asia

Asia Central (Indian Subcontinent & Sri Lanka), Southeast Asia, East Asia & China, Japan, Pacific

Central (Indian Subcontinent & Sri Lanka)

Amebiasis: See full discussion (Worldwide): Amebiasis is an amebic gastrointestinal infection (sometimes affecting other systems) that may be asymptomatic, chronic, or acute. Symptoms may include abdominal pain, diarrhea (with blood), weight loss, dehydration. Systemic dissemination is usually to the liver, but may also involve the brain, heart (pericarditis), lungs, and genitalia. Invasive amebiasis is treated with metronidazole and colonization without symptoms is treated with paromomycin or iodoquinol.

Boutonneuse fever (African tick fever, Marseilles fever, tick typhus) (North Africa, temperate areas of Southern and Eastern Europe, Middle East): Boutonneuse fever is a rickettsial (Rickettsia conorii) tick-born fever characterized by an ulcer with a black center at the site of the tick bite. Fever and general maculopapular rash may follow. The disease is usually mild. Treatment is with tetracycline, chloramphenicol, or ciprofloxacin.

Cholera (Southeast Asia, India, Middle East, East and North Africa): Cholera is an endemic and epidemic acute Vibrio cholera (bacterial) infection transmitted via feces or vomitus-contaminated water. Raw or under-cooked seafood may also be contaminated and result in cholera infection. The incubation period is 1-5 days. Most infections are subclinical, but 10% or fewer infected persons experience sudden and explosive diarrhea (first fecal, then watery and mucous-flecked), vomiting, and prostration leading rapidly to fluid and electrolyte depletion, metabolic acidosis, shock, renal failure, and death. Rehydration (Ringer's lactate initially for severe cases, then oral rehydration therapy; or in milder cases, oral rehydration therapy throughout) is critical. After vomiting ends, the duration of symptoms is shortened by tetracycline 500 mg po qid for 3 days or furazolidone 400 mg daily for 3 days or a single dose of 300 mg doxycycline.

Dengue Fever: See full discussion (East and West Africa, Southeast and East Asia, Pacific Islands, Eastern Australia, Central and South America, Mexico, South Texas, Caribbean Islands - with distribution increasing, especially in urban areas): Dengue Fever is a flavivirus (several serotypes) infection transmitted by mosquitos. There is increasing incidence and prevalence of cocirculation of multiple serotypes. Dengue is usually a self-limited illness characterized by abrupt onset high (biphasic) fever, chills, headache, rash, signs of bleeding, changes in taste, sore throat, nausea, vomiting, diarrhea, anorexia, severe aching myalgia and arthralgia (hence "bone-break" fever), and depression. Complications include meningoencephalitis, dengue hemorrhagic fever (DHF), and dengue shock syndrom (DSS). Treatment is supportive and convalescence tends to be lengthy.

Filariasis: See full discussion (Distribution given below). The filarial parasites are tissue-dwelling roundworms whose microfilarial (mf) larvae are transmitted by several species of mosquitos or flies. The most problematic forms of filariasis are (1) Bancroftian filariasis and Malayan filariasis (much of the tropical and subtropical world between the Tropics of Cancer and Capricorn) which involve the lymphatic system and result in elephantiasisis; (2) loiasis or loa loa (tropical Africa) in which worms live in subcutaneous tissue; and (3) Onchocerciasis (tropical Africa and to a lesser extent Central and South America) which causes river blindness and skin disorders. Treatment in most cases is effective only against the mf, hence the infection continues and repeated treatment (with ivermectin and/or DEC) may be necessary.

Granuloma inguinale or Donovanosis (Tropics, especially Southern India, Southern Africa, Pacific Islands, Papua, New Guinea, Caribbean Islands): Granuloma inguinale is a sexually transmitted disease caused by Calymmatobacterium granulomatous and characterized by an initial papule on the penis or labia. The papule ulcerates and develops into a painless granulomatous (beefy red and friable) raised area that spreads. Secondary anaeorobic infections are common and result in pain and foul-smelling drainage. Extension to the inguinal region may produce swelling similar in appearance to bubos. Early lesions of granuloma inguinale may be mistaken for syphilis, ulcerative stages mistaken for lymphogranuloma venereum, and the granulomatous tissue may be mistaken for carcinoma. Treatment is with TMP/SMX, azithromycin, tetracyclines, or newer quinolones.

Hepatitis: Hepatitis B surface antigen carrier rates in the tropics are > 40 times greater than in the West. Persons from China and Southeast Asia are at highest risk and perinatal transmission is common.

HIV/AIDS: HIV/AIDS is found world-wide, and is especially common in sub-Saharan Africa, Southeast Asia, and India. Heterosexual transmission is common in these areas. Readers are referred to the CDC and other current sources of information (See links).

Hookworm: See full discussion (Most tropical and subtropical areas of the world). An important cause of anemia, hookworms are intestinal parasites (nematodes, including Ancylostoma duodenale, Unicinaria stenocephala, and Necator americanus) whose larvae are transmitted from soil through the skin. Incubation is 2-8 weeks. Most people (with small parasite loads) are asymptomatic. Entry points are sometimes pruritic. Higher loads result in anorexia or increased appetite, abdominal discomfort, weight loss, nausea and vomiting, diarrhea and/or constipation, and anemia. Respiratory symptoms occur in a few patients. Infants and children may experience severe anemia, protein deficiency, and developmental delays. Treatment is with mebendazole, albendazole, or pyrantel pamoate. None of these are safe in pregnancy and neither mebendazole nor albendazole should be given to children under 1 year of age. The anemia should be treated with ferrous sulfate.

Hymenolepiasis (Americas, Mediterranean, Near East, India, Australia): Hymenolepsis nana is the smallest and most common tapeworm (cestode) parasitizing humans. H. nana is spread by the fecal-oral route and is especially common in institutions. Most infected persons are asymptomatic, but very high loads may produce anorexia, abdominal pain, and diarrhea. Treatment is with praziquantel 25 mg/kg in one po dose.

