Final ReviewFinal ReviewFinal ReviewFinal ReviewDaniel Caplivski M DDaniel Caplivski M DDaniel Caplivski, M.D.Daniel Caplivski, M.D.

Division of Infectious DiseasesDivision of Infectious DiseasesDirector, Travel Medicine ProgramDirector, Travel Medicine Program

General Tips for ExamsGeneral Tips for ExamsGeneral Tips for ExamsGeneral Tips for Exams Read each question very carefullyRead each question very carefully——

board questions love to throw you off board questions love to throw you off i hi h “ i d ”“ i d ”with with “trigger words”“trigger words”

Use the Use the process of eliminationprocess of elimination when when you are not 100% sure of the answeryou are not 100% sure of the answer——you are not 100% sure of the answeryou are not 100% sure of the answerthis is often how we think on the wards this is often how we think on the wards (“Diagnosis of exclusion”)(“Diagnosis of exclusion”)

Don’t change your first impressionDon’t change your first impression Don t change your first impressionDon t change your first impressionunless you have a logical basis to do unless you have a logical basis to do soso

Get a Get a good night’s sleepgood night’s sleep and plenty of and plenty of exerciseexercise——this has been scientifically this has been scientifically shown to improve performance onshown to improve performance onshown to improve performance on shown to improve performance on examsexams

Notecards for VirusesNotecards for Viruses Name of organismName of organismgg Sites of entry/Sites of entry/mode of transmissionmode of transmission Vectors, Reservoir hostsVectors, Reservoir hosts

I b ti i dI b ti i d Incubation periodsIncubation periods Geographic association, Geographic association, Seasonal variationSeasonal variation EpidemiologyEpidemiology//populations at high riskpopulations at high riskp gyp gy p p gp p g Basic Replication CycleBasic Replication Cycle (target cells, receptors)(target cells, receptors) Genetic componentsGenetic components

S l h l l i diS l h l l i di Structural components that play a role in diseaseStructural components that play a role in disease Immune responseImmune response Sites of infection and diseases (Sites of infection and diseases (presenting symptomspresenting symptoms)) Sites of infection and diseases (Sites of infection and diseases (presenting symptomspresenting symptoms)) NonNon--infectious consequences (infectious consequences (malignanciesmalignancies)) Other diagnostic studies (pcr, Other diagnostic studies (pcr, serologyserology, antigens), antigens) Target sites of antiviral treatments Target sites of antiviral treatments preventionprevention (vaccines),(vaccines), infection controlinfection control

Notecards for FungiNotecards for FungiNotecards for FungiNotecards for Fungi

Name of organismName of organism Name of organismName of organism Geographic associationGeographic association Epidemiology/Epidemiology/populations at high riskpopulations at high risk Epidemiology/Epidemiology/populations at high riskpopulations at high risk Sites of entry/mode of transmission Sites of entry/mode of transmission Sites of infection and diseasesSites of infection and diseases Sites of infection and diseasesSites of infection and diseases Virulence factors (eg: capsule of Virulence factors (eg: capsule of CryptococcusCryptococcus)) Morphologic characteristicsMorphologic characteristics in tissuein tissue Morphologic characteristicsMorphologic characteristics in tissuein tissue Morphologic characteristics in culture (Dimorphic?)Morphologic characteristics in culture (Dimorphic?)

Oth di ti t diOth di ti t di ( l ti )( l ti ) Other diagnostic studiesOther diagnostic studies (serology, antigens)(serology, antigens)

Notecards for ParasitesNotecards for Parasites Name of organismName of organism Sites of entry/Sites of entry/mode of transmissionmode of transmissionyy VectorsVectors Reservoir hostsReservoir hosts Geographic associationGeographic association EpidemiologyEpidemiology/populations at high risk/populations at high risk EpidemiologyEpidemiology/populations at high risk /populations at high risk Sites of infection and diseasesSites of infection and diseases LifecycleLifecycle within the principle hostwithin the principle host LifecycleLifecycle within the principle hostwithin the principle host Morphologic characteristics of ova, parasitesMorphologic characteristics of ova, parasites OtherOther diagnostic studiesdiagnostic studies (ova in stool blood(ova in stool blood Other Other diagnostic studiesdiagnostic studies (ova in stool, blood (ova in stool, blood

smears, serology, antigens)smears, serology, antigens)

Concept and Pharmacology Lectures

Viral pathogenesis Antifungals Viral pathogenesis Viral immunology Viral vaccines

Antifungals Antiparasitics Bioterrorism Viral vaccines

Global Health Antivirals (HIV

Bioterrorism Perinatal Infections Opportunistic Antivirals (HIV

treatment) Opportunistic

Infections

Medical Classification of FungiMedical Classification of FungiMedical Classification of FungiMedical Classification of Fungi Systemic dimorphic endemic fungiSystemic dimorphic endemic fungi Histoplasma, Coccidioides, Blastomyces, Histoplasma, Coccidioides, Blastomyces,

Paracoccidioides, PenicilliumParacoccidioides, Penicillium Opportunistic fungi: Opportunistic fungi: Candida, Cryptococcus, Aspergillus, Candida, Cryptococcus, Aspergillus,

Mucorales, PneumocystisMucorales, Pneumocystis Superficial dermatophytesSuperficial dermatophytes Trichophyton, MalasseziaTrichophyton, Malassezia

