14/03/62

A 45-year-old female
 Poorly controlled type 2 DM
Common Tropical Diseases  Fever and right upper quadrant abdominal pain for 1 week
 Hepatomegaly with tenderness
 B. pseudomallei antibody titer 1:160

Methee Chayakulkeeree, MD, PhD, FECMM

Division of Infectious Diseases and Tropical Medicine
Department of Medicine
Faculty of Medicine Siriraj Hospital CT abdomen Gram stain of pus Colony on Macconkey agar
MAHIDOL UNIVERSITY Oxidase test - negative

What is the diagnosis and etiologic agent?

Answer A 45-year-old female

 Poorly controlled type 2 DM
A. Pyogenic liver abscess  Fever and right upper quadrant abdominal pain for 1 week
 Hepatomegaly with tenderness
B. Amoebic liver abscess  Melioidosis titer 1:128
C. Melioidosis
D. Primary bacteremic liver abscess
E. Fasciola hepatica infestation Klebsiella pneumoniae

CT abdomen Gram stain of pus Colony on Macconkey agar

Oxidase test - negative

What is the diagnosis and etiologic agent?

Burkholderia pseudomallei antibody:

Indirect hamagglutination assay (IHA) Liver Abscess
• General population in Thailand : titer ≥ 1:10
• Pyogenic liver abscess – 80%
• 40% - titer≥ 1:80
• Direct spread: Biliary tract, portal circulation or bowel
• 30% - titer≥ 1:160
Gall stone
• Acute septicemic melioidosis – 50% • Hematogenous seeding (primary bacteremic liver abscess)
• Seroconversion • Amoebic liver abscess – 10%
• Positive  negative : 10% • E. histolytica
• Negative  positive : 70%
• Fungal liver abscess – 10%
• Persistent seronegative : 15-30% • Candida spp.
• Persistent seropositive : 50-90%
NOT recommend for routine use as standard diagnostic test

Am J trop Med Hyg 2006;74:330-4., Am J trop Med Hyg 2018;99:1378-85.

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Liver Abscess Pus Gram Stain

• Pyogenic liver abscess

• Direct spread: biliary tract, portal circulation or bowel:
• Mixed organisms:
• E. coli, anaerobes e.g. Bacteroides fragilis, Actinomyces israelii
• Hematogenous seeding: - monomicrobial infection Polymicrobial
• Burkholderia pseudomallei
• Klebsiella pneumoniae
• Viridans streptococci: S. anginosus group (S. anginosus, S.
intermidius, S. constellatus)

Diagnosis: Blood culture and pus examination

Actinomyces

Pus Gram Stain Klebsiella pneumoniae genotype K1

• Community-acquired Klebsiella pneumoniae invasive infection

• magA gene is associated with K1 genotype
(hypermucoviscous K. pneumonia; HMKP)
• Liver abscess, endophthalmitis, osteomyelitis, pneumonia,
B. pseudomallei K. pneumoniae
brain abscess/meningitis (distinctive syndrome)
• Bacteremia-common
• Prevalent in East and Southeast Asians: Taiwan, Korea,
Thailand, Singapore

S. intermediate

Clin Infect Dis 2006;42:1359–61

Hypermucovicous Klebsiella pneumoniae Melioidosis

• Caused by a gram-negative bacterium
Burkholderia pseudomallei
• Category B bioterrerism

String test
5 mm

N Eng J Med 2012;367:1035-44

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Risk factors Clinical Classifications

• Incubation 1-21 days (average 9 days), longest 62 yr.

