‘The Merck Manual of Diagnosis & Therapy, 19th Edition Chapter 142. Fungi Specific diagnosis requires culture and species identification and is crucial because not all of these organisms respond to any single antifungal drug, For example, Scedosporium sp are typically resistant to amphotericin B. Optimal regimens of antifungal therapy for each member of this group of fungal opportunists must be defined 1492‘The Merck Manual of Diagnosis & Therapy, 19th Edition Chapter 143. Approach to Parasitic Infections Chapter 143. Approach to Parasitic Infections. Introdu n Parasitic infections are responsible for substantial morbidity and mortality worldwide. They are prevalent in Central and South America, Africa, and Asia. They are much less common in Australia, Canada, Europe, Japan, New Zealand, and the US, By far, the greatest impact is on residents of developing areas, but parasitic infections are encountered in developed countries among immigrants and travelers returning from endemic regions and, on occasion, even among residents who have not traveled, particularly those with AIDS or other causes of immunodeficiency. Many parasitic infections are spread through fecal contamination of food or water. They are most frequent in impoverished areas where sanitation and hygiene are poor. Some parasites, such as the hookworm, can enter the skin during contact with infected dirt or, in the case of schistosomes, with freshwater. Others, such as malaria, are transmitted by arthropod vectors. Rarely, parasites are transmitted via blood transfusions or shared needles or congenitally from mother to fetus. ‘Some parasites are enderric in the US and other developed countries. Examples are the pinworm, Enterobius vermicularis, Trichomonas vaginalis, toxoplasmosis, and enteric parasites such as Giardia intestinalis (lamblia) and Cryptosporidium spp. Taxonorrically, parasites can be divided into 2 major groups: + Protozoa + Helminths (worms) The characteristics of protozoan and helminthic infections vary in important ways. Protozoa: Protozoa are single-celled organisms that multiply by simple binary division (see Chs, 147 and 148), Protozoa can multiply in their human hosts, increasing in number to cause overwhelming infection. With rare exceptions, protozoan infections do not cause eosinophilia Helminths: Helminths are multicellular and have complex organ systems. Helminths can be further divided into + Roundworms (nematodes—see Ch. 144) + Flatworms (platyhelminthes), which include tapeworms (cestodes—see Ch. 146) + Flukes (trematodes—see Ch. 145) ‘Some parasites have adapted to living in the lumen of the intestine where conditions are anaerobic; others reside in blood or tissues in aerobic conditions. In contrast to protozoa, helminths do not muiply in humans but can elicit eosinophilic responses when they migrate through tissue. Most helminths have complex ife cycles that involve substantial time outside their human hosts. Exceptions are Strongyloides stercoralis, Capillaria philippinensis, and Hymenolepis nana, which can increase in number because of autoinfection. In strongyloidiasis, autoinfection can result in life-threatening, disserrinated hyperinfections in immunosuppressed people, particularly those taking corticosteroids. The severity of helminthic infections usually correlates with the worm burden, but there are exceptions as when a single ascaris causes life-threatening pancreatitis by migrating into the pancreatic duct. The worm burden depends on the degree of environmental exposure, parasite factors, and the host's genetically determined immune responses. If a person moves from an endemic area, the number of adult worms diminishes over time. Although a few parasites (eg, Clonorchis sinensis) can survive for decades, many 1493‘The Merck Manual of Diagnosis & Therapy, 19th Edition Chapter 143. Approach to Parasitic Infections species have life spans of only a few years or less. More information about parasitic infections is available at the CDC's Division of Parasitic Diseases. Diagnosis Methods for the diagnosis of specific parasitic infections are discussed in the chapters to follow and are summarized in Table 143-4 Parasitic infections should be considered in the differential diagnosis of clinical syndromes in residents of or travelers to areas where sanitation and hygiene are poor or where vector-bome diseases are enderric. For example, fever in the retuming traveler suggests the possibilty of malaria. Experience indicates that immigrants from developing areas to developed countries who return home to visit friends and relatives are at particular risk. They frequently do not seek or cannot afford pretravel advice on disease prevention and are more likely to enter high-risk settings than tourists who stay at resor facilities. Although less frequent, the possibilty of an endemic or imported parasitic infection must also be considered in residents of developed countries who present with suggestive [Table 143-1. Collecting and Handling Specimens for Microscopic Diagnosis of Parasitic Infections] clinical syndromes, even if they have not traveled, Historical information, physical findings, and laboratory data may also suggest specific parasitic infections. For example, eosinophilia is common when helminths migrate through tissue and suggests a parasitic infection in an immigrant or returning traveler. Physicians with expertise in parasitic infections and tropical medicine are available for consultation at many major medical centers, travel clinics, and public health facilities. “Laboratory lentification of Parasites of Public Health Concem" provides detailed descriptions of diagnostic methods and is available from the Centers for Disease Control and Prevention (CDC) at www.dpd.cde.govidpdx. Gl tract parasites: Various stages of protozoa and helminths that infect the Gl tract are typically shed in the stool. Routine detection requires examination of stool specimens, preferably 3 collected on different days, because shedding can be sporadic. With some parasites, relatively sensitive and specific assays are available to detect antigens in stool. Freshly passed stools uncontaminated with urine, water, dirt, or disinfectants should be sent to the laboratory within 1 h; unformed or watery stools are most likely to contain motile trophozoites. If not examined immediately, stools should be refrigerated, but not frozen. Portions of fresh stools should also be emulsified in fixative to preserve Gl protozoa. Concentration techniques can be used to improve sensitivity. Anal cellophane tape or swabs may collect pinworm or tapeworm eggs. If strongyloidiasis is suspected, fresh stool should be smeared on an agar plate and incubated to identify the tracks of migrating larvae. Antibiotics, x-ray contrast material, purgatives, and antacids can hinder detection of ova and parasites for several weeks, Serologic assays, antigen detection tests (eg, for Giardia intestinalis, Cryptosporidium sp, or Entamoeba histolytica), or PCR testing may aid in diagnosis (see Table 143-2). Sensitivity of stool examinations for ova and parasites is low enough that when clinical suspicion is strong, empirical treatment may be given. Sigmoidoscopy or colonoscopy should be considered when routine stool examinations are negative and amebiasis is suspected in patients with persistent Gl symptoms. Sigmoidoscopic specimens should be collected with a curet or spoon (cotton swabs are not suitable) and processed immediately for microscopy. Duodenal aspirates or small-bowel biopsy specimens may be necessary for diagnosis of such infections as eryptosporidiosis and microsporidiosis. [Table 143-2. Serologic and Molecular Tests for Parasitic Infection] 1494