Helminth infections - cdn.ymaws.com...• Caused by Trichobilharzia and Bilharziella spp. (avian...
Transcript of Helminth infections - cdn.ymaws.com...• Caused by Trichobilharzia and Bilharziella spp. (avian...
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HELMINTH INFECTIONS& THEIR CUTANEOUS MANIFESTATIONS
Brittany Grady, DO
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DISCLOSURES
I have no conflicts of interest to declare
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LEARNING OBJECTIVES:
• Describe the cutaneous manifestations of helminth
infections
• Recognize recent developments and incidence of
helminth infections within the United States of America
• Evaluate, diagnose, and treat affected patients more
knowledgeably and effectively
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WHAT IS A HELMINTH?
• Helminths (worms) are large, multicellular organisms
• Often visible to the naked eye
• Free-living or parasitic
• Belong to 2 different phyla:
• Roundworms (Nematodes)
• Flatworms (Platyhelminthes)
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ROUNDWORMS (NEMATODES)
• Unsegmented
• Each species has 2 different sexes
• Contain a body cavity and digestive tract
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FLATWORMS (PLATYHELMINTHES)
• Segmented or unsegmented
• Primarily hermaphroditic
• Do not have a body cavity
• Further subdivided into 2 different classes:
• Flukes (Trematodes)
• Tapeworms (Cestodes)
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ROUNDWORM (NEMATODE) INFECTIONS
• Cutaneous Larva Migrans
• Onchocerciasis
• Filariasis
• Strongyloidiasis
• Trichinosis
• Toxocariasis
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CUTANEOUS LARVA MIGRANS (CLM)
• AKA Creeping Eruption
• CLM primarily affects people in tropical and
subtropical climates, including the SE United States
• Caused by animal hookworms, most commonly
Ancylostoma braziliense and A. caninum
• Eggs are eliminated via animal (cat or dog) feces
and larvae mature in the sand/soil
• Larvae infiltrate exposed skin surfaces of humans (end
hosts)
• Confined to the epidermis (lack collagenase)
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XX X
CLM
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CUTANEOUS LARVA MIGRANS (CLM)
• Larval migration through the epidermis (1-2 cm/day)
• Clinical features:
• Localized, intense pruritus
• Linear or serpiginous raised erythematous “tracts”
• +/- vesiculation
• Most frequent location is distal lower extremities or
buttocks
• Diagnosis usually made clinically (biopsy rarely helpful)
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W. Infectious Diseases of the Skin. In: McKee’s Pathology of the Skin 4th ed. Edinburgh:
ElsevierGrayson/Saunders; 2012: 761-895
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Nelson SA, Warschaw KE. Protozoa and Worms. In: Dermatology 3rd
ed. Edinburgh: Elsevier/Saunders; 2012: 1391-1421
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Grady BE, Baum B. A Classic Case of Cutaneous Larva Migrans. 2013.
http://www.consultantlive.com/skin-diseases/content/article/10162/2148906
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CUTANEOUS LARVA MIGRANS (CLM)
• Self-limited, but patients typically seek medical treatment
• Treatment options:
• PO Albendazole 400-800mg/day (Peds: 10-15 mg/kg/day) x 3-5 days
• PO Ivermectin 12mg (Peds: 150 mcg/kg) x 1
• Topical 10-15% thiabendazole solution or ointment TID x 15 days
• Cryotherapy to leading edge of skin tract (often unreliable)
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ONCHOCERCIASIS
• AKA River Blindness
• Onchocerciasis primarily affects people in tropical Africa
• Caused by Onchocerca volvulus
• Transmitted via blood meal of infected black fly (Simulium
spp.)
• Larvae mature into adult worms in the dermis and subcutis
• Mature adult female worms become encapsulated in
fibrous tissue (onchocercomas)
• Each worm produces hundreds of microfilariae which
migrate to the skin, connective tissue, eyes, and lymph
nodes
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Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of
the Skin 4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895
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Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of the Skin 4th ed.
Edinburgh: Elsevier/Saunders; 2012: 761-895www.who.int/intestinal_worms/en
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ONCHOCERCIASIS
• Clinical features:
• Onchocercomas- firm, freely mobile subQ nodules often
located over bony prominences
• Acute papular onchodermatitis chronic onchodermatitis
lichenification, atrophy, depigmentation
• “Hanging groin”- chronic lymphatic obstruction of inguinal
lymph nodes
• Progressive sclerosing keratitis can lead to blindness in severe
cases
• 2nd most common cause of infection-related blindness
• Accounts for 0.8% of overall blindness globally
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Nelson SA, Warschaw KE. Protozoa and Worms. In:
Dermatology 3rd ed. Edinburgh: Elsevier/Saunders; 2012:
1391-1421
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Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of
the Skin 4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895
Nelson SA, Warschaw KE. Protozoa and Worms. In: Dermatology
3rd ed. Edinburgh: Elsevier/Saunders; 2012: 1391-1421
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Grayson W. Infectious Diseases of the Skin. In:
McKee’s Pathology of the Skin 4th ed.