• Disseminated septicemic melioidosis
• 75 to 81% rainy season
• Non-disseminated septicemic melioidosis
• Incidence peaks between age 40 and 60 years
• 80% of patients have one or more risk factors • Multifocal localized melioidosis
• Diabetes (23 to 60%) • Localized melioidosis
• Heavy alcohol use (12 to 39%)
• Chronic pulmonary disease (12 to 27%)
• Probable melioidosis
• Chronic renal disease (10 to 27%) • Subclinical melioidosis
• Thalassemia (7%)
• Glucocorticoid therapy (<5%)
• Cancer (in 5%)

Clinical Classifications Clinical Classifications

• Pneumonia (51%)
• Genitourinary infection (14%) – prostatic abscess
• Skin infection (13%)
• Bacteremia without evident focus (11%)
• Septic arthritis or osteomyelitis (4%)
• Neurologic involvement (3%)
• Internal-organ abscesses and secondary foci in the
lungs, joints, or both - common

N Eng J Med 2012;367:1035-44

Clinical Classifications Clinical Classifications

• Acute fulminant septic illness to a chronic infection • Suppurative parotitis 40% in children in Thailand and Cambodia
(symptoms for >2 months for 11% of cases) (extremely rare in Australia)
• May mimic cancer or tuberculosis • Prostatic melioidosis - 20% of male (in Australia)
– the great imitator • neurologic melioidosis
• Brain-stem encephalitis w/wo cranial-nerve palsies (esp. CN VII)
• > 50% have bacteremia on presentation • Myelitis with peripheral motor weakness
• Septic shock - approximately 20% • Recurrent melioidosis occurs 1 in 16 patients, often in the first
year
• About 25% reinfection
• 75% relapse

• Mortality 40%

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A 45-year-old female with DM A midddle-age man with DM

มงคล แซ่ภู,่ Siriraj Hospital
Mongkol Sae-Phoo, Definition
52738097 ABDOMINAL C TA

28/9/2553 12:03:11

THK: 7

Page: 20 of 37 IM: 20
cm

A midddle-age man with DM

Mongkol Sae-Phoo,
Mongkol Sae-Phoo, Diagnosis

• Culture is a must
• Serologic testing alone is inadequate for confirming the
diagnosis, especially in endemic regions (> 50% positive)
• Empirical therapy for melioidosis should not be continued if B.
pseudomallei is not detected in adequate cultures of specimens
obtained before therapy
• Molecular identification – PCR, sequencing is useful

Page: 8 of 40 Page: 10 of 40 IM: 8 IM: 10

Treatment Treatment
Initial intensive therapy (10-14 days) • ≥ 4 weeks IV therapy may be necessary in patients with
• Ceftazidime 50 mg/kg of body weight (up to 2 g), every 6–8 hr severe disease
• Meropenem 25 mg/kg (up to 1 g), every 8 hr • Combined with TMP/SMX 8/40 mg per kg (up to 320/1600
• Imipenem 25 mg/kg (up to 1 g), every 6 hr mg) q 12 h should be considered in neurologic, prostatic,
Oral eradication therapy (3-6 months) bone, or joint melioidosis
• TMP-SMX - based on body weight • Second-line oral therapy
• > 60 kg: TMP/SMX DS 2 tabs q 12 hr • Amoxicillin–clavulanate or doxycycline
• 40–60 kg: TMP/SMX SS 3 tabs q 12 hr • Amoxicillin–clavulanate 20 mg of amoxicillin and 5 mg of
• < 40 kg, adult TMP/SMX SS 2 tabs q 12 hr clavulanate per kg 3 times daily (high rate of relapse)
• < 40 kg, child 8 mg of TMP/kg and 40 mg of SMX/kg, every 12 hr

N Eng J Med 2012;367:1035-44

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A 17-year-old man A 17-year-old man : Angiography

• β Thal/HbE disease
• Chronic leg ulcer for 2 months after flood
• Not improved with oral antibiotic treatment
Pythium insidiosum
antibody- Positive

Human pythiosis (Pythiosis insidiosi) Epidemiology & Pathogenesis of Human Pythiosis

• Organism: Pythium insidiosum • Tropical and subtropical regions

• A water mold closely related to algae more than fungi (Oomycetes)
• Non-septate broad hyphae with branching
• Produce sporangia
• Aquatic motile biflagellated zoospore
Zoospore
• Mostly in Thailand
• Direct contact to contaminated sources
• Risk factors
• Hematological diseases
• Thalassemia-hemoglobinopathy syndrome – mostly
• Non-thalssemia: PNH, AA, AML, ITP
• Mechanism: unknown (may be related to iron overload?)
• No underlying disease - ocular pythiosis

