Geographic Medicine for the Practitioner

215 Pages·1985·4.69 MB·English

by  Kenneth S. Warren M.D.

Geographic Medicine
for the Practitioner
Second Edition
Kenneth S. Warren
Adel A. F. Mahmoud
Geographic Medicine
for the Practitioner
Second Edition
With 32 Figures
Springer-Verlag
New York Berlin Heidelberg Tokyo
Kenneth S. Warren, M.D. Adel A. F. Mahmoud, M.D.
Rockefeller Foundation University Hospital of Cleveland
New York, New York 10036 Cleveland, Ohio 44106
U.S.A. U.S.A.
Library of Congress Cataloging in Publication Data
Warren, Kenneth S.
Geographic medicine for the practitioner.
Includes bibliographies and index.
Rev. ed. of: Geographic medicine for the practi
tioner / edited by Kenneth S. Warren and Adel A. F.
Mahmoud. 1978.
I. Communicable diseases-Tropics-Addresses, essays,
lectures. 2. Tropical medicine-Addresses, essays,
lectures. 3. Travel-Hygienic aspects-Addresses,
essays, lectures. I. Mahmoud, Ade1 A. F. II. Geo
graphic medicine for the practitioner. III. Title.
[DNLM: I. Communicable Diseases-collected works.
2. Developing Countries-collected works. 3. Tropical
Medicine-collected works. WC 100 W289g]
RClIl.W371985 616.9 85-9983
This is a revised edition of Geographic Medicine for the Practitioner, Algorithms in the
Diagnosis and Management of Exotic Diseases edited by Kenneth S. Warren and Adel
A. F. Mahmoud, first published in 1978 under the auspices of the Journal of Infectious
Diseases. © 1978 by the University of Chicago. All rights reserved.
© 1985 by Springer-Verlag New York Inc.
Softcover reprint of the hardcover 2nd edition 1985
All rights reserved. No part of this book may be translated or reproduced in any form
without written permission from Springer-Verlag, 175 Fifth Avenue, New York, New York
10010, U.S.A.
The use of general descriptive names, trade names, trademarks, etc., in this publication,
even if the former are not especially identified, is not to be taken as a sign that such names,
as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used
freely by anyone. While the advice and information of this book is believed to be true and
accurate at the date of going to press, neither the authors nor the editors nor the publisher
can accept any legal responsibility for any errors or omissions that may be made. The
publisher makes no warranty, express or implied, with respect to material contained herein.
Typeset by Bi-Comp, Inc., York, Pennsylvania.
987654321
ISBN -13: 978-1-4613-8580-6 e-ISBN-13: 978-1-4613-8578-3
DOl: 10.1007/978-1-4613-8578-3
Contents
Introduction vii
1. Prevention of Exotic Diseases: Advice to Travelers
Viral Infections
2. Acute Viral Hepatitis 11
3. Major Tropical Viral Infections: Yellow Fever, Dengue, and
Hemorrhagic Fevers (Arena and Ebola) 17
Bacterial Infections
4. Cholera 27
5. Leprosy 33
6. Plague 42
7. Shigellosis 47
8. Tuberculosis 52
9. Typhoid Fever 60
Protozoan Infections
10. Amebiasis 67
11. Giardiasis 75
12. Leishmaniases 81
13. Malaria 86
14. Toxoplasmosis 93
vi Contents
15. African Trypanosomiases 99
16. American Trypanosomiasis 106
Helminth Infections
17. Ascariasis and Toxocariasis 115
18. Echinococcosis 123
19. Enterobiasis 130
20. The Filariases 135
21. Flukes: Liver, Intestinal, and Lung 153
22. Hookworm 160
23. Schistosomiasis 166
24. Strongyloidiasis 176
25. Tapeworms 182
26. Trichinosis 190
27. Trichuriasis 196
Index 201
Introduction
Physicians in most developed countries are at a great disadvantage when
confronted with geographic and tropical diseases. They may be faced with
prevention for patients who are outward bound or with diagnosis and
treatment on their return. The practitioners' difficulties relate to inade
quate teaching in medical schools and to the infrequency with which they
are confronted with these exotic diseases. It is quite surprising to realize
the extent of travel by Americans to areas where the tropical diseases
abound: in 1979 there were 3 million trips by U.S. residents to Central and
South America and almost 1 million to Africa and Asia. Further, the
I
influx from the tropics to the United States in 1978 involved 4.5 million
visitors and more than half a million immigrants. I The single most danger
ous ofthese infections is malaria, which is now averaging about 500 cases
yearly in the United States; it is important to realize that infection with
one species of this organism (Plasmodium falciparum) can be lethal
within a few days of the onset of fever. Highly contagious infections such
as the newly discovered and extremely lethal Lassa and Ebola fevers may
be imported to our shores, plus cholera, antibiotic-resistant bacillary dys
entery, and amebic dysentery and liver abscess. Chronic worm infections
such as schistosomiasis, although rarely lethal, may have severe conse
quences such as paraplegia2 or hematemesis.
