Subject: Microbiology and Parasitology Topic: Parasites Associated with Skin Infection Lecturer: Dra.

Dalay Date of Lecture: July 19, 2011 Transcriptionist: Erwin Editor: Bewildered Pages: 12 CATEGORIES OF CLASSIFICATION OF SKIN PARASITES: TAXONOMIC CLASSIFICATIONS Protazoans (blood agulates) o Trypanosama cruzi o Leishmania spp. Helminths o Filarial Worms: Brugia, Wuchereria, Onchocerca, Loa loa o Hookworm and Strongyloides o Trichinella spiralis o Gnathostoma spinigerum o Cysticercus cellulosae o Schistosoma spp. Arthropods o Ectoparasites: Sarcoptes and Pediculus CLINICAL PRESENTATION Transient Erythematous/ maculopapular skin reaction o Eg. SWIMMERS ITCH From infected water Schistosoma spp. o Eg. GROUND ITCH From infected soil Localized edema / inammation or lesion o Eg. Trypanosoma and Loa From bites Localized skin lesion with or without systemic manifestation o Eg. Leishemania Some species may provide continuous involvement Subcutaneous nodules o Eg. Onchocerca, Trichinella, Taenia Food-borne parasites Onchocerca are found on boney prominences Trichinella are found on the subcutaneous parts of the body Dermal atropy / edema with or without skin discoloration o Eg. Onchocerca volvulus Increased expression of the melanin pigment MODE OF TRANSMISSION Direct Skin Contact o Schistosoma spp. Cercarial Dermatitis or Swimmers Itch o Hookworm and Strongyloides Ground Itch & Creeping eruption o Ectoparasites: Sarcoptes and Pediculus Vector-borne Parasites o Trypanosoma cruzi Chagoma = inammatory reaction due to proliferation of amastigotes on the site of the bite of the kissing bug Romanas Sign = unilateral inammation of orbit/periorbial area secondary to bite of kissing bug o Leishmania spp. o Filarial Worms: Brugia, Wuchereria, Onchocerca, Loa Food-Borne Parasites o Trichinella spiralis nematode, eating raw pork o Gnathostoma spinigerum shborne nematode, also produce creeping eruptions o Cysticercus cellulosae from eating raw pork PARASITES AFFECTING THE SKIN Parasitic Agent Sapcoptes scabei Pediculus humanus Pediculus humanus capitis Pediculus humanus humanus Phthirus pubis Onchocerca volvulus Loa Disease Scabies Pediculosis Elephants Leg (Lymphatic obstructions are possible as well)

Onchocerciasis Calabar Swelling

ECTOPARASITES - resides in the stratum corneum Sarcoptes scabei A. Features Class: Arachnida Parasite: OBLIGATE ECTOPARASITE of Man Disease: o Scabies o Sarcoptic Itch o Galis Aso o Kurikong Habitat: Corneus layer of the human skin Distribution: Worldwide Associated with: o Poverty o Overcrowding (slums, jails, armies) o Poor Hygiene PREVENTABLE and CURABLE disease B. Morphology Adult small, oval, dorsally convex but ventrally attened Size: Male: 200 250 um Female: 330 450 um Has 4 pairs of legs o 1st pair: anterior legs with pulvilli & claws o 2nd and 3rd pairs: long bristles in females o 4th pair: suckers in males Egg Large Thin shelled Ovoid Transparent C. Life Cycle Direct Life Cycle o Completed: 8 15 days o Life Span: 4 5 weeks Reservoir Host: o Dogs, Cats, Cows, Sheep, Horses Infective and Diagnostic Stage: ALL STAGES o Adult, Larvae, Nymph, Egg Habitat: Corneous Layer of the skin Mode of Transmission: DIRECT CONTACT o Personal Contact Sleeping together Sharing towels and bed linen o Sexual Contact