5 months later Chronic leg ulcers in an anemic man

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Extensive Vascular Pythiosis Clinical Syndromes of Pythiosis

C haroen Kladsuk, Siriraj Hospital
52962856 LEG C TA
15/04/14 AW electronic film

Human pythiosis in Thailand (102 cases: 1985-2003)

41 YEAR 19/06/55 3:04:33
F 22588552
---
---
---

• Localized forms
• Cutaneous/subcutaneous pythiosis (5%)
• Ocular pythiosis (33%)
• Systemic forms
• Vascular pythiosis (59%)*
• Disseminated pythiosis (3%)
Overall mortality 40%
Limb amputation 78%
Enucleation/evisceration 78% (ocular form)

Z: 1
C : 128
W: 256

Page: 2 of 2 IM: 3057

cm
Human Pythiosis in Thailand. CID 2006:43, 569-76.

Diagnosis of Human Pythiosis Treatment

• Direct microscopic examination • Surgical treatment
• Radical surgery : the main effective treatment
• Culture (gold standard)
• Vascular pythiosis :
• Histopathology  Resection of infected arteries
• Serology***  BK, AK amputation
• Immunodiffusion test (ID)  Aneurysmectomy
• Immunochromatographic test (ICT)  Thrombo-embolectomy – Contraindication**
• Molecular identification  Grossly normal looking not indicate adequate excision
 Microscopic demonstration of organism-free surgical margin
• PCR
needed***

A 2-year-old boy with periorbital cellulitis

Medical Treatment extended to nasopharynx and maxillay sinus

Medical treatment alone is ineffective

• Pythium immunotherapy
• SSKI (saturated solutions of potassium iodide)
• Itraconazole + terbinafine

Pythiosis:
1 year course of
Itraconazole
plus terbinafine

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Anthrax The Spore of B. anthracis

• Sporulation requires
• Poor nutrient conditions
• Presence of oxygen
• Spores
• Bacillus anthracis • Very resistant to extremes
• Large, gram positive, non-motile rod • Survive for decades
• Taken up by host and germinate
• Vegetative form and spores
• Lethal dose 2,500 to 55,000 spores

Human Transmission Cutaneous Anthrax

• 95% of all cases globally

• Cutaneous
• Contact with infected tissues, wool, hide, soil • Incubation: 2-3 days (up to 12 days)
• Biting flies • Spores enter skin through open wound or abrasion
• Inhalational • Papule progresses to black eschar
• Processing wool or bone Three forms • Severe edema
• Textile mills • Cutaneous
• Fever and malaise
• Gastrointestinal • Inhalational
• Undercooked meat • Gastrointestinal

Cutaneous Anthrax Gastrointestinal Anthrax

• Case fatality rate 5-20% • Severe gastroenteritis
• Untreated – septicemia and death • Incubation: 2-5 days after consumption of
• Edema can lead to death from asphyxiation undercooked, contaminated meat
• Case fatality rate: 25-75%
• GI anthrax never documented in U.S.

Oropharyngeal anthrax

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Inhalational Anthrax Diagnosis in Humans

• Incubation: 1-7 days (highly variable)
• Isolation of B. anthracis
• Initial phase • Blood, skin
• Nonspecific - Mild fever, malaise • Respiratory secretions
• Second phase • Serology
• Severe respiratory distress
• ELISA
• Dyspnea, stridor, cyanosis, mediastinal widening
(hemorrhagic mediastinitis), death in 24-36 hours • Nasal swabs
• Case fatality: 75-90% (untreated) • Screening tool

Treatment Malaria

• Penicillin > 90% Pv

• Has been the drug of choice
• Some strains resistant to penicillin and doxycycline
• Ciprofloxacin
• Chosen as treatment of choice in 2001 Mixed
• No strains known to be resistant
• Doxycycline may be preferable > 90% Pf

P. ovale: mostly in Africa (especially West Africa) and the In Thailand: P. vivax 56.8%,
islands of the western Pacific P. falciparum 42.5%

Plasmodium Life Cycle Morphology of Plasmodium spp.

