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Europe and Russia Endemic to Europe and Russia, Worldwide/Europe
Babesiosis (Europe, U.S., Mexico): Babesiosis is a rare tick-borne protozoal infection (Babesia sp.) of red blood cells. Babesiosis is self-limited with a duration of weeks to months and is characterized by irregular fever, chills, diaphoresis, headache, myalgia, and fatigue. Moderate hemolytic anemia, jaundice, hemoglobinuria, and hepatosplenomegaly are common. Treatment is focused on symptoms.
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.
Echinococcosis (Hydatid disease): See full discussion (Most of the world; endemic in South America, North Africa, Middle East, Southern Europe - especially in areas where sheep are raised). Echinococcosis or hydatid disease is a tapeworm infection that often is asymptomatic, especially in the lengthy early stages. Echinococcus embryos trapped in various organs (especially the liver or lung) develop into hydatid cyst(s), which grow and eventually cause dysfunction according to the function or area of the organ(s). Surgical excision of the cyst remains the treatment of choice. Albendazole is given pre and post-operatively. Drug treatment includes albendazole or mebendazole or praziquantel - all with poor cure rates.
Encephalitis (Worldwide): Encephalitis among refugees and immigrants from Europe is most likely to be tick-borne.
Hemorrhagic fevers (HFs): See full discussion of HFs. The major HFs include hemorrhagic fever with renal syndrome, hantavirus pulmonary syndrome, South American HFs, Lassa HF, Marburg and Ebola HFs, Kyasanur Forest HF, Omsk HF, Crimean-Congo HF, Chikungunya fever, dengue fever and HF, and Rift Valley fever (distribution is noted in the full discussion). The viral hemorrhagic syndrome (VHS) results from widespread increased permeability of microvasculature. Depending on the severity of vascular instability and decrease in platelet function, presentation may range from mild to severe illness; and hemorrhagic manifestations are not always apparent. A common course of illness begins with an abrupt onset of fever, myalgia, cutaneous flushing, and conjunctival suffusion. Within several days, the patient's condition worsens to include syncope, photophobia, headache, hyperesthesia, abdominal pain, nausea/vomiting, anorexia, and prostration. Treatment is primarily supportive, except that Lassa fever, South American HFs, and possibly Crimean-Congo HF and Rift Valley HF may be treated with a slow infusion of IV ribavirin.
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).
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.
Omsk hemorrhagic fever: See full discussion of HFs (Russia): Omsk HF is caused by a tick-borne flavivirus and currently is found only in Russia. 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. Incubation is 3-8 days. Treatment is supportive as described in the full discussion of HFs.
Opisthorchiasis (trematode infection) (Eastern Europe and Russia; Thailand) Opisthorchiasis 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.
Illnesses Found Worldwide, Including Europe
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.
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.
Ascariasis: See full discussion (Worldwide): Ascariasis is a nematode or roundworm infection with Ascaris lumbricoides causing transient respiratory symptoms initially and chronic gastrointestinal symptoms. The adult worms are more than 20 cm. in length, hence are easily seen in stool and may also emerge from the nose or mouth as a result of coughing or vomiting. Treatment is with albendazole single dose of 400 mg po (not FDA approved) or mebendazole or pyrantel pamoate.
Bacillus cereus (Worldwide): Bacillus cereus is a pathogen causing self-limited food poisoning with vomiting or diarrhea and abdominal cramps.
Botulism (Worldwide): Botulism is a severe food poisoning resulting from ingesting the neurotoxin produced by Clostridium botulinum in canned or preserved foods (such as those produced under unsanitary conditions and imported). Symptoms include abdominal pain, vomiting, and CNS disturbances.
Campylobacter enteritis (Worldwide): Campylobacter enteritis is caused by gram negative non-spore forming rods (Campylobacter sp.) resulting in acute gastroenteritis characterized by fever, abdominal pain, and acute watery diarrhea. Campylobacter fetus causes systemic infections that are sometimes fatal.
Clostridium botulinum and C. perfringens (Worldwide): C. botulinum causes botulism (see above) and C. perfringens causes gas gangrene and also enteritis or food poisoning especially from poultry.