Kala-azar: See leishmaniasis (visceral) below or full discussion.

Kyasanur Forest hemorrhagic fever: See full discussion of HFs (India). Kyasanur Forest HF is caused by a tick-borne flavivirus and currently is found only in the Mysore State of India. Incubation is 3-8 days. The illness is characterized by sudden onset fever and headache, followed by back and extremity pain, bradycardia, lymphadenopathy, conjunctival injection, palantine injection, petechiae, and other hemorrhagic signs. Meningoencephalitis is relatively common. Treatment is supportive as described in the full discussion of hemorrhagic fevers.

Leishmaniasis: See full discussion or brief discussions of the various types (visceral, cutaneous, mucocutaneous) (East and North Africa, Middle East, Southern Europe, Central, South, and East Asia, South America, West Mexico): The protozoal parasite species Leishmania is transmitted by sandflies. Major types of leishmaniasis include visceral leishmaniasis or kala-azar, cutaneous leishmaniasis, and mucocutaneous leishmaniasis (espundia). Incubation is usually 2-6 months or longer and relapse may occur as many as 10 years after first episode. Signs and symptoms vary according to the type of leishmaniasis. See visceral leishmaniasis, cutaneous leishmaniasis, and mucocutaneous leishmaniasis (espundia).

Leprosy: See full discussion (Tropical and sub-tropical Africa, Asia, Pacific Islands, South America, Central America, and Mexico): Leprosy is caused by the acid-fast rod Mycobacterium leprae which is transmitted probably via the respiratory route through prolonged exposure in childhood. Incubation is usually 2-5 years; and up to 20 years. There are two basic types of leprosy: lepromatous leprosy (LL) and tuberculoid leprosy (TL) and either of these may be classified as borderline or indeterminate. Most initial infections involve few symptoms and spontaneous recovery is common with a minority of patients developing clinical disease. LL is a progressive malignant process including skin lesions/changes; as well as nerve damage and disability. TL is not as disabling as LL and includes skin lesions and nerve damage. Borderline leprosy may have features of both LL and TL, and may evolve into either form. Indeterminate leprosy is manifested by one or several macules or poorly defined skin lesions, that may heal spontaneously, remain stable, or progress to forms described above. Multi-drug therapy is the current accepted standard for all types of leprosy, and for LL generally includes dapsone, clofazamine, and rifampin daily for at least 2-3 years until all biopsies are negative for acid-fast bacilli. Patients with indeterminate or tuberculoid leprosy may be treated with dapsone and rifampin as above for 6-12 months, followed by dapsone alone for a total of at least two years of therapy. Antigen-antibody complex reactions (to therapy) are common and are treated with prednisone or thalidomide.

Maduromycosis: See mycetoma below.

Malaria: See full discussion (Tropical Africa, Asia, South and Central Americas; East China, Middle East): Malaria is caused by the protozoas Plasmodium falciporum, P. vivax, P. ovale, and P. malariae and is transmitted by mosquito bite, parenteral injection, or congenitally. Malaria is usually characterized by sudden onset of high fever, sweating, chills, uncontrollable shaking, headache, and splenomegaly. Fever tends to wax and wane in 48-72 hour cycles, though cycles may be irregular, especially with infection by P. falciporum. Onset may also be insidious, with less dramatic symptoms such as fever, headache, dyspnea, abdominal pain, nausea, diarrhea, myalgias, and splenomegaly. P. falciporum may cause parasitemia resulting in a life-threatening condition characterized by hemolysis, jaundice, anemia, acute renal failure, and hemoglobinuria. Cerebral malaria, also life-threatening, is characterized by gradual onset of severe headache, drowsiness, delerium, and coma. Seizures may also occur and are most common in children. P. faciporum causes death in as many as 25% of untreated cases. Treatment depends on the organism, immune status of the patient, and severity of the attack. Oral chloroquine is a mainstay of treatment except for infection with chloroquine-resistant P. falciporum. P. falciporum presents the greatest challenge because of severity of attacks as well as the existence of multidrug (especially chloroquine)-resistant strains. Combination drug treatment is common, e.g., mefloquine combined with artesunate for multidrug-resistant strains as described in the full discussion.

Malnutrition: Though not a communicable disease, malnutrition bears mention here as a common problem among refugees and, to a lesser extent, immigrants. We expect at some time to have a full discussion of malnutrition. Malnutrition may be the result of decreased intake of one or all food groups or to decreased absorption. Metabolic disorders, diarrheal illnesses, or the indirect effects of chronic illnesses are common causes of decreased absorption. Malnutrition has long-term deleterious effects on the person suffering from decreased intake or absorption; or on the fetus or on the children of the person with malnutrition. Loss of intellectual potential, incomplete physical or mental development, and vulnerability to illness are among the long-term effects of malnutrition. Basic types of malnutrition include marasmus, protein malnutrition (Kwashiorkor), and cachexia. Though not often a problem among refugees, obesity may also be viewed as malnutrition. Marasmus is due to inadequate caloric intake and is characterized by failure to gain weight, then weight loss with resultant emaciation. Loss of subcutaneous fat causes poor turgor and wrinkling of skin. With advanced marasmus, the basal metabolic rate slows with resulting decreased vital signs and profound weakness. Children with marasmus often are the subject of the most dramatic photographs of Somali, Ethiopian, and other children of famine. Kwashiorkor or protein-calorie malnutrition (PCM) may be due to inadequate intake or absorption (or loss) of protein. Kwashiorkor is more common and the clinical picture is less dramatic than the emaciation of marasmus. Initially, inadequate protein causes lethargy or irritability. As the condition progresses, anorexia develops, weakness increases, muscle tissue decreases, and growth is retarded. Hepatomegaly occurs, kidney function decreases, and cardiac function is impaired. Edema is common and may mask other aspects of the disorder. Skin changes include dermatitis, changes in pigmentation, and changes in hair. Typically, hair is sparse, thin, and often streaked with red or gray color. Immune function is decreased and infection is common and often is the cause of death. Treatment of marasmus and Kwashiorkor includes fluid replacement, gradual protein and calorie replacement (fats are poorly tolerated in Kwashiorkor), and correction of vitamin and other deficiencies. A concern in both refugee camps and countries of second asylum, is the tendency of parents to overfeed when food becomes available. Cachexia is a metabolic disorder marked by general ill health and malnutrition, with weakness and emaciation; and is common in cancer, AIDS and other severe illnesses. In contradistinction to anorexia or starvation, in cachexia, there is approximately equal loss of fat and muscle, significant loss of bone mineral content, and cachexia does not respond to nutritional supplements or increased intake.