Rings Trophozoites Schizonts Gametocytes

 Parasitized RBC = normal RBC

P. falciparum
 RBCs contain immature trophozoites (ring form)
IP: 12 days  Maurer’s dots
 16-32 merozoites/schizont

 Parasitized RBC (young) > normal RBC

 Trophozoites  amoeboid form
Erythrocytic stage: P. vivax  RBCs contain all stages
IP: 13 days  Schuffner’s dots
 12-24 merozoites/schizont
P. falciparum - irregular (about 48 h)  Hypnozoites in liver*
P. vivax and P. ovale - 48 h
P. malariae - 72 h  Parasitized RBC = normal RBC
P. malariae  Trophozoites  amoeboid form
P. knowlesi - 24 h  RBCs contain all stages
IP: 17 days  Trophozoites – band shape
 6-12 merozoites/schizont, Rosette

 Parasitized RBC slightly > normal RBC

 Oval RBC with fimbriae
P. ovale  RBCs contain all stages
 Schuffner’s dots (James’ dot)
IP: 28 days  8-14 merozoites/schizont
 Hypnozoites in liver

 Parasitized RBC = normal RBC

 Trophozoites  pigment spreads inside cytoplasm,
P. knowlesi band maybe seen (like P. malariae)
IP: 12 days  RBCs contain all stages
 Multiple invasion and high parasitemia (like P.
falciparum)
IP: incubation period

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What you should know? Severe Falciparum Malaria

• New species P. knowlesi: Malaysia, Indonesia, Phillippines, Thailand (Yala, Clinical
Krabi, Prachuab kirikhan, Chantaburi)
• Knowlesi malaria can be severe • Impaired consciousness
• Erythrocytic stage of P. knowlesi = 24 h (shortest) • Prostration
• Multiple convulsions
• Deep breathing and respiratory distress
• P. vivax infection can be severe (increased mortality)
• Acute pulmonary edema and acute
• P. vivax and P. ovale relapse weeks to months later (hypnozoites) respiratory distress syndrome
• Treating the hypnozoite with a second agent (primaquine)
• Circulatory collapse or shock
• When P. vivax and P. ovale are transmitted via blood, treatment with • Acute kidney injury
primaquine is not necessary
• Clinical jaundice plus evidence of other
• No sporozoites that form hypnozoites in blood vital organ dysfunction
• Abnormal bleeding
Laboratory
• Hypoglycemia (< 40 mg/dl)
• Metabolic acidosis
• Severe normocytic anaemia (hemoglobin <
5 g/dl)
• Hemoglobinuria
• Hyperlactataemia (lactate > 5 mmol/l)
• Renal impairment (Cr > 3 mg/dl)
• Pulmonary oedema (radiological)
Parasitemia ≥ 5% or schizontemia is
associated with severity

Severe Vivax Malaria Severe Knowlesi Malaria

• P. knowlesi replicates every 24 h  rapidly increasing parasite

• Similar to those of severe P. falciparum densities
malaria and can be fatal • Severe disease and death in some
• Severe anemia and respiratory distress occur • Severe disease are similar to severe falciparum malaria, with
at all ages the exception of coma
• Patients with P. malariae-like infections (band form) and
• Severe anaemia is particularly common in unusually high parasite densities (parasitemia > 0.5% by
young children microscopy) should be managed as P. knowlesi infection
• Definitive diagnosis is made by PCR

