Back to Infectious Diseases or Refugees
Skin (Not including disorders familiar in the West. Note that in some disorders, lesions change; and that in some cases, more than one feature is present.) Analgesia, Pruritis, Macules, Papules, Plaques, Vesicles, Urticaria, Nodules, Swelling or Erythematous Lesions, Ulcer, Pustule, Abscess
Analgesia
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.
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).
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).
Onchocerciasis (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.
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.
Trichuriasis (trichocephaliasis or whipworm) (Worldwide, especially tropical and subtropical areas): Trichuriasis is a nematode (roundworm) infection with Trichuris trichiura. Heavy infections may result in abdominal cramping, nausea, vomiting, flatulence, diarrhea, tenesmus, and weight loss. Mild infections are usually asymptomatic. Treatment is with albendazole single po dose of 400 mg (not FDA approved) or mebendazole 100 mg po bid for 3 days. Ivermectin is sometimes also used in combination with albendazole.
Tungiasis (tropical areas of Africa and the Americas): Tungiasis is infestation with Tunga penetrans (sand fleas, jiggers), usually of the foot. Other fleas also bite humans and can transmit a variety of diseases.
Malnutrition (especially pellegra): 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.
Onchocerciasis (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.
Pinta (mal de pinto, carate) (Rural areas of Latin America): Pinta is a spirochetal (Treponema carateum) skin infection characterized by a painless scaling papule with regional lymphadenopathy progressing to non-ulcerating maculopapular erythematous areas. Spread is by extension and by secondary lesions (pintides), which may be numerous. Pintides may be psoriatic or circinate in configuration. Initially the pintides are red, then slate blue, and then loss of pigmentation occurs, resulting first in brown areas, and eventually in mottled white skin. Lesions appear in various stages of development and are seen most commonly on the extremities and face. Pinta is decreasing in incidence and prevalence. The preferred treatment is 2.4 million units of IM benzathine penicillin G for adults and 1.2 million units for children.
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.
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.
Myiasis (Worldwide - uncommon in countries of second asylum): Myiasis is the infestation of a wound with larvae of flies.
Onchocerciasis (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.
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.
Chromomycosis (Worldwide; greatest in Costa Rica and Madagascar): Chromomycosis is a chronic mycosis of the skin and subcutaneous tissue most common among people (primarily adults) who walk barefoot or are exposed to thorn or similar wounds. The disease begins with a warty papule or pustule, plaque, or ulcer. The lesion progresses to a verrucoid (warty) plaque that thickens with time. Lesions tend to spread by inoculation rather than growing peripherally. Chromomycosis must be differentiated from blastomycosis. Superinfection leads to cutaneous and other complications.
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.
Sporotrichosis (Worldwide): Sporotrichosis is a mycotic infection from inoculation of tissue with Sporothrix schenckii mold via an open wound - often associated with gardening activities. Sporotrichosis occurs in several forms, including (1) plaque sporotrichosis - a non-tender maculopapular granuloma at the site of inoculation; (2) lymphangitic sporotrichosis - a papule at the site of inoculation, followed by draining nodules along proximal lymphatic channels; (3) osteoarticular sporotrichosis - polyarticular arthritis that develops slowly and may include draining sinuses at joints. Treatment for plaque sporotrichosis is with potassium iodide or itraconazole. Treatment for lymphangitic or osteoarticular sporotrichosis is with a prolonged course of itraconazole and only about 50% of patients are cured.
Pemphigus disorders (foliaceus, vulgaris, etc.) (Worldwide, uncommon): Pemphigus disorders are immunologically mediated skin diseases characterized by blistering or formation of vesicles at various skin depths, depending on the specific disorder. Systemic glucocorticoids and immunosuppresive agents are used to treat severe cases, while mild cases sometimes respond to topical steroids.
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.