Edinburgh: Elsevier/Saunders; 2012: 761-895
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ONCHOCERCIASIS
• Treatment options:
• DOC: PO Ivermectin 150 mcg/kg x 1 q3-12 months
• Treatment continued for worm’s lifetime (10-15 years)
• Adjunct: PO Doxycycline 100-200mg/day x 6 weeks
• Targets Wolbachia endobacteria that reside within the O.
volvulus nematodes
• Wolbachia is responsible for inflammation that leads to
subsequent protective fibrosis
• Nodulectomy: surgical removal of onchocercomas
from head/neck reduces the incidence of ocular
disease
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FILARIASIS
• AKA Elephantiasis
• Filariasis primarily affects individuals in tropical or subtropical
regions, including the Caribbean Islands and South America
• Caused by Wucheria bancrofti (90% of cases)
• Transmitted via bite of infected mosquitoes
• Deposited larvae migrate to lymphatic system and develop into
adult worms
• Adult worms release microfilariae into the bloodstream
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Cano J, Rebollo MP, Golding N, et al. The Global Distribution and Transmission Limits
of Lymphatic Filariasis: Past and Present. Parasites & Vectors. 2014 Oct; 7: 466
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FILARIASIS
• After 10-15 years of infection, the clinical features of
chronic disease become evident
• Leading cause of permanent disability worldwide
• Clinical features:
• Acute adenolymphangitis associated with fevers and chills
(recurrent)
• Chronic lymphedema hypertrophy of skin
(hyperkeratotic, verrucous, fibrotic) redundant folds
deformity
• Secondary bacterial and fungal infections common
• Most commonly affected sites: lower extremities and genitalia
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James WD, Berger TG, Elston DM. Parasitic Infestations, Stings, and Bites. In: Andrews’ Diseases of the Skin: Clinical Dermatology 11th ed. Edinburgh: Elsevier/Saunders; 2011: 414-447
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FILARIASIS
• Treatment options:
• DOC: PO Diethylcarbamazine 6 mg/kg/day x 12 days
• Active against microfilariae, limited effect on adult worms
• Adult worm lifespan in host approx. 5-10 years
• Adjunct: PO Doxycycline 200mg/day x 4-8 weeks
• Targets Wolbachia endobacteria
• Supportive care: limb elevation, compression stockings,
protection from trauma, NSAIDs
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STRONGLYLOIDIASIS
• AKA Larva Currens
• Worldwide distribution, especially in tropical and subtropical regions, including SE United States and Appalachia
• Caused by the human parasite Strongyloidesstercoralis
• Transmitted via direct contact with free-living larvae, usually through contaminated soil
• Larvae penetrate skin migrate to intestine to mature into adult worms lay eggs develop into infective larvae in intestine
• Infective larvae migrate toward the perianal opening
• Penetrate skin
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Puthiyakunnon S, Boddu S, Li Y, et al. Strongyloidiasis-An Insight into
Its Global Prevalence and Management. PLoS Negl Trop Dis. 2014
Aug; 8(8): e3018
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www.cdc.gov/par
asites
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STRONGLYLOIDIASIS
• Most patients with strongyloidiasis are asymptomatic
• Larval migration through skin (up to 10 cm/day)
• Clinical features:
• Urticarial serpiginous, raised, erythematous “tract” usually
located on the buttocks or trunk
• Autoinfection can cause the rash to recur for weeks to years
• Hyperinfection with Strongyloides- diffuse petechiael
“thumbprint purpura” eruption
• Seen in immunocompromised individuals
• Dermal invasion of a large number of larvae that migrate
through vessel walls
• High mortality
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www.cdc.gov/parasi
tes
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STRONGLYLOIDIASIS
• Recommended to treat all known infected patients,
whether symptomatic or not
• Consider testing patients at risk prior to initiating
immunosuppressive drugs i.e. corticosteroids
• Microscopic stool examination
• Treatment options:
• DOC: PO Ivermectin 0.2 mg/kg/day x 2 days (consider
repeating in 2 weeks)
• PO Albendazole 400 mg BID x 7 days
• PO Thiabendazole 25 mg/kg BID x 2 days (7-10 days for
hyperinfection syndrome)
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TRICHINOSIS
• Worldwide distribution, including the United States
• Caused by Trichinella spp. (most commonly Trichinella
spiralis)
• Transmission via ingestion of larva-containing cysts in raw or
undercooked meat
• Ingested larvae invade small bowel and mature into adult
worms
• Adult female worms release larvae that migrate to striated
muscle and encyst (may remain viable for several years)
• Disease severity categorized as light (1-10 ingested larvae),
moderate (50-500 ingested larvae), or severe (>1000
ingested larvae)
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TRICHINOSIS
• Pigs are the most common source of human infection
• Typically from consumption of home-prepared
sausage or undercooked wild game in the U.S.