Subcutaneous mycosesSubcutaneous mycosesSubcutaneous mycosesSubcutaneous mycoses Sporothrix, MadurellaSporothrix, Madurella, etc, etc

CandidaCandida summarysummary Candida can be a normal human Candida can be a normal human

colonizercolonizerS t i didi iS t i didi i llll Systemic candidiasisSystemic candidiasis generally generally occurs in patients with prolonged occurs in patients with prolonged neutropenia, catheters, parenteral neutropenia, catheters, parenteral nutrition broadnutrition broad spectrum antibioticsspectrum antibioticsnutrition, broadnutrition, broad--spectrum antibioticsspectrum antibiotics

Mucocutaneous diseaseMucocutaneous disease can occur in can occur in immunocompetent hosts, but is more immunocompetent hosts, but is more frequent in patient withfrequent in patient with cellularcellularfrequent in patient with frequent in patient with cellular cellular immune defects (AIDS)immune defects (AIDS)

Diagnosis with blood cultures or Diagnosis with blood cultures or direct visualization on biopsydirect visualization on biopsydirect visualization on biopsydirect visualization on biopsy

Treatment with Amphotericin, Treatment with Amphotericin, FluconazoleFluconazole, or echinocandins, or echinocandins Thrush in a patient with AIDS)

Cryptococcus neoformansCryptococcus neoformans summarysummary

An encapsulated yeast commonly found in An encapsulated yeast commonly found in the environmentthe environment——many asypmtomatic many asypmtomatic i f tii f tiinfectionsinfections

Inhalation is initial route of infectionInhalation is initial route of infection Most serious infections in patients with Most serious infections in patients with

defects in defects in cellular immunity (AIDS)cellular immunity (AIDS) Predisposition for Central Nervous SystemPredisposition for Central Nervous System Diagnosis with blood or cerebrospinal Diagnosis with blood or cerebrospinal g pg p

culturescultures Diagnosis also from visualization of Diagnosis also from visualization of

organism on organism on biopsy or CSF (India Ink)biopsy or CSF (India Ink)gg p y ( )p y ( ) Cryptococcal capsular antigenCryptococcal capsular antigen can be can be

measured in blood or CSFmeasured in blood or CSF——rapid rapid diagnosisdiagnosisgg

Treatement with Treatement with amphotericin amphotericin (sometimes (sometimes combined with 5combined with 5--fluorouracil (5FC), fluorouracil (5FC), fluconazole fluconazole

Histoplasma capsulatumHistoplasma capsulatumsummarysummary

Dimorphic fungusDimorphic fungusDimorphic fungus Dimorphic fungus Worldwide distribution, but in US highest Worldwide distribution, but in US highest

prevalence along prevalence along Ohio river valleyOhio river valley Inhalation most common route ofInhalation most common route of Inhalation most common route of Inhalation most common route of

infectioninfection Ranges from Ranges from asymptomatic infection asymptomatic infection to to

disseminateddisseminated septic pictureseptic picture in patientsin patientsdisseminated disseminated septic picture septic picture in patients in patients with immunocompromisewith immunocompromise

Diagnosis with Diagnosis with urine antigenurine antigen, direct , direct vizualizaton on sputum blood smearvizualizaton on sputum blood smearvizualizaton on sputum, blood smear, vizualizaton on sputum, blood smear, tissue biopsy, or culture. tissue biopsy, or culture.

Utility of serology limitedUtility of serology limited Treatment with amphotericinTreatment with amphotericin Treatment with amphotericin, Treatment with amphotericin,

itraconazole, voriconazoleitraconazole, voriconazole

BlastomycesBlastomyces dermatitidisdermatitidis SummarySummary

Dimorphic fungus in moist soilDimorphic fungus in moist soil Endemic in South Central and NorthEndemic in South Central and North Endemic in South Central and North Endemic in South Central and North

Central United States, Wisconsin, Central United States, Wisconsin, Minnesota, Canada, (Minnesota, Canada, (Geographic Geographic overlap with overlap with HistoplasmosisHistoplasmosis))

Most disease is pulmonary, but can Most disease is pulmonary, but can causecause cutaneouscutaneous diseasediseasecause cause cutaneouscutaneous diseasedisease

Diagnosis by culture or visualization Diagnosis by culture or visualization of yeast phase with of yeast phase with broadbroad--based based buddingbudding

Treatment with Treatment with amphotericinamphotericin B, B, itraconazoleitraconazole fluconazolefluconazoleitraconazoleitraconazole, , fluconazolefluconazole

Coccidioides immitis Coccidioides immitis summarysummaryff Dimorphic fungusDimorphic fungus

Endemic to the dry desert of the Endemic to the dry desert of the Southwest Southwest (San Joaquin Valley fever)(San Joaquin Valley fever)

Many asymptomatic infectionsMany asymptomatic infections Pulmonary manifestations can be Pulmonary manifestations can be

severesevere Disseminated infections occur in Disseminated infections occur in

immunocompromised and some immunocompromised and some genetically high risk groups: Filipino> genetically high risk groups: Filipino> Af iAf i A i N ti A iA i N ti A iAfricanAfrican--American> Native AmericanAmerican> Native American

Diagnosis by culture of pulmonary Diagnosis by culture of pulmonary specimensspecimens——spherulespherule is diagnosticis diagnostic

Treatment with amphotericin B, then Treatment with amphotericin B, then fluconazole in immunocompromised fluconazole in immunocompromised patientspatients

