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Home , Cordylobia anthropophaga, Dehydroemetine, Gongylonema, Gongylonema pulchrum, Tick paralysis

Appendix I. Therapeutic Recommendations (Reprinted from The Medical Letter) The Medical Letter® On Drugs and Therapeutics

Published by The Medical Letter, Inc .• 1000 Main Street, New Rochelle, NY. 10801 • A Nonprofit Publication Vol. 35 (Issue 911) December 10, 1993

DRUGS FOR PARASITIC INFECTIONS

Parasitic infections are found throughout the world. With increasing travel, immigration, use of immunosuppressive drugs, and the spread of AIDS, physicians anywhere may see infections caused by previously unfamiliar parasites. The table below lists first-choice and alternative drugs for most parasitic infections. Adverse effects of drugs are listed on page 120. For information on the safety of antiparasitic drugs in pregnancy, see The Medical Letter Handbook of Antimicrobial Therapy, 1992, page 151.

DRUGS FOR TREATMENT OF PARASITIC INFECTIONS

Infection Drug Adult Dosage* Pediatric Dosage* AMEBIASIS () a.ymptomatlc Drug of choice: lodoquinol' 650 mg tid x 20d 30-40 mg/kg/d in 3 doses x 20d OR 25-30 mg/kg/d in 3 doses x 7d 25-30 mg/kg/d in 3 doses x 7d Alternative: furoate' 500 mg tid x 10d 20 mg/kg/d in 3 doses x 10d mild to mod.rat. Int•• tlnal dl••••• Drugs of choice:3 750 mg tid x 10d 35-50 mg/kg/d in 3 doses x 10d OR ' 2 grams/d x 3d 50 mg/kg (max. 2 grams) qd x 3d s.v.r. Int•• tlnal dis.as. Drugs of choice:3 Metronidazole 750 mg tid x 10d 35-50 mg/kg/d in 3 doses x 10d OR Tinidazole' 600 mg bid x 5d 50 mg/kg (max. 2 grams) qd x 3d Alternative: Dehydroemetine' 1 to 1.5 mg/kg/d (max. 90 mg/d) 1 to 1.5 mg/kg/d (max. 90 mg/d) 1M in 2 1M for up to 5d doses for up to 5d h.patlc .b.c••• Drugs of choice:3 Metronidazole 750 mg tid x 10d 35-50 mg/kg/d in 3 doses x 10d OR Tinidazole' 800 mg tid x 5d 60 mg/kg (max. 2 grams) qd x 3d Alternatives: Dehydroemetine' 1 to 1.5 mg/kg/d (max. 90 mg/d) 1 to 1.5 mg/kg/d (max. 90 mg/d) 1M in 2 1M for up to 5d doses for up to 5d follow.d by chloro• 600 mg base (1 gram)/d x 2d, 10 mg base/kg (max. 300 mg base)/d quine phosphate then 300 mg base (500 mg)/d x 2-3 wks x 2-3wks AMEBIC MENINGOENCEPHALITIS, PRIMARY

DrugN.·I1'er'. of choice: Amphotericin 85.8 1 mg/kg/d IV, uncertain duration 1 mg/kg/d IV, uncertain duration Acanthamoab. Drug of choice: See footnote 7

* The letter d stands for day. 1. Dosage and duration of administration should not be exceeded because of possibility of causing optic neuritis; maximum dosage is 2 grams/day. 2. In the USA, this drug is available from the CDC Drug Service, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; telephone: 404-1139-3670 (evenings, weekends, end holidays: 404-639-2888). 3. Treatment should be followed by a course of iodoquinol or one of the other intraluminal drugs used to treat asymptomatic amebiasis. 4. A nitro-imidazole similar to metronidazole, but not marketed in the USA; tinidazole appears to be at least as effective as metronidazole and better tolerated. , a similar drug, is also used outside the USA. 5. One patient with a Naaglaria infection was successfully treated with amphotericin 8, miconazole, and rifampin (JS Seidel et ai, N Engl J Med, 306:346, 1982). 6. An approved drug, but considered investigational for this condition by the U.S. Food and Drug Administration

EDITOR: Merk Abramowicz. M.D. EDITORIAL BOARD: Martin A. Rinck. M.D .• Ph.D., Consulting Editor, Rockef.ller Univ.; Jul •• Hirsch, M.D .• Rockef.ller Univ.; JIm •• D. Ken· ney. M.D .• Vele UnlV'. School of Med.; Lewll P. Rowlend. M.D., Coli. of PhYI .• Surg. of Columbia Unlv.; Finton SchaWnlr, M.D .• Mt. Sinai School of Med.; N.a' H. Stelgblg.', M.D .• Albert Einstein Call. of Med. ADVISORY BOARD: Martin D. AblloW. M.D., Johns Hopkins Uni"'; William T. ae."er, M.D .• Georgetown Univ. School 0' Med.; Alan J. Gelan• berg, M.D •• Univ. of Arizonl Health Sciencea Clnter; Louis S. Goodman, M.D .• Univ. of Utah Coli. of Med.; Philip D. Hanstan. Pharm. D.• Univ. of Washington: Gerhard L,vy. Pharm. D.• State Univ. of N.Y. at Buffalo; Gerald L. Mand,n. M.D., Univ. of Virginia School of Mad.; Dan M. Roden, M.D .• Vanderbilt School of Med.; F. Eat,nl R. Simons. M.D .• University of Manitoba; John H. Tinker. M.D .• Univ. of low. Call. of Med. ASSOCIATE EDITOR: Donna Goodatlln; ASSISTANT EDITOR: Am, Faucard PUBLISHER: C. J. 'arllins Founded 1969 by Arthur Kanet and Harold Aaron. M.D. Copyright" ,.13. The Medical Letter. Inc. (lSSN 0025·732X) Reprinted by permission of The Medical Letter, Copyright 1993. 288 Therapeutic Recommendations

Infection Drug Adult Dosage· Pediatric Dosage· Ant:y/ostoma duodena". see Anlllos"onllylus cantonens/s Drug of choice: Mebendazole'·... 100 rng bid x 5d 100 mg bid x 5d Anlliosuonllylus coster/cens/s Drug of choice: Thiabendazole'" 75 mg/kg/d in 3 doses x 3d (max. 75 mg/kg/d in 3 doses x 3d (max. 3 3 grams/d) '0 grams/d)'o ANISAKIASIS () Treatment of choice: Surgical or endoscopic removal (. roundworm) Drug of choice: Mebendazole 100 mg bid x 3d 100 mg bid x 3d OR Pyrantel pamoate 11 mg/kg once (max. 1 gram) 11 mg/kg once (max. 1 gram) OR 400 mg once 400 mg once () Drugs of choice:" Clindamycin' 1.2 grams bid parenteral or 600 20-40 rng/kg/d in 3 doses x 7d mg tid oral x 7d plus quinine 650 mg tid oral x 7d 25 mg/kg/d in 3 doses x 7d BALANTIDIASIS (Balantidium coli) Drug of choice: Tetracycline· 500 mg qid x 10d 40 mg/kg/d in 4 dosas x 10d (max. 2 grams/d)u Alternatives: 10doquinolU 650 mg tid x 20d 40 mg/kg/d in 3 doses x 20d Metronidazole' 750 mg tid x 5d 35-50 mg/kg/d in 3 doses x 5d BAYLISASCARIASIS ( procyon/s) Drug of choice: See footnote 13 BLASTOCYSTIS hominis infection Drug of choice: See footnote 14 (Capillaria philippinensis) Drug of choice: Mebendazole8 200 mg bid x 20d 200 mg bid x 20d Alternatives: Albendazole 200 mg bid x 10d 200 mg bid x 10d Thiabendazole· 25 mg/kg/d in 2 doses x 30d 25 mg/kg/d in 2 doses x 30d Ch.Da.· dl•••••• see TRYPANOSOMIASIS Clonorchis .Inens". see FLUKE infection CRYPTOSPORIDIOSIS (Cryptosporidium) Drug of choice: See footnote 15 CUTANEOUS MIGRANS (creeping eruption. dog and cat hookworm) Drug of choice:'8 Thiabendazole Topically and/or 50 mg/kg/d in 2 Topically and/or 50 mg/k~/d in 2 doses doses (max. 3 grams/d) x 2-5d'0 (max. 3 grams/d) x 2-5d 0 OR Albendazole17 200 mg bid x 3d 200 mg bid x 3d CYCLOSPORA infection 18 Drug of choice: Trimethoprim• TMP 160 mg. TMP 5 mg/kg. sulfamethoxa• SMX800 mg SMX 25 mg/kg zole'· bid x 3 days bid x 3 days

• The letter d stands for day. 7. Strains of Acanthamoeba isolated from fatal granulomatous amebic encephalitis are usually sensitive in vitro to pentamidine. ketoconazole (NizoralJ. flucytosine. and (less so) to amphotericin B (RJ Duma et al. Antimicrob Agents Chemother. 10:370. 1976). For treatment of keratitis caused by Acanthamoeba. concurrent topical use of 0.1% isethionate (Bro/ene - RhOne-Poulenc Rorer. Canade) plus neosporin. or oral itraconazole plus topical miconazole. have been successful (MB Moore and JP McCulley. Br J Ophthalmol. 73:271. 1989; V Ishibashi et al. Am J Ophthalmol. 109:121. 1990). Topical polyhex• amethylene biguanide has also been effective in a few patients with keratitis (JH Varga et al. Am J Ophthalmol. 115:466. 1993). 8. Effectiveness documented only in 9. Most patients recover spontaneously without antiparasitic drug therapy. Analgesics. corticosteroids. and careful removal of CSF at frequent intervals can relieve symptoms (J Koo et al. Rev Infect Dis. 10:1155. 1988). Albendazole. levamisole (Ergam• isol). or ivermectin has also been used successfully in animals. 10. This dosa is likely to be toxic end may have to be decreased. 11. Exchange transfusion has been used in severely ill patients with high (>10%) parasitemia (V lacopino and T Earnhart. Arch In• tern Med. 150:1527. 1990). One report indicates that azithromycin (Zithromax). 500-1000 mg daily. plus quinine may also be effective (LM Weiss et al. J Infect Dis. 168:1289. 1993). Concurrent use of pentamidine and trimethoprim-sulfamethoxazole has been reported to cura an infection with B. divergens (0 Raoult et al. Ann Intern Med. 107:944. 1987). 12. Not recommended for use in children less than eight years old. 13. Drugs that could be tried include diethylcarbamazine. levamisole. and fenbendazole (KR Kazacos. J Am Vat Med Assoc. 195:894. 1989) and ivermectin. Steroid therapy may be helpful. especially in eye or CNS infection. Ocular baylisascariasis has been treated successfully using laser therapy to destroy intraretinallarvae. 14. Clinical significance of these organisms is controversial. but metronidazole 750 mg tid x 10d or iodoquinol 650 mg tid x 20d anecdotally have been reported to be effective (I Grossman et al. Am J Gastroenterol. 87:729.1992; PFL Boreham and 0 Sten• zel. Adv Parasitol. 32:2. 1993). 15. Infection is self-limited in immunocompetent patients. In HIV-infected patients with large-volume intractable diarrhea. octreo• tide (Sandostatin) 300-500 (1g tid subcutaneously may control the diarrhea. but not the infection (JD Cello et al. Ann Intern Med. 115:705. 1991). Paromomycin may sometimes be helpful (K Armitaga et al. Arch Intern Med. 152:2497. 1992). In unpub• lished clinical trials. azithromycin. 1250 mg daily for two waeks followed by 500 mg daily. has apparently been effective in some patients. 16. Several reports suggest that ivermectin. 150-200 (1g/kg once. is also effective (E Caumes et al. Arch Dermatol. 128:994. 1992). 17. SK Jones et al. Br J Dermatol. 122:99. 1990; HD Davies et al. Arch Dermatol. 129:588. 1993 18. A newly described coccidian parasite. previously designated a cyanobacterium-like body. which causes severe self-limited diarrhea (YR Ortega et al. N Engl J Med. 328:1308.1993; RP Bendall et al. Lancet. 341:590.1993) Therapeutic Recommendations 289

Infection Drug Adult Dosage* Pediatric Dosage" . see TAPEWORM infection DIENTAMOEBA fragilis infection Drug of choice: lodoquinol' 650 mg tid x 20d 40 mg/kg/d in 3 doses x 20d OR Paromomycin 25-30 mg/kg/d in 3 doses x 7d 25-30 mg/kg/d in 3 doses x 7d OR Tetracycline6 500 mg qid x 10d 40 mg/kg/d (max. 2 grams/d) in 4 doses x 10d'2 latum. see TAPEWORM infection (guinea worm) infection Drug of choice: Metronidazole&.20 250 mg tid x 10d 25 mg/kg/d (max. 750 mg/d) in 3 doses x 10d Alternative: Thiabendazole6•2o 50-75 mg/kg/d in 2 dosas x 3d'o 50-75 mg/kg/d in 2 doses x 3d'o Echinococcus. see TAPEWORM infection Entamoeba hlstolytlca, see AMEBIASIS ENTAMOEBA polecki infection Drug of choice: Metronidazoles 750 mg tid x 10d 35-50 mg/kg/d in 3 doses x 10d ENTEROBIUS vermicularis () infection Drug of choice: Pyrantel pamoate 11 mg/kg once (max. 1 gram); re• 11 mg/kg once (max. 1 gram); repeat peat after 2 weeks after 2 weeks OR Mebendazole A single dose of 100 mg; repeat A single dose of 100 mg; repeat after 2 after 2 weeks weeks OR Albendazole 400 mg once; repeat in 2 weeks 400 mg once, repeat in 2 weeks , see FLUKE infection . Brugia malayl Drug of choice:2' Diethylcarbama- Day 1: 50 mg. Day 1: 1 mg/kg. zine22 oral, p.c. oral. p.c. Day 2: 50 mg tid Day 2: 1 mg/kg tid Day 3: 100 mg tid Day 3: 1-2 mg/kg tid Days 4 through 21: Days 4 through 21: 6 mg/kg/d in 3 doses23 6 mg/kg/d in 3 doses23 Drug of choice:2' Diethylcarbama• Day 1: 50 mg, Day 1: 1 mg/kg. zine22 oral. p.c. oral. p.c. Day 2: 50 mg tid Day 2: 1 mg/kg tid Day 3: 100 mg tid Day 3: 1-2 mg/kg tid Days 4 through 21: Days 4 through 21: 9 mg/kg/d in 3 doses23 9 mg/kg/d in 3 doses23 ozzardi Drug of choice: See footnote 25 Drug of choice: Mebendazole6 100 mg bid x 30d Tropical Pulmonary (TPE) Drug of choice: Diethylcarbamazine 6 mg/kg/d in 3 doses x 21d 6 mg/kg/d in 3 doses x 21d Drug of choice: Ivermectin2 150 Ilg/kg oral once, repeated 150 Ilg/kg oral once, repeated every 6 every 6 to 12 months to 12 months FLUKE. hermaphroditic, infection (Chinese ) Drug of choice: Praziquantel 75 mg/kg/d in 3 doses x 1d 75 mg/kg/d in 3 doses x 1d Fasciola hepatica (sheep liver fluke) Drug of choice:26 Bithionol2 30-50 mg/kg on alternate days x 30-50 mg/kg on alternate days x 10-15 10·15 doses doses

* The letter d stands for day. 19. G Madico et ai, Lancet, 342:122, 1993 20. Not curative, but decreases and facilitates removing the worm. Mebendazole 400-800 mg/d for 6d has been re• ported to kill the worm directly. 21. A single dose of ivermectin, 20-200 Ilg/kg. has been reported to be effective for treatment of microfilaremia (EA Ottesen et ai, N Engl J Med, 322:1113, 1990; M Sabry et ai, Trans R Soc Trop Med Hyg, 85:640, 1991; JW Mak et ai, Am J Trap Med Hyg, 48:591, 1993). 22. Antihistamines or corticosteroids may be required to decrease allergiC reactions due to disintegration of microfilariae in treat• ment of filarial infections, especially those caused by Loa lOB. 23. For patients with no microfilariae in the blood or skin, full doses can be given from day one. 24. Diethylcarbamazine should be administered with special caution in heavy infections with Loa loa because rapid killing of microfilariae can provoke an encephalopathy (B Carme et al. Am J Trop Med Hyg, 44:684, 1991). Ivermectin or albendazole has been used to reduce microfilaremia (V Martin-Prevel et ai, Am J Trop Med Hyg, 48:186, 1993; AD Klion et ai, J Infect Dis, 168:202. 1993). Apheresis has been reported to be effective in lowering microfilarial counts in patients heavily infected with Loa loa (EA Ottesen, Infect Dis Clin North Am, 7:619, 1993). Diethylcarbamazine, 300 mg once weekly, has been recommended for prevention of loiasis (TB Nutman et ai, N Engl J Med, 319:752, 1988). 25. Diethylcarbamazine has no effect. Ivermectin, 150 Ilg/kg. may be effective (TB Nutman et ai, J Infect Dis, 156:622, 1987). 26. Unlike infections with other flukes. hepatica infections may not respond to praziquantel. Limited data indicate that triclaben• dazole (Fasinexl. a veterinary fasciolide, is safe and effective in a single oral dose of 10 mg/kg (L Loutan et ai, Lancet, 2:383, 1989; U Bechtel et al. Dtsch Med Wochenschr. 117:978. 1992). 290 Therapeutic Recommendations