Mycetoma - also known as maduramycosis (Worldwide, especially tropics): Fungal infection, that begins as a small abscess, papule, or nodule and progresses to localized larger and multiple abscesses with sinuses; and ultimately to destruction of deep tissue, fascia, and bone. The usual route of infection is via a break in the skin (commonly from a thorn wound) through which the fungus is implanted from contaminated soil or plant. Secondary bacterial infection may occur. The foot is the most common site of infection, leading to "madura foot." Eumycetoma is infection due to filamentous fungi and is resistant to treatment. Actinomycetoma is infection due to actinomycetes and treatment is often effective. Treatment is with long-term combination therapy, e.g., streptomycin + dapsone or TMP/SMX. Surgical debridement + long-term ketoconazole or itraconazole is also used in treatment.

Poliomyelitis (Primarily on the Indian subcontinent and Africa - "on the verge of worldwide eradication" [Chin, 2000]): Poliomyelitis is caused by an enterovirus and in the great majority of cases, infection is asymptomatic. The types of symptomatic poliomyelitis are: (1) Abortive poliomyelitis is characterized by self-limited fever, headache, sore throat, nausea, vomiting, diarrhea, and constipation. (2) Nonparalytic poliomyelitis is characterized by meningeal signs (e.g., headache, stiff neck, irritabilty, nausea, vomiting), muscle spasms, and the constitutional signs noted under abortive poliomyelitis. (3) Paralytic poliomyelitis may develop during the febrile stage of illness. There are two types of paralytic poliomyelitis: (1) Spinal involves weakness or paralysis of muscles ennervated by spinal nerves. Bulbar involves weakness or paralysis of muscles ennervated by cranial nerves IX and X, as well as respiratory and vagal centers. Development of paralysis is decreased by strict bedrest. Treatment otherwise, is supportive.

Strongylodiasis (Most of the tropical world): Strongylodiasis is a nematode (roundworm) infection by Strongyloides stercoralis following larval penetration of the skin. A minority of infected persons are asymptomatic. Cutaneous manifestions may occur at the site of penetration (often feet), and include inflammation, serpiginous or urticarial tracts, and pruritis. Intestinal manifestations follow cutaneous, and include abdominal pain, nausea, flatulence, and diarrhea. Larval migration to lungs results in a variety of pulmonary symptoms, ranging from cough to pneumonia, pleural effusion, and miliary abscesses. Hyperinfection syndrome causes life-threatening CNS, cardiac, and wide-ranging gastrointestinal problems. Treatment is with ivermectin 200 mcg/kg/day po for two days. Albendazole and thiabendazole have also been used.

Subcutaneous mycotic infection: See mycetoma.

Thalassemias (Africa, Mediterranean, Middle East, Indian subcontinent, Southeast Asia): The thalassemias are inherited defect in globin chain production leading to hypochromic microcytic anemia. There are about 100 geographically unique mutations that produce thalassemia phenotypes. Interestingly, these are found in areas where Plasmodium falciporum malaria was or is endemic. The two most best known thalassemias are homozygous thalassemia major (Cooley's anemia) and heterozygous thalassemia minor. Thalassemia major is a life-threatening progressive hemolytic anemia. In untreated infants, the disease causes cardiac decompensation, profound weakness, expansion of marrow, thinning of bones, jaundice, organomegaly, and without treatment, death within about two years. Older patients have growth retardation, delayed puberty, diabetes, and heart disease. Laboratory findings include hypochromia, microcytosis, low hemoglobin, high serum iron, and high serum bilirubin. Regular blood transfusions are required to prevent or delay complications, but the transfusions themselves result in pathology. Thalassemia minor is characterized by chronic mild microcytic anemia, but no clinical symptoms.

Trachoma (Worldwide; more commonly endemic in poor rural communities in developing countries and common among nomadic and semi-nomadic cattle-herder): Trachoma is a recurrent conjunctivitis beginning in childhood and caused by Chlamydia trachomatis. Trachoma is a major cause of blindness in developing countries. Childhood infections and reinfections result in bilateral follicular conjunctivitis, epithelial keratitis, and corneal vascularization. Conjunctival scarring results in ingrown/in-turned eyelashes and lid deformities that, in turn, cause corneal scarring. Secondary bacterial infections are common, resulting in further complications. Treatment is with po tetracycline or erythromycin, both 250 mg 6 times daily for 3-5 weeks. Doxycycline 100 mg po bid for 3-5 weeks is also a common treatment. A single dose of azithromycin 20 mg/kg po is also used.

Tropical ulcer (correctly termed cutaneous leishmaniasis; and also known as oriental sore, tropical sore, Delhi boil, Allepo boil): See cutaneous leishmaniasis above or full discussion of leishmaniasis.