Crimean-Congo hemorrhagic fever: See hemorrhagic fevers (HFs) below or full discussion of HFs (Africa, Middle East, Eastern Europe, Russia, Western China): Incubation is 3-12 days. Crimean-Congo HF is transmitted by the bite or crushing of infected ticks, or by contact with live or dead infected mammals. The clinical picture includes sudden onset fever and myalgia, headache, dizziness, photophobia, hyperesthesias, chest and/or abdominal pain, nausea and vomiting, conjunctival injection, flushing, hypotension, axillary or other petechiae, decreased blood pressure, increased heart rate, periorbital edema, proteinuria, and significant liver abnormalities (>AST, >phosphokinase, >bilirubin), leukocytosis, and signs of disseminated intravascular coagulation. Though treatment is not definitive, more severe cases are often successfully treated with IV ribavirin as described in the full discussion of Hemorrhagic Fevers.
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 larva migrans (Worldwide, including Southeastern U.S.): Cutaneous larva migrans is a distinctive serpinginous dermatitis caused by hookworm larval penetration of the skin. See hookworm.
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.
Diphtheria (Worldwide): Diphtheria is an acute upper respiratory infection caused by virulent strains of the toxin-producing gram positive bacillus, Cornybacterium diphtheriae. Symptoms include fever, serosanguinous nasal discharge, sore throat, and gray pseudomembrane in the pharynx, nasopharynx, and/or trachea. Complications include respiratory tract obstruction, pneumonia, peripheral neuritis, and/or myocarditis. Immunization is essentially universal among younger people in the U.S., but some refugees and immigrants may not be immunized. Treatment includes (1) diptheria antitoxin within 48 hours of onset (after testing for sensitivity to antitoxin); (2) procaine penicillin G 600,000 units IM bid for 14 days (150,000 units/kg/day IV for 10 days for pediatric patients) or erythromycin 500 mg parenterally or po qid; (3) bedrest and supportive care; and (4) isolation until secretions are noncontagious. With some differences in regime, carriers are also treated.
Enterobiasis or Pinworm infection (Worldwide; most common helminthic infection in Western Europe and U.S.): Enterobiasis is a nematode infection of the intestinal tract caused by Enterobius vermicularis eggs which are ingested via contaminated food or soiled hands. Manifestations/associated problems include perianal pruritis, vulvovaginitis in prepubertal girls, and secondary enuresis and urinary tract infection. Treatment is with mebendazole single dose of 100 mg po, repeated in 2 weeks or albendazole single dose of 400 mg po, repeated in 2 weeks (Not FDA approved for this use).
Enterovirus exanthems: Enterovirus exanthems are rashes secondary to gastrointestinal tract infection by picornaviruses, including poliovirus, coxsackieviruses, and echoviruses.
Escherichia coli (Woldwide): E. coli are gram negative motile or nonmotile short rods that are a common cause of urinary tract and epidemic diarrheal diseases.
Familial Mediterranean fever (Mediterranean area, primarily among persons of Sephardic Jewish, Armenian, and Arab ancestry): Familial Mediterranean fever (FMF) is an inherited disorder whose etiology is unknown. FMF is characterized by recurrent episodes of fever, abdominal pain, peritonitis and/or pleuritis or other chest pain; and in some cases, amyloidoses, arthritis, and skin lesions (especially on lower extremities). Onset is usually between the ages of 5 and 15 years. Treatment of acute attacks is supportive. Prophylactic treatment with colchicine 0.6 mg po tid or bid is effective. Fascioliasis: See trematodes, liver-dwelling.
Giardiasis: See full discussion (Worldwide): Giardiasis or giardia is caused Giardia lamblia, a protozoan transmitted via water or food contaminated with human feces; and is also transmitted sexually (usually anal-oral). Many infected persons are asymptomatic, while others experience diarrhea as the primary symptom. Diarrhea ranges from one loose stool/day to frequent copious watery stools, may be acute or chronic, and continuous or intermittent (with bouts of constipation). When copious, stools often contain mucous, but seldom blood, and are greasy/steatorrheic, frothy and foul-smelling. Other common symptoms are abdominal pain, nausea and vomiting, anorexia, flatulence, fatigue, and weight loss. The acute phase may last days or weeks, with resolution usually spontaneous. Some patients develop chronic giardiasis, which persists for many years. Metronidazole 250 mg. tid x 5 days is a common treatment. Alternatives include furazolidone, albendazole, and paramomycin. Empiric treatment is common.
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.
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.
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.