Infection Drug Adult Dosaga· Pediatric Dosage· FLUKE, hermaphroditic, infection (continued) busklllnt.stinal fluke) Drug of choice: Praziquantel8 75 mg/kg/d in 3 doses x ld 75 mg/kg/d in 3 doses x ld OR Niclosamide8 a singla dosa of " tablats (2 g), 11-3" kg: 2 tablets (1 g) chewed thoroughly >3" kg: 3 tablets (1.5 g) Heterophy_ heterophye. IInt.stlnal fluke) Drug of choice: Praziquantel8 75 mg/kg/d in 3 doses x ld 75 mg/kg/d in 3 doses x ld Metagonimus yokogawallintestinal fluke) Drug of choice: Praziquantel8 75 mg/kg/d in 3 doses x ld 75 mg/kg/d in 3 doses x ld Nanophyetus salmlncola Drug of choice: Praziquantel8 60 mg/kg/d in 3 doses x ld 60 mg/kg/d in 3 doses x ld Opl.thorchls "1"e,,lnllllv.r fluk.) Drug of choice: Praziquantel 75 mg/kg/d in 3 doses x ld 75 mg/kg/d in 3 doses x ld Paragonimus we.t.rmanillunll fluk.) Drug of choice: Praziquantel8 75 mg/kg/d in 3 doses x 2d 75 mg/kg/d in 3 doses x 2d Alternative:27 Bithionol2 30-50 mg/kg on alternate days x 30-50 mg/kg on alternate days x 10-15 10-15 doses doses GIARDIASIS (Giardia lamblia) Drug of choice: Metronidazole8 250 mg tid x 5d 15 mg/kg/d in 3 doses x 5d Alternatives:28 Quinacrine HCI 100 mg tid p.c. x 5d 6 mg/kg/d in 3 doses p.c. x 5d (max. 300 mg/d) Tinidazole4 2 grams onca 50 mg/kg once (max. 2 grams) Furazolidone 100 mg qid x 7-10d 6 mg/kg/d in " doses x 7-10d Paromomycin29 25-30 mg/kg/d in 3 doses x 7d ( spinigerum) Treatment of choice:3o Surgical removal plus Albendazole31 "00-800 mg qd x 21d (, ) Drug of choice: Mebendazole 100 mg bid x 3d 100 mg bid x 3d OR Pyrantel pamoate8 11 mg/kg (max. 1 gram) x 3d 11 mg/kg (max. 1 gram) x 3d OR Albendazole 400 mg once 400 mg once Hydatid cyst, see TAPEWORM infection , see TAPEWORM infection ISOSPORIASIS (Isospora belli) Drug of choice: Trimethoprim- 160 mg TMP. 800 mg SMX qid x sulfamethoxa• 1Od, then bid x 3 wks zole6•32 LEISHMANIASIS (L. mexican a, L. tropica, L. major, L. braziliensis, L. donovani [Kala-azar)) Drug of choice: Sodium stibo- 20 mg Sb/kg/d IV or 1M x 20-28d33 20 mg Sb/kg/d IV or 1M x 20-28d33 gluconate 2 OR Meglumine an• 20 mg Sb/kg/d x 20-28d 33 20 mg Sb/kg/d x 20-28d33 timon ate Alternatives:34 Amphotericin B6 0.25 to 1 mg/kg by slow infusion 0.25 to 1 mg/kg by slow infusion daily daily or every 2d for up to 8 wks or every 2d for up to 8 wks Pentamidine 2-4 mg/kg daily or every 2d 1M for 2-4 mg/kg daily or every 2d 1M for up isethionate8 up to 15 doses33 to 15 doses33

* The letter d stands for day. 27. Unpublished data indicate triclabendazole may be effective in a dosage of 5 mg/kg once daily for 3 days or 10 mg/kg twice in one day. 28. Albendazole 400 mg daily x 5d has also been reported to be highly effective against giardiasis (A Hall and Q Nahar, Trans R Soc Trop Med Hyg, 87:84, 1993). 29. Not absorbed and not highly effective, but may be useful for treatment of giardiasis in pregnancy 30. Ivermectin has been reported to be effective in animals (MT Anantaphruti et al. Trap Med Parasitol, 43:65. 1992). 31. P Kraivichian et ai, Trans R Soc Trap Med Hyg, 86:418,1992 32. In sulfonamide-sensitive patients, such as some HIV-infected patients, pyrimethamine 50-75 mg daily has been effective (LM Weiss et ai, Ann Intern Med, 109:474, 1988). In immunocompromised patients, it may be necessary to continue therapy indefinitely. 33. May be repeated or continued. A longer duration may be needed for some forms of visceral leishmaniasis. 34. Limited data indicate that ketoconazole, 400 to 600 mg daily for four to eight weeks, may be effective for treatment of cutane• ous and mucosal leishmaniasis (RE Saenz et ai, Am J Med, 89:147, 1990; V Ramesh et ai, Arch Dermatol, 128:411, 1992). Some studies indicate that L. donovani resistant to sodium stibogluconate or meglumine antimonate may respond to recombinant gamma interferon in addition to antimony (R Badaro and WD Johnson, J Infect Dis, 167 suppl 1:S13, 1993), pentami• dine followed by a course of antimony (CP Thakur et ai, Am J Trop Med Hyg, 45:435, 1991), or ketoconazole (JP Wali et ai, J In• fect Dis, 166:215, 1992). Liposomal encapsulated amphotericin B (AmBisome, Vestar, San Dimas, CAl has been used success• fully to treat multiple-drug-resistant visceral leishmaniasis (RN Davidson et ai, Lancet, 337:1061, 1991). Recently, aminosidine (parenteral paromomycin) plus sodium stibogluconate apparently decreased time to clinical and parasitological cure of vis• ceral leishmaniasis (J Seaman et ai, J Infect Dis, 168:715, 1993). 292 Therapeutic Recommendations

Infection Drug Adult Dosage* Pediatric Dosage* MALARIA. Tr.atm.nt of (continued) All Plasmodium .xc.pt Chloroquln.·r•• I.tant P. fa/clparum3• ORAL Drug of choice: Chloroquine 600 mg base (1 gram). then 300 10 mg base/kg (max. 600 mg base). phosphate52 •53 mg base (500 mg) 6 hrs later. then 5 mg base/kg 6 hrs later. then 5 then 300 mg base (500 mg) at 24 mg base/kg at 24 and 48 hrs and 48 hrs PARENTERAL Drug of choice:49 Quinidine gluco· same as above same as above nate50 OR Quinine dihydro· same as above same as above chloride5' Pr.v.ntlon of r.lap••• : P. vivax and P. oval. only Drug of choice: Primaquine 15 mg base (26.3 mgl/d x 14d or 0.3 mg base/kg/d x 14d phosphate54•56 45 mg base (79 mg)/Wk x 8 wks MALARIA. Pr.v.ntion of56•67 Chloroquln.·•• n.ltlv. ar.a. Drug of choice: Chloroquine 300 mg base (500 mg salt) orally. 5 mg/kg base (8.3 mg/kg salt) phosphate58 once/week69 once/week. up to adult dose of 300 mg base Chloroquln ••r.sl.tant ar•• s 38 Drug of choice: Mefloquineu.58.so 250 mg oral once/Week59 15·19 kg: Yo tablet 20·30 kg: Y, tablet 31·45 kg: % tablet >45 kg: 1 tablet OR Doxycycline68.s, 100 mg dailys, >8 years of age: 2 mg/kg/d orally. up to 100 mg/day Alternatives: Chloroquine same as above same as above phosphate68 plus pyrimetha· mine·sulfadoxine4o Carry a single dose (3 tablets) for <1 yr: Yo tablet for presumptive self·treatment of febrile illness 1·3 yrs: Y, tablet treatment when medical care is not im· 4·8 yrs: 1 tablet mediately available 9-14 yrs: 2 tablets or plus proguanilS2 200 mg dailys2 <2 yrs: 50 mg daily (in Africa south of 2-6 yrs: 100 mg daily the Sahara) 7-10 yrs: 150 mg daily >10 yrs: 200 mg daily

* The letter d stands for day. 52. If chloroquine phosphate is not available. hydroxychloroquine sulfate is as effective; 400 mg of hydroxychloroquine sulfate is equivalent to 500 mg of chloroquine phosphate. 53. In P. falciparum malaria. if the patient has not shown a response to conventional doses of chloroquine in 48-72 hours. parasi• tic resistance to this drug should be considered. P. vivax with decreased susceptibility to chloroquine has been reported from New Guinea (KH Rieckmann et al. Lancet. 2:1183.1989) and from Indonesia (lK Schwartz et al. N Engl J Med. 324:927.1991); a single dose of mefloquine. 15 mg/kg. has been recommended to treat these infections. 54. Some relapses have been reported with this regimen; relapses should be treated with chloroquine plus primaquine. 30 mg base/d x 14 days. 55. Primaquine phosphate can cause hemolytic anemia. especially in patients whose red cells are deficient in glucose-6-phosphate dehydrogenase. This deficiency is most common in African. Asian. and Mediterranean peoples. Patients should be screened for G·6-PD deficiency before treatment. Primaquine should not be used during pregnancy. 56. No drug regimen guarantees protection against malaria. If fever develops within a year (particularly within the first two months) after travel to malarious areas. travelers should be advised to seek medical attention. repellents. insecticide• impregnated bed nets. and proper clothing are important adjuncts for malaria prophylaxis. 57. In pregnancy. chloroquine prophylaxis has been used extensively and safely. but the safety of other prophylactic antimalarial agents in pregnancy is unclear. Therefore. travel during pregnancy to chloroquine-resistant areas should be discouraged. 58. For prevention of attack after departure from areas where P. vivax and P. ova/e are endemic. which includes almost all areas where malaria is found (except Haiti). some experts prescribe in addition primaquine phosphate 15 mg base (26.3 mgl/d or. for children. 0.3 mg base/kg/d during the last two weeks of prophylaxiS. Others prefer to avoid the of primaquine and rely on surveillance to detect cases when they occur. particularly when exposure was limited or doubtful. See also footnotes 54 and 55. 59. Beginning one week before travel and continuing weekly for the duration of stay and for four weeks after leaving. 60. The pediatric dosage has not been approved by the FDA. and the drug has not been approved for use during pregnancy. Women should take contraceptive precautions while taking mefloquine and for two months after the last dose. Mefloquine is not recommended for children weighing less than 15 kg. or for patients with cardiac conduction abnormalities. Patients with a history of seizures or psychiatric disorders and those whose occupation requires fine coordination or spatial discrimination should probably avoid mefloquine (Medical letter. 32:13. 1990). Resistance to mefloquine has been reported in some areas. such as Thailand; in these areas. doxycycline should be used for prophylaxis. 61. Beginning one day before travel and continuing for the duration of stay and for four weeks after leaving. Use of tetracyclines is contraindicated in pregnancy and in children less than eight years old. Doxycycline can cause gastrointestinal disturbances. vaginal moniliasis and photosensitivity reactions. 62. Proguanil (Paludrine - Ayerst. Canada; ICI. England). which is not available in the USA but is widely available overseas. is recommended mainly for use in Africa south of the Sahara. Prophylaxis is recommended during exposure and for four weeks afterwards. Failures in prophylaxis with chloroquine and proguanil have been reported in travelers to Kenya (AJ Barnes. lan• cet. 338:1338. 1991). Therapeutic Recommendations 293

Infection Drug Adult Dosage- Pediatric Dosage- MICROSPORIDIOSIS Ocular (Encephalitozoon hellem, Nosema corneum) Drug of choice: See footnote 63 Intestinal (Enterocytozoon bieneusi, Septata intestinalis) Drug of choice: See footnote 64 Disseminated (Encephalitozoon hellem, Encephalitozoon cuniculi Pleistophora sp.) Drug of choice: See footnote 65 Mites, see MONILIFORMIS moniliformis infection Drug of choice: Pyrantel pamoate6 11 mg/kg once, repeat twice, 2 11 mg/kg once, repeat twice, 2 wks wks apart apart Naeg/eria , see AMEBIC MENINGOENCEPHALITIS, PRIMARV Necator amer/canus, see HOOKWORM infection Oesophagostomum bilurcum Drug of choice: See footnote 66 Onchocerca volvulus, see FILARIASIS , see FLUKE infection Paragonimus westermanl, see FLUKE infection Pediculus capitis, humanus, Phthirus pubis, see LICE Pinworm, see ENTEROBIUS PNEUMOCYSTIS carinii pneumonia67 Drug of choice: Trimethoprim- sul- TMP 15-20 mg/kg/d, SMX 75-100 Same as adult dose famethoxazole mg/kg/d, oral or IV in 3 or 4 doses x 14-21d OR Pentamidine 3-4 mg/kg IV qd x 14-21 days Same as adult dose Alternatives:B8 TrimethoprimB 5 mg/kg PO q6h x 21 days plus dapsoneB•B9 100 mg PO qd x 21 days Atovaquone70 750 mg tid PO x 21 d PrimaquineB,55 15 mg base PO qd x 21 days plus clindamycin6 600 mg IV q6h x 21 days, or 300-450 mg PO q6h x 21 days 45 mg/m2 IV qd x 21 days plus folinic acid 20 mg/m2 PO or IV q6h x 21 days Primary and secondary prophylaxis Drug of Choice: Trimethoprim- 1 OS tab PO qd or 3x/Week sulfamethoxazole Alternatives: DapsoneB,B9 25-50 mg PO qd, or 100 mg PO 2x/week Aerosol pentami• 300 mg inhaled monthly via dine Respirgard 1/ nebulizer or Sys• tem 22 Mizer Jet Nebulizer

* The letter d stands for day. 63. Ocular lesions due to E. hel/em in HIV-infected patients have responded to eyedrops prepared from Fumidil-B, a commercial product used to control a microsporidial disease of honey bees, available from Mid-Continent Agrimarketing, Inc., Lenexa, Kansas 66215 (MC Diesenhouse, Am J Ophthalmol, 115:293, 1993). Fumagillin from other sources has also been used successfully (OF Rosberger et ai, Cornea, 12:261, 1993). In one report, a keratopathy due to E. hellem in an HIV-infected pa• tient was treated successfully with surgical debridement, topical antibiotics, and itraconazole (RW Vee et ai, Ophthalmology, 98:196, 1991). For lesions due to N. corneum, topical therapy is generally not effective and keratoplasty may be required (RM Davis et ai, Ophthalmology, 97:953, 1990). 64. Octreotide (Sandostatin) has provided symptomatic relief of E. bieneusi infection (JP Cello et ai, Ann Intern Med, 115:705, 1991). Albendazole, 400 mg b.i.d., may be helpful for E. bieneusi (DT Dieterich et ai, J Infect Dis, 1994, in press) and can cure S. intestinalis (C Blanshard et ai, AIDS, 6:311,1992). 65. No established treatment 66. Albendazole or pyrantel pamoate may be effective (HP Krepel et ai, Trans R Soc Trop Med Hyg, 87:87, 1993). 67. HIV-infected patients should be treated for 21 days. In severe disease with room air P02 s: 70 mmHg or Aa gradient ~ 35 mmHg, prednisone should also be used (Medical Letter, 35:79, 1993). 68. For patients who have failed or are intolerant to standard therapy. 69. Assay for G-6-PD deficiency recommended before therapy. 70. Recommended in mild to moderate disease (room air P02 > 60 mmHg) (W Hughes, N Engl J Med, 328:1521, 1993). 294 Therapeutic Recommendations

Infection Drug Adult Do ••g.- Pedietrlc Do ••g.- Roundworm•••• ASCARIASIS SCABES (Sarcopt.. sc.blel} Drug of cholc.: 5% P.rrnethrln Toplcilly Toplc.lly AIt.metlves: Llnd.n." Toplcilly Toplc.lly 10% Crot.mlton Topically Toplc.lly (Sf/hanlas/s} S. h_lIfrIblum Drug of cholc.: Pr.zlqu.nt.1 40 mglkg/d In 2 do••• x 1d 40 mglkg/d In 2 do... x 1d S./epo"lcum Drug of cholc.: Pr.zlqu.nt.1 60 mglkg/d In 3 do... x 1d 60 mglkgld In 3 do••• x 1d S. ma"so,,1 Drug of cholc.: Pr.zlqu.nt.1 40 mglkgld In 2 do... x 1d 40 mglkgld in 2 do... x 1d AIt.metlve: Ox.mnlquln.71 15 mglkg onc.7I 20 mglkg/d In 2 do... x 1d7Z