D. Diagnosis Clinical Diagnosis o Symptom: INTENSE ITCHING, aggravated by warmth and perspiration o Sign: RED VESICULOPAPULAR LESIONS in the skin (where the mites reside) o Usual Sites: Interdigital spaces Hands Axillae Groin Breast Penis Laboratory Diagnosis o Direct Observation of the skin tracts/ burrows DARK MATERIAL at the end of the lesion = Female Mite o Recovery fo mite from the lesion using sharp, at needle o Microscopic Identication of the eggs and mites They appear as HIGHLY REFRACTIVE, OPALESCENT E. Treatment GOALS: Eradicate the mite Control the Symptoms Prevent Secondary Infection Treatment of Choice: PERMETHRIN CREAMS / 1% BENZENE HEXACHLORIDE (KWELL) o Apply thin from neck down, left overnight, washed off for 5 7 days Alternative Treatment: 1 ounce of 1% lotion of 20g of LINDANE o PRECAUTION Can cause seizures when absorbed into skin Should not be used when irritated or wet o CONTRA-INDICATION Not used in Pregnant or Nursing women or children younger than 2 years old Oral medication F. Prevention and Control Early diagnosis and treatment of cases Sterilization of clothes by boiling Health education Personal cleanliness

Parasitic Lice of Man 3 types of human lice: 1.Pediculus humanus capitis head louse 2.Pediculus humanus humanus Body louse 3.Phthirus pubis Pubic or Crab Louse

Ovoid, operculated Yellow to white Size: 0.6 0.8 mm Attached to the hair(kuto) or cloth bers Hatch after 7 days

C. LIFE CYCLE Pediculus spp. A. FEATURES Class: insect Parasite: OBLIGATE ECTOPARASITE of man Diseases PEDICULOSIS / PHTHIRIASIS Habitat: Hair Mode of Transmission: DIRECT CONTACT Distribution: Worldwide o CHILDREN o Common in persons with UNCLEAN HABITS Reservoir: INFECTED PERSON Disease transmitted by Body Louse (as Vector) o Epidemic typus o Epidemic Relapsing fever o Trench fever PREVENTABLE and CURABLE B. MORPHOLOGY 1. Pediculus spp. ADULT Body louse = more robust than head louse Dorsoventrally attened, wingless Head o Angular ovoid o Piercing and sucking mouth parts o A pair of simple lateral eyes o A pair of jointed antennae Thorax o 3 fused chitinosis o 3 pairs of legs with single hooklike claw, and a THUMB Abdomen o 9 segments, median dorsal opening in last segment 2. Phthirus pubis Adult Small Size: 0.8 12 mm OBLONG turtle shape Rectangular head with paired and jointed antennae Indistinctly segmented abdomen Large heavy claws used for attachment to pubic hair 3. Pediculus EGG Direct Life Cycle o Completion: 8 10 days o Life Span: 30 days o No. of Eggs/lay: 100 eggs/day Infective and Diagnostic Stage: o Adult o Nymph o Egg Habitat: o Hair of the head, body and pubic area Mode of Transmission: DIRECT CONTACT o Personal Contact Sleeping together Sharing clothes, head gear, combs, hats and bed linen o Sexual contact (pubic louse) Through toilet seats, clothing, beddings, etc D. DIAGNOSIS Clinical Diagnosis o ITCHY PAPULAR scalp / skin eruptions Due to irritating saliva o Individuals vary in sensitivity o Scratching increases inammation o May lead to secondary bacterial infection o Symptom: ITCHING most prominent & earliest symptom o Sign: SCRATCHING most characterstic sign Laboratory Diagnosis o Finding nits, nymphs and the adult lice o Attached to the hair shaft (capitis, pubis) or clothes linings (humanus) E. TREATMENT Treatment of choice: 1% BENZENE HEXACHLORIDE (KWELL) Topical application of soothing lotions relieves irritation Alternative Treatment: MIXTURE OF PYRENTINS (0.2%) AND PIPRONYL

BUTOXIDE (2%) OR COPPER OLEATE (effective and less toxic) F. PREVENTION AND CONTROL OF PEDICULOSIS 1.Health Education 2.Improve hygienic practices 3.Early diagnosis and treatment

A. MORPHOLOGY Leishmania spp. Amastigote = DIAGNOSITC STAGE o Small: 2-5 u x 1-3 u o Oval o Intracellular organism o NO agellum o Rod-shaped kinetoplast o Nucleus Promastigote = INFECTIVE STAGE o Small: 14-20 u x 1.5-4.0 u o Pyriform to fusiform shape o Motile organism o WITH long delicate agellum o Rod-shaped kinetoplast o Nucleus o Basal body

