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Wes Van Voorhis Fellows Course 2010. Travelers’ and Tropical Medicine. 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

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wes van voorhis fellows course 2010

Wes Van VoorhisFellows Course 2010

Travelers’ and Tropical Medicine

28 yo female with fever
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
malaria complications
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

(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.

therapy of p falciparum malaria
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
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
leishmaniasis clinical syndrome leishmania species
Visceral (Kala azar)

Old World Cutaneous

New World Cutaneous


L. donovani complex

L. tropica complex

L. major complex

L. mexicana complex

L. braziliensis complex

L. braziliensis complex

LeishmaniasisClinical SyndromeLeishmania species
old world cutaneous leishmaniasis wet type rural l major most common sp from iraq us troops
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

  • 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
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?
  • 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
42 yo male with worm in eye
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
  • 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
filaria thread like nematodes
Filaria (Thread-like Nematodes)
  • Loaiasis:
    • Transmitted by deer flies (Chrysops)
    • Conjunctival or dermal migration (Calabar Swellings)
37 yo male with an itchy linear rash
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
cutaneous larva migrans etiology epidemiology and clinical
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


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

cutaneous larva migrans lab rx prognosis prevention
CUTANEOUS LARVA MIGRANS: Lab, Rx, Prognosis, Prevention


1. Eosinophilia rare

2. Larvae rarely found in skin biopsy


1. Ivermectin or albendazole p.o.

2. Thiabendazole applied topically

3. Treat bacterial infections


1. Untreated lesion may persist for weeks or months

2. Therapy usually successful


Pet control

3 yo male
3 yo male
  • Buttock rash
    • Linear
    • Itchy
  • Moved from SE USA in last month
strongyloidiasis larva currens in a photographer who traveled widely and had eosinophilia
Strongyloidiasis: Larva currens in a Photographer who traveled widely and had eosinophilia
strongyloidiasis laboratory diagnosis
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
strongyloidiasis treatment and prevention
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.
25 yo male with fever
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

(Tanzania, Oceania)

(Fansidar or Malarone for vivax?)

(P. malariae ChloroR is now reported)

47 yo male with hemoptysis
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
  • Laboratory
    • 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
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 ago @ 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

43 y.o. male after visiting Panama,

Lake fishing at 1,500 ft altitude


Third instar larva of Cordylobia anthropophaga, the Tumbu fly.The powerful mouth hooks, with which the larva feeds, are seen as long, dark bars.


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.