Meningitis, chronic and recurrent, is common worldwide, often as a complication of communicable diseases caused by a variety of pathogens as follows: (1) Bacterial causes include incompletely treated suppurative meningitis, parameningeal infection, Lyme disease, mycobacterium tuberculosis, syphilis; and less commonly actinomycosis brucellosis, leptospirosis, nocardial infection, and Whipple's disease. (2) Fungal infections with the potential to cause meningitis include aspergillosis, blastomycosis, cryptococcus, coccidiomycosis, candidiasis, histoplasma, and sporotrichosis. (3) Protozoal causes include toxoplasmosis and trypanosomiasis. (4) Helminthic causes include angiostrongyliasis, cysticercosis, gnathostomiasis, and trichinosis. (5) Viral causes include echoviral infections, herpes, HIV, lymphocytic choriomeningitis, and mumps. Viral or aseptic meningitis is characterized by sudden onset of fever and signs and symptoms of meningeal involvement (headache, neck stiffness, irritability/malaise, and sometimes rash and nausea and vomiting (from Chin, 2000; Koroshetz & Swartz, 1998).
Meningoencephalitis is relatively common worldwide and in some cases occurs as a complication of communicable diseases. Viruses are the most common pathogen, especially enteroviruses, but also arboviruses, herpesviruses, and other pathogens in illnesses including African trypanosomiasis, amebiasis, angiostrongyliasis, candidiasis, Chagas' disease, cryptococcosis, cytomegalovirus, dengue fever, hemorrhagic fevers, herpes, listeria, toxoplasmosis, and others. Young age and immunocompromise increase the risk of meningoencephalitis.
Naegleria infection (Worldwide): Naegleria fowleri (a protozoal) infection is the cause of amebic meningoencephalitis, which currently is rare. There are two forms: (1) acute and often fatal CNS infection in otherwise healthy persons and (2) granulomatous infection in immunocompromised persons. Meningoencephalitis is also related to other illnesses. See meningoencephalitis above.
Omsk hemorrhagic fever: See full discussion of HFs (Russia): Omsk HF is caused by a tick-borne flavivirus and currently is found only in Russia. 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. Incubation is 3-8 days. Treatment is supportive as described in the full discussion of HFs.
Psittacosis (Worldwide): Psittacosis is Chlamydia psittaci infection contracted from infected birds. Psittacosis is characterized by rapid onset of fever, chills, headache, dry cough, myalgia; and later development of dyspnea and atypical pneumonia. Complications include endocarditis, hepatitis, or neurologic complications. Except for contact with birds, psittacosis is indistinguishable from viral, mycoplasmic, or other atypical pneumonias. Treatment is with tetracycline or erythromycin.
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.
Rickettsioses (Worldwide): The rickettsioses are febrile exanthematous illnesses caused by arthropod carried rickettsiae. Rickettsioses include the typhus group, spotted fever group, Q fever, trench fever, and erlichiosis. See Boutonneuse fever, Q fever, spotted fevers, trench fever, and typhus.
Rotavirus (Worldwide): Rotavirus noninflammatory diarrhea is the most common cause of dehydrating diarrhea in children worldwide. Rotavirus gastroenteritis is more severe in children than adults. Treatment is supportive.
Salmonellosis (Worldwide): Salmonella sp. infections are well known in the Western world. In addition to the usual mild GI Salmonella sp. infections (more severe in the elderly), the more virulent Salmonella typhi causes typhoid fever.
Shigellosis or bacillary dysentary (Worldwide): Acute diarrheal illness from Shigella sp. transmitted via fecal-oral route. Shigellosis is especially common in children. Treatment is supportive and focused on prevention of dehydration.
Sickle cell disease or sickle cell hemoglobulinopathies (Occurs primarily in people of African lineage, but also to a lesser extent among people from the Mediterranean area, Arabs, and Indians): Sickle hemoglobulinopathies are distortions (sickle shaped and rigid) in erythrocytes and a tendency for the sickled cells to clump together causing tissue ischemia and infarction. Clinical characteristics of the various sickle hemoglobulinopathies include:
Sickle cell diseases are well known as an African-American disease in the Western world, but may be missed among refugees or immigrants.
Staphylococcus aureus infection (Worldwide): S. aureus produces an eneterotoxin that causes an acute and short-lived gastroenteritis, for which treatment is supportive.
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.
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.