DrugS. ""'''.' of cholc.: Pr.zlqu.nt.1 60 mglkgld In 3 do••• x 1d 60 mglkg/d In 3 do••• x 1d S .....ln •• Iolm_ •••• TRYPANOSOMIASIS (Strongylold.. stercora"s} Drug of cholc.:71 Thl.b.ndazol. 60 mglkgld In 2 do•• a Im.x. 3 50 mglka/d In 2 do... Im.x. 3 gr.m./dl grams Idl x 2d'D.u x 2d10•ii OR Iv.rmectln71 200 "glkgld x 1-2d TAPEWORM Infection - Adult (lntestln.1 et••• , DIphyllobothrium lRum IfI.hl. THIll. s ••'nate Ibeefl. T_I. sollum Iporkl. DipylidIum ca,,/num Ido., Drug of cholc.: Pr.ziqu.nt.11 5-10 mglkg onc. 5-10 mglkg once OR Nlclo•• mld. A .Ingl. do•• of 4 tablet. 12 11-34 kg: ••Ingle do•• of 2 t.blets 11 gram.', ch.w.d thoroughly gr.ml; >34 kg: ••ingle do.e of 3 ta• blet. 11.5 gl Hymeno/.",. nan. Idwarf t.p_orml Drug of cholc.: Pr.zlqu.nt.11 25 mglkg one. 25 mglkg once Alt.m.tlv.: Nlclo•• mld. A .Ingl. d.ily do•• of 4 tablet. 12 11-34 kg: a .ingl. dose of 2 tablet. 11 gl, ch_.d thoroughly, th.n 2 gl x 1d, th.n 1 t.blet 10.5 gr.msl/d x t.blets d.ily x 6d 6d; >34 kg: ••Ingle do.e of 3 tablets 11.5 g) x 1d, then 2 t.blet. 11 gild x6d - L.rv.1 It".u. eta•• ' EchInococcus .r.nulosus Ihydatld cyetl Drug of cholc.: Alb.nd.zol.7 ••77 400 mg bid x 28 d.y., r.p•• ted •• 15 mglkg/d x 28 days, repe.ted a. nec•••• ry nec.... ry EchInococcus multlloculerle Tr•• tm.nt of cholc.: S •• footnote 78 Cptlnn:us cellvl_ Icyetl... o.'" Drug of choic.:78 Alb.nd.zol." 15 mglkgld in 3 do••• x 28d, re• 15 mglkg/d in 3 do.es x 28d, repeated peated •• nec.ss.ry as nece.s.ry OR Pr.ziqu.nt.11 50 mglkg/d in 3 dose. x 15d 50 mglkg/d In 3 do.es x 15d Alt.rn.tlv.: Surg.ry Toxoc.rl•• I ••• ee TOXOPLASMOSIS (Toxopla.ma gondiiJ" Drug. of cholce:'z Pyrim.thamine 25-100 mgld x 3-4 wk. 2 mglkg/d x 3d, then 1 mglkg/d Imax. 25 mg/d) x 4 wk.a3 plu•• ulf.dl.zine a4 1-2 grams qld x 3-4 wks 100-200 mglkg/d x 3-4 wks Altern.tlv.: Splr.mycln88 3-4 grams/d 50-100 mglkg/d x 3-4 wks (Trichlne"a splra"s} Drug. of choice: Steroid. for s.vere .ymptom. plu. meb.nd.zole··.. 200-400 mg tid x 3d, then 400-500 mg tid x 10d

- Th. letter d .t.nd. for d.y.. 71. Neurop.ychl.trlc di.turbances .nd .eizur•• have been reported In some patient. IH Stokvl. et .1, Am J Trap Med Hyg, 35:330, 19861. 72. In E.st Afric., the do.e .hould be Increa.ed to 30 mglkg, and in Egypt and South Afrlc., 30 mg/kg/d x 2d. Some exp.rts recommend 40-60 mglkg over 2-3 d.ys In.II of AfricalKC Sh.khar, Drugs, 42:379,19911. 73. In Immunocomproml.ed p.tlent. it m.y be nece•• ary to contlnu. th.rapy or u.e other ag.nt•. 74. In di.seminet.d .trongyloldl•• I., thlabend.zole therapy should be continued for et I.ast five d.ys. 75. C N.qulr. et ai, Am J Trap Med Hyg, 40:304,1989; M Ly.goubl et ai, Tr.n. R Soc Trap Med Hyg, 86:541,1992 76. With. f.tty me.1 to .nh.nc•• b.orptlon. Some petlent. may benefit from or require .urglc.1 re•• ction of cyst. IRK Tompkin., M.yo CUn Proc, 66:1281, 19911. Pr.ziqu.ntel m.y .Iso be u.eful preoperetively or in ca.e of spill during surgery. 77. Recently, percut.neou. dr.ln.ge with ultr•• ound guidance plu. albend.zol. therapy h •• been effective for management of h.p.tlc hyd.tld cyet dl..... IMS Khuroo et .1, G•• troenterology, 104:1452, 19931. 78. Surgical excl.ion i. the only r.li.bl. me.n. of treatment, although .ome reports h.ve .uggested use of albendazol. or meben• d.zol. IJF WiI.on et .1, Am J Trap Med Hyg, 37:162, 1987;.A D.vl. et .1, Bull WHO, 64:383, 19861. 79. Cortico.teroid•• hould b. given for two to thr.. d.ys before .nd during drug ther.py for neurocystlcercosl.. Any cysticerco• cid.1 drug m.y c.u.e Irrep.r.ble d.m.ge when u.ed to tr.at ocul.r or spinal cyst., even when cortico.teroids .re u ••d. 80. Alb.nd.zol. should b. tak.n with a f.tty m ••1 to .nhance absorption. 81. In ocular toxopla.mo.i., cortlco.t.roids should .Iso be us.d for an antl-infl.mm.tory .ff8ct on the .y••. Therapeutic Recommendations 295

Infection Drug Adult Dosage· Pediatric Dosage· TRICHOMONIASIS (Trichomonas vaginalis} Drug of choice:87 Metronidazole 2 grams once or 250 mg tid orally 15 mglkg/d orally in 3 doses x 7d x 7d OR Tinidazole' 2 grams once 50 mglkg once (max. 2 grams) infection Drug of choice: Pyrantel pamoate5 11 mglkg once (max. 1 gram) 11 mglkg once (max. 1 gram) Alternative: Mebendazole5 100 mg bid x 3d 100 mg bid x 3d OR Albendazole 400 mg once 400 mg once (. whipworm) Drug of choice: Mebendazole 100 mg bid x 3d 100 mg bid x 3d OR Albendazole 400 mg once" 400 mg once88 TRYPANOSOMIASIS T. cruzl (South Am.rlc.n trypano.oml•• I •• Ch.II ••• dl••••• ) Drug of choice: Nifurtimox2.B9 8-10 mglkg/d orally in 4 doses x 1-10 yrs: 15-20 mglkg/d in 4 doses x 120d 90d; 11-16 yrs: 12.5-15 mglkg/d in 4 doses x 90d Alternative: Benznidazole'o 5-7 mglkg/d x 30-120d T. bruc.1 "amblan.a; T. b. rhod,,/an.a (Afrlc.n tryp.no.oml•• I •••I ••plnll .Icknn.' hemolymph.tlc .t.lI. Drug of choice: Suramin2 100-200 mg (test dose) IV. then 1 20 mglkg on days 1,3,7,14. and 21 gram IV on days 1.3.7.14. and 21 OR Eflornithine See footnote 91 Alternative: Pentamidine 4 mglkg/d 1M x 10d 4 mglkg/d 1M x 10d isethionate8 I.te dl••••• with CNS Involv.m.nt Drug of choice: Melarsoprol2•92 2-3.6 mglkg/d IV x 3 d; after 1 wk 18-25 mglkg total over 1 month; initial 3.6 mglkg per day IV x 3d; repeat dose of 0.36 mglkg IV. increasing gra• again after 10-21 days dually to max. 3.6 mglkg at intervals of 1-5d for total of 9-10 doses OR Eflornithine See footnote 91 Alternatives: Tryparsamide One injection of 30 mglkg (max. 2g) IV every 5d to total of 12 in• jections; may be repeated after 1 month plu. suramin2 One injection of 10 mglkg IV every 5d to total of 12 injections; may be repeated after 1 month VISCERAL LARVA MIGRANS93 Drug of choice: Diethylcarbamazine8 6 mglkg/d in 3 doses x 7-10d 6 mglkg/d in 3 doses x 7-10d Alternatives: Albendazole" 400 mg bid x 3-5d 400 mg bid x 3-5d Mebendazolel.95 100-200 mg bid x 5d Whipworm. see TRICHURIASIS Wucharer/a bancroftl, see FILARIASIS

• The letter d stands for day. 82. Pyrimethamine is teratogenic in animals. To prevent hematological toxicity from pyrimethamine. it is advisable to give leuco• vorin (folinic acid). about 10 mg/day. either by injection or orally. To treat CNS toxoplasmosis in HIV-infected patients. some clinicians use pyrimethamine 50 to 100 mg daily after a loading dose of 200 mg with a sulfonamide and. when sulfonamide sensitivity developed. have given clindamycin 1.8 to 2.4 g/d in divided doses instead of the sulfonamide (JS Remington et ai, Lancet. 338:1142. 1991; BJ Luft et al. N Engl J Med. 329:995. 1993). Atovaquone. 750 mg qid. appears to be an effective alterna• tive in sulfa-intolerant patients (JA Kovacs et al. Lancet. 340:637, 1992). Dapsone-pyrimethamine can prevent first episodes of toxoplasmosis (P-M Girard et al. N Engl J Med. 328:1514. 1993). In HIV-infected patients. chronic suppr8Ssiva treatment should continue indefinitely (Medical Letter. 35:79. 1993). 83. Congenitally infected newborns should be treated with pyrimethamine every two or three days and a sulfonamide daily for about one year (JS Remington and G Desmonts in JS Remington and JO Klein. eds. Infectious Disease of the Fetus and Newborn Infant, 3rd ed. Philadelphia:Saunders. 1990. page 89). 84. Available temporarily from the CDC. 404-488-4928. 85. For use during pregnancy. continue the drug until delivery. 86. Albendazole or flubendazole (not available in the USA) may also be effective. 87. Sexual partners should be treated simultaneously. Outside the USA. ornidazole has also been used for this condition. Metronidazole-resistant strains have been reported; higher doses of metronidazole for longer periods are sometimes effective against these strains (J Lossick. Rev Infect Dis. 12:5665. 1990). 88. In heavy infection it may be necessary to extend therapy for 3 days. 89. The addition of gamma interferon to nifurtimox for 20 days in a limited number of patients and in experimental animals ap• pears to have shortened the acute phase of Chagas' disease (RE McCabe et al. J Infect Dis. 163:912. 1991). 90. Limited data 91. In T. b. gambiense infections, eflornithine is highly effective in both the hemolymphatic and CNS stages. Its effectiveness in T. b. rhodesiense infections has been variable. Some clinicians have given 400 mglkg/d IV in 4 divided doses for 14 days. fol• lowed by oral treatment with 300 mglkg/d for 3-4 wks (F Milord et al. Lancet. 340:652. 1992). 92. In frail patients. begin with as little as 18 mg and increase the dose progressively. Pretreatment with suramin has been advo• cated for debilitated patients. Corticosteroids have been used to prevent arsenical encephalopathy (J Pepin et al. Lancet. 1:1246.1989). 93. For severe symptoms or eye involvement. corticosteroids can be used in addition. 94. 0 StOrchler et ai, Ann Trap Med Parasitol. 83:473. 1989 95. One report of a cure using 1 gram tid for 21 days has been published (A Bekhti. Ann Intern Med. 100:463. 1984). 296 Therapeutic Recommendations

MANUFACTURERS OF ANTIPARASITIC DRUGS

* albendazole - Zentel (SmithKline Beecham) ** ornidazole - Tiberal (Hoffman-LaRoche, Switzerland) atovaquone - Mepron (Burroughs-Wellcome) oxamniquine - Vansil (Pfizer) ** benznidazole - Rochagan (Roche, Br87i1) paromomycin - Humatin (Parke-Davis) t bithionol - Bitin (Tanabe, Japan) pentamidine isethionate - Pentam 300 (Fujisawa), Nebu• chloroquine - Ara/en (Sanofi Winthrop), others Pent (Fujisawa) crotamiton - Eurax (Westwood-Squibb) permethrin - Nix (Burroughs Wellcome), Elimite t dehydroemetine - (Hoffmann-LaRoche, Switzerland) (Herbert) * diethylcarbamazine - Hetrazan (Lederle), others praziquantel - Biltricide (Miles) t diloxanide furoate - Furamide (Boots, England) primaquine phosphate - (Sanofi Winthrop) * eflornithine (difluoromethylornithine, DFMO) - Ornidyl ** proguanil - Paludrine (Ayerst, Canada, ICI, England) (Merrell Dow) pyrantel pamoate - Antiminth (Pfizer) ** flubendazole - (Janssen) pyrethrins and piperonyl butoxide - RID (Pfizer), others furazolidone - Furoxone (Roberts) pyrimethamine - Daraprim (Burroughs Wellcome) ** halofantrine - Halfan (SmithKline Beecham) pyrimethamine-sulfadoxine - Fansidar (Roche) hydroxychloroquine - Plaquenil (Sanofi Winthrop) ** quinacrine - Atabrine (Sanofi Winthrop) iodoquinol (diiodohydroxyquin) - Yodoxin (Glenwood). quinidine gluconate - (Lilly) others ** quinine dihydrochloride t ivermectin - Mectizan (Merck) quinine sulfate - many manufacturers lindane (gamma benzene hexachloride) - Kwel/ (Reed & t sodium stibogluconate (antimony sodium gluconate) - Carnrick), others Pentostam (Burroughs Wellcome, England) malathion - Ovide (GenDerm) * spiramycin - Rovamycine (Rh6ne-Poulenc Rorer) mebendazole - Vermox (Janssen) t suramin - Germanin (Bayer, Germany) mefloquine - Lariam (Roche) thiabendazole - Mintezol (Merck) ** meglumine antimonate - Glucantime (Rh6ne-Poulenc ** tinidazole - Fasigyn (Pfizer) Rorer, France) ** triclabendazole (Ciba-Geigy) t melarsoprol - Arsobal (Rhone Poulenc Rorer, France) *trimetrexate - (US Bioscience) metronidazole - Flagyl (Searle), others ** tryparsamide niclosamide - Niclocide (Miles) t nifurtimox - Lampit (Bayer, Germany)

• Available in the USA only from the manufacturer ** Not available in the USA t Available from the CDC Drug Service, Centers for Disease Control and Prevention. Atlanta. Georgia 30333; 404-639-3670 (evenings. weekends. or holidays: 404-639-2888) * Available from the National Institute of Allergy and Infectious Diseases. 1-800-537-9978

ADVERSE EFFECTS OF SOME ANTIPARASITIC DRUGS*

ALBENDAZOLE (Zentel) mucus membranes; -type deafness; peripheral neuro• Occasional: diarrhea; abdominal pain; migration of ascaris pathy and myopathy; heart block; blood dyscrasias; hema• through mouth and nose temesis Rare: leukopenia; alopecia; increased serum transaminase activity CROTAMITON (Eurax) Occasional: rash; conjunctivitis ATOVAQUONE (Mepron) Frequent: rash, nausea DEHYDROEMETINE Occasional: diarrhea Frequent: cardiac arrhythmias; precordial pain; muscle weakness; cellulitis at site of injection BENZNIDAZOLE (Rochagan) Occasional: diarrhea; vomiting; peripheral neuropathy; Frequent: allergic rash; dose-dependent polyneuropathy; heart failure; headache; dyspnea gastrointestinal disturbances; psychic disturbances DIETHYLCARBAMAZINE CITRATE USP (Hetrazan) BITHIONOL (Bitin) Frequent: severe allergic or febrile reactions in patients Frequent: photosensitivity reactions; vomiting; diarrhea; with microfilariae in the blood or the skin; GI disturbances abdominal pain; urticaria Rare: encephalopathy Rare: leukopenia; toxic hepatitis DILOXANIDE FUROATE (Furamide) CHLOROQUINE HCI and CHLOROQUINE PHOSPHATE (Aralen, Frequent: flatulence and others) Occasional: nausea; vomiting; diarrhea Occasional: pruritus; vomiting; headache; confusion; depig• Rare: diplopia; dizziness; urticaria; pruritus mentation of hair; skin eruptions; corneal opacity; weight loss; partial alopecia; extraocular muscle palsies; exacerba• EFLORNITHINE (Difluoromethylornithine, DFMO, Ornidyf) tion of psoriasis, eczema, and other exfoliative dermatoses; Frequent: anemia; leukopenia myalgias; photophobia Occasional: diarrhea; thrombocytopenia; seizures Rare: irreversible retinal injury (especially when total Rare: hearing loss dosage exceeds 100 grams); discoloration of nails and FLUBENDAZOLE - similar to mebendazole Therapeutic Recommendations 297

FURAZOLIDONE (Furoxon6) NIFURTIMOX (Lampit) Frequent: naUS6a; vomiting Frequent: anorexia; vomiting; weight loss; loss of memory; Occasional: all6rgic reactions, including pulmonary sleep disorders; tremor; paresthesias; weakness; polyneu• infiltration, hypotension, urticaria, fever, vesicular rash; ritis hypoglycemia; headache Rare: convulsions; fever; pulmonary infiltrates and pleural Rare: hemolytic anemia in G-6-PD deficiency and neonates; effusion disulfiram-like reaction with ; MAO-inhibitor interac• tions; polyneuritis ORNIDAZOLE (Tib6ra/) Occasional: dizziness; headache; gastrointestinal distur• HALOFANTRINE (Halfan) bances Occasional: diarrhea; abdominal pain; pruritus; prolonga• Rare: reversible peripheral neuropathy tion of QTc and PR interval OXAMNIQUINE (Vansi/) IODOQUINOL (Yodoxin) Occasional: headache; fever; dizziness; somnolence; Occasional: rash; acne; slight enlargement of the thyroid nausea; diarrhea; rash; insomnia; hepatic enzyme changes; gland; nausea; diarrhea; cramps; anal pruritus ECG changes; EEG changes; orange-red discoloration of Rare: optic neuritis; optic atrophy, loss of vision, peripheral urine neuropathy after prolonged use in high dosage (for Rare: seizures; neuropsychiatric disturbances months); iodine sensitivity PAROMOMYCIN (Aminosidine; Humatin) IVERMECTIN (Mectizan) Frequent: GI disturbances Occasional: Mazzotti-type reaction seen in , Occasional: eighth-nerve damage (mainly auditory); renal including fever, pruritus, tender lymph nodes, headache, damage and joint and bone pain PENTAMIDINE ISETHIONATE (Pentam 300, NebuPent) Rare: hypotension Frequent: hypotension; hypoglycemia often followed by diabetes mellitus; vomiting; blood dyscrasias; renal dam• LINDANE (Kwell, and others) age; pain at injection site; GI disturbances Occasional: eczematous rash; conjunctivitis Occasional: may aggravate diabetes; shock; hypocalcemia; Rare: convulsions; aplastic anemia liver damage; cardiotoxicity; delirium; rash Rare: Herxheimer-type reaction; ; acute pan• MALATHION (Ovide) creatitis; hyperkalemia Occasional: local irritation