PROTAZOANS PROTOZOAN PARAISTES AFFECTING THE SKIN PARASITE DISEASE MOST COMMON CLINICAL SYMPTOM Oriental sore CHRONIC Cutaneous URTICARIA of leishamaniasis the skin Allepo or Baghdad boil

Leishmania tropica complex L. tropica L major L eithiopia OLD WORLD CUTANEOUS LEISHMANIASIS Leishmania Mucocutaneou ULCERATION of mexicana s leishmaniasis naso-oral complex Espundia region L. mexicana (deformity) L.
amazonen sis L. pifanoi L. garmhami

B. Life Cycle *** Refer to the Last Pages for Larger picture C. MODE OF TRANSMISSION Main: BITES of infected SANDFLY (Phlebotomine y) Sharing of injection equipment Sexually Congenitally: mother could transmit it to the fetus Transfusion o Occur more frequently among IMMUNOCOMPROMISED individuals o New routes could potentially complicate some attempts to reduce the burden of the disease through means such as vector and reservoir elimination Leishmania tropica complex Dry or Chronic leishmaniasis o Leishmania tropica Wet or Acute Cutaneous Leishmaniasis o Leishmania major Diffuse or disseminated Leishmaniasis o Leishmania aethiopia

NEW WORLD CUTANEOUS LEISHMANIASIS Leishmania Cutaneous An indolent brazillensis leishmaniasis ulcer complex Chiclero Ulcer L.
brazillenis is

L.
panamens is L. peruviana

NEW WOLRD CUTANEOUS LEISHMANIASIS Leishmania Kala-Azar Death Fever donovani Visceral Dumdum fever complex Leishmaniasis Enlarged liver L. infantum Spleen L. chagasi Leucopenia

CHARACTERSITIC Geographic Distribution Transmission

Leishmania tropica Children and young adults in Mediterrania, Middle East, Republic of Georiga, India Through BITES of infected sandy -man to man -direct contact Dogs Phlebotomus papatasil Phlebotomus sergenti Stomoxys cacitrans

Leishmania major

Leishmania aethopia

Desert areas in Middle Ethiopian and Kenyan east to Afghanistan and highlands Affrica Through BITES of infected sandy Through BITES of infected Sandy

Reservoir Vector

Rodent (gerbil), Sand rat Rock hydraxes Phlebotomus paptasil Phlebotomus longipes Phlebotomus Longifer

A. CLINICAL FEATURES Dry/Chronic Cutaneous Leishmaniasis -Incubation Period: 2 24 months -Stages: o Early Lesion: Single, red pruritic papule at site of bite Early ulceration of the central area o Late Lesion: Multiple papules on exposed body parts site of bites of metastatic sites -Healing: 1 2 years even without treatment Wet/Moist Acute Incubation period: 2 6 weeks Stages o Early Lesion: Multiple lesions on lower extremities with rapid and SEVERE CENTRAL ULCERATION o Late Lesion: Multiple lesions on exposed body parts with SEROSANGUINOUS FLUID (wet oriental sore) Diffuse or Disseminated Cutaneous Leishmaniasis Incubation Period: 2 months - 3 years Stages: o Early Lesion: Multiple on lower extremities that may have rapid and SEVERE CENTRAL ULCERATION

Late Lesion: Dry multiple on exposed body parts like L. tropica

B. DIAGNOSIS Microscopy o With amastigotes in macrophages in skin lesion smears using Giemsa stain Culture o Presence of Promastigote in cultre using the NNN (NovyMacneal-Nicolle) medium Skin Testing o Montenegro Test (Leishmanin Test) An intradermal hypersensitivity testing with reading done after 2-3 days Using leishmanial promastigote antigen with 4-5 mm induratin Serology o IHA, IFA, CF are useful test but lack sensitivity and it may crossreact with T. cruzi Leishmania mexicanna/braziliensis Characteristic L. Mexicana complex Lesion in Mainly human cutaneous Growth in Grow well culture Lesion in Prominent Hamsters or BALB L. brazillensis complex Mucocutaneou s Relatively poor Low virulence