Dracunculiasis (Guinea worm disease) (Primarily West Africa [Nigeria] and Sudan; other areas of tropical Asia and Africa, Middle East, South America): Dracunculiasis is a tissue nematode infection with Dracunculus medinensis, the largest (up to one meter in length) filarial worm affecting humans. Infection occurs when small Cyclops (crustaceans) that contain larvae are ingested in contaminated fresh water such as that from large open wells. Infected persons are asymptomatic for approximately one year. Then, as the female worm reaches maturity, a papule, or in some cases, a sepinginous elevation of the skin develops - usually on a lower extremity. The papule progresses to a painful and pruritic blister, then an ulcer, and then the prolapsed uterus of the worm becomes visible and on contact with water releases larvae in a milky fluid. After repeated emptying, the worm dies and can then be slowly pulled forth and wound around a stick over a period of several weeks. Metronidazole 250 mg po tid for 10 days is used as an adjunct to mechanical removal. In most cases one to two worms emerge/year. Most people with dracunculiasis are incapacitated for about a month. Secondary bacterial infections are the most common complication.
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.
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.
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, with urticaria. 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).
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).
Bartonellosis (Oroya fever) (South America/Andes Mountains): Bartonellosis is a gram negative bacterial systemic infection with Bartonella bacilliformis, which is transmitted by sandflies. Infection is characterized by insidious onset of fever, malaise, headache, myalgia; or in other cases, acute onset high fever, chills, drenching sweats, lymphadenopathy, hemolytic anemia, liver involvement and altered consciousness. Essential features are fever, progressive hemolytic anemia, generalized lymphadenopathy, and exposure to sandflies. Salmonellosis is a common complication of bartonellosis. Nodular (and often ulcerated) lesions occur one to three months after the onset of illness. Treatment is with penicillin, tetracycline, streptomycin, or chloramphenicol.
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.
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.
Chromomycosis (Worldwide; greatest in Costa Rica and Madagascar): Chromomycosis is a chronic mycosis of the skin and subcutaneous tissue most common among people (primarily adults) who walk barefoot or are exposed to thorn or similar wounds. The disease begins with a warty papule or pustule, plaque, or ulcer. The lesion progresses to a verrucoid (warty) plaque that thickens with time. Lesions tend to spread by inoculation rather than growing peripherally. Chromomycosis must be differentiated from blastomycosis. Superinfection leads to cutaneous and other complications.
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.
Enterovirus exanthems: Enterovirus exanthems are rashes secondary to gastrointestinal tract infection by picornaviruses, including poliovirus, coxsackieviruses, and echoviruses.
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.
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.
Myiasis (Worldwide - uncommon in countries of second asylum): Myiasis is the infestation of a wound with larvae of flies.
Sporotrichosis (Worldwide): Sporotrichosis is a mycotic infection from inoculation of tissue with Sporothrix schenckii mold via an open wound - often associated with gardening activities. Sporotrichosis occurs in several forms, including (1) plaque sporotrichosis - a non-tender maculopapular granuloma at the site of inoculation; (2) lymphangitic sporotrichosis - a papule at the site of inoculation, followed by draining nodules along proximal lymphatic channels; (3) osteoarticular sporotrichosis - polyarticular arthritis that develops slowly and may include draining sinuses at joints. Treatment for plaque sporotrichosis is with potassium iodide or itraconazole. Treatment for lymphangitic or osteoarticular sporotrichosis is with a prolonged course of itraconazole and only about 50% of patients are cured.
Swelling or Erythematous Lesions
Chagas' Disease or American trypanosomiais: See full discussion (Most of Latin America): Chagas' disease is a protozoan infection with Trypanosoma cruzi transmitted by insect bite. Patients may be asymptomatic or have a lesion at the site of the bite; and symptoms of prolonged fever, tachycardia, fatigue, weakness, splenomegaly, and lymphadenopathy. Myocarditis or meningoencephalitis may also occur. Most patients experience spontaneous remission of symptoms, followed by a lifelong low-grade parasitemia. There is not currently a satisfactory treatment for any stage of Chagas' disease. Current treatment includes nifurtimox 8-10 mg/kg/day po qid for 90-120 days or benznidazole 5 mg/kg/day po for 60 days. These long-term therapies are toxic to some patients. In the United States, nifurtimox is available only from the Centers for Disease Control and benznidazole is not available in the U.S.
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).