PERMETHRIN (Nix, Elimite) MEBENDAZOLE (Vermox) Occasional: burning; stinging; numbness; increased pru• Occasional: diarrhea; abdominal pain; migration of ascaris ritus; pain; edema; erythema; rash through mouth and nose Rare: leukopenia; agranulocytosis; hypospermia PRAZIQUANTEL (8iltricide) Frequent: malaise; headache; dizziness MEFLOQUINE (Lariam) Occasional: sedation; abdominal discomfort; fever; sweat• Frequent: vertigo; lightheadedness; nausea; other gastroin• ing; nausea; eosinophilia; fatigue testinal disturbances; nightmares; visual disturbances; Rare: pruritus; rash headache Occasional: confusion PRIMAQUINE PHOSPHATE USP Rare: psychosis; hypotension; convulsions; coma; Frequent: hemolytic anemia in G-6-PD deficiency paresthesias Occasional: neutropenia; GI disturbances; methemoglo• binemia in G-6-PD deficiency MEGLUMINE ANTIMONATE (Glucantime) Similar to sodium Rare: CNS symptoms; hypertension; arrhythmias stibogluconate PROGUANIL (Paludrine) MELARSOPROL (Arsoba/) Occasional: oral ulceration; hair loss; scaling of palms and Frequent: myocardial damage; albuminuria; hypertension; soles; urticaria colic; Herxheimer-type reaction; encephalopathy; vomiting; Rare: hematuria (with large doses); vomiting; abdominal peripheral neuropathy pain; diarrhea (with large doses); thrombocytopenia Rare: shock PYRANTEL PAMOATE (Antiminth) METRONIDAZOLE (Flagyl, and others) Occasional: GI disturbances; headache; dizziness; rash; Frequent: nausea; headache; dry mouth; metallic taste fever Occasional: vomiting; diarrhea; insomnia; weakness; stoma• titis; vertigo; paresthesias; rash; dark urine; urethral burn• PYRETHRINS and PIPERONYL BUTOXIDE (RID, others) ing; disulfiram-like reaction with alcohol Occasional: allergic reactions Rare: seizures; encephalopathy; pseudomembranous colitis; ; leukopenia; peripheral neuropathy; pancreatitis PYRIMETHAMINE USP (Oaraprim) Occasional: blood dyscrasias; folic acid deficiency NICLOSAMIDE (Niclocide) Rare: rash; vomiting; convulsions; shock; possibly pul• Occasional: nausea; abdominal pain monary eosinophilia; fatal cutaneous reactions with pyrimethamine-sulfadoxine (Fansidar)

* Drug interactions are generally not included here; see the current edition of The Medical Letter Handbook of Adverse Drug Interactions. 298 Therapeutic Recommendations

QUINACRINE HCI USP (Atabrine) SURAMIN SODIUM (Germanin) Frequent: dizziness; headache; vomiting; diarrhea Frequent: vomiting; pruritus; urticaria; paresthesias; Occa.lonal: yellow staining of skin; toxic psychosis; insom• hyperesthesia of hands and feet; photophobia; peripheral nia; bizarre dreams; blood dyscrasias; urticaria; blue and neuropathy black nail pigmentation; psoriasis-like rash Occa.ional: kidney damage; blood dyscrasias; shock; optic Rare: acute hepatic necrosis; convulsions; severe exfolia• atrophy tive dermatitis; ocular effects similar to those caused by chloroquine THIABENDAZOLE (Mintezol) Frequent: nausea; vomiting; vertigo QUININE DIHVDROCHLORIDE and SULFATE Occasional: leukopenia; crystalluria; rash; hallucinations; Frequent: (tinnitus, headache, nausea, abdomi• olfactory disturbance; erythema multiforme nal pain, visual disturbance) Rare: shock; tinnitus; intrahepatic cholestasis; convulsions; Occa.lonal: deafness; hemolytic anemia; other blood dys• angioneurotic edema; Stevens-Johnson syndrome crasias; photosensitivity reactions; hypoglycemia; arrhyth• mias; hypotension; drug fever TINIDAZOLE (Fasigyn) Rare: blindness; sudden death if injected too rapidly Occasional: metallic taste; nausea; vomiting; rash

SODIUM STIBOGLUCONATE (Pentostam) TRIMETREXATE (with "leucovorin rescue") Frequent: muscle pain and joint stiffness; nausea; transam• Occasional: rash; peripheral neuropathy; bone marrow inase elevations; T-wave flattening or inversion depression; increased serum aminotransferase concentra• Occastonal: weakness; colic; liver damage; bradycardia; leu• tions kopenia Rare: diarrhea; rash; pruritus; myocardial damage; hemo• TRVPARSAMIDE lytic anemia; renal damage; shock; sudden death Frequent: nausea; vomiting Occa.ional: impaired vision; optic atrophy; fever; exfoliative SPIRAMVCIN (Rovamycine) dermatitis; allergic reactions; tinnitus Occa.ional: GI disturbances Rare: allergic reactions

* Drug interactions are generally not included here; see the Cllrrent edition of The Medical Letter Handbook of Adverse Drug Interactions.

THE MEDICAL LETTER® (lSSN 0025-732X) is published and printed in the USA bi-weeklv bV The Medical Letter. Inc., a non-profit corporation. Secol)d• class postage paid at New Rochelle, N.Y.. and at additional mailing otlices. POSTMASTER: Send address changes to THE MEDICAL LETTER at 1000 Main Street, New Rochelle, N.Y. 10801-7537. Subscription fees: 1 vear, 537.50: 2 vears, 561.00; 3 vears, 583.50 (518.75 - U.S. Funds - par vaar for indivi• dual subscriptions to students, interns. residents, and fellows in the USA and Canada; special fees for bulk orders). Subscriptions are accepted with the understanding that no part of the materia' may be reproduced or transmitted by any process in whole or in part without prior permisSion in writing. Appendix II. Procedures Suggested for Examining Clinical Specimens for Agents of Parasitic Diseases *

There is no general agreement about diagnostic ation cannot be carried out, formed speci• laboratory procedures in clinical parasitology. mens may be refrigerated for 1-2 days. Certain minimum standards have been estab• 3. If specimens are delayed in reaching the lab• lished and employ techniques that can be used oratory or if they cannot be examined even in small clinical laboratories. However, promptly (such as those received at night, technicians who are not experienced in diagnos• on weekends, or when no parasitologist is tic parasitology and who do not have frequent available), portions should be preserved in exposure to these techniques will not be able to fixatives such as 8% aqueous formalin or carry out these tests reliably. It is far better formol-saline or with and polyvinyl alcohol under such circumstances to utilize the re• (PVA). Formalin preserves cysts, eggs and sources of regional reference laboratories. larvae for subsequent wet-mount examina• Nevertheless, small laboratories can be helpful tion or for concentration tests; PVA-fixa• in situations when speed is of the essence, as, tive preserves trophozoites, cysts, and eggs for example, when making the diagnosis of ma• for subsequent permanent staining. A ratio laria. A permanent collection of identified of one part offeces to three parts of fixative stained fecal and blood smears, as well as forma• is recommended. The specimen may be linized specimens of adult worms, eggs, larvae, placed in fixatives in the laboratory, or the and cysts, may be purchased initially and added patient may be provided with fixatives and to over the years, to be used as reference ma• instructions for collection and preservation terial. of his or her own specimens.

Collection of Stool Specimens Methods of Stool Examination Collection of satisfactory specimens is essential and Related Procedures for reliability, whether the tests are done locally or elsewhere. The following procedures are sug• Stool specimens may be examined by the three gested for proper collection of stool specimens: complementary methods listed below. The ad• vantages and limitations of each technique must 1. Fresh, unpreserved feces should be ob• be recognized. tained and transported to the laboratory im• mediately. Fresh specimens are preferred 1. Saline mounts are of value primarily for for examinations for trophozoites and are demonstrating the characteristic motility of necessary when tests for Strongyloides lar• certain amebae and flagellates. These or• vae are to be performed. ganisms may be found in fresh uniformed 2. Unpreserved feces should be examined stools or at times in bloody mucus adhering within 1 hour after passage, especially if the to the surface of formed stools. Material stool is loose or watery and might contain should be obtained from several parts of the protozoan trophozoites. Examination of specimen. An iodine stain (a drop of 1% io• formed feces may be delayed for a short dine in 2% potassium iodide) mixed with a time but must be completed on the day on stool suspension in saline solution facili• which the specimen is received in the labo• tates identification of protozoan cysts, but ratory. If prompt examination or proper fix- it kills and distorts trophozoites. 2. Concentration techniques, useful for de• * Modified from a statement by the Council of the tecting small numbers of cysts and helminth American Society of Parasitologists, the American Society eggs, may be used on unpreserved stool for Medical Technologists, the Board of Scientific Advisors specimens, those preserved in aqueous for• of the American Association of Bioanalysis, and the Board of Directors of the International Society for Clinical Labora• malin or formol-saline. or on PV A-fixed ma• tory Technology. terial. 300 Procedures Suggested for Examining Clinical Specimens for Agents of Parasitic Diseases 3. Stained fecal films should be made if possi• Examination of Blood ble on all specimens obtained fresh or fixed in PV A. If properly prepared they comprise 1. Smears for malaria should consist of both the single most productive stool examina• thick and thin films. It is important that all tion for protozoa. Films may be stained with involved laboratory personnel be aware of trichrome solution or with iron-hematoxy• the technique for making thick films; if im• lin. Stained slides of positive specimens properly made, they are useless. Smears should be placed in a permanent file, analo• should be stained with Giemsa solution, and gous to those used for surgical and cytologic a minimum of 100 microscopic fields exam• specimens. ined before a specimen is reported negative. If the first specimen is negative, additional thick and thin films should be taken every 7 hours for 24 hours. Number of Specimens Examined 2. When examining for filarial infection one and Appropriate Intervals must consider the possibility of diurnal or nocturnal periodicity of microfilariae in the 1. To detect amebae, a minimum of three spec• peripheral blood and obtain specimens ac• imens should be examined; if these samples cordingly. Thick smears or blood concen• (obtained preferably at intervals of 2-3 tration methods are most likely to demon• days) are negative and amebic infection re• strate infection. mains a diagnostic consideration, additional specimens should be examined. 2. With suspected giardiasis, initially three Serologic Methods specimens should be examined. If they are negative, additional specimens should be A variety of immunodiagnostic methods may obtained at weekly intervals for 3 weeks. serve as useful adjuncts to the clinical diagnosis Duodenal aspiration or the enteric string of parasitic infections. In some cases, serologic test may also be of value for detecting occult methods may be the only laboratory recourse infections. for making a diagnosis. Certain serologic tests 3. A single concentrate from one stool speci• provide a high degree of diagnostic accuracy; men is frequently sufficient to detect intes• however, mixed infections, antigen-sharing by tinal helminthic infections of clinical impor• related and unrelated parasites, and other dis• tance. With very light sp. in• eases or physiologic conditions in may fections, few or no eggs may be found in interfere with this diagnostic accuracy. Tests the feces or urine. Strongyloides may also employing capture techniques in which mono• require concentrating the specimen for diag• clonal antibody are used increases the likeli• nosis, but this method is not always reliable; hood of a true positive result. various fecal culture methods or the enteric Most serum specimens may be shipped frozen string test may also be used. or preserved with thimerosal to a final concen• 4. Examination after treatment, under most tration of 1: 10,000 to a state public health labo• circumstances, should be delayed until 1 ratory for forwarding to the Centers for Disease month after completion of therapy (3 Control and Prevention in Atlanta, Georgia. The months after treatment for schistosomiasis vial, containing at least 2 ml of serum, should or tapeworms). indicate the preservative used. Appendix III. Laboratory Diagnostic Methods *

This section presents the most effective tests for Direct Examination identifying protozoan and helminthic parasites. The first part deals with unpreserved specimens Gross examination consists in the following and the second with preserved specimens. steps: There is no single method for diagnosing all 1. Observe and record the appearance of the stages of all parasites, and often several tests entire specimen, noting the color, consis• must be performed to obtain optimal results. tency, and odor. 2. Examine the specimen for the presence of living parasites. 3. Perform a microscopic examination. Unpreserved Specimens 4. Examine a direct smear of the material. The direct examination is most effective for For best results the specimens should be less diagnosing living parasites (e.g., Entamoeba than 1 hour old when first examined, although histolytica, Giardia lamblia, Strongyloides it may not always be possible. Specimens that stercoralis), and should be performed on loose, are up to 24 hours old may still be useful for diarrheic, or purged stool. When motile amebae recovering protozoan cysts and helminthic lar• are found on a direct smear, a stained prepara• vae and eggs, but trophozoites rarely survive tion should also be examined for the definitive that long. A confounding factor when examining diagnosis. (If the ameba contains erythrocytes specimens left at room temperature for more within the cytoplasm it is E. histolytica, and than 24 hours is that the living organism can stained specimens are not necessary for further grow and develop. Refrigeration helps prevent identification. ) this problem. The specimen should not be fro• If the specimen appears negative, as may zen, as it would alter the morphology of the or• occur with light infections, it is necessary to ganisms examined. concentrate the sample. 1. Dip a wooden applicator stick into the spec• imen to coat the tip of it with stool. Stool 2. Smear the stool onto a clear glass micro• scope slide on which a drop of normal saline Because of the daily variability in the quantity solution has been placed and overlay with of various stages of parasite shed by the infected a coverslip. (Smears must be thin enough individual, the parasite may be missed in a single to facilitate microscopic observation.) casual specimen, particularly when the infection is light. Multiple samples-generally consid• Staining the Direct Smear. With the Wheatly• ered a total of three specimens collected on con• Gomori trichrome stain the protozoan nuclei secutive days-are needed to detect most infec• stain red to dark blue, the cytoplasm stains a tions. Some parasites (e.g., the schistosomes lighter blue, and the background material stains and Giardia) tend to require more specimens for green. Trophozoites and cysts tend to shrink detection. away from the background material and are Barium or oil interferes with identifi• therefore relatively easy to locate. cation of parasites. Therefore patients should By modifying the standard mix of staining re• not be subjected to radiographic studies involv• agents, a more specific diagnosis of microspor• ing barium or given laxatives containing mineral dial agents can be made.! The solution consists oil until the stool specimens have been obtained. of 6.0 g chromotrope 2R, 0.5 g aniline blue CI42755, and 0.25 g dodecatungstophosphoric acid AR in 3 ml glacial acetic acid. The rest of the procedure of staining is as described in the * Text: Judith A. Despommier. text. Enterocytozoon bieneusi and Encephalit- 302 Laboratory Diagnostic Methods ozoon- or Septata-like spores stain pink-red and 6. Discard the supernatant and save the sed• are easily distinguished from other organisms iment. found in feces, including small budding yeasts. 7. Add 10 ml of 7.5% formaldehyde to the sed• This stain is applied to a thin smear of stool iment. on a coverslip and the coverslip is immersed 8. Let stand 10-30 minutes. sequentially in the solution enumerated below 9. Add approximately 3 ml of ether, plug the for the prescribed lengths of time. tubes with stoppers, and agitate the mixture vigorously. Solution Time 10. Remove the stoppers and centrifuge the Schaudinn's fixative 5 minutes at 50 + DC tubes at 1500 rpm for 1 minute. or 1 hour at room 11. Gently loosen the debris from the tube wall temperature with an applicator stick, being careful not Ethanol-iodine 70% 1 minute to disturb the pellet. Ethanol 70% 1 minute 12. Discard the supernatant. Ethanol 70% 1 minute 13. Examine the sediment under a microscope. Trichrome stain 2-8 minutes 14. Add a drop of 70% ethanol-iodine solution Ethanol 90% 10-20 seconds (Lugol's solution) and examine again if in• (acidified) ternal structures of cysts are not recognized For de staining the material, dip the coverslip on first examination. in the de staining solution once or twice. Rinse Many facilities have difficulty meeting the in 90% ethanol to stop the de staining process. safety requirements for the use of ether. As an Thin smears de stain quickly; thicker ones may alternative, ethyl acetate can be used as a substi• require 3 or 4 dips to obtain optimal differentia• tute for ether. tion. The de staining process is as follows. Sedimentation by Gravity: Water Sedimenta• Solution Time tion. The water sedimentation test is used Ethanol 95% or 100% Two rinses primarily for the concentration and recovery of 1 minute Ethanol 100% and Schistosoma japoni• Xylol 1 minute cum eggs, and it is effective for determining Mount the stained-destained coverslip and ex• their viability. An entire day's worth of stool amine under a microscope. should be examined in a single test because schistosome eggs are shed sporadically. 1. Emulsify the entire stool sample in water. Concentration Methods 2. Strain the specimen through a single layer Sedimentation by Centrifugation: Formalde• of gauze into conical sedimentation flasks. hyde-Ether Method. Sedimentation by concen• 3. Allow the sediment to settle (approximately tration and exposure to formaldehyde-ether 20 minutes) and discard the supernatant. concentrates cysts and eggs of parasites by cen• 4. Resuspend the sediment in water. trifugation, but debris and ether-soluble materi• 5. Repeat steps 3 and 4 until the supernatant als localize in the formaldehyde-ether interface is clear. or the ether layer in the top of the tube. (This 6. Discard the final supernatant and save the process destroys trophozoites because they dis• sediment. integrate in ether.) 7. Examine the entire sediment under a micro• scope. 1. Mix stool 1: 10 with water. 8. If schistosome eggs are present, determine 2. Strain through a single layer of gauze into their viability by examining them under oil a 15-ml centrifuge tube. immersion or high magnification (400 x ) to 3. Centrifuge the strained stool (1 minute at determine the activity of flame cells. 2000 rpm) and discard the supernatant. 4. Wash the sediment once with water. The entire water sedimentation procedure 5. Repeat steps 3 and 4. should be done within 2 hours of starting it be- Laboratory Diagnostic Methods 303