Tetanus (Worldwide): Tetanus is a neurological disorder caused by the neurotoxin elaborated by the ubiquitous soil-dwelling anaerobic bacillus Clostridium tetani. Infection occurs as a result of introduction of Clostridium spores into wounds. Early manifestations are stiffness of the neck and jaw (lockjaw), dysphagia, and irritability. Pain and tingling at the wound site, followed by regional fasciculations may also be presenting symptoms. Progression includes trismus (jaw muscle spasms), facial muscle rigidity, life-threatening airway /pulmonary muscle spasms, and neck, back, and abdominal muscle spasms, and tonic convulsions. Treatment is in an acute care facility and includes antibiotic therapy, antitoxin, and neurological, pulmonary, and other supportive care - often in a critical care unit. Illness does not confer immunity, hence immunization is included in treatment.
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.
Toxocariasis (Worldwide): Toxocariasis is the most common visceral larva migrans and is due to infection with the tissue nematode (roundworm) toxocara canis or T. cati. Toxocariasis is most common among children who eat feces-contaminated dirt. Most infections are small load and asymptomatic except for mild eosinophilia. Heavy worm loads, decreased immune competence, and other factors may lead to malaise, fever, cough and wheezing, hepatomegaly, anorexia, and weight loss. Ocular toxocariasis also occurs and usually leads to decreased vision. For symptomatic infections, the treatment of choice is diethylcarbamazine 6 mg/kg/day po tid for 10 days. Asymptomatic infections are not necessary to treat.
Toxoplasmosis (Worldwide): Toxoplasmosis is infection with Toxoplasma gondii, an obligate intracellular parasite (protozoan) usually transmitted by ingestion of undercooked meat or contaminated soil. There are two forms of toxoplasmosis, congenital and acquired. Congenital toxoplasmosis is associated with maternal infection shortly before conception, and is characterized by CNS involvement (convulsions, microcephaly or hydrocephaly, mental retardation and blindness) and liver involvement. Choreoretinitis is also common. Acquired toxoplasmosis is a well-known problem among immunocompromised persons, leading commonly to encephalitis, multiple organ infection, and death if not quickly treated. Among immunocompetent persons, toxoplasmosis is most commonly manifested by cervical lymphadenopathy, and less frequently by malaise, fatigue, fever, and headache. Choreoretinitis is common among both immunocompromised and immunocompetent persons. Treatment depends on immunocompetence and degree of symptomatology, and includes multi-drug regimes (commonly pyrimethamine + sulfadiazine or clindamycin) for 4-52 weeks; and in immunocompromised patients, lifelong maintenance therapy.
Trichinosis (trichinella) (Worldwide): Trichinosis is a nematode (roundworm) infection with Trichinella sp. from ingestion of meat that contains cysts, especially undercooked pork or meat from a carnivore. Infection ranges from light and asymptomatic to heavy and life-threatening. Manifestations vary according to the life cycle of the worms: Initially there is malaise, nausea, cramping abdominal pain, and diarrhea. Gastrointestinal symptoms are followed in 1-6 weeks by fever, eosinophilia, periorbital and facial edema, conjunctivitis, dysphagia, dyspnea, cough, myalgia, and muscle spasms. Complications include meningitis and other neurological disorders, myocarditis, pneumonia, and nephritis. The current treatment of choice is mebendazole 300 mg po tid for 10 days (sometimes with prednisone to control symptoms).
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: See full discussion (Numerous areas of the world): Endemic (murine) typhus is transmitted by the bite of infected fleas and is found worldwide. Endemic typhus is characterized by several days of prodromal constitutional symptoms, followed by the abrupt onset of fever, chills, and nausea and vomiting. Pulmonary involvement is common and may include interstitial pneumonia, pleural effusion, and/or pulmonary edema. Treatment is with doxycycline 100 mg bid po for 7-14 days; or chloramphenicol 500 mg qid po for 7-14 days.
Vibrio parahaemolyticus and other vibrio species (worldwide): Vibrio are motile, anaerobic, curved, gram-negative rods that cause (according to species) gastrointestinal (notably cholera) and septic illnesses; and wound, skin, and opthalmic infections. In the U.S., Vibrio parahaemolyticus is transmitted by ingestion of undercooked seafood. In the U.S., infection results in abdominal pain, nausea, vomiting, and watery diarrhea; while in South Asia, infection causes more serious dysentery, but is seldom life-threatening. Treatment is supportive.