ParacoccidiodesParacoccidiodes brasiliensisbrasiliensis summarysummary Dimorphic fungus endemic in rural Dimorphic fungus endemic in rural

South AmericaSouth America Mariner’s wheelMariner’s wheel appearance in appearance in

cultured mold phasecultured mold phase Can be asymptomatic, but Can be asymptomatic, but

pulmonary diseasepulmonary disease predominates, predominates, often accompanied by mucosal or often accompanied by mucosal or p yp ylymph node involvementlymph node involvement

Diagnosis by culture of biopsied Diagnosis by culture of biopsied t i l BAL it i l BAL imaterial or BAL specimensmaterial or BAL specimens

Treatment with Treatment with itraconazoleitraconazole, , amphotericin B or trimethoprimamphotericin B or trimethoprim--amphotericin B or trimethoprimamphotericin B or trimethoprimsulfamethoxazolesulfamethoxazole

PenicilliumPenicillium marneffeimarneffei SummarySummary

Dimorphic fungus endemic Dimorphic fungus endemic

PenicilliumPenicillium marneffeimarneffei SummarySummary

p gp gto Southeast Asiato Southeast Asia

Often presents as Often presents as t dt dcutaneous and cutaneous and

disseminate disease in disseminate disease in patients with AIDSpatients with AIDS

Diagnosis by visualization Diagnosis by visualization of yeast phaseof yeast phase----characterized by binarycharacterized by binarycharacterized by binary characterized by binary fissionfission

Treatment with Treatment with amphotericin and 5amphotericin and 5--FCFC

Zygomycetes summary slideZygomycetes summary slideA f i t l ldA f i t l ld A group of environmental molds A group of environmental molds that cause invasive disease in that cause invasive disease in immunocompromised hostsimmunocompromised hosts

Diabetes (DKA), Bone Marrow Diabetes (DKA), Bone Marrow Transplant, Neutropenia, Iron Transplant, Neutropenia, Iron chelation therapy chelation therapy are important are important risk facorsrisk facors

Cause invasive disease Cause invasive disease characterized bycharacterized by angioinvasionangioinvasioncharacterized by characterized by angioinvasionangioinvasionand tissue destruction leading to and tissue destruction leading to black necrosisblack necrosis

Produce wideProduce wide nonseptatenonseptate Produce wide, Produce wide, nonseptatenonseptate(coenocytic) ribbon(coenocytic) ribbon--like hyphae like hyphae with wide (with wide (right angleright angle) branching) branchingR i i l d b id t fR i i l d b id t f Require surgical debridement for Require surgical debridement for cure, adjunctive therapy with cure, adjunctive therapy with amphotericin, posaconazoleamphotericin, posaconazole

AspergillusAspergillus Summary SlideSummary SlideA i t l ldA i t l ld A common environmental moldA common environmental mold

In immunocompromised hosts In immunocompromised hosts ((neutropenianeutropenia)causes invasive)causes invasive((neutropenianeutropenia)causes invasive )causes invasive diseasedisease

Can also cause ABPA or Can also cause ABPA or A illA illAspergillomaAspergilloma

Characterized by thin, Characterized by thin, septate septate hyphae with acute anglehyphae with acute anglehyphae with acute angle hyphae with acute angle branchingbranching

Voriconazole or amphotericin are Voriconazole or amphotericin are used to treat invasive diseaseused to treat invasive disease

Survival in invasive disease is Survival in invasive disease is mainly determined bymainly determined by immuneimmunemainly determined by mainly determined by immune immune recoveryrecovery

PneumocystisPneumocystis jirovecijiroveci SummarySummary

Classified as a fungus, but cannot Classified as a fungus, but cannot be grown in culturebe grown in culture

Diagnosis based on morphology or Diagnosis based on morphology or on on direct fluorescence antibodydirect fluorescence antibody

Causes a ground glass pneumonia Causes a ground glass pneumonia in patients with AIDSin patients with AIDS

Filling of alveolar spaces leads to Filling of alveolar spaces leads to impaired gas exchange.impaired gas exchange.

Severe cases can also present Severe cases can also present with with pneumothoraxpneumothorax..

T t d ithT t d ith Treated with Treated with trimethoprimtrimethoprim//sulfamethoxazolesulfamethoxazole

Summary for topical Summary for topical dermatophytesdermatophytes

The most common human The most common human fungal infectionsfungal infections

TrycophytonTrycophyton and and MalasseziaMalasseziai t ti t tare important generaare important genera

Multiple species cause Multiple species cause cutaneous infectionscutaneous infectionscutaneous infectionscutaneous infections

Grow well in moist Grow well in moist intertriginous areasintertriginous areas

Can be diagnosed by Can be diagnosed by visualization of hyphae visualization of hyphae stained with KOH or calcafluorstained with KOH or calcafluorstained with KOH or calcafluor stained with KOH or calcafluor whitewhite

Generally treated topicallyGenerally treated topically

EumycetomaEumycetoma summarysummaryEumycetomaEumycetoma summarysummary Caused by varies species Caused by varies species y py p

of fungi including of fungi including MadurellaMadurellamycetomatismycetomatis, , MadurellaMadurellagriseagrisea, , gg ,,

Slowly progressive Slowly progressive subcutaneous infection subcutaneous infection usually in farmersusually in farmersusually in farmersusually in farmers

Fungal granules Fungal granules are often are often black, with coarser textureblack, with coarser texture

Treatment usually surgicalTreatment usually surgical PosaconazolePosaconazole has been has been

used on compassionateused on compassionateused on compassionate used on compassionate use basis.use basis.