cause prolonged exposure of the eggs to water 4. Fill the tube to the top with more zinc sul• stimulates them to hatch. If hatching occurs, the fate solution. empty shells remain in the sediment and the cil• 5. Centrifuge the suspension for 1 minute at iated miracidia can be seen moving about 2500 rpm. Do not apply the brake to the rapidly. centrifuge or jar the tube, as either maneu• ver causes any eggs or cysts accumulated Baerman Sedimentation Method. The Baerman at the liquid-surface interface to sink. sedimentation method is specific for concentrat• 6. Using a bacteriologic loop, remove two ing and recovering the larvae of Strongyloides loopfuls of material from the surface and stercoralis . The test requires a funnel with a place them on a clean glass slide. piece of rubber tubing attached to it. An adjust• 7. Examine under a microscope. (A small drop able clamp is applied across the tubing, and the of Lugol's iodine may be added to provide entire apparatus is suspended from a ring stand more contrast.) in a 37°C incubator. Because Strongyloides lar• vae cannot swim against gravity, they concen• The sugar (Sheather's) flotation method is de• trate in the sediment that accumulates in the signed specifically for the recovery of Crypto• base of the rubber tube connected to the funnel sporidium sp. oocysts. and can then be expressed into a test tube for 1. Filter stool through three pieces of cheese• microscopic identification cloth. 1. Break apart 5-15 g of a stool sample. 2. Place 2 ml of stool filtrate in a conical tube. 2. Place the sample in gauze and rest it in a 3. Fill the tube to the top with sucrose so• funnel filled with water at 37°C so most of lution. the sample is submerged. 4. Place a coverslip on top of the tube. 3. Let it sit 1 hour, then drain 4 ml of the sedi• 5. Centrifuge at 1000 rpm for 5 minutes. (If the ment into a 15-ml tube. stool sample is watery, no centrifugation is 4. Centrifuge the sediment at 1000 rpm for 5 necessary.) Let the coverslip rest on the top minutes. of sucrose solution for 20 minutes. 5. Decant the supernatant. 6. Examine the coverslip under a microscope 6. Examine the pellet under a microscope. with magnification of 400 x . The focal plane is important because the oocysts are located Flotation by Centrifugation. Flotation methods on the inner surface of the coverslip, rather concentrate the parasites by taking advantage than on the slide itself. of their specific gravity. The unwanted debris The oocysts appear slightly pink in color with• sediments to the bottom of the tube during cen• out the addition of any stain. They are ovoid to trifugation, but the diagnostic forms float to the spherical in shape, range in size from 5 to 6 I-l-m surface. Cysts and most eggs can be recovered in diameter and are usually not sporulated. in large quantities by this method, but trophozo• There are no useful staining techniques. ites, operculated eggs, and schistosome eggs are either destroyed or sediment to the bottom of the tube. The zinc sulfate flotation method is performed Blood as follows. Fresh, heparinized, or citrated blood samples 1. Mix 1 part stool in 15 ml of water in a 15- are best for examination. Delays reduce the ml centrifuge tube. chances of finding the parasites. 2. Centrifuge for 1 minute at 2500 rpm; decant Place a drop of blood on a slide, overlay with the supernatant. a coverslip, and examine under a microscope 3. Add zinc sulfate solution (specific gravity for living microfilariae or trypanosomes. Both 1.18) until the tube is halffull and resuspend groups of parasites are motile and can be seen the sediment with a wooden applicator swimming among the formed blood elements. stick. Motility is significantly decreased if the blood 304 Laboratory Diagnostic Methods sample is refrigerated. If an organism is seen, Tissues the specimen should be stained, preferably with Giemsa solution. Place a small piece (1-3 cu mm) of tissue be• tween two clean glass slides using forceps, press to flatten, then examine under a microscope. Urine To examine skin scrapings, follow these steps. Gross Examination 1. Place the scrapings on a clean glass slide. Observe and record the degree of turbidity and 2. Add a drop of normal saline solution and the color of the specimen. overlay with a coverslip. 3. Let stand 30 minutes. Microscopic Examination 4. Press the coverslip gently to break up the 1. Take a drop of urine with a Pasteur pipette, skin pieces and then examine under a micro• preferably from the bottom of the container, scope. and transfer it to a glass slide. Tapeworm proglottids must be carefully ex• 2. Examine under a microscope. amined for a scolex. It is located at the narrow• If searching for Trichomonas vagina lis , the est end of the strobila. The scolex can adhere specimen must be fresh « 1 hour old), because to toilet paper and must be sought there. The the trophozoites quickly lose their characteristic uterus in the proglottids is injected with India morphology and motility. ink using a 25-gauge needle. A proglottid is then placed between two glass slides, compressed, and examined under the microscope to count Sedimentation by Centrifugation the lateral branches on one side ofthe main uter• 1. Divide the entire urine specimen into 15-ml ine stem. conical glass centrifuge tubes. are best identified preserved. The 2. Sediment at 1000 rpm for 5 minutes. specimen should be placed in 70% ethanol and, 3. Discard the supernatant. when it is no longer motile, transferred to a Petri 4. Resuspend the pellets with a Pasteur pipette dish for examination. and examine the material under a micro• scope. Aspirated Fluids Sputum Sedimentation by Centrifugation Gross Examination 1. Centrifuge clear fluid aspirates at 1000 rpm for 5 minutes in a conical centrifuge tube. Observe and record the appearance of the 2. Decant supernatant. specimen. 3. Examine the pellet under a microscope. 4. Stain by the Wheatly-Gomori trichrome Microscopic Examination procedure. 1. Transfer a small amount of sputum with a wooden applicator stick to a clean glass slide. Miscellaneous Tests 2. Add a drop of normal saline solution. 3. Examine under a microscope. Examination for Pinworms

Sedimentation by Centrifugation Clear tape preparations of various types, avail• able commercially, are routinely used to look 1. Mix sputum with equal parts of 3% NaOH. for pinworms. The tape is placed with the sticky 2. Let stand 5 minutes. side down on the perineum, and eggs or adult 3. Sediment at 1000 rpm for 5 minutes and ex• worms are thus picked up. The tape is then ex• amine under a microscope. amined under a low-power lens of a microscope. Laboratory Diagnostic Methods 305

Adult pinworms are also occasionally found on Dip the coverslip in the de staining solution once the surface of formed stool samples. or twice. Rinse in 95% alcohol to stop the de• staining process. Thin smears de stain quickly; thicker smears require 3 to 5 dips. Preserved Specimens Destaining Solution Time Ethanol 95% Rinse Whenever a delay of 24 hours or longer is antici• Ethanol 95% 5 minutes pated, it is advisable to preserve the specimen. Xylol 10 minutes The preservative to be employed depends on the type of test selected. Mount the stained coverslip and examine it under a microscope.

Stool Blood Direct Smear Microscopic Examination Merthiolate-iodine-formaldehyde (MIF) Method A thick smear consists of several drops of blood A solution of merthiolate, iodine, and formalde• on a slide, dried in air, and hemolyzed by immer• hyde (MIF) preserves and stains trophozoites sion in a hypotonic solution. This process con• and cysts. The organisms develop an orange centrates the parasites. A thin smear is prepared color. A permanent stain should also be done by making a film of blood analogous to that used on the same stool sample. At present, there is for a differential count of the white cells. Both no permanent staining procedure that can be must be stained by the Giemsa stain method. carried out on an MIF-treated specimen. For example, ifthe Wheatly-Gomori trichrome stain 1. Immerse the slide in 100% ethanol or metha• is run on such a sample, the material peels off nol for 2-3 minutes. the coverslip. 2. Make a solution consisting of 1 drop of con• centrated Giemsa stain per 1 ml of distilled 1. Emulsify 1 g of stool sample in 10 ml of MIF water (pH 7.4) and fill a Copeland jar with solution. 50 ml of the mixture. 2. Place a drop of stool-MIF emulsion on a 3. Stain for 10-30 minutes. clean glass slide and examine under a micro• 4. Wash in distilled water. scope. 5. Air-dry the slide. Stools preserved in MIF can be concentrated 6. Examine under an oil immersion lens of a by sedimentation using the formaldehyde-ether microscope. View 100 fields of a thin smear. method (see above). Stool specimens preserved in polyvinyl alco• Concentration by Sedimentation hol (PV A) can be stained by the Wheatly-Go• mori trichrome solution in the same manner as The Knott technique concentrates and pre• described previously for unpreserved stool. The serves microfilariae, which can be stained by technique is the same as the one used on unpre• the Giemsa solution and identified morphologi• served stools except that Schaudinn's fixative cally. The Knott Technique is as follows. is not necessary and the staining time differs. 1. Mix 1 ml of heparinized blood with 9 ml of 2% formaldehyde. Wheatly-Gomori Trichrome Stain for PV A-Pre• 2. Centrifuge at 2,000 rpm for 10 minutes. served Stool 3. Decant the supernatant. Staining Solution Time 4. Examine the sediment under a microscope. Ethanol-iodine 70% 10-20 minutes If microfilariae are present, the material can Ethanol 70% 3-5 minutes then be stained as follows. Ethanol 70% 3-5 minutes Trichrome stain 8-10 minutes 1. Spread the sediment on a clean glass slide. Ethanol 90% (acidified) 1-10 seconds 2. Dry overnight. 306 Laboratory Diagnostic Methods

3. Stain with Giemsa solution (1 ml of concen• Adjust the specific gravity to 1.18 by adding trated Giemsa stain in 50 ml of distilled either more water or more zinc sulfate crystals. water at pH 7.4). 4. Destain 10-15 minutes in water. 5. Air-dry. Sugar Solution (Sheather's Method) 6. Examine under a microscope. Sucrose 500 g Water 320 ml Solutions Phenol 6.5 g

Schaudinn's Fixative Merthiolate-Iodine-Formaldehyde HgCh, saturated aqueous solution: 666 ml (add Solution 80 g HgCh to 1 liter deionized water; stir 3-4 hours and then filter) Tincture of Merthiolate No. 99 (Lilly) Ethyl alcohol 95%: 333 ml 1:1000 100 ml Ethanol-iodine solution 70% (add enough crys• Formaldehyde solution 37-40% 25 ml talline iodine to 70% ethanol to turn the solu• Glycerol 5 ml tion deep amber-brown; filter before using) Water 250 ml Store solution in a dark bottle. Wheatly-Gomori Trichrome Stain

Chromotrope 2R 0.6 g Lugol's Iodine Solution Light green SF 0.3 g Phosphotungstic acid 0.7 g Iodine 5g Mix with 1 ml of glacial acetic acid and stir Potassium iodide 109 gently for 20 minutes. Add 100 ml of distilled Water 100 ml water, then store in dark brown bottle.

Polyvinyl alcohol Buffered Formaldehyde Polyvinyl alcohol is available commercially. Formaldehyde solution 37-40% 100 ml Schaudinn's fixative 935 ml Sodium phosphate (monobasic, 4.0 g Glycerol 15 ml anhydrous) Glacial acetic acid 50 ml Sodium phosphate (dibasic, 6.5 g Polyvinyl alcohol (powder) 50 g anhydrous) Water 1000 ml H 20 900 ml Adjust the pH of the solution to 7.0. Reference

Zinc Sulfate 1. Ryan NJ, Sutherland G, Coughlan K, et al.: A new trichrome-blue stain for detection of microspori• Zinc sulfate 333 g dial species in urine, stool, and nasopharyngeal Water (50°-55°C) 1000 ml specimens. J Clin Micro 31 :3264-3269, 1993 Appendix IV. Diagnostic Atlas of , Cestodes, Trematodes, and Protozoa *

Nematodes

Figure A.I. Enterobius vermicularis. x 760. Figure A.3. Ascaris lumbricoides (unfertilized). x 760.

Figure A.2. Trichuris trichiura. x 760. Figure A.4. Ascaris lumbricoides (decorticated). x 760.

* Photographs by Dickson Despommier. 308 Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa

Figure A.S. Ascaris lumbricoides (fertilized). x 760. Figure A.S. Capillaria philippinensis. x 760.

Figure A.6. Hookworm. x 760. Figure A.9. Herterodera (plant ). x 480.

Figure A. 7. . x 760. Figure A.I0. Trichostrongylus sp. x 480. Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa 309

Figure A.H. Oesophagostomum sp. x 480.

Figure A.14. . x 600.

Figure A.12. Dioctophyma renale. x 760.

Figure A.13. Gongy/onema pulchrum. x 760. Figure A.IS. Mansonella ozzardi. x 600. 310 Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa

Figure A.16. Wuchereria bancrofti. x 600.

Figure A.17. Loa loa. x 600. Figure A.19. Dracunculus medinensis. x 600.

Figure A.IS. Mansonella perstans. x 600. Figure A.20. Helicosporum (plant artifact). x 600. Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa 311 Cestodes

Figure A.21. Taenia sp. x 760.

Figure A.24. . x 760.

Figure A.22. Diphyllobothrium latum. x 475.

Figure A.23. Hymenolepis nana. x 760. Figure A.2S. Dipylidium caninum. x 760. 312 Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa Trematodes

Figure A.26. Schistosoma mansoni. x 340. Figure A.28. (Japan) Note small spine (arrow). x 340.

Figure A.27. . x 340. Figure A.29. Schistosomajaponicum. Some strains do not produce spined eggs. x 340. Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa 313

Figure A.33. Echinostoma ilocanum. x 450.

Figure A.30. . x 440.

Figure A.34. Clonorchis sinensis. x 760.

Figure A.31. Fasciola hepatica. x 450.

Figure A.3S. . x 760.

Figure A.36. . x 760. Figure A.32. Fasciolopsis huski. x 450. 314 Diagnostic Atlas of Nematodes, Cestodes, Trematodes, a'ld Protozoa Protozoa

Figure A.37. Trichomonas tenax (two trophozoites). Figure A.39. Giardia /amblia binucleate trophozoite. x 1600. x 1000.

Figure A.38. Trichomonas vagina/is trophozoite. x 1200. Figure A.40. Giardia /amb/ia quadrinucleate cyst. x 1000. Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa 315

Figure A.44. Dientamoeba fragilis binucleate trophozoite. Note the nuclei (arrows). x 2200.

Figure A.41. Chilomastix mesnili trophozoite. x 1770.

Figure A.42. Chilomastix mesnili cyst. x 1500. Figure A.45. Entamoeba histolytica trophozoite. N, nu• cleus; RBC, red blood cells. x 2800 .

..

Figure A.43. Retortamonas sp. trophozoite. x 1000. Figure A.46. Entamoeba histolytica trophozoite. N, nu• cleus. x 2800. 316 Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa

Figure A.47. Entamoeba histolytica trophozoite. x 2800. Figure A.SO. Entamoeba histolytica quadrinucJeate cyst. C, chromatoidal bar. x 600.

Figure A.48. Entamoeba histolytica uninucleate cyst. C, Figure A.SI. Entamoeba histolytica quadrinucleate cyst. chromatoidal bar. x 600. Only three nuclei are visible in this view. x 600.

Figure A.49. Entamoeba histolytica binucleate cyst. x 600. Figure A.S2. Entamoeba histolytica quadrinucleate cyst. Same as in Figure A.51 but a different focal plane. One nucleus is visible in this view. x 600. Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa 317

Figure A.53. Charcot·Leyden crystal. x 1400. Figure A.56. Entamoeba coli quadrinucleate cyst. Same as Figure A.55 but a different focal plane. Three nuclei are visible. x 500.

Figure A.54. Entamoeba coli trophozoite. x 600. Figure A.57. Entamoeba coli octanucleate cyst. Same as A.55 but a different focal plane. Two nuclei are visible in this view. x 500.

Figure A.55. Entamoeba coli octanucleate cyst. Three nu• Figure A.58. Entamoeba coli octanucleate cyst. Same as clei are visible in this view. x 500. Figure A.55 but a different focal plane. Two nuclei are visi• ble in this view. x 500. 318 Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa

Figure A.59. Entamoeba coli octanucleate cyst. Same as Figure A.62. Entamoeba hartmanni quadrinucleate cyst. Figure A.55 but a different focal plane. Two nuclei are visi• x 1500. ble in this view. x 500.