GEOGRAPHIC DISTRIBUTION L. Mexicana Mexicana Mexico L. braziliensis braziliensis L. brazilienseis Panamensis L. Mexicana amazonensis South America Central and Northern South America Northern and Central South America

Leishmania donovani complex A. FEATURES Zoonotic disease More common in children Males acquire disease more frequently than females Highest incidence in the rural areas Transmission by venereal contact is possible host B. EPIDEMIOLOGIC PATTERN 1.Classic Kala-azar a. In India b. Affects ADULTS c. DOGS (only reservoir) 2.Mediterranean or Infantile Kala-azar a. Reported in Mediterranean, S & N America, China, Meddle Asia b. Affects CHILDREN c. DOGS and other animals (reservoir) 3.Sudanese Kala-azar a. Affects ADULTS b. Resistant to ANTIMONY TREATMENT c. Rats (reservoir) C. PATHOLOGY AND SYMPTOMATOLOGY Dermal lesions at site of infection Phagocytosed parasites numerous in the reticuloendothelial cells Most prominent physical ndings: o Fever o Splenomegaly o Cachexia Hyperpigmentation in light skinned patients Kala-azar Hindu term for Black sickness Anemia due to reduced red cell life span and mild degree of infective erythropoiesis D. DIAGNOSIS History and PE: o Symptoms of person living in epidemic area is presumptive Demonstration if the parasties from blood tisuses: o Identication of AMASTIGOTES in early SKIN LESION (primary place to look) o L.D. bodies later in reticuloendothelial system, spleen, lymph nodes, bone marrow, and liver Culture:

A. CLINICAL FEATURES Incubation Period: weeks to months after the bite Stages o Early Lesion: Pruritic papule that rapidly ulcerates usually with secondary infection and mucocutaneous involvement o Late Lesion: Associated with gross deformity with erosion of the nasal septum, palate and larynx o Disguring scars caused a deformed face (ESPUNDIA) B. DIAGNOSIS Specimens o Scraping the biopsies from the margin of the lesion Microscopic examination of Giemsa stained smear to demonstrate amastigotes Culture N.N.N. (Novy-Macneal-Nicolle) medium, biphasic blood agar, Tobies Medium o Only promastigotes can be cultivated in the absence of living cells Serology (IHA, IFA, ELISA) Montenegro Test (Skin test) o Epidemiologically important in indicating past exposure to any of the leishmaniasis C. TREATMENT 1.Pentavalent antimony 2.Amphotericin B 3.Cortisone

Cultivation of organisms into NNN and animal inoculation Smear: from Bone Marrow Serology: o IHA, IFA, ELISA o Formol-gel aldehyde test of Napier: striking increase in gamma globulin Skin test Specimen Requirement o Fine needle ASPIRATION to get the amastigote from the base of the lesion o Using GIEMSA stain o Culture should be attempted for a complete diagnosis using aspirated material and a suitable culture medium E. TREATMENT 1.Pentavalent antimony sodium gluconate (Pentostam or Solustibosan) 2.Pentamide isethionate (Lomidine) 3.Amphotericin B F. PREVENTION AND CONTROL Diagnose and treat the source of the infection early Control the Vectors: Physical and Chemical Personal protection from sandy bites o Fine mesh screening houses o Application of insect repellents o Sleeping under the mesh netting o Wearing of long sleeves and trousers o Immunization G. PREVENTION 1.Treat patients 2.Avoid and destroy infected dogs 3.Destroy breeding places 4.Use effective repellants (dimethyl phthalate) 5.Spraying residual insecticides 6.Health education FILARIAL WORMS A. FEATURES Nematode, unsegmented roundworm Separate sexes (DIOECIOUS) Viviparous female gave birth to prelarval microlariae Arthropod borne; mosquito or y vectors PREVENTABLE and CURABLE if treated

B. TYPES HOST BLACK FLY ( Simullum sp.) DEER OR HORSE FLY (Chrysops) PARASITE DISEASE

Onchocerca ONCHOCERIASIS volvulus Loa loa Calabar swelling / fugitive swelling

1. Onchocerca volvulus (Black y) Disease: Onchocerciasis Transmitted by Black Fly Man is the ONLY denitive host Affects the subcutaneous tissue presented as disguring nodules Life cycle is INDIRECT Affects: 30 50 million people in Africa