Sporotrichosis summarySporotrichosis summary Associated with Associated with

d i (d i ( thth ))gardening (gardening (rose thornsrose thorns)) Innoculation of fungus Innoculation of fungus

in distal extremityin distal extremity Lymphangitic spread up Lymphangitic spread up y p g p py p g p p

the arm is characteristicthe arm is characteristic Caused byCaused by SporothrixSporothrix Caused by Caused by Sporothrix Sporothrix

schenckiischenckii Treated with SporonoxTreated with Sporonox Treated with Sporonox Treated with Sporonox

(Itraconazole)(Itraconazole)

Fungal structure and antifungal agentsFungal structure and antifungal agentsFungal structure and antifungal agentsFungal structure and antifungal agents

The World of Parasites: Eukaryotic The World of Parasites: Eukaryotic O iO iOrganismsOrganisms

HelminthsHelminths: : multicellularmulticellular ProtozoaProtozoa:: UnicellularUnicellularwormswormsNematodes (Round Worms)Nematodes (Round Worms)

I t ti lI t ti l A iA iIntestinal: Intestinal:

Entamoeba GiardiaEntamoeba Giardia etcetcIntestinalIntestinal——AscarisAscarisTissueTissue——filariasisfilariasis

Entamoeba,GiardiaEntamoeba,Giardia, etc., etc.

ApicomplexaApicomplexa:: Plasmodia, Plasmodia, PlatyhelminthesPlatyhelminthes

CestodesCestodes——TaeniaTaenia(Flatworms)(Flatworms)

ToxoplasmaToxoplasma, , CryptosporidiaCryptosporidia, etc., etc.

(Flatworms) (Flatworms) TrematodesTrematodes----SchistosomesSchistosomes

KinetoplastidsKinetoplastids::Leishmania, Leishmania, TT(Flukes)(Flukes) TrypanosomesTrypanosomes

Malaria Summary SlideMalaria Summary SlideMalaria Summary SlideMalaria Summary Slide

DistributionDistribution: prevalent in South/Central : prevalent in South/Central ppAmerica, Africa, AsiaAmerica, Africa, Asia

TransmissionTransmission: Human to human via : Human to human via anophelesanopheles mosquito vectormosquito vectoranophelesanopheles mosquito vectormosquito vector

Species: Species: Plasmodium falciparumPlasmodium falciparum, , Plasmodium ovale, Plasmodium vivax, Plasmodium ovale, Plasmodium vivax, Plasmodium malariaePlasmodium malariaePlasmodium malariaePlasmodium malariae

Clinical manifestationsClinical manifestations: : feverfever, chills, renal , chills, renal failure, prostration, failure, prostration, fatal infectionsfatal infections

DiagnosisDiagnosis: visualization of parasites on : visualization of parasites on peripheral blood smearperipheral blood smear

TreatmentTreatment: species, region dependent:: species, region dependent: TreatmentTreatment: species, region dependent: : species, region dependent: Chloroquine, quinine, doxycycline, ACT,Etc. Chloroquine, quinine, doxycycline, ACT,Etc.

Babesia microtiBabesia microtiBabesia microtiBabesia microti Transmission: Transmission: Ixodes Ixodes

l il i (( ti k th tti k th tscapularisscapularis ((same ticks that same ticks that carry Lyme disease and carry Lyme disease and Anaplasmosis), bloodAnaplasmosis), bloodAnaplasmosis), blood Anaplasmosis), blood transfusiontransfusion

Diagnosis: Diagnosis: peripheral blood peripheral blood smearsmear, PCR, serology, PCR, serology

Animal reservoir: white footed Animal reservoir: white footed mice and other small rodentsmice and other small rodentsmice and other small rodentsmice and other small rodents

Treatment: Treatment: Atovaquone+azithromycin orAtovaquone+azithromycin orAtovaquone azithromycin or Atovaquone azithromycin or Clindamycin+quinineClindamycin+quinine

Toxoplasmosis Summary slideToxoplasmosis Summary slideToxoplasmosis Summary slideToxoplasmosis Summary slide Infection via ingestion of undercooked Infection via ingestion of undercooked

beef or oocysts in cat fecesbeef or oocysts in cat fecesbeef or oocysts in cat fecesbeef or oocysts in cat feces Asymptomatic dormant infection, Asymptomatic dormant infection,

reactivationreactivation encephalitisencephalitis in AIDSin AIDSreactivation reactivation encephalitisencephalitis in AIDSin AIDS Acute infection in normal hosts: Acute infection in normal hosts:

mononucleosismononucleosis--type illnesstype illnessmononucleosismononucleosis type illnesstype illness, , retinopathyretinopathy

Severe Congenital infectionsSevere Congenital infections Severe Congenital infectionsSevere Congenital infections Diagnosis most commonly with Diagnosis most commonly with

serologyserologygygy

Toxoplasmosis: Clinical SyndromesToxoplasmosis: Clinical SyndromesToxoplasmosis: Clinical SyndromesToxoplasmosis: Clinical Syndromes

Congenital infectionCongenital infection: when: when newnew Congenital infectionCongenital infection: when : when new new infection occurs in woman during infection occurs in woman during pregnancy: neonatal infection pregnancy: neonatal infection usually subclinicalusually subclinical but may but may progress to cause mental progress to cause mental

t d ti h d h lt d ti h d h lretardation, hydrocephalus, retardation, hydrocephalus, blindness. blindness.