Tuberculosis (Worldwide): Tuberculosis (TB) is a chronic infection - most commonly pulmonary - caused by the acid-fast bacillus, Mycobacterium tuberculosis. Infection is usually acquired through inhalation of infected droplets expelled by cough from a person with active disease. Most cases (85%) of TB are pulmonary. Pulmonary symptoms include cough, chest pain, and hemoptysis. Constitutional symptoms are often present in pulmonary disease, and include fever, chills, night sweats, fatigue, decreased appetite, and weight loss. Symptoms of extrapulmonary TB depend on the site(s) of infection. Tuberculosis should always be ruled out in any person at-risk or with the above symptoms. Medical evaluation includes complete medical and family/close contacts/travel history, physical examination, Mantoux tuberculin skin test, chest x-ray, and appropriate bacteriologic or histologic examinations, e.g., smear and culture of sputum. Treatment is according to (1) classification of disease, e.g., exposure without infection, infection without disease, current TB disease, previous TB disease, or TB suspected; (2) whether disease is drug-resistant; (3) immune status of the patient; and (4) other factors. The treatment of TB is complex and is evolving at a rapid pace. Readers are referred to the U.S. Centers for Disease Control and Prevention: http://www.cdc.gov/ for current standards of testing and treatment.

Typhus, Scrub: See full discussion (numerous areas of the world as noted in discussion below): The typhus group of illnesses are one of several rickettsioses or febrile exanthematous illnesses caused by bites of rickettsial-infected arthropods or exposure to their feces. Scrub typhus is transmitted by the bite of infected mites or chiggers, and is found in most areas of Asia. Scrub typhus illness ranges from mild to severe, and is characterized by gradual onset of fever, chills, headache, myalgia (backache), cough, nausea and abdominal pain, eschar at the site of the infecting bite, regional lymphadenopathy and a maculopapular rash. Severe scrub typhus is characterized by encephalitis and pneumonia. Scrub typhus is treated with doxycycline 100 mg bid po for 7-14 days; or chloramphenicol 500 mg qid po for 7-14 days. Azithromycin is also effective.

Visceral leishmaniasis (kala-azar): See full discussion (East and North Africa, Middle East, Southern Europe, Central, South, and East Asia, South America, West Mexico): Cardinal signs of visceral leishmaniasis are prolonged fever, splenomegaly, anemia, leukopenia, or hypergammaglobulinemia. A cutaneous nodule may or may not appear at the site of the bite. Systemic symptoms include gradual onset fever that often rises and falls twice/day, fatigue, weight loss, dizziness, cough, and diarrhea. Visceral manifestations include pronounced splenomegaly (hard, non-tender) and to a lesser extent hepatomegaly. Other manifestations may include generalized lymphadenopathy; hyperpigmented skin of the forehead, abdomen, hands, and feet in light-skinned persons; skin lesions in dark-skinned persons; signs of bleeding (petechiae, epistaxis, bleeding gums); jaundice and ascites; and progressive wasting. Onset may also be acute, with the above manifestations appearing a few weeks after infection. Treatment has traditionally been unsatisfactory because of drug toxicities, poor responses, multiple disease syndromes, and other factors - including recently, the emergence of antimony-resistant strains. Orally administered miltefosine has recently shown great promise. Other treatments include intravenous sodium stibogluconate (a pentavalent antimony compound) for 10-60 days depending on where the disease was contracted and whether illness is first or second episode.

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Southeast Asia

Angiostrongyliasis (Caribbean, Southeast Asia, Pacific Islands): Angiostrongyliasis includes several distinct nematode (roundworm) infections caused by Angiostrongylus sp. as follows. (1) Nematode (rat lungworm) infection with A. cantonensis that often is subclinical. Larvae migrate to the CNS and may cause eosinophilic meningoencephalitis. Symptoms may include severe headache (most common symptom), stiff neck, low grade fever, nausea, vomiting, abdominal discomfort, paresthesias of trunk and extremities, and other neurologic signs, including unilateral facial paralysis. The disease is usually self-limiting. Treatment is supportive, and includes corticosteroids, spinal taps, and analgesics. Antihelminthics are not used because of host reaction to dead worms in the CNS. (2) Nematode infection with A. costaricensis of the gastrointestinal tract with cutaneous, intestinal, and pulmonary manifestations (related to the nematode life cycle in the host body); and in some cases, hyperinfection syndrome. Cutaneous manifestations include edema, inflammation, and pruritis. Intestinal manifestations include abdominal and flank pain, fever, malaise, anorexia, nausea, vomiting, and weight loss. Pulmonary manifestations include cough, rales, wheezing, low grade fever, and hemoptysis. Hyperinfection syndrome includes severe pulmonary, cardiac, neurologic symptoms, progressing to septicemia and death. Treatment includes supportive therapy and glucocorticoids; and in some cases ivermectin or thiabendazole or albendazole.

Anthrax (Any temperate or tropical rural area where animal husbandry is common): Anthrax is a gram positive spore-forming aerobic rod (Bacillus anthracis) cutaneous or pulmonary infection. Cutaneous anthrax is characterized by a dark centered erythematous papule surrounded by edematous and vesicular tissue. The papule enlarges, ulcerates, forms eschar, which later sloughs. Lymphadenopathy, fever, malaise, headache, and nausea and vomiting may also occur. After the eschar sloughs, hematogenous spread and sepsis may occur, with resulting shock, collapse, and hemorrhagic meningitis. Pulmonary anthrax (a concern with respect to biological warfare) is characterized by fever, malaise, headache, respiratory congestion, and pneumonia or mediastinitis. Anthrax is treated with penicillin G or tetracycline. Mortality is high, especially in pulmonary anthrax.

Bilharziasis or Bilharzia: See schistosomiasis (summary or full discussion).

Capillariasis, intestinal (Southeast Asia, especially Thailand and the Philippines): Capillariasis is a nematode (Capillaria philippinensis) infection resulting from ingestion of infected raw fish. Onset is insidious with abdominal pain and watery diarrhea. Progressive autoinfection may lead to enteropathy, protein loss, and severe malabsorption. Treatment is with mebendazole 200 mg bid po for 20 days or albendazole.

Cestode infections: See tapeworm.

Chikungunya (Topical areas, especially urban, of Asia, India, and East Africa): Chikungunya is an arboviral infection transmitted by the Aedes aegypti mosquito. Incubation is 2-4 days and the illness is self-limiting with acute symptoms (abrupt onset fever, headache, arthralgias, nausea, vomiting, abdominal pain, sore throat, lymphadenopathy, rash at defervescence, and malaise) lasting 3-10 days. Arthralgias remain a problem for weeks to several months after the acute phase. Febrile convulsions may occur in young children. Treatment is supportive for fever and pain.