Antimalarial Drug Activity in the Life Cycle of Plasmodia

Treatment of Uncomplicated Falciparum Malaria

Treat Acute attack Prevent

- Artesunate transmission RCPT MoPH
- Quinine Primaquine,
- Mefloquine Artemisinines
- Chloroquine First-line drugs • Dihydroartemisinin (DHA)-Piperaquine
- Tetracycline • Artesunate 4 mg/kg/day for 3 days+ (40/320 mg) 3 days
mefloquine 25 mg /kg in divided dose • <60 Kg 3 tabs OD
- Atovaquone
(3 tabs then 2 tabs) • 60-80 Kg 4 tabs OD
- Proguanil
• > 80 Kg 5 tabs OD
Second-line drugs
• Quinine 10 mg /kg + doxycycline 3 mg/kg
OD or BID, or clindamycin 10 mg/kg/ bid 7 Followed by
days
• Artesunate 2 mg/kg/day + doxycycline 3 • Primaquine 30 mg once
mg/kg OD or BID, or clindamycin 10
Prevent relapse mg/kg/ bid 7 days
Followed by Artemisinin combination therapy (ACT)
Primaquine, proguanil, - Artesunate+mefloquine
tetracycline • Primaquine 30 mg once - DHA-piperaquine

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Treatment of Uncomplicated Malaria Treatment of Uncomplicated Malaria

• Pregnant woman Non- P. falciparum

• Quinine+clindamycin (alternative DHA-pip) (MoPH) • Chloroquine 4-4-2 tabs (total 10 tabs)
• Second or third trimester • Primaquine for Pv and Po
• Artesunate (RCPT) • 15 mg OD for 14 day (unknown G-6-PD)
• DHA-piperaquine (MoPH) • 30 mg OD for 14 day (if no G-6-PD deficiency)
• Do not use doxycycline or primaquine (even single dose) • 45 mg weekly for 8 weeks (if mild G-6-PD deficiency)

• Relapsed Pf malaria within 2 months- do not use

• Pregnant women
mefloquine (if use before) • Chloroquine 300 mg weekly suppressive therapy for PV and PO
• Use quinine+doxy/clinda or artesunate+doxy/clinda in pregnant women until postpartum then use primaquine

Treatment of Severe Malaria A 18-year-old male

First-line drugs
• Artesunate IV
• 2.4 mg/kg IV PUSH at 0, 12, and 24 h Day 1 then 2.4 mg/kg once a day, if
improved
• Change to oral ACT for 3 days (DHA-pip; MoPH, Artesunate-mef; RCPT)
Second-line drugs
• Quinine IV
• Loading 20 mg/kg IV DRIP > 4 h then 10 mg/kg IV DRIP in 2-4 h q 8 h, if
improved
• Change to oral ACT for 3 days (DHA-pip; MoPH, Artesunate-mef; RCPT) or
• Change to quinine+doxy/clinda or artesunate+doxy/clinda for 7 days

•Doxycycline can be given once daily, starts when the patient has recovered sufficiently
•Mefloquine should be avoided due to risk of neuropsychiatric complications in the patient
presented initially with impaired consciousness

What is the diagnosis ? Leptospirosis

• Leptospira interrogans
A. Infective endocarditis • Reservoir: 160 mammals, most important-rodent
B. Leptospirosis esp. rat (shed in urine)
C. Dengue hemorrhagic fever • Transmission: skin contact with water, soil
D. Gram-negative sepsis with DIC • Incubation period: 2-26 days (average 10 days)
E. Scrub typhus

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Four broad clinical categories Clinical Manifestations

• A mild, influenza-like illness • Subclinical infection 40-70%

• Weil's syndrome • Symptomatic cases – 90% mild or anicteric form
• Jaundice • Acute febrile illness with a biphasic course (leptospiremic
• Renal failure and immune phases) - good prognosis
• Hemorrhage • Nonspecific signs and symptoms (flu-like)
• Myocarditis with arrhythmia • Severe or icteric leptospirosis (Weil disease)– 10%
• Meningitis/meningoencephalitis • Mortality 10%
• Multiple organ involvement
• Pulmonary hemorrhage with respiratory failure
• Loss of biphasic fever