ChorioretinitisChorioretinitis: may complicate: may complicate ChorioretinitisChorioretinitis: may complicate : may complicate congenital or acquired infection congenital or acquired infection in normal or compromised hostin normal or compromised hostin normal or compromised hostin normal or compromised host

Entamoeba histolytica Entamoeba histolytica (Amebiasis)(Amebiasis)

DistributionDistribution: worldwide, : worldwide, higher incidence in areas ofhigher incidence in areas ofhigher incidence in areas of higher incidence in areas of povertypoverty

TransmissionTransmission: ingestion of: ingestion of TransmissionTransmission: ingestion of : ingestion of cystscysts in fecally in fecally contaminated food/watercontaminated food/water

Clinical manifestationClinical manifestation: : diarrhea, diarrhea, colitiscolitis, amebic , amebic liver, lung, or brain abscessliver, lung, or brain abscess

DiagnosisDiagnosis: cysts in stool: cysts in stool TreatmentTreatment: metronidazole : metronidazole

or tinidazoleor tinidazole

FreeFree--living Amoeba Summary Slideliving Amoeba Summary SlideFreeFree living Amoeba Summary Slideliving Amoeba Summary Slide

DistributionDistribution: world: world--wide, including wide, including , g, gNorth AmericaNorth America

TransmissionTransmission: direct inoculation of : direct inoculation of f li i bf li i bfree living amoebafree living amoeba

Clinical manifestationClinical manifestation: skin : skin lesions, keratitis,lesions, keratitis,lesions, keratitis, lesions, keratitis, meningoencephalitismeningoencephalitis

DiagnosisDiagnosis: visualization of : visualization of t h it i bit h it i bi t tt ttrophozoites in biopsy or trophozoites in biopsy or contact contact lens fluidlens fluid

TreatmentTreatment: no definitive treatment: no definitive treatment TreatmentTreatment: no definitive treatment: no definitive treatment

Summary slide:Summary slide: Giardia lambliaGiardia lambliaSummary slide: Summary slide: Giardia lambliaGiardia lamblia

DistributionDistribution: world: world wide includingwide including DistributionDistribution: world: world--wide, including wide, including North AmericaNorth America

TransmissionTransmission:: ingestion of cystsingestion of cysts inin TransmissionTransmission: : ingestion of cystsingestion of cysts in in fecally contaminated food/waterfecally contaminated food/water

Clinical manifestationClinical manifestation: diarrhea,: diarrhea, Clinical manifestationClinical manifestation: diarrhea, : diarrhea, abdominal bloating, abdominal bloating, sulfur burpssulfur burps

DiagnosisDiagnosis: cysts in stool: cysts in stoolgg yy TreatmentTreatment: metronidazole or : metronidazole or

tinidazoletinidazole

Summary Slide:Summary Slide: Trichomonas vaginalisTrichomonas vaginalisSummary Slide:Summary Slide: Trichomonas vaginalisTrichomonas vaginalis

Distribution:Distribution: WorldwideWorldwide.. Higher Higher l ithl ithprevalence among persons with prevalence among persons with

multiple sexual partners or other multiple sexual partners or other venereal diseasesvenereal diseases

TransmissionTransmission: sexual intercourse: sexual intercourse Clinical manifestationsClinical manifestations: : 50% 50%

asymptomatic carriersasymptomatic carriers VaginalVaginalasymptomatic carriersasymptomatic carriers, Vaginal , Vaginal discharge, pruritis, irritation, edemadischarge, pruritis, irritation, edema

DiagnosisDiagnosis: : wet mountswet mounts may may establish the diagnosis byestablish the diagnosis byestablish the diagnosis by establish the diagnosis by detecting actively motile organisms detecting actively motile organisms

TreatmentTreatment: metronidazole or : metronidazole or tinidazoletinidazole

Summary Slide Intestinal SporeSummary Slide Intestinal Spore--Forming Protozoa: Forming Protozoa: CryptosporidiumCryptosporidium,, IsosporaIsospora,, CyclosporaCyclospora,,CryptosporidiumCryptosporidium,, IsosporaIsospora,, CyclosporaCyclospora, ,

MicrosporidiumMicrosporidium DistributionDistribution: Worldwide : Worldwide

distributiondistribution-- TransmissionTransmission: ingestion of cyst: ingestion of cyst Clinical manifestations: severeClinical manifestations: severe Clinical manifestations: severe Clinical manifestations: severe

watery diarrheawatery diarrhea Diagnosis: visualization of Diagnosis: visualization of

it ith id f tit ith id f tparasites with acid fast or parasites with acid fast or immunstain of stool sampleimmunstain of stool sample

Treatment: immune Treatment: immune reconstitution (reconstitution (MicrosporidiaMicrosporidia, , CryptosporidiaCryptosporidia), nitazoxanide, ), nitazoxanide, trimethoprim/sulfamethoxazole trimethoprim/sulfamethoxazole pp((IsosporaIsospora, , CyclosporaCyclospora))

Leishmaniasis summary slideLeishmaniasis summary slideLeishmaniasis summary slideLeishmaniasis summary slide