Clonorchiasis: See trematodes below.

Cryptococcosis (U.S., Australia, tropical Asia, Africa, South America): Cryptococcosis is a yeast (Cryptococcus neoformans) infection beginning in the lungs and spreading to the CNS and thus resulting in meningitis and in some cases, disseminated disease. Immunocompromised persons are at increased risk. Treatment is with amphotericin B alone or in combination with flucytosine. Mild cases may be treated with fluconazole; and fluconazole is also used for maintenance therapy.

Cryptosporidiosis (Worldwide, with increased prevalence in tropical areas): Cryptosporidiosis is a protozoan (Cryptosporidium sp.) infection of the GI tract causing diarrhea which ranges from self-limited to chronic secretory, high volume and ultimately fatal. Immunocompromised persons are at increased risk. There is not currently a satisfactory treatment.

Cutaneous leishmaniasis (sometimes termed tropical ulcer or tropical sore): See full discussion of leishmaniasis (East and North Africa, Middle East, Southern Europe, Central, South, and East Asia, South America, West Mexico): Cutaneous leishmaniasis is caused by Leishmania sp. and is characterized by single or multiple lesions typically progress from papules to nodules to non-ulcerated dry plaques or ulcers that usually are painless unless secondarily infected. Lesions are sometimes described as wet or dry. Distribution may be a single primary lesion, multiple primary lesions, and/or satellite lesions. Low-grade fever, regional lymphadenopathy and/or lymphangitis, and lesion pruritis or pain may be present. In many cases, healing is spontaneous within months or years of onset. In other cases, however, the disease is progressive with visceral manifestations or spreading skin lesions. Treatment depends on whether the patient is immunocompromised and/or at risk for mucosal leishmaniasis (in which case, treatment is provided) and on site and severity of lesions, with metastatic lesions treated and inobtrusive lesions not always treated. Treatment includes intramuscular or intravenous antimony preparations such as sodium stibogluconate. Other treatments are pentamidine, miltefosine, or rifampin and isoniazid in combination. Also see full discussion of leishmaniasis or mucocutaneous leishmaniasis.

Cysticercosis: See tapeworm.

Gnathostomiasis (China, Japan, Southeast Asia, Pacific Islands): Gnathostomiasis is a tissue nematode (roundworm) infection with Gnathostoma spinigerum following ingestion of undercooked fish or fowl. Initial symptoms are nausea, vomiting, right upper quadrant abdominal pain, hepatomegaly, fever, and eosinophilia; followed 2-4 weeks later by diffuse painless, pruritic subcutaneous swelling which may migrate, wax and wane, or appear as serpiginous. Swelling is due to migration of the immature worm, and usually is found on an arm or leg, but may also occur in the eyelid (with associated ocular symptoms) or may also affect visceral organs. Eosinophilic myeloencephalitis occurs when the worm migrates along a large nerve trunk resulting in nerve root pain, paralysis, severe headache, and/or signs of cerebral hemorrhage. Treatment includes surgical removal + albendazole 400 mg po for 21 days (not FDA approved and not highly effective).

Helminthiasis: See ascariasis (summary or full discussion), echinococcosis/hydatid disease (summary or full discussion), schistosomiasis (summary or full discussion).

Junin hemorrhagic fever: See South American hemorrhagic fevers or go to full discussion of HFs.

Leptospirosis: See full discussion (Worldwide, especially tropical areas of Latin America and Southeast Asia): Leptospirosis is a spirochette (Leptospira interrogans) infection transmitted primarily through exposure to water contaminated with urine from infected animals. Leptospirosis varies from asymptomatic to a severe or fatal illness. There are two common forms (anicteric and icteric or Weil's syndrome). Anicteric leptospirosis is the more common and milder form, and often is biphasic, with the first phase characterized by sudden onset high fever with chills, headache, conjunctival suffusion, cough and pulmonary chest pain, abdominal pain, nausea and vomiting, and myalgia. The illness may resolve after about one week with no further manifestations; or, after one to three days, recur with milder and more varied symptoms than in the first phase - except that aseptic meningitis may occur. Icteric leptospirosis or Weil's syndrome is the more severe form and is characterized by symptoms as described above (except not usually biphasic); and after about one week, the development of decreased renal function, pulmonary complications, jaundice, and/or hemorrhagic manifestations. Treatment includes antibiotics (doxycycline, penicillin, or others) and support.

Melioidosis (Southeast Asia): Melioidosis is infection by Pseudomonas pseudomallei (gram negative bacillus) with symptoms of fever, pulmonary infection that may range from bronchitis to necrotizing pneumonia. Acute septicemic melioidosis is most common among debilitated persons. Focal suppuration (nodule, lymphangitis, lymphadenopathy) results from inoculation through a break in the skin. Chronic suppurative disease may involve virtually any body system. Recrudescence may occur many years after the initial infection. Treatment is according to susceptibility. Common antibiotics used are TMP-SMX (not in Thailand), Augmentin, doxycycline, and cephalosporins.

Nematode infections: See angiostrongyliasis, anisakiasis, ascariasis, capillariasis, dracunculiasis, enterobiasis, filariasis, gnathostomiasis, hookworm, strongylodiasis, trichostrongyliasis, trichuriasis (some with full discussions).

Nutritional deficits: See malnutrition.

Opisthorchiasis: See trematodes (biliary tract-dwelling) below.

Paragonimiasis: See trematodes, lung-dwelling below.