It is worthy of note that certain of these so-called tropical diseases are
widely spread throughout the United States or are highly endemic in
particular regions. With respect to the former, it has been estimated that
pinworms infect 20 million Americans in every state including Alaska,
and trichinosis and tapeworms are also distributed widely, but at rela
tively low levels of prevalence.3 Toxoplasmosis, an infection that may
cause birth defects and blindness, has infected over 30% of our popula
tion; giardiasis is now considered by the Centers for Disease Control to be
the most common cause of water-borne epidemics of diarrhea in the
United States; and Entamoeba histolytica infects up to 5% of Americans.3
In the southwestern states, hookworm, whipworm, and the foot-long in
testinal roundworm (Ascaris) are prevalent; and in certain southwestern
viii Introduction
states the highly dangerous hydatid cyst of Echinococcus granulosus has
now been shown to be endemic. Bubonic plague is spread throughout the
rodents of the western states, and some human infections and fatalities
are reported annually. Further, it must always be kept in mind that pa
tients immunosuppressed either by certain disease states, especially the
acquired immunodeficiency syndrome, or by therapy to prevent graft
rejection are susceptible to fatal opportunistic infections with certain of
these agents (e.g., Strongyloides, Toxoplasma).
When a patient is suspected of suffering from one of these infections, it
would be helpful if physicians had a clear, unambiguous source of infor
mation on the infection, its disease syndromes, and the means of coping
with them. When they turn to the usual textbook of tropical medicine or
clinical parasitology, however, practitioners are confronted with a de
tailed discussion including all of the minutiae of morphology, life cycle,
epidemiology, and presumed disease syndromes. When they arrive at
methods of diagnosis, they are often referred to an appendix in which
mUltiple procedures are described, each involving equipment and supplies
that may not be readily obtainable. Serologic and skin tests are frequently
recommended, but the antigens are rarely available. The descriptions of
treatment may be even more frustrating, since as many as 10 different
drug regimens may be described with no criteria for selection among
them, and with frequent mention of drugs that are unlicensed or unavail
able.
In an attempt to solve these problems, an abbreviated format has been
developed in which the basic facts of life cycle and epidemiology are
briefly described and the disease syndromes, diagnosis, and treatment are
presented in the form of algorithms. As described in an editorial in the
New England Journal of Medicine, algorithms should be "unambiguous
step-by-step instructions for solving a clinical problem."4 Our algorithms,
which are presented as flow sheets with accompanying text, begin with a
list of clinical observations suggesting the presence of a given exotic
infection and then proceed through important diagnostic indicators such
as geography, water contact, and insect bites. This descriptive informa
tion is followed by the recommendation of a single laboratory procedure
or a linked sequence of tests in which the methodology is clearly deline
ated. When serologic tests are indicated, the most expeditious means by
which they can be obtained is described. For treatment, only one drug
regimen is usually recommended on the basis of a careful examination of
all of the latest information.
The number of references appended to each article are few; 4-16. Most
of these are citations to the original literature and include the most impor
tant papers of the past (not superseded by more recent efforts) as well as
up-to-date information, particularly on diagnosis and treatment. Wher
ever possible only carefully controlled studies are cited. especially those
Introduction ix
concerning the usually uncontrolled descriptions of the clinical syn
dromes.
Three tables are presented as an aid to approaching the 26 articles
concerned with particular infections. Table I.1 presents the geographic
aspects of the infections, revealing that they are either worldwide in dis
tribution or are confined to Asia, Africa, and/or Latin America. Table 1.2
lists the major signs and symptoms of the infections; it does not include
the relatively minor, rare, or transient clinical aspects of the disease syn
dromes. Table 1.3 presents the major sampling sites for the diagnosis of
the infection, via either demonstration of the infectious agent or serodiag
nosis.
The first edition of this work was a cooperative venture of a group of
physicians associated with the Division of Geographic Medicine at Case
Western Reserve University School of Medicine. The articles were edited
to a standard format by the present authors, who have now performed all
the revisions themselves. It is almost a decade since the original articles
were written and some remarkable changes have taken place. On the
negative side we are now confronted with a remarkable and devastating
new disease, the acquired immunodeficiency syndrome, by the continuing
spread of drug-resistant malaria, and by the realization that we cannot
control tuberculosis in the developing world with the weapons now at
TABLE 1.1. Major areas of distribution of the exotic infections.
Worldwide Africa Asia Latin America
Hepatitis Yellow fever Plague Yellow fever
Cholera Lassa fever Leishmaniasis Plague"
Leprosy Plague Malaria Leishmaniasis
Shigellosis Leishmaniasis Filariasis Malaria
Tuberculosis Malaria Clonorchiasis Trypanosomiasis, Am.
