococcus, cysticercosis | **CSF serologies/ELISA for echinococcus, cysticercosis | ||
*Ultrasound or CT can localize cyst of echinococcus | *Ultrasound or CT can localize cyst of echinococcus | ||
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*[[Whipworm]] (Trichuris): albendazole 400 mg x 1 dose | *[[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 | **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 <ref>Speich B, Ame S, et al. "Oxantel Pamoate–Albendazole for Trichuris Trichiura Infection." New England Journal of Medicine, 2014; 370: 610-620.</ref> | ||
*[[Hookworm]]: albendazole 400 mg x 1 dose (high efficacy) OR mebendazole 500 mg x 1 dose (low to moderate efficacy) | *[[Hookworm]]: albendazole 400 mg x 1 dose (high efficacy) OR mebendazole 500 mg x 1 dose (low to moderate efficacy) | ||
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==Sources== | ==Sources== | ||
<references/> | <references/> | ||
[[Category:ID]] | [[Category:ID]] |
Revision as of 23:14, 6 September 2014
Background
- Approximately 2 billion people infected worldwide
- Many are WHO-designated Neglected Tropical Diseases[1]
- At-risk populations include impoverished, children, immigrants, tourists, HIV/AIDS patients, refugees [2]
- Most common in subtropical and tropical areas, moist climates, poor sanitation and hygiene [3]
Transmission:
- No direct person-to-person transmission
- Fecal-oral transmission (ingestion of eggs in contaminated soil / vegetables / water)[3]
- 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:
- Roundworm
- Whipworm (Trichuris trichiura)
- Hookworm
- Tapeworm
- Cysticercosis
- 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)
- 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[4]</ref>
- 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)[2]
- 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[2]
- Rarely, migrating proglottids can cause cholangitis, cholecystitis, or intestinal obstruction
- Competes for absorption of vitamin B12, causes pernicious anemia
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
- 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 [7]
- Hookworm: albendazole 400 mg x 1 dose (high efficacy) OR mebendazole 500 mg x 1 dose (low to moderate efficacy)
- Iron supplements in anemia
See Also
External Links
Sources
- ↑ The 17 Neglected Tropical Diseases." World Health Organization. http://www.who.int/neglected_diseases/diseases/en/. Web. 11 Aug. 2014.
- ↑ 2.0 2.1 2.2 "Parasites." Centers for Disease Control and Prevention. http://www.cdc.gov/parasites/. Web. 11 Aug. 2014.
- ↑ 3.0 3.1 "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.
- ↑ Wilcox S, Thomas S, Brown D, Nadel E. “Gastrointestinal Parasite.” The Journal of Emergency Medicine, 2007; 33(3):277-280
- ↑ Del Brutto OH, Rajshekhar V, White A, et al. “Proposed diagnostic criteria for neurocysticercosis.” Neurology, 2001; 57:177-183.
- ↑ Del Brutto OH. “Diagnostic criteria for neurocysticercosis, revisited.” Pathogens and Global Health, 2012; 106(5):299-304.
- ↑ Speich B, Ame S, et al. "Oxantel Pamoate–Albendazole for Trichuris Trichiura Infection." New England Journal of Medicine, 2014; 370: 610-620.