Schistosomiasis or Bilharzia: See full discussion (Numerous areas of the world, especially Africa and Asia with variants and locations noted in the full discussion). Schistosomiasis is caused by Schistosoma sp. and encompasses several syndromes, not all of which are evident in all infected persons. Initial symptoms may include a pruritic, papular rash - most commonly in persons who do not live in endemic areas. Acute schistosomiasis (Katayama fever) occurs in primary infection 1-2 months after exposure to heavy parasite loads. Symptoms may include fever of several weeks duration, headache, urticaria, cough, hepatosplenomegaly, lymphadenopathy, diarrhea, and eosinophilia. Hematuria and dysuria occur in some infections. Symptoms tend to gradually diminish over several months, but may intensify as more eggs are deposited. Chronic hepatosplenic schistosomiasis is a consequence of eggs retained in tissue and prolonged infection - usually > 10 years duration. The liver may be large or small and firm with nodularity. Portal hypertension, splenomegaly, or esophageal or gastric varices may occur. Hematemesis and splenomegaly are common presenting symptoms, with normal liver function. Periportal fibrosis and portal hypertension is associated with glomerulonephritis (proteinuria, renal failure) and pulmonary hypertension (cor pulmonale). Granulomatous tissue in the bowel results in bloody diarrhea. The last (chronic) stage varies according to species, with some species primarily affecting the liver and intestines, and one species affecting primarily the urinary tract. In general, patients with chronic schistosomiasis tend to present in developed countries with lethargy, colicky abdominal pain, mucoid/bloody diarrhea, or dysuria and hematuria. Salmonella infection concurrent with schistosomiasis is common and is resistant to treatment unless the schistosomiasis is also treated. Complications include progression of liver, kidney, or other organ dysfunction for many years after transmission has been interrupted - especially with heavy infection and re-exposure. Central nervous system lesions occur, but rarely. Treatment is according to species: For S. haematobium and S. mansoni, praziquantel 20/kg po bid for one day; for S. japonica and S. mekongi, praziquantel 20/kg po tid for one day are the treatments of choice. S. mansoni may also be treated with oxamniquine in a single po dose (with food) of 15 mg/kg. S. haematobium in North and East Africa may be treated with metrifonate 7.5-10 mg/kg every other week for a total of 3 doses.

Subcutaneous mycotic infection: See mycetoma.

Tapeworms and cysticercosis (Worldwide, but endemic in certain areas): Tapeworm or cestode infections result from the ingestion of Taeniasis sp. eggs, often found in undercooked meat or excreted proglottids (segments) of the adult tapeworm. Depending on the species, adult tapeworms reach a length of eight meters and live as long as 25 years. The beef tapeworm (Taeniasis saginata) usually causes gastrointestinal discomfort and weight loss. Awareness of infection often is through discovery of proglottids in the stool. Manifestations of intestinal infection with the pork tapeworm (Taeniasis solium) are similar to those of the beef tapeworm. However, ingestion of food that is fecally contaminated with T. solium eggs results in cysticercosis. The symptoms of cysticercosis are caused by the presence of cysticeri (encapsulated larvae) and the resulting inflammatory reaction or space-occupying lesions. The incubation period is as long as five years. Manifestions are most commonly varied neurologic problems, including fever, headache, CVA, hydrocephalus, seizures, and other symptoms of increased intracranial pressure. Visual manifestations may be from increased intracranial pressure or a cyst in the eye. Cysts are also found in subcutaneous and muscle tissue. Treatment of intestinal tapeworms is with a single dose of praziquantel 5-10 mg/kg. Treatment of cysticercosis is with albendazole 5 mg/kg po tid for 8-30 days or praziquantel 20 mg/kg po tid for 14 days. Therapy may increase symptoms, in which case dexamethasone helps reduce distress. Also see echinococcosis and hymenolepiasis.

Trematodes (flukes): See schistosomiasis above or full discussion and see trematode infection by affected system below. Trematodes, biliary duct-dwelling cause diseases including clonorchiasis and opisthorchiasis. (1) Clonorchiasis (China, Taiwan, Korea, Japan, Vietnam, and other areas of Asia) is a liver fluke (Clonorchis sinensis) infection of the biliary tract following ingestion of raw or pickled fish. Symptoms include upper abdominal pain, irregular high fever, lymphadenopathy, myalgia, and arthralgia. The condition may be chronic and include intermittent fever, vague abdominal symptoms, anorexia, and fatigue. Eosinophilia is pronounced. Treatment is with praziquantel 25 mg/kg po tid for one day. (2) Opisthorchiasis (Eastern Europe and Russia; Thailand) is a liver fluke infection of the biliary tract following ingestion of raw or pickled fish. Most infected persons have no significant symptoms. If the parasite load is high, symptoms may include upper abdominal pain, feeling that something is moving in the liver, hepatomegaly with tenderness, jaundice, intermittent fever, lymphadenopathy, myalgia, and arthralgia. The condition may be chronic and include intermittent fever, vague abdominal symptoms, anorexia, and fatigue. Eosinophilia is pronounced. Treatment is with praziquantel 25 mg/kg po tid for one day.

Trematodes, blood-dwelling (schistosomiasis or Bilharzia): See full discussion (Numerous areas of the world, especially Africa and Asia with variants and locations noted in the full discussion). Schistosomiasis is caused by Schistosoma sp. and encompasses several syndromes, not all of which are evident in all infected persons. Initial symptoms may include a pruritic, papular rash - most commonly in persons who do not live in endemic areas. Acute schistosomiasis (Katayama fever) occurs in primary infection 1-2 months after exposure to heavy parasite loads. Symptoms may include fever of several weeks duration, headache, urticaria, cough, hepatosplenomegaly, lymphadenopathy, diarrhea, and eosinophilia. Hematuria and dysuria occur in some infections. Symptoms tend to gradually diminish over several months, but may intensify as more eggs are deposited. Chronic hepatosplenic schistosomiasis is a consequence of eggs retained in tissue and prolonged infection - usually > 10 years duration. The liver may be large or small and firm with nodularity. Portal hypertension, splenomegaly, or esophageal or gastric varices may occur. Hematemesis and splenomegaly are common presenting symptoms, with normal liver function. Periportal fibrosis and portal hypertension is associated with glomerulonephritis (proteinuria, renal failure) and pulmonary hypertension (cor pulmonale). Granulomatous tissue in the bowel results in bloody diarrhea. The last (chronic) stage varies according to species, with some species primarily affecting the liver and intestines, and one species affecting primarily the urinary tract. In general, patients with chronic schistosomiasis tend to present in developed countries with lethargy, colicky abdominal pain, mucoid/bloody diarrhea, or dysuria and hematuria. Salmonella infection concurrent with schistosomiasis is common and is resistant to treatment unless the schistosomiasis is also treated. Complications include progression of liver, kidney, or other organ dysfunction for many years after transmission has been interrupted - especially with heavy infection and re-exposure. Central nervous system lesions occur, but rarely. Treatment is according to species: For S. haematobium and S. mansoni, praziquantel 20/kg po bid for one day; for S. japonica and S. mekongi, praziquantel 20/kg po tid for one day are the treatments of choice. S. mansoni may also be treated with oxamniquine in a single po dose (with food) of 15 mg/kg. S. haematobium in North and East Africa may be treated with metrifonate 7.5-10 mg/kg every other week for a total of 3 doses.