Clinical Course Diagnosis

Anicteric leptospirosis Icteric leptospirosis
(Incubation Leptospiremic Immune Leptospiremic Immune phase
period 2-20 phase phase phase 0-30 days
days) 3-7 days 0-30 days 3-7 days
• Antibody detection (IgG, IgM)
Fever • IFA
• Need 4-fold rising for diagnosis
Associated Myalgia Meningitis
Uveitis
Jaundice
• Single cutoff titer varies (for IFA ≥ 1:400)
symptoms Headache Hemorrhage
Nausea,
Rash
Acute renal failure • PCR
Vomiting Myocarditis
Abdominal pain Hemorrhagic pneumonitis
Conjunctival Meningoencephalitis
suffusion Hypotension
Leptospires Blood Blood
present in
CSF CSF
Urine Urine

Siriluck Anunnatsiri (with permission)

Treatment
A 42 years old

A farmer
• Mild leptospirosis
Fever with headache
• Doxycycline, ampicillin, or amoxicillin for 10 day

• Severe leptospirosis Myalgia

• Intravenous penicillin G - drug of choice The diagnosis is…….

• Third-generation cephalosporins: Scrub typhus

• Cefotaxime and ceftriaxone

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Rickettsioses Clinical Characteristics

• Spotted fever group (15 rickettsioses) • Small, painless, gradually enlarging papule, which
• Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii leads to an area of central necrosis and is followed
• Rickettsialpox caused by Rickettsia akari by eschar formation (30-50%)
• Thailand: Thai tick typhus (R. honei) • At axilla, perineum, groin, under breast line
R. helvetica , R. conorii, R. felis
• Typhus group
• Epidemic (louse-borne) typhus caused by Rickettsia prowazekii
• Endemic (murine) typhus caused by Rickettsia typhi
• Scrub typhus group
• Caused by Orientia tsutsugamushi

Chigger Eschar

Eschars Severe Scrub Typhus

Scrub typhus Ecthyma grangrenosum

 Pneumonitis, ARDS
 Encephalitis, aseptic meningitis
 Rarely, acute renal failure, shock, and disseminated intravascular coagulation (DIC)
Cutaneous anthrax Plague  Cardiac involvement is often minor and rare, but can cause fatal myocarditis

Diagnosis and Treatment Murine typhus

• Headache, fever, muscle pain, joint pain, nausea
Diagnosis: and vomiting
 Serology by IFA
• MP rash 40-50% - about six days after the onset
- IgM titer ≥ 1:400, IgG titer ≥ 1:1,600 or
- 4-fold rising 14 D apart with titer ≥ 1:200 • Neurological signs 45% - confusion, stupor, seizures
or imbalance
Treatment: • Symptoms may resemble those of measles or
rubella
- Doxycycline 100 mg po bid 3 days after symptoms resolve
- Azithromycin (in pregnancy or IV azithromycin in severe form)
Investigation and treatment
• Same as scrub typhus

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A woman with severe murine typhus and ARDS A man post liver transplantation 8 years
Bronchoscopy

วราภรณ์ วิ ม ลสิริ สุข, SIRIRAJ HOSPITAL(R228)

WARAPORN WIMOLSIRISUK CHEST
53332475 12/2/2558 10:38:26
วราภรณ์ วิ ม ลสิริ สุข, SIRIRAJ HOSPITAL (PORTABLE)
20/12/2501 23670914
WARAPORN WIMOLSIRISUK
53332475
Age: 56 YEAR
F
CHEST
8/2/2558 6:31:49
---
---
Date 17/6/56 18/6/56 19/6/56 20/6/56 21/6/56 22/6/56 23/6/56
20/12/2501 23665156
---
Age: 56 YEAR ---
F ---
---

Meropenem Ganciclovir
Vancomycin
Cotrimoxzole

5 days after treatment

• CMV viral load < 20 copies/mL
S: 552
Z: 0.58
• Serum gallactomanan: negative
C: 512
W: 1024
S: 310
Z: 0.48 • Serum cryptococcus Ag: negative
C: 512
Page: 1 of 1 IM: 1001 W: 1024
cm
Page: 1 of 1 IM: 1001
cm

A man post liver transplantation 8 years Intestinal nematodes

Lab 18/6/56 23/6/56
Hb (g/dL)/Hct (%) 12.1/35.1 9.6/28.1 Date 19/6/56

WBC (/mm3) 6,140 3,130 IFA (IgG+M) Leptospira spp.