• Worldwide incidence has declined dramatically in
past 2-3 decades
• Improved pig-raising practices
• Improved inspection processes
• Commercial and home freezing of pork
• Public awareness of danger of eating undercooked
meats
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www.cdc.gov/para
sites
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www.cdc.gov/parasites
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TRICHINOSIS
• Nonspecific GI symptoms occur first (1-2 days post consumption)
• Classic symptoms occur within 2 weeks of eating contaminated meat
• Clinical features:
• Myalgias (approx. 90% cases)
• Periorbital edema
• Nonpruritic morbilliform exanthem (uncommon)
• Subungual splinter hemorrhages
• Rare, severe cases may affect CNS, heart, and/or lungsdeath
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TRICHINOSIS
• Self-limited if mild disease
• Treatment options:
• PO Corticosteroids- Prednisone 40-60 mg/day until symptoms
resolve (followed by gradual taper)
• Highly recommended to address allergic-reaction related signs and
symptoms
• Especially if CNS, cardiac, or pulmonary involvement
• Caution: Corticosteroid monotherapy may decrease the number of adult worms expelled via GI tract increased number of larvae
produced
• PO Albendazole 400 mg BID x 8-14 days
• PO Mebendazole 200-400 mg TID x 3 days, then 400-500 mg TID x
10 days
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TOXOCARIASIS
• Endemic in the United States
• Highest prevalence in hot, humid regions
• Caused by Toxocara canis and T. catis (dog and cat
roundworms, respectively)
• Transmission via accidental ingestion of eggs from the
environment or (more rarely) ingestion of undercooked meat
infected with Toxocara larvae
• Eggs hatch and travel hematogenously to various body tissues
including liver, heart, brain, lungs, muscles, or eyes
• Disease primarily affects children
• 13.9% of the U.S. population ≥ 6 years of age are seropositive for
toxocariasis
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TOXOCARIASIS
• A U.S. study in 1996 showed that 30% of dogs younger
than 6 months deposit Toxocara eggs in their feces
• Studies have shown that almost all puppies are born
already infected with Toxocara canis
• Research suggests that 25% of all cats are infected
with Toxocara cati
• Via Centers for Disease Control and Prevention (CDC)
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TOXOCARIASIS
• Most people who are infected do not have any symptoms
• Manifestations reflect the number of migrating larvae, where the larvae
have migrated in the body, and the degree of inflammation that
developed in response to the presence of the larvae
• Clinical features:
• Transient rash, chronic urticaria, eczematous dermatitis, cutaneous
nodules
• In 2 case control studies, 65% of patients with chronic urticaria and 38.1% of patients with chronic prurigo were found to be seropositive for Toxocara
• Anti-helminthic treatment cured the chronic urticaria in 50% of cases and
the chronic prurigo in 80% of cases
• Visceral toxocariasis
• Ocular toxocariasis- at least 70 people are blinded by this disease each
year in the U.S.
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www.cdc.gov/mmwr/preview/mmwrhtml/mm6022a2.htm
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Kollipara R, Peranteau AJ, Nawas ZY, et al. Emerging
Infectious Diseases with Cutaneous Manifestations. J Am
Acad Dermatol. 2016 Jul; 75(1): 19-31
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TOXOCARIASIS
• Treatment indicated for symptomatic visceral or
ocular disease
• Treatment options:
• PO Albendazole 400 mg BID x 5 days
• PO Mebendazole 100-200 mg BID x 5 days
• Systemic corticosteroids may be necessary to control
inflammatory response
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FLATWORM (PLATYHELMINTH) INFECTIONS
• Fluke (Trematode) infections
• Schistosomiasis
• Tapeworm (Cestode) infections
• Cysticercosis
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SCHISTOSOMIASIS
• AKA Bilharziasis, Cercarial Dermatitis, “Swimmer’s Itch”
• Worldwide distribution, especially tropical climates
• Caused by Schistosoma mansoni, S. haematobium,
and S. japonicum (human schistosomes- not seen in
U.S.)