Figure A.60. Entamoeba coli octanucleate cyst. Same as Figure A.63. Iodamoeba beatschlii trophozoite. x 1800. Figure A.55 but a different focal plane. Two nuclei are visi• ble in this view. x 500.

Figure A.61. Entamoeba hartmanni trophozoite. x 1500. Figure A.64. Iodamoeba beutschlii cyst. x 1800. Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa 319

Figure A.6S. Endolimax nana (two trophozoites). x 1300. Figure A.68. Balantidium coli trophozoite. x 600.

Figure A.66. Endolimax nana quadrinucleate cyst. x \300. Figure A.69. Balantidium coli cyst. x 430.

Figure A.67. Entamoeba gingivalis trophozoite. x 750. Figure A.70. Isospora sp. un sporulated oocyst. x 900. 320 Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa

Figure A.71. Isospora sp. sporulated oocyst. x 1000.

Figure A.74. Microsporidia sp. (arrows). x 1350.

Figure A.72. Sarcocystis bovicanus sporulated oocyst. x 800.

Figure A.73. Cyciospora sp. unsporulated oocyst. x 2600. Figure A.7S. Trypanosoma cruzi trypomastigote. x 1500. Diagnostic Atlas of Nematodes, Cestodes, Trematodes, and Protozoa 321

Figure A.76. Trypanosoma brucei rhodesiense trypomasti• Figure A.77. Babesia sp. x 1750. gote. x 1500. INDEX

Page numbers in italics refer to illustrations; page numbers followed by t refer to tables

A historical information, 17-18 Ants, 264 Acanthamoeba castellani, 226-228 larva in skin. 22 Apidae, 263-264 trophozoite, 227 life cycle, 18, 20-22 Apis mellifera, 262, 263, 265 Acarina, 268-279, 269t morphology of, 20t Arachnidism, necrotic, 279-280 ACL (American cutaneous pathogenesis, 22 Arachnids, 268-281 leishmaniasis), 203, 207, 210 prevention and control, 23-24 Acarina, 268-279, 269t Adenocele formation, 51 rhabditiform larva, 21 Araneida, 268, 269t, 279-280 Aedes aegypti, 242, 243,244 tail of adult male, 20 incomplete metamorphosis in, 268 Aedes albopictus, 235 third-stage filariform larva, 21 mites, 268, 269t, 275-279; see Aedes scutellaris, 243 treatment, 23 also Mites Aedes sollicitans, 243 Anemia Scorpionida, 268, 269t, 280-281, Aedes taeniorhynchus, 243 hookworm, 23 281 Aedes togoi, 245 iron-deficiency, 23 , 268-275; see also Ticks Aedes triseriatus, 243, 245 Trichuris, 9-10 Araneida, 268, 269t, 279-280 African , 273 Angiostrongyliasis, 67-69 Argas persicus, 272, 272 African trypanosomes, 196-202 drugs for treatment of, 288t Argasidae, 268, 269t, 272-275 AIDS virus, 235 Angiostrongylus cantonensis, 62t, Arthropods, 235-285 Albendazole, adverse effects, 228, 296 67, 67-69, 68 arachnids, 268-281; see also Alveolar hydatid disease, 98 Angiostrongylus costaricensis, 62t, Arachnids americanum, 271 67-69 , 236-266, 238t; see also , 271 Anguillula stercoralis, 25 Insects Amebae, commensal, 230t, 231-234 scabies, 277 of medical importance, 238t-239t, Amebiasis Anisakiasis,69 269t cerebral, 156 drugs for treatment of, 288t of minor medical importance, cutaneous, 155 Anisakis sp., 62t, 69 283-285 drugs for treatment of, 287t Anopheles balabacensis, 243 Ascariasis hepatic, 155 Anopheles culicifacies, 242 fatal case of, 15 pathogenic effects of, 154-155 Anopheles dirus, 242 hepatobiliary, 15 Amebic liver abscesses, 156 Anopheles freeborni, 186, 242 Ascaris lumbricoides, 11-16,307, Amebic meningoencephalitis, 227 Anopheles funestus, 242, 243 308 drugs for treatment of, 287t Anopheles gambiae, 242, 243 adult male, 12 Amebic pericarditis, 156 Anopheles hermsi, 186 clinical disease, 15 Amebomas, 155 Anopheles hyrcanus, 243 diagnosis, 15-16 American cockroach, 284 Anopheles maculipennis, 243 eggs, 14, 16 American cutaneous leishmaniasis Anopheles , 186 historical information, 11-12 (ACL), 203, 207, 210 Anopheles quadrimaculatus, 186, larvae, 14 Ammonium sulfate, 125 242 life cycle, 12-14, 13 Anatrichosoma cutaneum, 62t Anopheles stephensi, 242 pathogenesis, 15 Ancylostoma braziliensis, 17, 62t Anopheles varbirostris, 243 prevention and control, 16 , 17 Anophelinae subfamily, 242-243 treatment, 16 filariform larva, 64 Anoplura, 238t, 250-255 Ascaris suum, 12 serpiginous lesion due to, 64 clinical disease, 253-254 Aspirated fluids, unpreserved, , 17 diagnosis, 254 laboratory diagnostic Ancylostoma duodenale epidemiology, 254 methods for, 304 clinical disease, 22-23 historical i!tformation, 250 Assassin bugs, 260-262 cross section of adult, 18 life cycle, 250-252 Atabrine, 148-149 diagnosis, 23 -borne diseases, 254-255 Atovaquone, adverse effects, 296 drugs for treatment of, 290t pathogenesis, 253 ATPase, 75 egg,20 treatment, 254 Atrax spider, 280 head of adult, 18 Antimony, pentavalent, 218 Auchmeromyia luteola, 249 324 INDEX

Austrobilharzia, 116 Bot , 248 Cetrimide, 97 Autoinfection, 26 , 274 CF antibodies, 167 Azithromycin, 173 Bradyzoites, 164 Chagas cardiomyopathy, 194 Breakbone fever, 244 Chagas disease, 192-193 B Brill-Zinsser disease, 255 acute, 193-194 Babesia bigemina, 224 Brown dog , 275 chronic, 194 Babesia bovis, 224, 225 Brugia beveri, 40 Chagoma, 193-194 Babesia divergens, 224, 225 Brugia lepori, 40 primary, 192 Babesia microti, 224-225 Brugia malayi, 40-46 Charcot-Leyden crystals, 10, 133, red blood cells infected with, 225 clinical disease, 43-45 157, 157,317 Babesiosis, 224-225, 275 diagnosis, 45-46 Chiclero's ulcer, 207 drugs for treatment of, 288t historical information, 40 Chigger mites, 277-278, 278 Baerman sedimentation method, 303 life cycle, 40, 42-43 Chigoe, 257 Balantidiasis, drugs for treatment microfilaria, 72 Chilomastix mesnili, 230t, 230-231 of, 288t pathogenesis, 43 cyst, 231, 315 Balantidium coli, 159-162 prevention and control, 46 trophozoites, 231,315 clinical disease, 160 treatment, 46 Chilopoda, 284t, 285 cyst, 160, 319 , 40 Chiracanthium mildei, 280,280 diagnosis, 160, 162 Bubonic plague, 258 Chloroquine, Plasmodium historical information, 159 Buffered formaldehyde, 306 Jalciparum resistance to, life cycle, 159-160, 161 Bugs, see Heteroptera 186-187 pathogenesis, 160 Bulinus, 108 Chloroquine hydrochloride, 186 prevention and control, 162 Bumble bees, 264 adverse effects, 296 treatment, 162 Bush yaws, 210 Chloroquine phosphate, adverse trophozoites, 160, 160,319 Butterflies, 283 effects, 296 Bartonella bacilliformis, 240 Cholangiocarcinoma, 124 Bartonellosis, 240 Cholecystitis, 148 Baylisascariasis, drugs for treatment C Chromatoidal bodies, 154, 154 of, 288t Calabar swelling, 53, 54, 55 Chrysomyia, 249 , 62t, 67 Calliphora sp., 249 Chrysops dimidiata, 53 Bed bugs, see lectularius , 239t, 248-250 Chrysops silacae, 53 Bees, 262-264 Capillaria aerophila, 73 Cimex boueti, 258 , 283, 284t Capillaria hepatica, 7lt, 73-74,308 Cimex hemipterus, 258 Benznidazole, 195 eggs, 74 Cimex lectularius, 258 adverse effects, 296 Capillaria philippinensis, 25, 7lt, adult, 259 Berenil, 225 73,308 bites, 260 Biomphalaria, 108 Capillaria plica, 73 Cimicidae, 258-260 Biomphalaria glabrata, 114 Capillariasis, drugs for treatment of, Cinchona tree, 176 Bithionol, 129 288t CL, see Cutaneous leishmaniasis adverse effects, 296 Cardiomyopathy, Chagas, 194 Clam digger's itch, 116 Biting midges, 236, 238t, 239 Carrion's disease, 240 Clinical specimens, examining, Black widow spiders, 279 Centipedes, 284t, 285 299-300 Blackflies, 48, 49, 50, 238t, 241 Ceratopogonidae, 236, 238t, 239 CLM, see Blackwater fever, 183 Cerithidia, 137 Clonorchis sinensis, 122-125, 137, Bladder worms, 76 Cestodes, 75-106 313 Blastocystis hominis, 226 diagnostic atlas of, 311 adult, 122 Blatella germanica, 284 Diphyllobothrium latum, 84-89, clinical disease, 124-125 Blepharoplasts, 144 311 diagnosis, 125 Blister beetles, 283 Dipylidium caninum, 104-106, embryonated egg, 124 Blocking antibodies, 116 311 historical information, 122 Blood , 89, life cycle, 122-124, 123 examination of, 300 93-98 metacercaria, 124 preserved, laboratory diagnostic Echinococcus multilocularis, 89, pathogenesis, 124 methods for, 305-306 98 prevention and control, 125 unpreserved, laboratory Hymenolepis diminufa, 102-104, sections of adult in common bile diagnostic methods for, 311 duct, 124 303-304 Hymenolepis nana, 100-102,311 treatment, 125 Blue bottle , 249 larval, 89-99 Cochin China diarrhea, 25 , 250,250-253,251,252, of minor medical importance, Cochliomyia, 249 253 100-106 Cockroaches, 283-284, 284t Boophilus, 272 , 76-80, 311 Coenurus disease, 98-99 Borrelia burgdorJeri, 275 , 81-84,311 Coleoptera, 283, 284t INDEX 325

Colitis Cutaneous larva migrans (CLM), Dipetalonema perstans microfilaria, Trichuris, 10 61-62,64 72 ulcerative, 155 clinical manifestations, 62t Dipetalonema streptocercum , 271, 274 drugs for treatment of, 288t microfilaria, 72 Colpitis macularis, 142 Cutaneous leishmaniasis (CL), 203, Diphyllobothrium alascense, 84 Commensal amebae, 230t, 231-234 207 Diphyllobothrium latum, 84-89, 311 Commensal flagellates, 230t, American (ACL), 203, 207, 210 clinical disease, 88 230-231 diffuse (DCL), 207 diagnosis, 88 Congo floor , 249 Cuterebridae, 239t, 248-250 eggs, 87 Contracoecum sp., 69 Cyclops sp., 86 free-swimming larva, 87 Cooties, 252 Cyclospora sp., 169, 172-173 historical information, 84 Copepods, 58, 60 infection, drugs for treatment of, life cycle, 85, 86-88 Coracidium, 86, 87 288t mature proglottids, 86 anthropophaga, 249 unsporulated oocyst, 173,320 pathogenesis, 88 Coxiella burnetii, 274 Cyclosporidiosis, 169 plerocercoid larva, 87 , 250, 250-254,251 Cysticercosis, 89-93 prevention and control, 88-89 Crotamiton, adverse effects, 296 cerebral, 90 procercoid larvae, 87 Croton bug, 284 Cysticercus, 89, 90, 92 treatment, 88 Crustacea, 284t, 285 Diptera, 236-250, 238t-239t Cryptosporidiosis, 172-173 Ceratopogonidae, 236, 238t, 239 drugs for treatment of, 288t D Culicidae, 238t, 241-245 Cryptosporidium parvum, 169 DCL (diffuse cutaneous Muscidae, 238t, 246-286 Cryptosporidium sp., 169-173 leishmaniasis), 207 Psychodidae, 238t, 239-240 clinical disease, 172-173 DEC, see Diethylcarbamazine Simuliidae, 238t, 241 diagnosis, 173 Deerflies, 238t, 245-246 Tabanidae, 238t, 245-246 historical information, 169 DEET (diethyltoluamide), 225 Dipylidium caninum, 104-106, 311 life cycle, 170-172, 171 Dehydroemetine, 158 clinical disease, 104 macrogametocyte, 172 adverse effects, 296 diagnosis, 104, 106 merozoites, 170 folliculorum, 278 eggs, 105 pathogenesis, 172 Dengue, 244-245 gravid proglottid, 105 prevention and control, 173 andersoni, 271, 271 immature proglottids, 105 treatment, 173 , 270, 271, life cycle, 104, 105 trophozoite, 170 271 pathogenesis, 104 unsporulated oocyst, 170 Dermatitis, mites and, 278 prevention and control, 106 Ctenocephalides canis, 104, 256 , 248 scolex, 105 Ctenocephalides felis, 104,255,256 Dexamethasone, 93 treatment, 106 Ctenodactylus gondii, 162 DFMO (difluoromethylornithine), Dirofilaria conjunctivae, 62t Culex pipiens, 245 201 Dirofilaria immitis, 62t, 72-73 Culex pipiens pipiens, 243 Diagnostic atlas , 62t Culex pipiens quinquefasiatus, 243, of cestodes, 311 Dracunculus medinensis, 57-61,310 244 of nematodes, 307-310 adult female, 58 Culex tarsalis, 245 of protozoa, 313-320 clinical disease, 60 Culex tritaniorhynchus, 245 of trematodes, 312-313 copepod intermediate host for, 60 Culicidae, 238t, 241-245 Diamanus montanus, 256-256 diagnosis, 60 historical information, 241-242 Diaptomus sp., 86 first -stage larva, 58 life cycle, 242 Dicrocoelium dendriticum, 313 historical information, 57 mosquito-borne viral diseases, Dientamoeba fragilis, 226 infection, drugs for treatment of, 244-245 infection, drugs for treatment of, 289t mosquito control, 245 289t life cycle, 57-58, 59 pathogenesis of mosquito bite, trophozoites, 226, 315 pathogenesis, 60 244 Diethylcarbamazine (DEC), 54, 56 prevention and control, 60-61 subfamily Anophelinae, 242-243 adverse effects, 296 treatment, 60 subfamily Culicinae, 243-244 Diethyltoluamide (DEET), 225 Drugs for parasitic infections, treatment, 244 Difluoromethylornithine (DFMO), 287-298 Culicinae subfamily, 243-244 201 Duffy blood type, 185 Culicoides, 236 Digenea, 107 Dysentery, Trichuris, 10 Culicoides variipennis, 239 Diidohydroxyquin, 157 Culiseta, 244 Diloxanide furoate, 157 Culiseta melanura, 245 adverse effects, 296 Cunningham-Leishman-Donovan Diminazene aceturate, 225 E body, 213 Dioctophyma renale, 7lt, 309 Eastern equine encephalitis (EEE), Cutaneous amebiasis, 155 Dioecious flukes, 107 245 326 INDEX

