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K Ectoparasitic Diseases K Ectoparasitic Diseases Introduction to Ectoparasitic 291 Diseases James H. Diaz Ectoparasites infest the skin and its appendages, such as the hair and miscellaneous insects, and 7 mites. Most of the arthropod dermatoses sebaceous glands, and most external orifices, especially the ears, nares, originated in the United Kingdom (n = 46; 63%), and were caused by and orbits. Like endoparasites, ectoparasites may be obligatory parasites, tick bites (n = 18), principally Ixodes ricinus (the common sheep tick), programmed to feed on human hosts to complete their life cycles, or an important European vector of Lyme disease and neuroborreliosis. facultative parasites, preferring to feed on nonhuman hosts, infesting Myiasis cases predominated in returning travelers (n = 18; 67%), humans only as accidental or dead-end hosts. Over the past 2 decades, principally furuncular myiasis from larval infestation by Cordylobia there have been several reports of significant outbreaks of ectoparasitic anthropophaga (n = 9), the tumbu fly, or Dermatobia hominis (n = 4), diseases, principally myiasis, scabies, and tungiasis, both in indigenous the human botfly. Among the arthropod dermatoses caused by miscel- populations and in travelers returning from developing nations and laneous arthropods, most were pediculosis pubis caused by infestation even exclusive tropical beach resorts.1,2 Many common ectoparasites, with Phthirus pubis, the pubic louse (n = 7), or hemorrhagic, bullous such as head lice and scabies mites, are also developing increasing bite groupings caused by Cimex lectularius, the common bedbug (n = resistance to medical therapies, including the safest topical insecticides.3–6 3). The authors concluded that exotic ectoparasitic infestations, par- Other ectoparasites, such as the New World human botfly, Dermatobia ticularly myiasis, predominated in returning travelers from Africa and hominis, and the jigger or chigoe flea, Tunga penetrans, are resistant to Latin America; pubic lice were domestic, likely sexually transmitted, systemic and topical antiparasitics and can be treated only surgically. infestations; and bedbug infestations were domestically and internation- Ectoparasitic diseases have reemerged as unusual, but not uncommon, ally acquired, often from exposure to fomites, including bedding and infectious diseases worldwide, especially in high-risk populations. luggage. Indigenous populations of ectoparasite-endemic tropical nations often have recurrent infestations and superinfestations that can result in severe MECHANISMS OF disfigurement from facial cavitary myiasis or permanent disability from ECTOPARASITE-BORNE tungiasis-associated autoamputations. DISEASES AND INJURIES The a rarthropodthropod ectopa ectoparasitesrasites ca cann t hrthreatenea human health directly by TAXONOMY OF ECTOPARASITES burrowing into and feeding, dwelling, and reproducing in human skin The p hphylumylum Ar Arthropodathropoda i sis t hthee l alargestrgest p hphylumylum o fof th the animal kingdom and orifices (mites, fleas, flies), or by blood or tissue juice sucking (fleas, and includes the subphylum Crustacea and the classes Insecta and lice, mites, ticks). The arthropod ectoparasites can also threaten human Arachnida. All the medically important ectoparasites, including fleas, health indirectly by infectious disease transmission (fleas, mites, ticks). flies, lice, mites, and ticks, are members of the phylum Arthropoda and Ticks are the most versatile ectoparasitic arthropods and can transmit have chitinous exoskeletons, segmented bodies, and jointed appendages. a variety of infectious diseases (viral, bacterial, and protozoan) and Fleas, flies, and lice are six-legged members of the class Insecta, which even inject paralytic toxins (tick paralysis) during their prolonged blood also includes the mosquitoes and true bugs (order Hemiptera). Mites, meals. Unlike other ectoparasites, ticks can be infective as males and including chigger and scabies mites, and ticks are the eight-legged females at birth (by transovarial pathogen transmission) and throughout members of the class Arachnida, subclass Acari. The arthropod ecto- all stages of their development (by transstadial pathogen transmission). parasites of medical importance are stratified yb taxonomic classes and The most commonly encountered arthropod ectoparasites, excluding distinguishing external anatomic characteristics in Table 291.1. ticks, and the major clinical manifestations of their infestations are featured in Table 291.2. The tick-borne pathogens and the clinical EPIDEMIOLOGY OF manifestations of their infections are featured in Chapter 296, Tables ECTOPARASITIC DISEASES 296.1 through 296.8. EctoparasiticEctoparasitic diseasesdiseases shareshare mmanyany of ththe general