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Parasitic Infections Seen in Impoverished Areas

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Parasitic Infections Seen in Impoverished Areas 44 INFECTIOUS DISEASES NOVEMBER 15, 2010 • FAMILY PRACTICE NEWS Parasitic Infections Seen in Impoverished Areas The prevalence of Trichomonas vaginalis in the grate and encyst in humans but do not treatment. Visceral disease is treated develop into adults or reproduce in with 5 days of albendazole; cortico- United States is estimated at 20 million people. humans. steroids may be used for allergic symp- According to data from the National toms. Ocular toxocariasis is treated with BY KERRI WACHTER acute infection, a blood smear, hemo- Health and Nutrition Examination Sur- 2-4 weeks of albendazole, along with ag- culture, and polymerase chain reaction vey (NHANES), approximately 14% of gressive anti-inflammatory treatment FROM A TELECONFERENCE SPONSORED BY THE CENTERS FOR DISEASE CONTROL (PCR) tests are useful. For chronic in- the U.S. population is infected. The high- with corticosteroids, and surgery. Al- AND PREVENTION fection, serologic tests are useful. How- est prevalence is in the southern United bendazole is not approved by the FDA ever, there is no preferred test. States (less than 17%). Toxocariasis af- for this indication. ertain infectious diseases can con- Tests for acute infection are sensitive, fects non-Hispanic blacks more than oth- centrate in impoverished areas but the acute phase often is not recog- er groups and is associated with pover- Trichomoniasis Cand disproportionately affect mi- nized. Tests for chronic infection have is- ty, low education level, and dog Trichomonas vaginalis is a parasite that is norities, women, and other disadvan- sues with sensitivity and specificity, and ownership. spread through sexual contact. It’s esti- taged groups, according to Dr. Paul T. usually positive results from two differ- Many infected individuals are asymp- mated that there are 5-7 million cases Cantey. ent tests are needed for diagnosis. tomatic, said Dr. Cantey. In children, yearly in the United States. However, the Clinicians often receive little training Nifurtimox or benznidazole are used symptoms include fever, headache, be- prevalence may be as great as 20 million. on infectious diseases seen in these areas, for treatment, although neither drug is havioral and sleep disturbances, cough, The rate is 10-fold greater among black which include tribal lands and border re- approved by the Food and Drug Admin- anorexia, abdominal pain, he- women, compared with non-Hispanic gions in the southwestern United States, istration. Both are available through patomegaly, nausea, and vomiting. white women (13.3% vs. 1.3% respec- the Mississippi CDC’s investiga- Eosinophils may or may not be present. tively). Delta, the Cotton Approximately 20%-30% of tional new drug In adults, symptoms include chronic Patients with trichomoniasis can be Belt, Appalachia, protocol for com- dyspnea, weakness, rash, pruritus, and asymptomatic. In women, symptoms in- and some dense individuals infected with passionate use. abdominal pain. Eosinophilia is often clude vaginal discharge, pruritus, and urban areas. Chagas disease will manifest Data on the effica- present in adults. dysuria; in men, symptoms include ure- Dr. Cantey out- cy of these two Visceral toxocariasis typically occurs in thral discharge and dysuria. lined the diagnosis symptomatic disease – heart drugs for the treat- children aged 2-7 years. Symptoms in- Physical examination may reveal mu- and treatment of failure, sudden death, ment of chronic clude fever, lower respiratory symptoms, copurulent discharge, “strawberry three of these dis- infection are still hepatomegaly, abdominal pain, and cervix” (colpitis macularis), cervical ery- eases – Chagas dis- stroke, or organomegaly. evolving. anorexia. Other symptoms are specific to thema, or cervical friability. ease, toxocariasis, Side effects are the organ involved and include hepatic T. vaginalis infection can cause pre- and trichomoniasis – during the tele- frequent, especially in adults, and re- granulomas, chronic prurigo, pruritus, mature rupture of membranes in preg- conference. quire monitoring. These effects include urticaria, eczema, vasculitis, eosinophilic nant women, preterm birth, low birth Dr. Cantey is a medical officer in the anorexia and weight loss, nausea and meningitis or encephalitis, myelitis, op- weight, pelvic inflammatory diseases, Centers for Disease Control and Pre- vomiting, insomnia, convulsions, tic neuritis, radiculitis, cranial nerve pal- and increased susceptibility to HIV vention’s division of parasitic diseases headache, myalgias