N (%) 92.5 62
IgG <1:50
L (%) 5 27.8
M (%) 2.3 8.9 IgM <1:50

E (%) 0 0.3 IFA (IgG+M) O. tsutsugamushi Enterobius vermicularis Trichuris trichiura Hookworm
Ascaris lumbricoides
B (%) 0.2 1 IgG <1:50 Asymptomatic Chronic diarrhea Abdominal pain Abdominal pain,
Platelets (/mm3) 56,000 93,000 Autoinfection Rectal prolapse Small bowel obstruction Iron-def anemia
IgM <1:50 Lung migration (larva)
BUN/Cr (mg/dL) 14.6/1.42 28.1/2.22
- Eosinophilic
TB/DB (mg/dL) 0.5/0.31 0.9/0.8 IFA (IgG+M) R. typhi pneumonitis
(LÖffler’s syndrome)
AST/ALT (mg/dL) 55/38 1,545/488 IgG 1:800
ALP (U/L) 96 616
Alb/Glob (mg/dL) 2.6/2.5 2.1/3.1
IgM 1:800 Treatment: Albendazole 400 mg x 1 day

Capillaria philippinensis Strongyloides stercoralis

Exposure
Acute infection:
• Undercooked fish
Symptoms • 1/3 - asymptomatic
• Chronic voluminous diarrhea • Larva currens, LÖffler’s syndrome, diarrhea
• Malabsorption syndrome
• Size 40x20 µ Chronic persisting infection:
Dx • 1/3-asymptomatic
• Peanut-shaped egg
• Triad: urticaria, abdominal pain, diarrhea
• Flatten bipolar plugs
Rx
Hyperinfection syndrome: Exacerbation of GI, pulmonary
• Albendazole 400 mg PO x 10 D
symptoms and increased numbers of larvae in stool and
• Mebendazole 200 mg BID x 20 D sputum

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Strongyloides stercoralis Gnasthostoma spinigerum

• Eating Raw fish or contaminated water with cyclops

Complication: Gram negative bacteremia
Rx - Ivermectin 200 µg/kg PO ODx2d
: For hyperinfection: repeat treatment every 15 days
while stool positive, then 1 more treatment cycle
: Hyperinfection in immunocompromised: 200 µg/kg
OD until neg. for 2 wks
- Albendazole 400 mg PO BID x 7 d (less effective)
• Larval gnasthostomiasis
• Intermittent subcutaneous migratory swelling
• Ocular gnathostomiasis
• Eosinophilic myeloencephalitis
• Dx: antibody detection (ELISA)
Rx: Surgery
J Travel Med. 2016;24(1). doi:10.1093/jtm/taw074

Albendazole 400 mg/d x 21 d or

Ivermectin 150-200 µg/kg single dose

Angiostrongylus cantonensis Visceral Larva Migrans

Undercooked snails,crabs,
freshwater shrimps
• Ingest egg of dog/cat ascarids
• Toxocara canis, Toxocara cati

• Mostly asymptomatic
• Visceral /ocular larva migrans
Angiostrongyliasis
Third stage larvae
• Dx: Toxocara antibody (ELISA)
• Eosinophilic meningoencephalitis Rx: Supportive
• Dx: antigen detection (ELISA) Prednisolone
• Rx: No specific treatment, CSF removal
Albendazole 800 mg bid x 5-20 d (intestinal parasites only)
Prednisolone 60 mg/day x 14 days