Loiasis or loa loa (filariasis): See full discussion (Tropical Africa): Loiasis or loa loa is a filarial infection in which worms live Loiasis is often asymptomatic among indigenous people of endemic areas, but more problematic among non-indigenous persons who are infected. The worms live in subcutaneous tissues and cause intermittent development of localized areas (> 10 cm) of erythema and angioedema (Calabar swellings), usually on the extremities. Moving worms are sometimes visible in the eye between the bulbar conjunctiva and sclera. Treatment is with diethylcarbamazine (DEC) given in graduated doses as follows: Day 1: 50 mg po; day 2: 50 mg po tid; day 3: 100 mg po tid; days 4-21: 9 mg/kg/d po in 3 divided doses. Alternative treatment is ivermectin in a single oral dose of 100-400 mcg/kg; sometimes combined with lower doses DEC (0.5-1.0 mg/kg/d in combination with corticosteroids. Multiple courses of treatment with DEC are required in about 50% of patients.
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.
Pinta (mal de pinto, carate) (Rural areas of Latin America): Pinta is a spirochetal (Treponema carateum) skin infection characterized by a painless scaling papule with regional lymphadenopathy progressing to non-ulcerating maculopapular erythematous areas. Spread is by extension and by secondary lesions (pintides), which may be numerous. Pintides may be psoriatic or circinate in configuration. Initially the pintides are red, then slate blue, and then loss of pigmentation occurs, resulting first in brown areas, and eventually in mottled white skin. Lesions appear in various stages of development and are seen most commonly on the extremities and face. Pinta is decreasing in incidence and prevalence. The preferred treatment is 2.4 million units of IM benzathine penicillin G for adults and 1.2 million units for children.
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.
Bartonellosis (Oroya fever) (South America/Andes Mountains): Bartonellosis is a gram negative bacterial systemic infection with Bartonella bacilliformis, which is transmitted by sandflies. Infection is characterized by insidious onset of fever, malaise, headache, myalgia; or in other cases, acute onset high fever, chills, drenching sweats, lymphadenopathy, hemolytic anemia, liver involvement and altered consciousness. Essential features are fever, progressive hemolytic anemia, generalized lymphadenopathy, and exposure to sandflies. Salmonellosis is a common complication of bartonellosis. Nodular (and often ulcerated) lesions occur one to three months after the onset of illness. Treatment is with penicillin, tetracycline, streptomycin, or chloramphenicol.
Buruli ulcer (Africa, Australia): Mycobacterial (ulcerans) infection resulting in a large ulcer. Surgery may be necessary.
Cancrum oris: Cancrum oris is a progressive necrotic ulceration of the face caused by infection with Treponema vincenti and/or Bacillus fusiformis. The infection is found most often in malnourished children and is often co-exists with other infections such as visceral leishmaniasis. Treatment is with systemic penicillin.
Chagas' Disease or American trypanosomiais: See full discussion (Most of Latin America): Chagas' disease is a protozoan infection with Trypanosoma cruzi transmitted by insect bite. Patients may be asymptomatic or have a lesion at the site of the bite; and symptoms of prolonged fever, tachycardia, fatigue, weakness, splenomegaly, and lymphadenopathy. Myocarditis or meningoencephalitis may also occur. Most patients experience spontaneous remission of symptoms, followed by a lifelong low-grade parasitemia. There is not currently a satisfactory treatment for any stage of Chagas' disease. Current treatment includes nifurtimox 8-10 mg/kg/day po qid for 90-120 days or benznidazole 5 mg/kg/day po for 60 days. These long-term therapies are toxic to some patients. In the United States, nifurtimox is available only from the Centers for Disease Control and benznidazole is not available in the U.S.
Coccidioidomycosis (United States, Mexico, and parts of Central and South America): Coccidioidomycosis is a fungal infection with Coccidioides immitis, usually pulmonary (cough, fever, chest pain, weight loss, malaise), but also of CNS, skin, lymph system, or liver. C. immitis occurs naturally in some soils (semi-arid with short rainy season) and is inhaled. Immunocompromised persons are at increased risk. Treatment is with amphotericin B or fluconazole or itraconazole. Maintenance therapy utilizes the same medications, especially fluconazole or itraconazole.
Cutaneous leishmaniasis: See leishmaniasis, cutaneous.