Cutaneous, Cutaneous, Mucocutaneous, Mucocutaneous, VisceralVisceral

Transmission viaTransmission via sandflysandfly Transmission viaTransmission via sandflysandfly Diagnosis skin Diagnosis skin

scrapings/biopsy: scrapings/biopsy: amastigotesamastigotes withwithamastigotes amastigotes with with kinetoplastkinetoplast, culture, pcr, culture, pcr

Treatment with Treatment with t l t tit l t tipentavalent antimony, pentavalent antimony,

amphotericin, amphotericin, miltefosinemiltefosine

Summary Slide: South American Summary Slide: South American T i iT i iTrypanosomiasisTrypanosomiasis

DistributionDistribution: South America: South America DistributionDistribution: South America: South America

TransmissionTransmission: feces of riduvid : feces of riduvid (“kissing” or triatomine) bug(“kissing” or triatomine) bug( kissing or triatomine) bug( kissing or triatomine) bug

Clinical manifestationsClinical manifestations: Chagas : Chagas didi i li ldisease, disease, visceromegalyvisceromegaly

DiagnosisDiagnosis: Peripheral blood : Peripheral blood smear or xenodiagnosis, culture, smear or xenodiagnosis, culture, serology, PCR. serology, PCR.

TreatmentTreatment: : Benznidazole or Benznidazole or nifurtimox nifurtimox (available from CDC). (available from CDC).

Summary Slide: African TrypanosomiasisSummary Slide: African Trypanosomiasis TransmissionTransmission : bite of the : bite of the TsetseTsetse flyfly Clinical ManifestationsClinical Manifestations: Sleeping : Sleeping

i ki ksicknesssickness DiagnosisDiagnosis: peripheral blood smear, : peripheral blood smear,

visualization in csfvisualization in csfvisualization in csfvisualization in csf Treatment/DistributionTreatment/Distribution: East African : East African

Sleeping SicknessSleeping Sickness----Trypanosoma Trypanosoma p gp g ypypbrucei rhodesiensebrucei rhodesiense: : Early disease: SuraminEarly disease: Suramin Late disease: MelarsoprolLate disease: Melarsoprol

DistributionDistribution: West African Sleeping : West African Sleeping SicknessSickness——Trypanosoma brucei Trypanosoma brucei gambiensegambiensegambiensegambiense Early disease: PentamidineEarly disease: Pentamidine Late disease: Melarsoprol Late disease: Melarsoprol

AscarisAscaris: Summary Slide: Summary SlideAscarisAscaris: Summary Slide: Summary Slide DistributionDistribution: worldwide in impoverished: worldwide in impoverished DistributionDistribution: worldwide in impoverished : worldwide in impoverished

areasareas TransmissionTransmission: Ingestion of : Ingestion of eggseggs in in gg gggg

fecally contaminated soil/foodfecally contaminated soil/food Clinical manifestationsClinical manifestations: Intestinal : Intestinal

obstructionobstruction, nutritional deficiencies, , nutritional deficiencies, pulmonary infiltratespulmonary infiltrates

DiagnosisDiagnosis: visualization of eggs in stool: visualization of eggs in stool TreatmentTreatment: mebendazole or : mebendazole or

albendazolealbendazole

Hookworm (Hookworm (Ancylostoma duodenale, Ancylostoma duodenale, N t iN t i ) S Slid) S SlidNecatur americanusNecatur americanus) Summary Slide) Summary Slide

DistributionDistribution: prevalent in South : prevalent in South A i Af i A iA i Af i A iAmerica, Africa, AsiaAmerica, Africa, Asia

TransmissionTransmission: penetration of : penetration of intact intact kikiskinskin

Clinical manifestationsClinical manifestations: chronic iron : chronic iron deficiencydeficiency anemiaanemia eosinophiliaeosinophiliadeficiency deficiency anemiaanemia, eosinophilia, eosinophilia

DiagnosisDiagnosis: visualization of eggs in : visualization of eggs in stoolstoolstoolstool

TreatmentTreatment: mebendazole or : mebendazole or albendazolealbendazolealbendazolealbendazole

Summary Slide forSummary Slide for StrongyloidesStrongyloidesSummary Slide for Summary Slide for StrongyloidesStrongyloides

DistributionDistribution: Worldwide, including the : Worldwide, including the ggSoutheastern United statesSoutheastern United states

TransmissionTransmission: Penetration of : Penetration of intact skin intact skin by filariform larvaeby filariform larvaeby filariform larvaeby filariform larvae

Clinical manifestationsClinical manifestations: Intestinal : Intestinal obstruction, nutritional deficiencies, obstruction, nutritional deficiencies,

l i filt tl i filt t h i f tih i f tipulmonary infiltrates, pulmonary infiltrates, hyperinfection hyperinfection syndromesyndrome

DiagnosisDiagnosis: visualization of : visualization of larvaelarvae in in ag os sag os s sua at o osua at o o a aea aestool, sputum, or biopsied tissue. Also stool, sputum, or biopsied tissue. Also by serologic evidence of past exposureby serologic evidence of past exposure

TreatmentTreatment: ivermectin thiabendazole or: ivermectin thiabendazole or TreatmentTreatment: ivermectin, thiabendazole or : ivermectin, thiabendazole or albendazolealbendazole

