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Approach to Parasitic Infections
Human parasites are organisms that live on or in a person and derive nutrients from that person (its host). There are 3 types of parasites: protozoa, helminths (worms), and ectoparasites such as scabies and lice. Parasitic infections due to protozoa and helminths are responsible for substantial morbidity and mortality worldwide. They are prevalent in Central and South America, Africa, and Asia. They are much less common in Australia, Canada, Europe, Japan, New Zealand, and the US. By far, the greatest impact is on residents of impoverished tropical areas, but parasitic infections are encountered in developed countries among immigrants and travelers returning from endemic regions and, on occasion, even among residents who have not traveled, particularly those with AIDS or other conditions that cause immunodeficiency.
Many parasitic infections are spread through fecal contamination of food or water. They are most frequent in areas where sanitation and hygiene are poor. Some parasites, such as the hookworm, can enter the skin during contact with contaminated dirt or, in the case of schistosomes, with freshwater. Others, such as malaria, are transmitted by arthropod vectors. Rarely, parasites are transmitted via blood transfusions or shared needles or congenitally from mother to fetus.
Some parasites are endemic in the US and other developed countries. Examples are the pinworm, Enterobius vermicularis, Trichomonas vaginalis, Toxoplasma gondii, and enteric parasites such as Giardia intestinalis (lamblia) and Cryptosporidium spp.
The characteristics of protozoan and helminthic infections vary in important ways.
Protozoa are single-celled organisms that multiply by simple binary division (see Intestinal Protozoa and in Extraintestinal Protozoa). Protozoa can multiply in their human hosts, increasing in number to cause overwhelming infection. With rare exceptions, protozoan infections do not cause eosinophilia.
Helminths are multicellular and have complex organ systems. Helminths can be further divided into
Roundworms (nematodes—see Nematodes (Roundworms))
Some parasites have adapted to living in the lumen of the intestine where conditions are anaerobic; others reside in blood or tissues in aerobic conditions.
In contrast to protozoa, helminths do not multiply in humans but can elicit eosinophilic responses when they migrate through tissue. Most helminths have complex life cycles that involve substantial time outside their human hosts. A few, including Strongyloides stercoralis, Capillaria philippinensis, and Hymenolepis nana, can increase in number because of autoinfection (offspring reinfect the same host rather than being shed to infect another host). In strongyloidiasis, autoinfection can result in life-threatening, disseminated hyperinfections in immunosuppressed people, particularly those taking corticosteroids.
The severity of helminthic infections usually correlates with the worm burden, but there are exceptions as when a single ascaris causes life-threatening pancreatitis by migrating into and obstructing the pancreatic duct. The worm burden depends on the degree of environmental exposure, parasite factors, and the host’s genetically determined immune responses. If a person moves from an endemic area, the number of adult worms diminishes over time. Although a few parasites (eg, Clonorchis sinensis) can survive for decades, many species have life spans of only a few years or less. More information about parasitic infections is available at the CDC’s Division of Parasitic Diseases .
Methods for the diagnosis of specific parasitic infections are discussed in the chapters to follow and are summarized in Collecting and Handling Specimens for Microscopic Diagnosis of Parasitic Infections.
Parasitic infections should be considered in the differential diagnosis of clinical syndromes in residents of or travelers to areas where sanitation and hygiene are poor or where vector-borne diseases are endemic. For example, fever in the returning traveler suggests the possibility of malaria. Experience indicates that immigrants from developing areas to developed countries who return home to visit friends and relatives are at particular risk. They frequently do not seek or cannot afford pretravel advice on disease prevention and are more likely to enter high-risk settings than tourists who stay at resort facilities. Although less frequent, the possibility of an endemic or imported parasitic infection must also be considered in residents of developed countries who present with suggestive clinical syndromes, even if they have not traveled.
Historical information, physical findings, and laboratory data may also suggest specific parasitic infections. For example, eosinophilia is common when helminths migrate through tissue and suggests a parasitic infection in an immigrant or returning traveler.
Physicians with expertise in parasitic infections and tropical medicine are available for consultation at many major medical centers, travel clinics, and public health facilities.