Trematodes, intestine-dwelling (Asia, Latin America, Africa) include several species ranging in size from 1 mm to 70 mm in length and causing gastrointestinal symptoms such as pain, nausea, vomiting, ascites, and obstruction; and cardiac problems including myocarditis. Treatment in most cases is with praziquantel 25 mg/kg tid for one day.

Trematodes, lung-dwelling cause paragonimiasis (Asia, Latin America, Africa): Paragonimus sp. are lung-dwelling (as well as other sites) trematodes. Infection is most frequently linked with ingestion of incompletely cooked or pickled shellfish. Paragonimiasis may persist for many years and thus present as acute or chronic illness - though chronic is the more common. Acute illness may include fever, cough, pleural effusion, and hepatosplenomegaly. Chronic paragonimiasis is characterized by cough, dyspnea, hemoptysis, brown-flecked sputum, and pleuritic chest pain. X-ray shows (depending on length of illness) diffuse or segmented infiltrates, nodules, cavities, ring cysts, and/or pleural effusions. Extrapulmonary infections may manifest with abdominal pain, diarrhea, and CNS symptoms. Treatment is with praziquantel 25 mg/kg tid for two days.

Trichuriasis or whipworm disease (worldwide)

Tropical sprue (Tropical areas of the world): Tropical sprue is a malabsorption disorder of unknown etiology (possibly coliform organisms) that affects residents of or visitors to endemic or epidemic areas. Note that the disorder may occur years after leaving the tropics. Common manifestations are anorexia, abdominal distension, weight loss, and other findings consistent with malabsorption disorders; and decreased iron, folate, and B12. Treatment is with folate, B12, and 2-4 weeks of antibiotic therapy (sulfonamide or tetracycline with folic acid).

Weil's syndrome: See leptospirosis.

Yaws (frambesia) (tropical areas worldwide): Yaws is a chronic childhood illness caused by Treponoma pallidum ssp. pertenue (see other treponematoses) spread primarily by skin to skin contact. Yaws is characterized by an initial papule, which enlarges and becomes papillomatous. The lesion erodes and infectious crusting exudate appears, as well as lymphadenopathy. The initial or "mother" lesion heals, but before or after healing of the initial lesion, secondary lesions appear in a variety of forms. Late or chronic yaws appear in about 10% of patients five or more years after the initial infection. Late yaws is characterized gummatous (granulomatous) lesions of the skin and subcutaneous tissues. The bones are also affected and eventually there is erosion of the nose and facial bones. The preferred treatment is 2.4 million units of IM benzathine penicillin G for adults and 1.2 million units for children.

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East Asia & China

Arbovirus encephalitis (Worldwide - according to specific disease): Among the most important (highest case- fatality rates) arbovirus or arthropod-borne encephalitides is Japanese encephalitis (JE), which is found throughout Asia and the Pacific. Severe infections are usually characterized by acute onset of fever, meningeal signs (headache, stiff neck, irritability, nausea and vomiting, delirium, >vital signs), tremors, convulsions, and stupor progressing to coma. Treatment is primarily supportive.

Bilharziasis or Bilharzia: See schistosomiasis (summary or full discussion).

Clonorchiasis: See trematodes below.

Fluke (trematode) infections: See trematodes below. These are divided according to primary system involvement and there is a complete discussion of schistosomiasis or blood flukes in a separate file.

Hemorrhagic fever with renal syndrome: See full discussion of HFs (Europe, Russia, East China, and Korea): Hemorrhagic fever with renal syndrome is caused by hantavirus. Incubation ranges from 9-35 days. Severity of the illness varies, mild or subclinical infections common. More severe cases are characterized by a febrile stage lasting 3-5 days with abrupt onset of fever, headache, photophobia, blurred vision, facial flushing extending to neck and shoulders, conjunctival petechiae, periorbital edema, pharyngeal injection and/or petechiae, axillary petechiae, lumbar back pain and CVA tenderness lasting 3-5 days. The illness may gradually resolve after this febrile stage or a hypotensive stage may begin as the temperature falls. The hypotensive stage is characterized by decreased blood pressure, tachycardia, and sometimes shock. Proteinuria, thrombocytopenia, leukocytosis, oliguria occur, as does renal failure in some cases. Renal function returns as the oliguric phase resolves and the polyuric phase ensues. Electrolyte imbalances and dehydration may occur in the polyuric phase. Disseminated intravascular coagulation may occur relatively early in the course of illness. Treatment is supportive as discussed in Hemorrhagic Fevers.

Histoplasmosis (Africa, Americas, East Asia, Australia): Best known in the West as an opportunistic infection of HIV, histoplasmosis is found among immigrants as the classic small-form histoplasmosis (primarily pulmonary) and as African histoplasmosis (primarily bone and cutaneous). Treatment is with amphotericin B initially, and itraconazole or fluconazole are used for maintenance therapy.