A. STAGES OF THE PARASITE Adult Worms are found in subcutaneous nodules usually KNOTTED TOGETHER in pairs

Female Worm Large, round worm 50 cm long Male Worm smaller, 43 cm long Microlariae NO sheath Short cephalic space Rigid body curves Well-separated large oval body nuclei No terminal nuclei Pointed tip B. LIFE CYCLE Indirect Life Cycle Denitive host: MAN Intermediate Host: o Black Fly (Simulium sp.) o Takes up microlariae in skin when feeding o They rasp or abrade skin surface until pool of blood forms an dthey lap

o Invade insects gut wall o Matures in thoracic muscles Infective Stage: L3 *** Detailed Life Cycle of Onchocerca volvulus On the Last Few Pages Please Refer *** C. PATHOLOGY Initially inammatory reaction with granulocyte, lymphocyte and plasma cells, maybe followed by brosis mainly by microlariae Granulomatous reaction Lead to destruction of connective tissue including the elastic tissue of the skin Loss of skin elasticity and cause depigmentation Eyes may be invaded in chronic forms resulting to blindness The parasite and the host compete for Vitamin A

E. DIAGNOSIS Clinical History P.E. History of prolonged stay in endemic area Laboratory Test: o Finding microlariae in skin snip smear o Serology o Skin Testing Mazzoti test

F. PREVENTION AND CONTROL Vector control o Elimination of breathing places o Insecticides spraying or use of larvicides Human Control o Early diagnosis and treatment of cases o Health Education o Mass treatment with Ivermectin 2. Loa loa A. FEATURES Disease: Loaiasis, Calabar Swelling Transmitted by BITES of infected DEER FLY (Chrysops sp.) Inhabit the subcutaneous tissue of the skin & the eye Life cycle is INDIRECT Limitied in Equatorial Africa Adult Thread-like cylindrical worms With characteristic cuticular markings Male smaller than female adult o Male: 30 36 x 0.6 mm o Female: 70 x 0.5 mm B. STAGES Microlariae o With sheath o SHORT cephalic space o Irregular, small body curves o Large, Overlapping body nuclei o With TERMINAL nuclei o Blunt tip o Has DIURNAL periodicity C. LIFE CYCLE *** REFER TO LAST PAGES ***

D. CLINICAL FEATURES Due to Simulium bites o Hypersensitivity, local tissue damage, depigmentation Mild skin manifestations o Maculopapular dermatitis, pruritus Severe skin manifestations o Complicated maculopapular dermatitis, lymphadenopathy, hyperpigmentation Chronic disease o Dermal Atrophy: Sowdah Leopard skin Pretibial atrophy and depigmentation Lizard or Elephants skin Thickening and wrinkling of the skin o Loss of Elasticity: Hanging groin deformity Redundant skin folds due to progressive loss of subepidermal and dermal elastic bers

o D. CLINCIAL FEATURES Calabar swelling or Fugitive swelling o Due to allergic reactions to the parasite or its by-products o Slightly painful, pruritic, nonpitting, subcutaneous swelling o Seen in hands, forearms and in the periorbital regions o Eye involvement can cause irritation, congestion, pain and tumefaction of the eyelids High grade eosinophilia o A form of cardiomyopathy developed in chronic cases Diurnal microlaremia o Afternoon microlaremia is found mainly in those with prolonged exposure Complications o Impaired vision and immune complex nephropathy E. TREATMENT Drug of o o o choice: Diethylcarbamizine (DEC) Is a microlaricidal drug It can slowly kill adult worms It is effective but risky due to its penetration of the blood brain barrier o Possible side effects are retinal hemorrhage and fatal encephalitis o A standard dosage is 2 mg/kg body weight, 3x a day for 21 days o

Treatment of heavily infected patients should begin at low dosage and steroid and antihistamine cover should be provided for the rst 2 3 days Pregnant women should NOT be treated until AFTER DELIVERY

F. PREVENTION AND CONTROL Vector Control o Destruction of vectors habitat o Insecticide spraying Human control o Propyhylactic treatment with Ivermectin o Early detection and management of cases o Health education

LEISHMANIA SPP LIFE CYCLE

LOA LOA LIFE CYCLE