Summary Slide forSummary Slide for EnterobiusEnterobiusSummary Slide for Summary Slide for EnterobiusEnterobius DistributionDistribution: Worldwide, the most : Worldwide, the most ,,

common intestinal nematode in the common intestinal nematode in the United StatesUnited StatesT i iT i i i i fi i f TransmissionTransmission: ingestion of : ingestion of embryonated eggs from stool of embryonated eggs from stool of infected individualinfected individualinfected individualinfected individual

Clinical manifestationsClinical manifestations: : perianal itch, perianal itch, vaginitisvaginitis in girlsin girls

DiagnosisDiagnosis: Identification of ova with : Identification of ova with Scotch Tape testScotch Tape test

TreatmentTreatment: pyrantel pamoate, or : pyrantel pamoate, or mebendazole or albendazolemebendazole or albendazole

Summary Slide forSummary Slide for TrichurisTrichurisSummary Slide for Summary Slide for TrichurisTrichuris DistributionDistribution: Worldwide, especially : Worldwide, especially , p y, p y

where human feces is used as where human feces is used as fertilizerfertilizerT i iT i i i i fi i f TransmissionTransmission: ingestion of eggs : ingestion of eggs from stoolfrom stool

Clinical manifestationsClinical manifestations: diarrhea: diarrhea Clinical manifestationsClinical manifestations: diarrhea, : diarrhea, abdominal pain, abdominal pain, rectal prolapserectal prolapse

DiagnosisDiagnosis: identification in stool of : identification in stool of ag os sag os s de t cat o stoo ode t cat o stoo obarrelbarrel--shaped eggs with shaped eggs with characteristic characteristic polar plugspolar plugs

TreatmentTreatment: mebendazole or : mebendazole or albendazolealbendazole

Lymphatic Filariasis Summary SlideLymphatic Filariasis Summary SlideW he e i b n oftiW he e i b n ofti i i Wuchereria bancroftiWuchereria bancrofti is is encountered in tropical encountered in tropical areas worldwideareas worldwide

Transmission via Transmission via mosquitoesmosquitoes

Adults in Lymph nodes Adults in Lymph nodes Adults in Lymph nodes Adults in Lymph nodes cause cause chronic scarringchronic scarring, , lymphedemalymphedema

Diagnosis Diagnosis peripheral peripheral Diagnosis Diagnosis peripheral peripheral blood smearblood smear for for microfilariae (night microfilariae (night time samples)time samples)time samples)time samples)

Treatment: DEC Treatment: DEC (diethylcarbamezine)(diethylcarbamezine)

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Onchocerciasis (River Blindness) Onchocerciasis (River Blindness) S SlidS SlidSummary SlideSummary Slide

Transmission by black flyTransmission by black flyy yy y Onchocerca volvulus Onchocerca volvulus adult adult

worms live in the worms live in the subcutaneous tissuesubcutaneous tissuesubcutaneous tissuesubcutaneous tissue

The microfilariae migrate in The microfilariae migrate in sucutaneous tissues: sucutaneous tissues: nodulesnodules, , hypopigmentationhypopigmentationhypopigmentationhypopigmentation

Chronic scarring in eye results Chronic scarring in eye results in in blindnessblindness

Diagnosis: skin snipsDiagnosis: skin snips Treatment: IvermectinTreatment: Ivermectin

Dracunculiasis (Guinea Worm) Dracunculiasis (Guinea Worm) S SlidS SlidSummary SlidesSummary Slides

Transmission:Transmission:D li di iD li di iDracunculis medinsisDracunculis medinsislarvae infect copepods larvae infect copepods in in drinking waterdrinking water

Diagnosis by Diagnosis by emergence of worm emergence of worm fromfrom cutaneous nodulecutaneous nodulefrom from cutaneous nodulecutaneous nodule

Prevention by Prevention by sequestrationsequestration of of patients lesions awaypatients lesions awaypatients lesions away patients lesions away from drinking water from drinking water supply, supply, filtrationfiltration of of

ttwaterwater

Parasites and their vectorsParasites and their vectorsParasites and their vectorsParasites and their vectors MalariaMalaria

PlasmodiumPlasmodium Anopheles Anopheles

mosquitomosquito PlasmodiumPlasmodiumspeciesspecies

BabesiosisBabesiosis

qq

IxodesIxodes TickTick BabesiosisBabesiosis B. microtiB. microti

IxodesIxodes TickTick

C lC l FilariasisFilariasis

W. bancroftiW. bancroftiB malayiB malayi

Culex, Culex, Aedes, Aedes, AnophelesAnophelesmosquitoesmosquitoes B. malayiB. malayi

RiverRiver

mosquitoesmosquitoes

River River BlindnessBlindness O.VolvulusO.Volvulus

Black FlyBlack Fly——Simulium Simulium

Parasites and their vectorsParasites and their vectorsParasites and their vectorsParasites and their vectorsLeishmaniasisLeishmaniasis Sandfly Sandfly

((LuczomyaLuczomya Leishmania Leishmania

speciesspecies((Luczomya, Luczomya, Phelbotomine Phelbotomine species)species)

Chagas Disease Chagas Disease (South American (South American Trypanosomiasis)Trypanosomiasis)

Kissing or Riduviid Kissing or Riduviid bug (bug (Triatoma Triatoma Trypanosomiasis)Trypanosomiasis)

Trypanosoma Trypanosoma cruzicruzi

g (g (speciesspecies))

Sleeping sickness Sleeping sickness (African (African trypanosomiasis) trypanosomiasis)

Tsetse fly Tsetse fly ((GlossinaGlossina

i )i )yp )yp )