Lyme disease (North America, Europe, Asia): Lyme borreliosis is a tick-borne spirochete, and though Lyme disease often considered (in the U.S.) as a North American illness, is also found in Europe and Asia. There also are similar tick-borne illnesses. Lyme disease occurs in three stages: (1) Early localized infection is characterized by erythema migrans, i.e., papule or macule expanding to large annular lesion with clearing center or center that becomes indurated or necrotic. (2) Early disseminated infection is characterized by fever with chills, secondary (and smaller) lesions, headache, stiff neck, myalgias, arthralgias, and malaise and fatigue; other neurological signs, and sometimes cardiac problems may also develop. (3) Late persistent infection is characterized by the development of arthritis, chronic synovitis, and other musculoskeletal problems. Central and peripheral nervous system disorders also occur, as well as skin lesions such as acrodermatitis chronicum atrophicans which presents as discoloration and swelling of a distal extremity progressing to a condition resembling localized scleroderma. Diagnosis of Lyme disease is based on exposure and presence of specific symptoms (erythema migrans + at least one late manifestion + laboratory confirmation - usually antibodies by ELISA). Treatment is with oral antibiotics (doxycycline or amoxicillin or cefuroxime axetil or erythromycin for 10-60 days, depending on severity/extent of illness) or, if neurological involvement, with IV antibiotics.

Nutritional deficits: See malnutrition.

Paragonimiasis: See trematodes, lung-dwelling below.

Trematodes, liver-dwelling cause fascioliasis (Worldwide where sheep and cattle are raised): Infection occurs after ingestion of contaminated water or water-dwelling vegetation, e.g., watercress. Acute fascioliasis is characterized by fever, abdominal pain (especially hepatic), nausea, diarrhea, and hepatomegaly. Cough may also occur. Liver enzymes and erythrocyte sedimentation rates are usually elevated, and anemia is common. Chronic disease results in a variety liver and gallbladder abnormalities. Bithionol 30-50 mg/kg orally qod for 10-15 doses is the treatment of choice as this is written. Bithionol is available in the U.S. from CDC. Triclabendazole in a single dose of 10 mg/kg may become the drug of choice when available in the U.S. (Rosenblatt, 1999).

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Japan

Anisakiasis (Mexico, Central and South America, Japan): Anisakiasis is a nematode (roundworm) infection of the stomach or intestinal wall with Anisakis. Manifestions vary according to primary site of infection and improvement usually occurs within a few weeks. Acute gastric anisakiasis has an acute onset of progressive epigastric pain, nausea, and vomiting within hours of ingesting lavae. Acute intestinal manifests as low-grade fever, colicky lower (or diffuse) abdominal pain, nausea, vomiting, and diarrhea. Chronic anisakiasis produces chronic symptoms similar to gastritis, peptic ulcer disease, inflammatory bowel disease, and other GI disorders. Treatment is symptomatic, and in a few cases, surgical.

Schistosomiasis or Bilharzia: See full discussion (Formerly found in Japan, hence the term Katayama fever for acute schistosomiasis. No longer a health problem in Japan).

Scrub Typhus: See full discussion (numerous areas of the world as noted in discussion below): The typhus group of illnesses are one of several rickettsioses or febrile exanthematous illnesses caused by bites of rickettsial-infected arthropods or exposure to their feces. The three most important typhus group diseases are: epidemic louse-borne typhus, scrub typhus (found in Japan), and endemic (murine) typhus. Scrub typhus is transmitted by the bite of infected mites or chiggers, and is found in most areas of Asia. Scrub typhus illness ranges from mild to severe, and is characterized by gradual onset of fever, chills, headache, myalgia (backache), cough, nausea and abdominal pain, eschar at the site of the infecting bite, regional lymphadenopathy and a maculopapular rash. Severe scrub typhus is characterized by encephalitis and pneumonia. Scrub typhus is treated with doxycycline 100 mg bid po for 7-14 days; or chloramphenicol 500 mg qid po for 7-14 days. Azithromycin is also effective.

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Pacific

Arbovirus encephalitis (Worldwide - according to specific disease): Among the most important (highest case- fatality rates) arbovirus or arthropod-borne encephalitides are (1) Japanese encephalitis (JE), which is found throughout Asia and the Pacific; and (2) Murray Valley (MV), which is found in Australia and New Guinea. Severe infections are usually characterized by acute onset of fever, meningeal signs (headache, stiff neck, irritability, nausea and vomiting, delirium, >vital signs), tremors, convulsions, and stupor progressing to coma. Treatment is primarily supportive.

Buruli ulcer (Africa, Australia): Mycobacterial (ulcerans) infection resulting in a large ulcer. Surgery may be necessary.

Donovanosis: See Granuloma inguinale.

Q fever (Worldwide): Q fever is a rickettsial zoonosis (infection with gram negative Coxiella burnetii) contracted primarily from inhalation of dust contaminated by infected animals, especially sheep, cattle, and goats; and also other mammals. Other routes of infection include contact with milk and tissue from infected animals. Manifestations of acute Q fever include fever, fatigue, headache, cough, abdominal pain, nausea, diarrhea, and myalgia. Pneumonia develops in a small number of patients. Other complications are hepatitis, pericarditis, myocarditis, and meningoencephalitis. Hepato/splenomegaly and endocarditis are common in chronic Q fever. Endocarditis is frequently associated with purpuric rash, renal insufficiency, stroke, and heart failure. Treatment of acute Q fever is with doxycycline or a quinolone. Chronic Q fever requires combination therapy such as rifampin and doxycycline.

Subcutaneous mycotic infection: See mycetoma.

Syphilis (Worldwide): There are both venereal and endemic forms of syphilis, with the latter being primarily an illness of childhood caused by Treponoma pallidum ssp. endemicum (vs. T. pallidum ssp. pallidum, the infectious agent in syphilis) and occurring primarily in arid climates of the developing world. The prevalence of (endemic) syphilis infection among children <10 years of age ranges up to 19% among some nomadic groups in Africa. T. pallidum ssp. endemicum cannot be distinguished from T. pallidum ssp. pallidum in the laboratory.

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