and arthralgias, mu- sy, and, less commonly, myocarditis, transmission. and malaria. cosal edema, hepatic intolerance, and nephrotic syndrome, and arthritis. Lab- In terms of diagnosis, wet preparation skin manifestations. examination is only 60%- Chagas disease Yearly physicals should 70% sensitive in women. Chagas disease is caused by the proto- be performed, along Two point-of-care tests zoan parasite Trypanosoma cruzi. The with an ECG with a (OSOM Trichomonas primary mode of transmission is rhythm strip. Rapid Test and Affirm VP through infected triatomine bugs. Other Treatment should al- III) are available. These modes of transmission include blood ways be offered for tests, performed on vaginal transfusion, organ and tissue transplan- acute infections, con- secretions, are more than tation, congenital infection, laboratory genital disease, and for 83% sensitive and more accidents, and food. children and adoles- than 97% specific. Pap Chagas disease is endemic in much of cents 18 years and smears are not recom- Latin America. However, both the para- younger with chronic mended for Trichomonas site and the triatomine bug are found in infection, and im- screening. In men, wet COM the United States. It’s estimated that munocompromised . preparation of urethral dis- there are at least 300,000 infected Latin patients with reactiva- charge, prostatic secre- LICKR American immigrants living in the Unit- tion, said Dr. Cantey. /F tions, or urethral scrapings ed States. California, Florida, and Texas Treatment generally is of uncertain sensitivity. are disproportionately affected. Other should be offered to Instead, PCR or culture on TRAVFOTOS geographic concentrations include Ari- women of reproduc- © special media should be zona, Georgia, Illinois, New York, North tive age, adults aged 50 The assassin bug, also known as the kissing bug, is a blood- used. Carolina, and Virginia. years and younger with sucking triatomine insect that carries Trypanosoma cruzi. Trichomoniasis is treat- Blood donor screening for T. cruzi indeterminate form ed with metronidazole or started in early 2007. Since then 1,267 in- disease or with mild to moderate car- oratory test results show marked tinidazole. If treatment with 2 g fected donors have been identified. More diomyopathy, and patients in whom im- eosinophilia, anemia, hypergammaglob- metronidazole given once fails (and re- than 40 of these individuals had no rec- munosuppression is anticipated. ulinemia, and increased titers to A and B infection is excluded), then patients ognized risk factors. Treatment generally should not be of- blood group antigens. should be treated with 500 g metro- The acute phase of the disease lasts 4- fered to patients with advanced car- Ocular toxocariasis typically occurs nidazole twice daily for 7 days or with 8 weeks. Patients are usually asympto- diomyopathy with congestive heart fail- in 5- to 10-year-olds. Usually a single eye 2 g tinidazole once. If either therapy matic during this period. An estimated ure and patients with impairment of is affected. Symptoms include strabis- fails, then treat with 2 g metronidazole 10%-20% of infected individuals may swallowing. Treatment should almost mus, unilateral decreased vision, and or 2 g tinidazole daily for 5 days. If this have nonspecific febrile illness. Romaña’s never be offered during pregnancy or to leukokoria. treatment fails, consult the CDC for sign (chagoma) occurs less frequently. patients with severe renal or hepatic in- Enzyme-linked immunosorbent assay testing and management (404-718-4141 The chronic phase is lifelong and may sufficiency, Dr. Cantey said. (ELISA) is 78% sensitive and 92% spe- or www.cdc.gov/std). Sex partners of be asymptomatic and indeterminate in cific for the diagnosis of visceral toxo- patients should be treated to prevent re- form. Approximately 20%-30% of in- Toxocariasis cariasis. However, the sensitivity is low- infection. fected individuals will manifest sympto- Toxocariasis in humans is caused by in- er for ocular toxocariasis. The disease Metronidazole is pregnancy category matic disease – heart failure, sudden fection with larval stages of dog/cat cannot be diagnosed from stool, as the B and tinidazole is pregnancy category C. death, stroke, or organomegaly. roundworm. Toxocara eggs are shed in eggs are not excreted by humans, said Asymptomatic pregnant women should Testing for Chagas disease is available dog and cat feces, and humans become Dr. Cantey. be counseled about the risks and bene- through the CDC, Dr. Cantey said. For infected through ingestion. Larvae mi- Mild toxocariasis often does not need fits of treatment, Dr. Cantey noted. ■.
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