Dracunculiasis (Guinea worm disease) (Primarily West Africa [Nigeria] and Sudan; other areas of tropical Asia and Africa, Middle East, South America): Dracunculiasis is a tissue nematode infection with Dracunculus medinensis, the largest (up to one meter in length) filarial worm affecting humans. Infection occurs when small Cyclops (crustaceans) that contain larvae are ingested in contaminated fresh water such as that from large open wells. Infected persons are asymptomatic for approximately one year. Then, as the female worm reaches maturity, a papule, or in some cases, a sepinginous elevation of the skin develops - usually on a lower extremity. The papule progresses to a painful and pruritic blister, then an ulcer, and then the prolapsed uterus of the worm becomes visible and on contact with water releases larvae in a milky fluid. After repeated emptying, the worm dies and can then be slowly pulled forth and wound around a stick over a period of several weeks. Metronidazole 250 mg po tid for 10 days is used as an adjunct to mechanical removal. In most cases one to two worms emerge/year. Most people with dracunculiasis are incapacitated for about a month. Secondary bacterial infections are the most common complication.
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.
Leishmaniasis, cutaneous (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.
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.
Lymphogranuloma venereum: See Granuloma inguinale or Donovanosis (some similarities in appearance.
Sporotrichosis (Worldwide): Sporotrichosis is a mycotic infection from inoculation of tissue with Sporothrix schenckii mold via an open wound - often associated with gardening activities. Sporotrichosis occurs in several forms, including (1) plaque sporotrichosis - a non-tender maculopapular granuloma at the site of inoculation; (2) lymphangitic sporotrichosis - a papule at the site of inoculation, followed by draining nodules along proximal lymphatic channels; (3) osteoarticular sporotrichosis - polyarticular arthritis that develops slowly and may include draining sinuses at joints. Treatment for plaque sporotrichosis is with potassium iodide or itraconazole. Treatment for lymphangitic or osteoarticular sporotrichosis is with a prolonged course of itraconazole and only about 50% of patients are cured.
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.
Trypanosomiasis (African) or African sleeping sickness (Tropical Africa): Trypanosomiasis is caused by protozoal parasites, Trypanosoma brucei rhodesiene or T b gambiense, transmitted by bite of the tsetse fly. T b rhodesiene infections are more virulent than T b gambiense; and in the former, patients experience three stages of illness (trypanosomal chancre, hemolymphatic, and meningoencephalitic) as opposed to two stages in the latter (trypanosomal chancre and meningoencephalitic) with significantly milder symptoms. The painful trypanosomal chancre (3-10 cm) appears about two days after the bite and lasts 2-4 weeks. The hemolymphatic stage is characterized by high fevers lasting several days, with symptom-free periods of days to weeks. Less common manifestations of this stage are severe headache, malaise, arthralgia, lymphadenopathy, circinate rash, pruritis, and hepatosplenomegaly. Weight loss and debilitation also occur, and myocarditis may develop. The meningoencephalitic stage is characterized by progressive apathy, nighttime insomnia and daytime somnolence, anorexia, retarded speech, extrapyramidal signs (tremors, fasciculations, choreiform movements, and Parkinsonian-like appearance), and finally, coma and death. Treatment is complex and toxic, and depends on the infecting organism and stage of illness. Among the medications currently in use are suramin, melarsoprol, pentamidine, eflornithine, and corticosteroids.
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, and endemic (murine) typhus. (1) Epidemic louse-borne typhus is caused by Rickettsia prowazekii, with infection favored by crowded, unsanitary living conditions such as in concentration or the more primitive refugee camps - especially those in cold areas. Epidemic louse-borne typhus is currently most prevalent in mountainous areas of Africa, Asia, and Latin America. It is characterized by a prodrome of headache and constitutional symptoms; then the abrupt onset of high fever, chills, and prostration; then a macular rash progressing to maculopapular and petechial. Other common manifestations are delirium, conjunctival injection, photophobia, eye pain, flushed facies, hearing loss, hypotension, pulmonary involvement, renal insufficiency, and splenomegaly. Recovery may be spontaneous, or complications, including pneumonia, circulatory collapse, myocarditis, and uremia may lead to death. Treatment is with doxycycline 200 mg in a single dose or until the patient is afebrile for 24 hours. (2) 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. (3) 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.
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.