Typhoid Trypanosomiasis, Afr. Opisthorchiasis Filariases
Amebiasis Filariases Fasciolopsiasis Schistosomiasisb
Giardiasis Paragonimiasis Paragonimiasis Arena Viruses
Toxoplasmosis Schistosomiasis Schistosomiasis Dengue
Ascariasis Ebola Virus Dengue
Toxocariasis Arena Viruses
Echinococcosis Dengue
Enterobiasis
Fascioliasis
Hookworm
Strongyloidiasis
Tapeworms
Trichinosis
Trichuriasis
a Also in the western United States
b Including the Caribbean
x Introduction
TABLE 1.2. Major clinical aspects of the exotic infections.
General Fever-Yellow fever; Dengue, Ebola and Arena Viruses;
Plague; Shigellosis; Tuberculosis; Typhoid; Leishma
niasis. visceral; Malaria; Toxoplasmosis; Trypanoso
miasis, African; Trypanosomiasis, American; Toxocar
iasis; Fascioliasis; Trichinosis
Anemia-Leishmaniasis, visceral; Malaria; Hookworm; Di
phyllobothriasis
Lymphadenopathy-Dengue; Plague; Toxoplasmosis; Try
panosomiasis, African; Trypanosomiasis. American; Fila
riases
Eosinophilia-Toxocariasis; Filariases; Fascioliasis; Schis
tosomiasis; Strongyloidiasis; Trichinosis
Chest Cough-Lassa fever; Plague; Tuberculosis; Paragonimiasis
Gut Abdominal pain-Shigellosis; Typhoid; Fascioliasis;
Strongyloidiasis
Diarrhea-Ebola Virus; Cholera; Shigellosis; Amebiasis;
Giardiasis; Strongyloidiasis; Trichinosis
Dysentery-Shigellosis; Amebiasis
Liver Jaundice-Hepatitis; Yellow fever
Hepatomegaly-Typhoid; Leishmaniasis, visceral; Toxo-
cariasis; Echinococcosis; Fascioliasis; Schistosomiasis
Splenomegaly-Typhoid; Leishmaniasis. visceral; Malaria;
Schistosomiasis
Skin Dengue; Leprosy; Leishmaniasis, cutaneous and muco-cu
taneous; Enterobiasis; Onchocerciasis
Central Nervous System Malaria; Toxoplasmosis; Trypanosomiasis, African; Schis
tosomiasis; Taeniasis solium
hand. The positive side outweighs the negative, however, with the trium
phant eradication of smallpox, the development of specific diagnostic
tests for hepatitis A and B and the production of a vaccine for hepatitis B,
the imminent availability of a new and far more effective oral vaccine for
typhoid, and the development of a miraculous new single dose oral drug
TABLE 1.3. Sampling sites for diagnosis of the exotic infections.
Blood Hepatitis; Yellow fever; Arena, Ebola and Dengue Viruses; Plague;
Typhoid; Malaria; Trypanosomiasis, African; Trypanosomiasis,
American; Filariases
Sputum Plague; Tuberculosis; Paragonimiasis
Stool Cholera; Shigellosis; Typhoid; Amebiasis; Giardiasis; Ascariasis;
Flukes; Hookworm; Schistosomiasis; Strongyloidiasis; Tape-
worms; Trichuriasis
Urine Schistosomiasis
Skin Leprosy; Leishmaniasis, cutaneous and muco-cutaneous; Enterobi
asis; Onchocerciasis
Immunodiagnosis Serum-Hepatitis; Yellow fever; Arena, Ebola and Dengue Vi
ruses; Plague; Typhoid; Amebiasis; Malaria; Toxoplasmosis; Try
panosomiasis, American; Toxocariasis; Echinococcosis; Taeniasis
solium (Cysticercosis); Trichinosis
Introduction xi
for all of the fluke infections including schistosomiasis, which also ap
pears to be efficacious for cerebral cysticercosis.
The power of modern biomedical science is at last being applied to
these diseases on a broad scale and in the next decade we may see the
development of vaccines for malaria and other major tropical diseases and
a spate of new and better drugs. We hope this small and practically
oriented book will continue to be useful for all physicians who are con
fronted with the traveller or the migrant.
References
1. U.S. Bureau of the Census: Statistical Abstract of the United States: (93rd ed.)
Washington, D.C., 1980.
2. Case Records of the Massachusetts General Hospital: Schistosoma mansoni
infections (with involvement of spinal cord). N Engl J Med 312:1376-1383,
1985
3. Walsh J: Human helminthic and protozoan infections in the North. In: Warren
KS, Bowers JZ (eds): Parasitology: A Global Perspective, pp 45-61. Springer
Verlag, New York, 1983
4. Ingelfinger FJ: Algorithms, anyone? N Engl J Med 288:847-848, 1973