“Laboratory Identification of Parasites of Public Health Concern” provides detailed descriptions of diagnostic methods and is available from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/dpdx/ .
Collecting and Handling Specimens for Microscopic Diagnosis of Parasitic Infections
Various stages of protozoa and helminths that infect the GI tract are typically shed in the stool. Routine detection requires examination of stool specimens, preferably 3 collected on different days, because shedding can be sporadic. With some parasites, relatively sensitive and specific assays are available to detect antigens in stool.
Freshly passed stools uncontaminated with urine, water, dirt, or disinfectants should be sent to the laboratory within 1 h; unformed or watery stools are most likely to contain motile trophozoites. If not examined immediately, stools should be refrigerated, but not frozen. Portions of fresh stools should also be emulsified in fixative to preserve GI protozoa. Concentration techniques can be used to improve sensitivity. Anal cellophane tape or swabs may collect pinworm or tapeworm eggs. If strongyloidiasis is suspected, fresh stool should be smeared on an agar plate and incubated to identify the tracks of migrating larvae. Antibiotics, x-ray contrast material, purgatives, and antacids can hinder detection of ova and parasites for several weeks. Serologic assays, fecal antigen detection tests (eg, for Giardia intestinalis, Cryptosporidium sp, or Entamoeba histolytica), or PCR testing may aid in diagnosis (see Table: Serologic and Molecular Tests for Parasitic Infections). Sensitivity of stool examinations for ova and parasites is low enough that when clinical suspicion is strong, empirical treatment may be given.
Sigmoidoscopy or colonoscopy should be considered when routine stool examinations are negative and amebiasis is suspected in patients with persistent GI symptoms. Sigmoidoscopic specimens should be collected with a curet or spoon (cotton swabs are not suitable) and processed immediately for microscopy. Duodenal aspirates or small-bowel biopsy specimens may be necessary for diagnosis of such infections as cryptosporidiosis and microsporidiosis.
Some parasites can be detected by serologic tests (see Table: Serologic and Molecular Tests for Parasitic Infections).
Serologic and Molecular Tests for Parasitic Infections
Advice for treating parasitic infections is available from experts at major medical and public health centers and travel clinics, in textbooks of infectious diseases and tropical medicine, and in summary form from The Medical Letter on Drugs and Therapeutics . Drugs for unusual parasitic infections can be obtained from the manufacturer or from the CDC Drug Service .
Despite substantial investment and research, no vaccines are yet available for prevention of human parasitic infections; however, studies of a new malaria vaccine suggest that it may slightly decrease but not eliminate risk of infection. Prevention is based on avoidance strategies.
Transmission of most intestinal parasites can be prevented by
For the international traveler, the best advice is “cook it, boil it, peel it, or forget it.” When followed, these measures reduce but do not eliminate the risk of intestinal parasitic infections as well as risk of bacterial and viral gastroenteritis. Meat, particularly pork, and fish, particularly freshwater varieties, should be thoroughly cooked before ingestion. Other safety measures include removing cat litter boxes from areas where food is prepared to prevent toxoplasmosis. People should not swim in freshwater lakes, streams, or rivers in areas where schistosomiasis is endemic or walk barefoot or sit bare-bottom in areas where hookworms are found.
The risk of malaria and many other vector-borne diseases can be decreased by wearing long-sleeved shirts and pants and applying diethyltoluamide (DEET)-containing insect repellants to exposed skin and permethrin to clothing (see Amebic Keratitis : Prevention). Window screens, air-conditioning, and mosquito nets impregnated with permethrin or other insecticides provide further protection. In addition, prophylactic antimalarial drugs should be taken by those traveling in endemic regions.
Travelers to rural Latin America should not sleep in adobe dwellings where reduviid bugs can transmit Chagas disease (see Chagas Disease : Prevention). In Africa, travelers should avoid bright-colored clothing and wear long-sleeved shirts and pants to avoid tsetse flies in regions where African sleeping sickness occurs (see African Trypanosomiasis : Prevention).
Country-specific recommendations for travel are available from the CDC web site ( http://wwwnc.cdc.gov/travel/ ) and in CDC Health Information for International Travel 2010.
Drug NameSelect Brand Names
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