• Caused by Trichobilharzia and Bilharziella spp. (avian
schistosomes- seen in Northern U.S. and California)
• Transmission via direct contact with free-living larvae
released by freshwater snails
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SCHISTOSOMIASIS (HUMAN)
• Larvae penetrate skin within minutes of contact
dermis vascular system
• Larvae mature into adult worms within vascular
system (mesenteric venules)
• Adults deposit eggs in venules intestines (S.
mansoni, S. japonicum) or bladder (S. haematobium)
• Eggs eliminated via feces or urine
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SCHISTOSOMIASIS (AVIAN)
• Larvae penetrate skin within minutes of contact
• Remain in stratum corneum
• Humans are accidental “dead end” hosts
• Larvae die shortly (within hours) after initial penetration
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Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of the
Skin 4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895
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www.cdc.gov/parasites
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www.cdc.gov/parasites
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SCHISTOSOMIASIS
• Skin manifestations begin within minutes to hours
• Represent a hypersensitivity reaction to larval penetration of skin
• Clinical features:
• Cercarial dermatitis “swimmer’s itch”- urticarial, pruritic erythematous
papular eruption
• Most commonly on lower legs/feet
• Seen with both human and avian schistosome larvae
• Katayama fever- fever, chills, diarrhea, headache
• Hypersensitivity reaction against migrating human schistosome larvae
• Bilharziasis cutanea tarda- papular, granulomatous, or verrucous lesions
• Seen in those with chronic, visceral disease
• Secondary to deposition of eggs in the dermis
• Genital and perineal regions most commonly affected
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Nelson SA, Warschaw KE. Protozoa and Worms. In: Dermatology 3rd ed. Edinburgh:
Elsevier/Saunders; 2012: 1391-1421
James WD, Berger TG, Elston DM. Parasitic Infestations, Stings, and
Bites. In: Andrews’ Diseases of the Skin: Clinical Dermatology 11th
ed. Edinburgh: Elsevier/Saunders; 2011: 414-447
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Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of the Skin
4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895
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SCHISTOSOMIASIS
• Cercarial dermatitis (acute skin eruption) is self-limiting,
but may persist for several weeks
• Treatment options (human):
• DOC: PO Praziquantel 20 mg/kg BID-TID x 1
• Treatment options (avaian):
• No treatment required for cercarial dermatitis caused by
avian schistosomes
• Antihistamines and topical corticosteroids for symptomatic
relief
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CYSTICERCOSIS
• Worldwide distribution, including the United States
(most commonly SW U.S.)
• Caused by Taenia solium (pork tapeworm)
• Transmission via fecal-oral ingestion of eggs via
contaminated food or water
• Ingested eggs hatch in the small bowel and penetrate
intestinal mucosa
• Spread hematogenously and encyst in various body
tissues including muscle, brain (neurocysticercosis),
heart, eyes, and skin
• Cysts remain viable for 3-5 years
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CYSTICERCOSIS
• Cysticercosis versus Taeniasis
• You cannot acquire cysticercosis from ingestion of infected undercooked pork
• A quick word about Taeniasis…
• Ingestion of T. solium larval cysts in undercooked pork
• Leads to infestation of small bowel with adult tapeworms (compared to eggs ingested in cysticercosis)
• Tapeworm lives and grows (up to 30 feet!) within the intestine
• Gravid proglottids or eggs are shed and expelled via feces (individual now an infectious carrier of disease)
• Autoinfection not uncommon ingestion of eggs cysticercosis
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www.cdc.gov/parasites
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www.cdc.gov/p
arasites
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CYSTICERCOSIS
• Incidence is rising in the United States, especially in
states with a large immigrant population (most
commonly from endemic Latin America)
• Cases are most frequently reported in New York,
California, Texas, Oregon, and Illinois
• There are an estimated 1,000 new hospitalizations for
neurocysticercosis in the United States each year
• Neurocysticercosis is a leading cause of adult onset
epilepsy worldwide
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Sorvillo, FJ, DeGiorgio C, Waterman SH. Deaths from
Cysticercosis, United States. Emerg Infect Dis. 2007 Feb;
13(2): 230-235