Echinococcus granulosus, 89, 93-98 infection, drugs for treatment of, Fever tree bark, 176 adult, 94 289t Fiery serpent, 57; see also clinical disease, 96 Enterobius vermicularis, 2-6, 307 Dracunculus medinensis daughter cysts, 96 adult, 5 Filariae, lymphatic, 40-46,310 diagnosis, 96-97 adult female, 2 Filariasis, drugs for treatment of, historical information, 93 clinical disease, 4 289t hooklets, 97 diagnosis, 4-5 Fire ants, 264, 264 life cycle, 93-94, 95 diminutive male, 2 Flagellates, commensal, 230t, pathogenesis, 94, 96 eggs, 5 230-231 prevention and control, 98 embryonated egg, 4 -borne diseases, epidemiology treatment, 97-98 historical information, 2 of, 258 Echinococcus granulosus var. infection, drugs for treatment of, , see Siphonaptera canadensis, 93 289t Flesh flies, 248 Echinococcus multilocularis, 89, life cycle, 2-4, 3 Flies, 236-250, 238t-239t; see also 98 pathogenesis, 4 Diptera alveolar cyst of, 98 prevention and control, 5-6 Flubendazole, adverse effects, 296 Echinostoma, 136 treatment, 5 Flukes, 107; see also Trematodes Echinostoma ilocanum, 313 Enterocytozoon, 228 dioecious, \07 egg, 136 Enteromonas hominis, 230t, drugs for treatment of, 289t-290t EEE (eastern equine encephalitis), 230-231 monoecious, \07 245 Epidemic typhus, 254-255 Follicle mites, 278 Eflornithine, adverse effects, 296 Erisipela de la costa, 51 Formicidae, 264 , 274 Espundia, 2 \0 Furazolidone, 149 Elephantiasis, 43 Eustrongyloides, 69 adverse effects, 297 , 158 Exflagellation, 181 Encephalitis, Toxoplasma, 166, 167 process of, 182 Encephalitozoon, 228 Exoerythrocytic schizogony, 179 G Endolimax nana, 230t, 232 Eye lesions, Onchocerca volvulus, Gates, F., 17 quadrinucleate cyst, 233, 319 51 German cockroach, 284 trophozoite stage, 233, 319 Giardia lamblia, 144-149 Entamoeba coli, 151, 230t, 232-233 binucleate trophozoites, 144, 314 cyst stage, 232 F clinical disease, 148 octanucleate cyst, 317, 318 Falciparum malaria, 178 cyst, 148 quadrinucleate cyst, 317 Fansidar, 185 diagnosis, 148 trophozoites, 232, 317 , 126 fluorescent antibody test, 147 Entamoeba gingivalis, 230t, Fasciola hepatica, 126-129,313 historical information, 144 231-232 adult. 126, 129 life cycle, 144-146, 145 trophozoites, 232, 319 cercaria, 128 pathogenesis, 146-147 Entamoeba hartmanni, 230t, 233 clinical disease, 128-129 prevention and control, 149 quadrinucleate cyst, 318 diagnosis, 129 quadrinucleate cysts, 144,314 trophozoites, 234, 318 fertilized egg, 128 treatment, 148-149 Entamoeba histolytica, 139, historical information, 126 trophozoites, 146, 147 151-158,316 life cycle, 126-128, 127 Giardiasis, 144-149 binucleate cyst, 316 metacercaria, 128 drugs for treatment of, 290t clinical disease, 155-156 miracidium, 128 Giardin, 146 cyst stage, 152 pathogenesis, 128 Glossina sp., 237-238, 247 diagnosis, 156-157 prevention and control, 129 Glucantime (meglumine flask-shaped ulcer resulting from treatment, 129 antimoniate), 208 infection, 152 Fascioliasis, 128-129 Glutathione S-transferase, 129 historical information, 151 Fasciolopsis buski, 135-136,313 , 62t, 69 life cycle, 151-154,153 adult, 135 drugs for treatment of, 290t pathogenesis, 154-155 cercaria, 136 pulchrum, 309 precyst stage, 154 clinical disease, 135 Granuloma formation, 116 prevention and control, 158 diagnosis, 135 Green bottle flies, 249 quadrinucleate cysts, 154, 316 fertilized nonembryonated egg, Gypsy moth, 283 treatment, 157-158 136 trophozoites, 151, 151-152,152, life cycle, 135 316 miracidium, 136 H ulcer in colon of infected patient, pathogenesis, 135 Halofantrine, adverse effects, 297 155 prevention and control, 136 Halzoun, 128, 129 uninucleate cyst, 316 treatment, 136 Hard ticks, 268, 269t, 269-272 Entamoeba polecki, 230t, 233 Felis domestica, 162 Hartmannella-Acanthamoeba, 226 INDEX 327

Harvester ants, 264 control, 265-266 K , 250-254,251,252,253 diagnosis, 265 Kala-azar, 213-219 Helicosporum, 310 historical information, 263 congenital, 217-218 Hematuria, 108 life cycle, 263-265 Kampala eye worm, 72 Hemoglobinuria, 183 pathogenesis, 265 Karyosome, 151 Hemoptysis, endemic, 133 treatment, 265 Katayama fever, 108, 117 Hemozoin, 224 Hyperinfection, 26 Kenya typhUS, 274 Hepatic amebiasis, 155 Hyperresponsive syndrome, 54 Kissing bugs, 260, 260-262, 261 Hepatocarcinoma, 124 Hypnozoites, 179 Knott technique, 305-306 Heppentis, 135 Knott test, 45 , 137-138 Koilonychia, 23 adult, 137 Koino, S., 12 diagnosis, 138 egg, 138 IFA (indirect immunofluorescence life cycle, 137-138 test), 167 L treatment, 138 IFN-')' (interferon-,),), 216, 218 Laboratory diagnostic methods Heteroptera, 238t, 258-262 IL-l (interleukin-I), 216 for preserved specimens, 305-306 Cimicidae, 258-260 Indirect immunofluorescence test for unpreserved specimens, Reduviidae, 260-262 (IFA), 167 301-305 Hexacanth, 76 Insects, 236-266, 238t LaCrosse virus, 245 HIV infection, 29 Anoplura, 238t, 250-255 Lactrodectus mactans, 279 Honeybees, 262,263,265 complete metamorphosis in, 237 Lagochilascaris minor, 62t stinging dart, 263 diptera, 236-250, 238t-239t, see Larval tapeworms, 89-99 , 17-24,308; see also also Diptera Leishmania aethiopica, 203, 207 Ancylostoma duodenale; Heteroptera, 238t, 258-262 Leishmania braziliensis, 209-212 Necator americanus Hymenoptera, 238t, 262, 262-266 clinical disease, 210 Hornets, 262,262 incomplete metamorphosis in, 237 diagnosis, 212 stinging dart, 263 Siphonaptera, 239t, 255-258 historical information, 209 Horseflies, 238t, 245-246 stinging, see Hymenoptera life cycle, 209, 211 Houseflies, 238t, 246-248 Interferon-,), (IFN-,),), 216, 218 nasal septum erosion, 210 Hyalomma, 272 lnterleukin-l (IL-I), 216 pathogenesis, 209-210 Hydatid cyst fluid, 96 Iodamoeba buetschlii, 230t, 232 prevention and control, 212 Hydatid cysts, 93, 94 cysts, 233, 318 promastigotes,212 mUltiple, 97 trophozoites, 233, 318 treatment, 212 Hydatid disease, 94, 96 lodoquinol, 157 Leishmania braziliensis braziliensis, Hydrogenosomes, 139, 140, 142 adverse effects, 297 209 Hylesia alinda, 283 Iron-deficiency anemia, 23 Leishmania braziliensis guyanensis, riymenolepis dim in uta , 102-104, Isoprinosine, 98 209,210 311 Isospora belli, 226 Leishmania braziliensis diagnosis, 104 Isospora hominis, 226 panamensis, 209, 210, 212 embryonated infectious egg, 104 Isospora sp. Leishmania chagasi, 213 historical information, 102 sporulated oocyst. 320 Leishmania donovani, 213-219 life cycle, 102-103 un sporulated oocyst, 319 amastogotes, 214, 216, 217 pathogenesis, 103-104 Isosporiasis, 226 clinical disease, 217-218 prevention and control, 104 drugs for treatment of, 290t diagnosis, 218 proglottids, 103 Itch mites, 276, 276-277,277 historical information, 213 scolex, 103 Ivermectin, 46, 51-52 life cycle, 213-216,215 treatment, 104 adverse effects, 297 pathogenesis, 216 Hymenolepis nan a , 100-102, 311 dammini, 271,272 prevention and control, 218-219 adult, 101 1xodes holocyclus, 272 promastigotes, 214 clinical disease, 102 , 271 treatment, 218 cysticercoid, 101 , 225 Leishmania infantum, 213 diagnosis, 102 , 224, 225,270, Leishmania mexicana, 203-208 embryonated infectious egg, 101 271,272 clinical disease, 207 historical information, 100 , 224, 268, 269t, 269-272 diagnosis, 207-208 life cycle, 100-101 historical information, 203-204 pathogenesis, 101-102 life cycle, 204 prevention and control, 102 J pathogenesis, 204-207 scolex, 102 Japanese B encephalitis, 245 prevention and control, 208 treatment, 102 Jarisch-Herxheimer reaction, 38 treatment, 208 Hymenoptera, 238t, 262, 262-266 Jigger flea, 257 Leishmania mexicana amazonensis, clinical disease, 265 Jumping salad, 73 203 328 INDEX

Leishmania mexicana mexicana, Lutzomyia, 209 Metagonimus yokogawai, \37-138, 203,207 Lutzomyia anthophora, 240 313 Leishmania mexicana Lutzomyia longipalpis, 213 adult, 137 venezuelensis, 203 Lutzomyia verrucarum, 240 diagnosis, 138 Leishmania peruviana, 209, 210 Lymantria dispar, 283 egg, 138 Leishmania tropica, 203-208 , 275 life cycle, 137-138 clinical disease, 207 Lymnea truncatula, 126 treatment, 138 cutaneous lesion, 206 Lymph node lesions, Onchocerca Metatrypanosomes, 198, 198-199 diagnosis, 207-208 volvulus, 51 Metronidazole, adverse effects, 297 "dry" skin lesion, 206 Lymphadenitis, 167 Microfilariae, 40 historical information, 203-204 Lymphatic filariae, 40-46, 310 Microgametocytes, male, 170,171, life cycle, 204, 205 181, 182 pathogenesis, 204-207 M Microsporidia, 228, 228,320 prevention and control, 208 Macrogametocytes, female, 170, Microsporidiosis, drugs for promastigotes, 204 171, 172,181, 181 treatment of, 293t treatment, 208 Malabsorption syndrome, 146-147, Midges, biting, 236, 238t, 239 "wet" skin lesion, 206 147 MIF (merthiolate-iodine• Leishmania tropica major, 203, 206 Malaria, 174, 176; see also formaldehyde) method, 305 Leishmaniasis, 203-208 Plasmodium spp, Migration inhibitory factor (MIF), cutaneous, see Cutaneous cerebral, 182, 183 216 leishmaniasis congenital, 184 Miracidium, 114-115 drugs for treatment of, 290t drugs for treatment of, 29Jt-292t Mites, 268, 269t, 275-279 mucocutaneous (MCL), 203, 210, historical information, 176 allergies caused by, 279 212 "induced," 181 chigger, 277-278, 278 post-kala-azar (PKDL), 218 relapse in, 179 dermatitis and, 278 visceral (VL), 203, 213; see also simian, 178 follicle, 278 Kala-azar spleen and, 183 itch, 276, 276-277, 277 Lepidoptera, 283 sporozoite stage of, 179 Molluscacides, 125 Leptoconops, 236 Malarial , 187 Moniliformis moniliformis, drugs for Leptomeningitis, 200 Malathion, adverse effects, 297 treatment of. 293t Letrazuril, 173 Mansonella ozzardi, 7Jt, 71,309 Monoecious flukes, 107 Leukocoria, , 66 microfilaria, 72 Monogenea, 107 Lice Mansonella perstans, 7lt, 71-72, Montenegro test, 206 body, 250,250-253,251,252,253 239, 310 Mosquito bite, pathogenesis of, 244 crab, 250, 250-254, 251 , 7Jt, 72, Mosquito-borne viral diseases, drugs for treatment of, 29lt 239 244-245 head, 250-254,251,252,253 Mansonia, 244 Mosquito control, 245 sucking, see Anoplura Mazzotti test, 51 Mosquito cycle, 175 Lindane, 277 MCL (mucocutaneous Mosquitoes, 238t, 241-245; see also adverse effects, 297 leishmaniasis), 203, 210, 212 Culicidae Liver abscesses, amebic, 156 Measly pork, 82 Anopheles, 186 Liver parenchymal cell, 179 Mebendazole, adverse effects, 297 Mothflies, 238t, 239-240 Loa loa, 53-56,310 Mefloquine, 185 Moths, 283 adult, 56 adverse effects, 297 Mucocutaneous leishmaniasis adult female, 54 Megaesophagus, 194 (MCL), 203, 210, 212 clinical disease, 54 Megalopyge operculis, 283 Multiceps brauni, 89 diagnosis, 54 Meglumine antimonate, adverse Multiceps multiceps, 89 historical information, 53 effects, 297 Multiceps serialis, 89 life cycle, 53-54, 55 Meglumine antimonate (glucantime), Multiceps sp" 89, 98-99 microfilaria, 56, 72 208 Murray Valley encephalitis, 245 pathogenesis, 54 Melani sp" 132, 133 Musca domestica, 246, 247 prevention and control, 56 Melarsoprol,201 Muscidae, 238t, 246-286 treatment, 54, 56 adverse effects, 297 Mutillidae, 264 Louse-borne diseases, 254-255 Meningoencephalitis, amebic, 227 , 248 Louse-borne relapsing fever, 255 drugs for treatment of, 287t Myiasis-causing flies, 239t, 248-250 Loxoceles arizonica, 279 Merozoites, 164 Loxoceles laeta, 279, 280 Merthiolate-iodine-formaldehyde Loxoceles rec/usa, 279-280, 280 (MIF) method, 305 N Loxoceles unicolor, 279 Merthiolate-iodine-formaldehyde Naegleria fowleri, 226-228 Lucilia sp" 249 solution, 306 trophozoite, 227 Lugol's iodine solution, 306 Mesocestoides sp" 106 Nagana, 196 Lumbricus teres, 11 Metacercaria, 122, 123, 124 Nanophyetlls salmincola, 138 INDEX 329

Necator americanus stephanostomum var. prevention and control, 134 clinical disease, 22-23 thomasi, 62t treatment, 134 diagnosis, 23 Oestrus ovis, 249 Parasitic infection drugs for treatment of, 290t Old World hookworm, see drugs for, 287-298 egg, 20 Ancylostoma duodenale procedures suggested for head of adult, 18 OLM (ocular larva migrans), 65-67 examining clinical specimens historical information, 17-18 Onchocerca volvulus, 47-52 for, 299-300 larva in skin, 22 clinical disease, 50-51 therapeutic recommendations for, life cycle, 18-22, 19 diagnosis, 51 287-298 morphology of, 20t eye lesions, 51 Parasitic protozoans, 139 pathogenesis, 22 historical information, 47 Paromomycin, 149 prevention and control, 23-24 life cycle, 47-48, 49 adverse effects, 297 third-stage filariform larva, 21 lymph node lesions, 51 Peau d'orange, 50 treatment, 23 microfilaria, 50, 51, 52,72 Pediculus human capitis, 250-254, Necrotic arachnidism, 279-280 nodule containing. 48. 51 251,252.253 Nematodes, 1-74 pathogenesis, 48, 50 Pediculus humanus humanus, 250, aberrant infections, 61-69 prevention and control, 52 250-253,251,252,253 Ascaris lumbricoides, 11-16,307 skin lesions, 50-51 Pentamidine isethionate, 201 Brugia malayi, 40-46 treatment, 51-52 adverse effect», 297 cutaneous larva migrans (eLM), Onchocerciasis control program, 52 , 284t, 285 61-62,64 Onchocercomas, 47 Pentostam, see Sodium diagnostic atlas of, 307-310 Oncomelania, 108, 115 stibogluconate digestive system of, 1 Oncospheres, 76, 79 Pericarditis, amebic, 156 Dracunculus medinensis, 57-61, O'nyong-nyong fever, 243 Periplaneta americana, 284 310 Oocysts, 181, 182 Permethrin, adverse effects, 297 Enterobius vermicularis, 2-6, 307 , 122 Pesticides, 235 hookworms, 17-24,307; see also Opisthorchis viverini, 122 Peyer's patches, 147 Ancylostoma duodenale; Oriental sore, 203 Phlebotominae, 238t, 239-240 Necator americanus Ornidazole, adverse effects, 297 Phlebotomus, 203 infections caused by, 1 Ornithobilharzia, 116 Phlebotomus papatasii, 240 infections of high prevalence, 7lt , 275 Phocanema sp., 62t, 69 infections of minor medical Ornithodorus moubata, 272-273 Phoneutria spider, 280 importance, 71-74 Oroya fever, 240 Phthirus pubis, 250,250-254,251 Loa loa, 53-56,310 Orthoptera, 283-284, 284t Pian-bois, 210 lymphatic filariae, 40-46, 310 Owen, R., 32 Ping-pong infection, 140 Mansonella ozzardi, 7lt, 71,309 Oxamniquine, adverse effects, 297 Pinworms, 2-6; see also Enterobius Onchocerca volvulus, 47-52 Oxantel, 11 vermicularis Strongyloides sp., 25-31; see also examination for, 304-305 Strongyloides stercora lis p Pipe stem fibrosis, 116 , 32-39 Paget, J., 32 Piperonyl butoxide, adverse effects, Trichuris trichiura, 6-11, 307 Palmetto bug, 284 297 Wuchereria bancrofti, 40-46, 310 Panstrongylus, 190 Piringa-Kuchenka cells, 167 Neorickettsia helmintheca, 138 Panstrongylus megistus, 260 Piroplasmosis, 224 Nephrotic syndrome, 184 Papatasi fever, 240 PKDL (post-kala-azar dermal Neurocysticercosis, 89 Papillon d'amour, 250 leishmaniasis), 218 New World hookworm, see Necator , 133-134 Plague, 258 americanus Paragonimus african us, 130 Plasmodium berghei, 178 Niclosamide, adverse effects, 297 Paragonimus ecuadoriensis, 130 Plasmodium cynomolgi, 178 Nifurtimox, 195 Paragonimus heterotremus, 130 Plasmodium falciparum, 174-187, adverse effects, 297 Paragonimus kellicoti, 130 178(insert); see also Nits, 252, 253 Paragonimus mexicanus, 130 Plasmodium spp. Northern rat flea, 256-257 Paragonimus miyazakii, 130 description, 176, 178 Nosema, 228 Paragonimus uterobilateralis, 130 merozoite, 180 Nosopsyllus fasciatus, 256-257 Paragonimus westermani, 130-134, red blood cell infected with, 183 Nurse cells, 34, 36 313 resistance to chloroquine, clinical disease, 133-134 186-187 o diagnosis, 134 trophozoite, 181 Ocular larva migrans (OLM), 65-67 fertilized unembryonated egg, 132 Plasmodium knowlesi, 178 Oesophagostomum bifurcum, 7lt, historical information, 130, 132 Plasmodium malariae, 174-187, 74,309 life cycle, 131, 132-133 178(insert); see also drugs for treatment of, 293t metacercaria, 133 Plasmodium spp. Oesophagostomum pathogenesis, 133 description, 178 330 INDEX