Cutaneous Larva Migrans Taeniasis

- Raised, erythematous, serpiginous, tunnel-like lesion 2-3 mm
Eat undercooked pork Eat undercooked beef Eat Taenia solium egg or
- Containing serous fluid
(cysticercus cellulosae) (cysticercus bovis) autoinfection
Etiology
• Ancylostoma braziliense (cat, dog hookworm)
Taenia solium Taenia saginata Neurocysticercosis
• Ancylostoma caninum (dog hookworm) (pork tapeworm) (beef tapeworm)
• Human hookworm
• Strongyloides stercoralis (larva currens)

Rx: - Albendazole 200-400 mg PO bid x 3-5 d Rx of intestinal parasite:

- Praziquantel 10 mg/kg PO once
- Ivermectin 200 mcg/kg PO once
Taenia egg:
Diameter 40 µ
Round shaped-egg
Thick shell with radial striation

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Cysticercosis Treatment of Neurocysticercosis

Vesicular cyst Colloidal cyst • Anticonvulsant therapy: mainstay of management of
neurocysticercosis-associated seizure disorders
• Antiparasitic therapy
 Symptomatic patients with multiple, live cysticerci  cyst reduction, fewer
and decreased seizure recurrences
 Not benefit in patients with calcified cysts
 Concomitant steroids before antiparasitic drug
 Anti-epileptic drug
 If >2 viable cysts:albendazole (15 mg/kg /d) plus praziquantel (50 mg/kg/d)
for 10-14 days
 If 1-2 viable cyst : albendazole alone
 Non-viable cyst: avoid antiparasitic drug
Multiple rice-grain
Granular stage Calcifications like cacification

Clinical Infectious Diseases, cix1084, https://doi.org/10.1093/cid/cix1084: 22 Feb 2018

Flukes Schistosomiasis (Blood flukes)

Liver fluke
Opisthorchis viverrini
 Undercooked fish
Symptoms
 Early: asymptomatic
 Abdominal pain
 Relapsing cholangitis
 Cholangiocarcinoma
Rx: Praziquantel 25 mg/kg PO
tid x 2 days
Intestinal fluke Lung fluke • Mesenteric venule:
• S. japonicum
• S. mansoni
• S. mekongi
Rx: Praziquantel 20 mg/kg PO BID x 1 d
• Venule of lower urinary tract :
Schistosoma mansoni Schistosoma haematobium
• S. haematobium - Non-operculum, oval - Non-operculum, oval
- Lateral spine - Terminal spine
• Thailand: S. japonicum
Fasciolopsis buski Paragonimus westermani
 Giant intestinal fluke Paragonimus heterotremus
(largest human parasite)  Eat metacercaria in undercooked
 Eat water contaminated with shrimp, crab Clinical form:
metacercaria Symptoms
Symptoms
- Schistosome dermatitis
 Pulmonary paragonimiasis
 abdominal pain and  Cerebral and spinal paragonimiasis - Acute schistosomiasis:2-8 wks
diarrhea Rx: Praziquantel 20 mg/kg PO TID x 1 d
 Migratory subcutaneous
Rx: Praziquantel 25 mg/kg PO paragonimiasis - Chronic schistosomiasis Schistosoma japonicum Schistosoma mekongi
tid x 1 days Rx: Praziquantel 25 mg/kg PO tid x 2 D - Non-operculum, round - Non-operculum, round
- Lateral knob - Lateral knob

Intestinal Protozoa
Good luck for your exam
Cryptosporidium Cyclospora Cystoisospora belli Giardia lambia
parvum cayetanensis

4-6 µM 6-10 µM 15-30 µM 10-14 µM

Protozoa Treatment
Cryptosporidium spp. No effective treatment (Nitazoxanide)

Cyclospora cayetanensis, TMP-SMX DS 1 tab bid x 7-10 days

Cystoisospora belli HIV: TMP-SMX DS 1 tab qid x 3-4 weeks

Giardia lambia Tinidazole 2 g po x 1

Metronidazole 250 mg po tid x 5-7 days
Albendazole 400 mg po OD x 5 days

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