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CYSTICERCOSIS
• Clinical features:
• Multiple, asymptomatic, firm subQ or intramuscular
1-2 cm nodules
• Can resemble other common cutaneous lesions such as
lipomas or epidermoid cysts
• Muscle involvement often associated with myalgias and
fever
• Neurocysticercosis can present with seizures
• Intraocular cysticercosis may lead to vision loss
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Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of
the Skin 4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895
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Kollipara R, Peranteau AJ, Nawas ZY, et al. Emerging
Infectious Diseases with Cutaneous Manifestations. J Am
Acad Dermatol. 2016 Jul; 75(1): 19-31
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CYSTICERCOSIS
• The natural history of the lesions of cysticercosis is spontaneous resolution (cysts degenerate after 3-5 years)
• Studies have indicated that treated patients with neurocysticercosis have fewer residual seizures than those not treated with an anti-helminthic medication
• Inactive lesions of cutaneous cysticercosis are treated surgically
• Treatment options:
• DOC: PO Albendazole 15 mg/kg/day x at least 8 days
• PO Praziquantel 50 mg/kg/day (in 3 divided doses) x 14 days
• Consider systemic corticosteroids prior to initiation of anti-helminthic therapy
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FINAL THOUGHTS
• 21st century has brought increased international travel
for vacation, business, medical missions, and
immigration
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Via U.S. Dept. of State
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Via U.S. Dept. of
Commerce
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Via U.S. Dept. of
Commerce
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FINAL THOUGHTS
• Approx. 17% of travelers seek medical care because
of cutaneous disorders
• Helminth infections are important causes of morbidity
and mortality worldwide
• Although many helminth infections are uncommon in
the United States, it is important to be aware of these
conditions (they do exist!)
• Little research has been done to calculate the
burden of these diseases within the United States
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REFERENCES• Cano J, Rebollo MP, Golding N, et al. The Global Distribution and Transmission Limits of Lymphatic Filariasis:
Past and Present. Parasites & Vectors. 2014 Oct; 7: 466
• Croker C, Reporter R, Redelings M, et al. Strongyloidiasis-Related Deaths in the United States, 1991-2006. Am
J Trop Med Hyg. 2010 Aug; 83(2): 422-426
• Gavignet B, Piarroux R, Aubin F, et al. Cutaneous Manifestations of Human Toxocariasis. Ja Am Acad
Dermatol. 2008 Dec; 59(6): 1031-1042
• Grady BE, Baum B. A Classic Case of Cutaneous Larva Migrans. 2013. http://www.consultantlive.com/skin-
diseases/content/article/10162/2148906
• Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of the Skin 4th ed. Edinburgh:
Elsevier/Saunders; 2012: 761-895
• Hoerauf A, Mand S, Volkmann L, et al. Doxycycline in the Treatment of Human Onchocerciasis: Kinetics of
Wolbachia Endobacteria Reduction and of Inhibition of Embryogenesis in Female Onchocerca worms.
Microbes Infect. 2003 Apr; 5(4): 261-73
• Housholder AL. Parasites and Other Creatures. In: Review of Dermatology. Toronto: Elsevier; 2017: 312-319
• James WD, Berger TG, Elston DM. Parasitic Infestations, Stings, and Bites. In: Andrews’ Diseases of the Skin:
Clinical Dermatology 11th ed. Edinburgh: Elsevier/Saunders; 2011: 414-447
• Kollipara R, Peranteau AJ, Nawas ZY, et al. Emerging Infectious Diseases with Cutaneous Manifestations. J
Am Acad Dermatol. 2016 Jul; 75(1): 19-31
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REFERENCES
• Lupi O, Downing C, Lee M, et al. Mucocutaneous Manifestations of Helminth Infections. J Am Acad
Dermatol. 2015 Dec; 73(6): 929-957
• Nelson SA, Warschaw KE. Protozoa and Worms. In: Dermatology 3rd ed. Edinburgh: Elsevier/Saunders; 2012:
1391-1421
• Puthiyakunnon S, Boddu S, Li Y, et al. Strongyloidiasis-An Insight into Its Global Prevalence and Management.
PLoS Negl Trop Dis. 2014 Aug; 8(8): e3018
• Sanprasert V, Sujariyakul A, Nuchprayoon S. A Single Dose of Doxycycline in Combination with
Diethylcarbamazine for Treatment of Bancroftian Filariasis. Southeast Asian J Trop Med Public Health. 2010
Jul; 41(4): 800-12
• Sorvillo, FJ, DeGiorgio C, Waterman SH. Deaths from Cysticercosis, United States. Emerg Infect Dis. 2007 Feb;
13(2): 230-235
• www.cdc.gov/parasites
• www.uptodate.com/contents/strongyloidiasis
• www.visualdx.com
• www.who.int/intestinal_worms/en
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QUESTIONS?