Plasmodium ovale, 174-187, diagnostic atlas of, 313-320 Quinine, 176 178(insert); see also Dientamoeba fragilis, 226 adverse effects, 298 Plasmodium spp. Entamoeba histolytica, 139, Quotidian fever, 178 description, 178 151-158 Plasmodium spp. Giardia lamblia, 144-149 clinical disease, 184-185 Isospora belli, 226 control, 187 Leishmania braziliensis, 209-212 R description, 176-178 Leishmania donovani, 204t, Reduviidae, 260-262 diagnosis, 185 213-219 Relapsing fever, 255, 275 historical information, 176 Leishmania mexicana, 203-208 Retinochoroiditis, 166 life cycle, 178-182 Leishmania tropica, 203-208 Rerortamonas intestinalis, 230t, asexual stages, 178-179 Microsporidia, 228,228 230-231 erythrocytic phase, 179-181 of minor medical importance, trophozoites,231 sexual stages, 181-182 224-228 Retortamonas sp., trophozoite, 315 macrogametocyte stage, 181 Naegleria fowleri, 226-228 Rhabditis niellyi. 62t microgametocyte stage, 182 nonpathogenic, 230-234 sanguineus, 272, 274 mosquito cycle, 175 Plasmodium falciparum, 174-187, Rhodnius, 190 "signet ring" stage, 180 178(insert); see also Rhodnius prolixus, 260, 260-262, treatment, 185-186 Plasmodium spp. 261 Plasmodium vivax, 174-187, Plasmodium malariae, 174-187, Rickettsia mooseri, 258 178(insert); see also 178(insert); see also Rickettsia tsutsugamushi, 278 Plasmodium spp. Plasmodium spp. Rickettsiae, 254-255 description, 178 Plasmodium ovale, 174-187, Rickettsial diseases, 274-275 life cycle, 177 178(insert); see also Rift Valley fever, 245 Plerocercoid larva, 87, 87 Plasmodium spp. Rocky Mountain spotted fever, 271, Pneumocystis carinii, 219-223 Plasmodium vivax, 174-187, 274-275 clinical disease, 222 178(insert); see also Romafia sign, 193 cyst, 220 Plasmodium spp. Roundworms, see Nematodes diagnosis, 222 Pneumocystis carinii, 219-223 drugs for treatment of, 293t Toxoplasma gondii, 162-168 historical information, 220 Trichomonas vaginalis, 140-143 S life cycle, 220-221 Trypanosoma brucei gambiense, Sabin-Feldman dye test, 167 lung biopsy specimen from 196-202 St. Louis encephalitis (SLE), 245 infected adult, 221 Trypanosoma brucei rhodesiense, Sandflies, 204-206, 205, 238t, pathogenesis, 221 196-202 239-240 pneumonia, 219-220, 222-223 Trypanosoma cruzi, 190-195 Sandfly fever, 240 prevention and control, 222-223 Protozoans, parasitic, 139 Sarcocystis bovicanus sporulated treatment, 222 Pseudocysts, 164, 165, 166 oocyst, 320 Pneumonia, Pneumocystis carinii, Psorophora, 244 Sarcophaga larvae, 248 21-9-220, 222-223 Psychodidae, 238t, 239-240 Sarcophagidae, 239t, 248-250 Polyvinyl alcohol (PVA), 299-300 Pulex irritans, 256 , 276, 276-277, solution, 306 Pulex simulans, 256 277 Post-kala-azar dermal leishmaniasis Pulmonary eosinophilia, tropical SBS (swollen belly syndrome), 25, (PKDL),218 (TPE),45 26 Praziquantel, adverse effects, 297 Puss moth, 283 Scabies Preserved specimens, laboratory PV A, see Polyvinyl alcohol animal,277 diagnostic methods for, Pyrantel pamoate, adverse effects, drugs for treatment of, 294t 305-306 297 Scavenger beetles, 283 Primaquine phosphate USP, adverse Pyrethrins, adverse effects, 297 Schaudinn's fixative, 306 effects, 297 Pyrimethamine, 168 Schistosoma caUoi, 108 Proglottids, 75 adverse effects, 297 Schistosoma haematobium, Proguanil, adverse effects, 297 108-120,312 Protoscoleces, 93, 94 clinical disease, 117-118 Protozoa, 139-234 Q diagnosis, 118-119 Acanthamoeba castellani, Q fever, 274 eggs within wall of bladder, Il7 226-228 QBC (quantitative buffy coat) embryonated egg, 114 African trypanosomes, 196-202 system, 182 historical information, 108, 110 Babesia sp., 224-226, 320 Quantitative buffy coat (QBC) life cycle, 110, 112-115,113 Balantidium coli, 159-162 system, 182 pathogenesis, 115-117 Blastocystis hominis, 226 Quartan malaria, 178 prevention and control, 119-120 Cryptosporidium sp., 169-173 Quinacrine, 148-149 treatment, 119 Cyc/ospora sp., 169, 172-173 adverse effects, 298 Schistosoma intercalatum, 108 INDEX 331

Schistosoma japonicum, 108-120, historical information, 255 free-living adult female, 26 312 life cycle, 255-257 free-living phase, 25 clinical disease, 117-118 pathogenesis, 257 historical information, 25 diagnosis, 118-119 treatment, 258 infective third-stage larva, 28 embryonated egg, 114 SLE (St. Louis encephalitis), 245 larvae, 29, 30 historical information, 108, 110 Sleeping sickness, 196 life cycle, 25-26, 27 life cycle, 110-112,111,114-115 Sodium stibogluconate (Pentostam), parasitic female, 28 pathogenesis, 115-117 208,212 parasitic phase, 26 prevention and control, 119-120 adverse effects, 298 pathogenesis, 28-29 treatment, 119 Soft ticks, 268, 269t, 272-275 prevention and control, 31 Schistosoma mansoni, 108-120, 312 Solenopsis invicta, 264, 264 rhabditiform larva, 26 adults, 110, 112 Soluble egg antigens (SEAs), 116 treatment, 31 in liver, 116 Solutions, 306 Strongyloidiasis, drugs for treatment cercaria, 115 South African tick bite fever, 274 of,294t ciliated miracidium, 114 Specimens Sucking lice, see Anoplura clinical disease, 117-118 preserved, laboratory diagnostic Sugar tlotation method, 303 diagnosis, 118-119 methods for, 305-306 Sugar solution for Sheather's eggs, 114 unpreserved, laboratory method, 306 embryonated, 112 diagnostic methods for, Suramin sodium, adverse effects, in liver, 117 301-305 298 historical information, 108, 110 Spiders, 268, 269t, 279-280 Swimmer's itch, 116 life cycle, 109, 110, 1I2, 114-115 Spiramycin, adverse effects, 298 Swollen belly syndrome (SBS), 25, pathogenesis, 115-117 Spirometra mansonoides, 99 26 prevention and control, 119-120 Spirometra ranorum, 99 Symmer's fibrosis, 116 rectal "snip" from infected Spirometra sp., 89, 99 Syngamus laryngeus, 7lt patient, 118 Spleen, malaria and, 183 Syphacia oblevata, 4 treatment, 119 Sporogany, 175 Schistosoma matthei, 116 Sputum, unpreserved, laboratory , 108 diagnostic methods for, T Schistosomatium douthitti, 116 304_ Tabanidae, 238t, 245-246 Schistosomiasis, 108 Squirrel flea, 256-257 Tachyzoites, 164, 164-166 chronic stage, 1l7-118 Stableflies, 238t, 246-247 Taenia saginata, 76-80,311 drugs for treatment of, 294t Steatorrhea, 148 adult, 78 prevention, 120 Stichocytes, 73 clinical disease, 78 Schistosomula, 115, 116 Stinging insects, see Hymenoptera diagnosis, 78-79 Schizogony, 179 Stomoxys calcitrans, 238t, 246-247 egg, 79 exoerythrocytic, 179 Stool examination, methods of, gravid proglottid, 79 Schizont, 180, 180 299-300 historical information, 76 Schneider's medium, 212 Stool specimens life cycle, 76, 77 Schuffner's dots, 178 collection of, 299 oncospheres, 79 Scolex, 75 number examined and appropriate pathogenesis, 76, 78 Scorpionida, 268, 269t, 280-281, 281 intervals, 300 prevention and control, 80 , 268, 269t, 280-281, 281 preserved, laboratory diagnostic scolex, 78 Screw worm, 249 methods for, 305 treatment, 79-80 , 278 unpreserved Taenia solium, 81-84,311 SEAs (soluble egg antigens), 116 concentration methods, clinical disease, 81 Segmentina, 135 302-303 cysticercus stage, 82 Semisulcospira sp., 132, 137 direct examination, 301-302 diagnosis, 81-82 Serologic methods, 300 laboratory diagnostic methods gravid proglottid, 82 Sheather's flotation method, 303 for, 301-303 historical information, 81 Sheep bot, 249 Strawberry cervix, 142 larval, 89-93 Sickle cell trait, 184 String test, 148 clinical disease, 90, 92 "Signet ring" stage of Plasmodium Strobila, 75 diagnosis, 92 spp., 180 Strongyloides fuelleborni, 25-31, egg, 90 Simuliidae, 238t, 241 see also Strongyloides life cycle, 89, 91 Simulium damnosum, 48, 49, 50 stercoralis pathogenesis, 89-90 Siphonaptera, 239t, 255-258 Strongyloides stercoralis, 25-31 treatment, 92-93 clinical disease, 257 adults, 28 life cycle, 81, 83 control, 258 catch-up growth of child infected pathogenesis, 81 diagnosis, 257-258 with, after thiabendazole, 30 prevention and control, 84 epidemiology of flea-borne clinical disease, 29 scolex, 81 diseases, 258 diagnosis, 29-31 treatment, 82 332 INDEX

Tampan tick, 273 Heterophyes heterophyes, adult Tapeworms, 75; see also Cestodes 137-138 cross section of, 10 infection, drugs for treatment of, Metagonimus yokogawai, female, 8 294t 137-138,313 in large intestine, 9 Tarantulas, 279 of minor medical importance, male, 8 Ternidens deminutus, 7lt 135-138 clinical disease, 10 Terranova sp., 62t, 69 Nanophyetus salmincola, 138 diagnosis, 10 Tertian fever, 178 Paragonimus westermani, fertilized nonembryonated egg, 9 Tetrathyridia, 106 130-134,312 historical information, 6 THI helper cell, 206 Schistosoma haematobium, life cycle, 6-8, 7 callipaeda, 62t 108-120,312 pathogenesis, 8-10 Thiabendazole, adverse effects, 298 Schistosoma japonicum, 108-120, prevention and control, II Thiara sp., 132, 137 312 treatment, 10-11 Tick bites, pathogenesis and Schistosoma mansoni, 108-120, Trichuris vulpis, 6 treatment of, 273 312 Trimethoprim-sulfamethoxazole Tick-borne diseases in humans, 274 Trench fever, 255 (TMP-SFX), 222 Tick-borne relapsing fever, 255 Triatoma infestans, 260 Trimetrexate, adverse effects, 298 Tick-borne typhus, 275 Trichinella nativa, 32 Trombicula alfreddugesi, 278 Tick hypostome, 273 Trichinella nelsoni, 32 Trophozoites Tick , 273-274 Trichinella spiralis, 32-39 Balantidium coli, 160, 160,318 Tick-transmitted infections, adult female, 34 Chilomastix mesnili, 231,314 prevention and control of, adult male, 35 Dientamoebafragilis, 226, 314 275 clinical disease, 37 Entamoeba coli, 232, 316 Ticks, 268-275 diagnosis, 37-38 Entamoeba gingivalis, 232, 318 hard, 268, 269t, 269-272 enteral stages, 36 Entamoeba hartmanni, 234, 317 soft, 268, 269t, 272-275 historical information, 32 Entamoeba histolytica, 151, Tinidazole, adverse effects, 298 infective larva, 34 151-152, 152,315 Tissues, unpreserved, laboratory life cycle, 32-34, 33 Giardia lamblia, 144, 146, 146, diagnostic methods for, 304 muscle biopsy positive for, 38 147,314 TMP-SFX (trimethoprim- newborn larva, 35 Iodamoeba buetschlii, 233, 318 sulfamethoxazole), 222 Nurse cell-infective larva PLasmodium falciparum, 181 TNF (tumor necrosis factor), 216 complex, 36 Retortamonas intestinalis, 231 Tongue worms, 284t, 285 parenteral stages, 36-37 Trichomonas tenax, 23/, 3/3 Toxocara canis, 62t, 63, 64-66, 65, pathogenesis, 36-37 Tropical pulmonary eosinophilia 66 prevention and control, 38-39 (TPE),45 Toxocara cati, 62t, 64-66 treatment, 38 Trypanosoma brucei gambiense, Toxoplasma gondii, 162-168 Trichinosis, drugs for treatment of, 196-202 asexual phase, 164-166 294t clinical disease, 200-201 clinical disease, 166-167 Trichobilharzia, 116 diagnosis, 201 diagnosis, 167 Trichomonas hominis, 230t, 230 historical information, 196, 198 historical information, 162, 164 Trichomonas tenax, 230t, 230 life cycle, 197, 198-199 life cycle, 163,164-166 trophozoites, 231, 314 pathogenesis, 199-200 macrophage infected with, 165 Trichomonas vaginale, 140 prevention and control, 201-202 pathogenesis, 166 Trichomonas vaginalis, 140-143 treatment, 201 prevention and control, 168 clinical disease, 142 Trypanosoma brucei rhodesiense, pseudocyst, 164 diagnosis, 142 196-202 sexual phase, 164 historical information, 140 clinical disease, 200-201 tachyzoites, 164, 164-166 life cycle, 140, 141 course of parasitemia in patient, treatment, 167-168 pathogenesis, 142 200 Toxoplasmosis, 162-168 prevention and control, 143 diagnosis, 201 acquired, 166 treatment, 143 historical information, 196, 198 congenital, 166, 168 trophozoites, 140, 142, 314 life cycle, 197, 198-199 drugs for treatment of, 294t Trichomoniasis, 140-143 metatrypanosome, 198 recrudescent, 167 drugs for treatment of, 295t pathogenesis, 199-200 TPE (tropical pulmonary Trichostrongylus spp., 7lt, 308 prevention and control, 201-202 eosinophilia), 45 drugs for treatment of, 295t procyclic trypomastigote stage, Trematodes, 107-138 Trichuriasis, drugs for treatment of, 199 Clonorchis sinensis, 122-125,313 295t treatment, 201 diagnostic atlas of, 312-313 Trichuris muris, 6 try po mastigote stage, 198,321 Fasciola hepatica, 126-129, 312 Trichuris suis, 6 vein from brain of infected Fasciolopsis buski, 135-136,313 Trichuris trichiura, 6-11, 307 patient, 200 INDEX 333

Trypanosoma cruzi, 190-195 Unpreserved specimens, laboratory Whipworm, see Trichuris trichiura amastigote stage, 192 diagnostic methods for, Winterbottom's sign, 201 chronic infection, 193 301-305 Wuchereria bancrofti, 40-46, 310 clinical disease, 193-194 Urine, unpreserved, laboratory adult diagnosis, 194 diagnostic methods for, 304 calcified dead, 46 epimastigote stage, 193 Uta, 210 female, 42 historical information, 190 lymphatic vessel occupied by, life cycle, 190-192, 191 43 pathogenesis, 192-193 V male, 42 prevention and control, 195 Vagabond's disease, 254 clinical disease, 43-45 treatment, 194-195 Vaginulus plebius, 67 diagnosis, 45-46 trypomastigote stage, 192,320 Velvet ants, 264 historical information, 40 Trypanosomes Verruga peruana, 240 larvae, 45 African, 196-202 Vespidae, 264 life cycle, 40-43, 41 antigenic variation, 199 Visceral larva migrans (VLM), microfilaria, 44, 72 immune suppression and, 199-200 64-69 pathogenesis, 43 Trypanosomiasis, 190-195 clinical manifestations, 62t prevention and control, 46 African, 196-202 drugs for treatment of, 295t treatment, 46 drugs for treatment of, 295t Visceral leishmaniasis (VL), 203, Tryparsamide, adverse effects, 298 213; see also Kala-azar Tsetse flies, 199, 237-238, 247 Vitamin B12 deficiency, 88 X Tsutsugamushi fever, 278 Vivax-like malaria, 178 Xenodiagnosis, 194 Tubulin, 146 Vivax malaria, 178 Xenopsylla cheopis, 256, 256 , 275 VL (visceral leishmaniasis), 203, Tumbu fly, 249 213; see also Kala-azar Tumor necrosis factor (TNF), 216 VLM, see Visceral larva migrans y , 257, 257 Yellow fever, 244 Typhus, epidemic, 254-255 Yellow jackets, 262, 262 W Yersinia pestis, 258 Wakana disease, 23 U Wasps, 264 Ugandan eye worm, 72 Western equine encephalitis (WEE), Z Ulcera de bejuco, 210 245 Zinc sulfate flotation method, 303 Ulcerative colitis, 155 Wheatly-Gomori trichrome stain, Zinc sulfate solution, 306 Uncinaria stenocephala, 61 306 Zygote, 139