characteristics of emerging infectious diseases. Commonly shared characteristics of CONCLUSIONS ectoparasitoses and emerging infectious diseases include the following: RecentRecent epidemiologicepidemiologic evidencee now supports the endemicity of several (1) origination as zoonoses, with disease establishment dependent on ectoparasitic diseases and their arthropod vectors (Table 291.3) and arthropod vector competency; (2) introduction into new, susceptible host human and animal reservoir hosts throughout the developing world populations; (3) infection by endemic agents given selective advantages by and in many parts of the developed world, including Europe and the changing ecologic or socioeconomic conditions; and (4) recent movement United States. Ectoparasitic diseases have also reemerged in regions from rural to urban endemic areas, often following migrating human where they were once effectively controlled. Ectoparasitic diseases will host populations seeking better economic opportunities.7–9 continue to reemerge in the developed world for several reasons, including To assess the potential combined impact of increasing international the following: (1) the globalization of trade and commerce with ecto- travel and the relaxation of quarantine regulations for imported animals parasites and their human and animal hosts traveling worldwide on in the United Kingdom on arthropod-induced ectoparasitic dermatoses, airplanes and container ships; (2) mass movements of populations from McGarry and colleagues analyzed 73 insect specimens removed from rural to urban areas and from developing to developed nations; (3) the symptomatic patients and submitted to their laboratory for identification worldwide legitimate and illegal trade of exotic animals and animal at the Liverpool School of Tropical Medicine during the years 1994 to hides and skins; (3) the accidental and intentional introduction of exotic 2000.10 Of the 73 specimens identified, there were 27 ticks, 24 flies, 15 animal species into new regions with welcoming ecosystems; (4) the 3479 3480 TABLE 291.1 Taxonomy of Arthropods (Phylum Arthropoda) of Major Medical Importancea NO. OF LEGS, NO. OF BODY SEGMENTS, s COMMON NAMES OTHER IDENTIFYING ANATOMIC FEATURES ent g Phylum Arthopoda, Class Insecta Order Diptera, family Culicidae Mosquitoes Six, three, wings ic A g Order Diptera Fliesa Six, three, wings tiolo Order Hemiptera True bugs (e.g., bedbugs, reduviid bugs) Six, three, ± wings E Order Hymenoptera Ants, bees, wasps Six, three, ± wings Order Phthiraptera Licea Six, three, no wings Order Siphonaptera Fleasa Six, three, no wings Phylum Arthropoda, Class Arachnida Subclass Acari Mites and ticksa Eight, one globose body, no distinct headsb, no wings Order Araneae Spiders Eight, two, no wings Order Scorpiones Scorpions Eight, two, abdomens with terminal stingers aThe arthropod ectoparasites of major medical importance by taxonomic order and distinctive anatomic features. ectious Diseases and Their b f Mouthparts visible dorsally only in ixodid (hard) ticks. In I TABLE 291.2 Common Arthropod Ectoparasites (Excluding Ticks) and Clinical Manifestations Part II of Ectoparasitoses REPRESENTATIVE SPECIES OF COMMON NAMES OF MAJOR CLINICAL INFESTING ARTHROPOD INFESTING ARTHROPOD MANIFESTATIONS OF ECTOPARASITES ECTOPARASITE GEOGRAPHIC DISTRIBUTION ECTOPARASITOSES Class Insecta, Order Phthiraptera, Lice Suborder Anoplura Pediculus humanus corporis Body louse Worldwide Pediculosis corporis Pediculus humanus capitis Head louse Worldwide Pediculosis capitis, trench fever (Bartonella quintana) Phthirus pubis Crab (pubic) louse Worldwide Pediculosis pubis (phthiriasis) Order Diptera Flies Family Calliphoridae Screwworms Auchmeromyia senegalensis Congo floor-maggot fly Sub-Saharan Africa, Cape Verde Larvae are nocturnal blood feeders, no myiasis Islands (tissue invasion); wound (cutaneous) myiasis Callitroga americana American screwworm North and Central America Cavitary (invasive) myiasis Chrysomyia bezziana Old World screwworm Tropical Africa, Asia, Indonesia Cavitary (invasive) myiasis Cochliomyia hominivorax New World screwworm Central and South America Furuncular myiasis Cordylobia anthropophaga Tumbu (mango) fly Africa Furuncular myiasis Family Oestridae Botflies Cuterebra spp. Rodent botfly North and Central America Furuncular myiasis Dermatobia hominis Human botfly Central and South America Furuncular myiasis Order Siphonaptera Fleas Ctenocephalides spp. Cat (C. felis) and dog fleas Worldwide Bite groupings (mechanical vectors of dog and (C. canis) rat tapeworms, less efficient bubonic plague vectors) Pulex irritans Human flea Worldwide Bite groupings (efficient plague vector in Chilean Andes) Tunga penetrans Chigoe (jigger) flea Central and South America, Africa Tungiasis Europe, Asia
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