Trypanosoma Trypanosoma brucei Gambiense brucei Gambiense or Rhodenseor Rhodense

species)species)

Summary points on cestodesSummary points on cestodesSummary points on cestodesSummary points on cestodes Different species infect different Different species infect different pp

animals:animals: T. solium T. solium porkpork

T i tT i t ttlttl T. saginata T. saginata cattlecattle D. latum D. latum fishfish E granulosisE granulosis sheep and dogssheep and dogs E. granulosis E. granulosis sheep and dogssheep and dogs

The disease manifestations in T. The disease manifestations in T. solium depend on whether the solium depend on whether the parasite is acquired via parasite is acquired via undercooked pork (undercooked pork (tapewormtapeworm) or ) or food contaminated by the feces offood contaminated by the feces offood contaminated by the feces of food contaminated by the feces of an infected human an infected human ((neurocystercercosisneurocystercercosis))

Summary points on TrematodesSummary points on TrematodesSummary points on TrematodesSummary points on Trematodes All trematodes have to spend All trematodes have to spend pp

part of their lifecycle in a part of their lifecycle in a snailsnail Environmental factorsEnvironmental factors that that

ff h l f ilff h l f ilaffect the prevalence of snails affect the prevalence of snails in the water increase the in the water increase the prevalence of diseaseprevalence of diseaseprevalence of diseaseprevalence of disease

Most human disease in Most human disease in schistosomiasis is caused by schistosomiasis is caused by an inflammatory reaction to an inflammatory reaction to the the eggseggs

Schistosomiasis summary slideSchistosomiasis summary slideSchistosomiasis summary slideSchistosomiasis summary slide

Transmission: penetrationTransmission: penetration Transmission: penetration Transmission: penetration of intact skin by cercariae of intact skin by cercariae in in fresh waterfresh water

Intermediate host: Intermediate host: snailsnail S. mansoniS. mansoni causes liver causes liver

scarring fromscarring from granulomagranulomascarring from scarring from granuloma granuloma formationformation around eggs around eggs (lateral or terminal spine)(lateral or terminal spine)

Diagnosis: visualization Diagnosis: visualization of eggs in stool, of eggs in stool, serologyserology

Treatment: praziquantelTreatment: praziquantel Treatment: praziquantelTreatment: praziquantel

Opistorchis (Clonorchis) sinensis Opistorchis (Clonorchis) sinensis Summary SlideSummary Slide

The chinese liver flukeThe chinese liver flukeA i t d ith tiA i t d ith ti Associated with eating raw Associated with eating raw fresh water fishfresh water fishFi d it’ t th bil d tFi d it’ t th bil d t Finds it’s way to the bile ducts Finds it’s way to the bile ducts after penetrating the intestinal after penetrating the intestinal wallwallwallwall

Chronic inflammation leads to Chronic inflammation leads to increased risk ofincreased risk ofincreased risk of increased risk of cholangiocarcinomacholangiocarcinoma (bile duct (bile duct cancer)cancer)

The operculated egg of O. sinensisThe operculated egg of O. sinensis

Fasciola hepaticaFasciola hepatica Summary slideSummary slideFasciola hepaticaFasciola hepatica Summary slideSummary slide

Fasciola require a Fasciola require a snail snail as intermediate host. as intermediate host. qq Cercariae leave the snail and attach to aquatic Cercariae leave the snail and attach to aquatic

vegetation.vegetation. Humans are infected when they eat rawHumans are infected when they eat raw

watercresswatercress. . T t t ithT t t ith t i dt i d (t i l b d l )(t i l b d l ) Treatment with Treatment with veterinary drugveterinary drug (triclabendazole)(triclabendazole)

Summary PointsSummary Points Round WormsRound Worms –– BenzimidazolesBenzimidazoles

Flat wormsFlat worms –– PraziquantelPraziquantel Larval forms (neurocysticercosis) Larval forms (neurocysticercosis) –– also also

albendazolealbendazoleM l i /B b iM l i /B b i Malaria/BabesiaMalaria/Babesia ––species/geography/severityspecies/geography/severity--dependentdependent

Anaerobic protozoansAnaerobic protozoans ((EntamoebaEntamoeba Anaerobic protozoansAnaerobic protozoans ((EntamoebaEntamoeba, , GiardiaGiardia, , TrichomonasTrichomonas) ) ––tinidazole/metronidazoletinidazole/metronidazole

Kinetoplastids Kinetoplastids ---- CDC restrictedCDC restricted

AIDS related OI’sAIDS related OI’s –– SulfasSulfas used for both used for both PneumocystisPneumocystis and Toxoplasmosisand Toxoplasmosis

BioterrorismBioterrorism SummarySummary slideslideBioterrorismBioterrorism SummarySummary slideslide WidenedWidened mediastinummediastinum withwith feverfever and and

iisepsissepsis:: InhalationalInhalational AnthraxAnthrax

LocalizedLocalized skinskin lesionlesion withwith a a depresseddepressedblackblack eschar (eschar (scabscab):): Cutaneous Cutaneous anthraxanthrax

Vesicular/Vesicular/pustularpustular rashrash startingstarting onon facefaceVesicular/Vesicular/pustularpustular rashrash startingstarting onon facefaceand and handshands, , withwith allall lesionslesions at at thethe samesamestagestage ofof developmentdevelopmentstagestage of of developmentdevelopment SmallpoxSmallpox