Persistent dermal lesions in a patient with previous history of visceral leishmaniasis.

Post-kala-azar dermal leishmaniasis (PKDL) is a complication of visceral leishmaniasis (VL) that most frequently occurs after an episode of VL caused by Leishmania donovani. In this case report, we present a 21-year-old male patient with persistent skin lesions and recurrent visceral leishmaniasis (VL) due to Leishmania infantum. The patient did not respond to multiple lines of anti-leishmanial treatment (including Liposomal amphotericin B and miltefosine) and later died from cerebral lesions presumed to be secondary to persistent VL.

Evaluation of targeted copper sulfate (CuSO4) application for controlling swimmer's itch at a freshwater recreation site in Michigan.

Swimmer's itch has historically been controlled by applying copper sulfate (CuSO4) to lakes as a way to eliminate snails that serve as the intermediate hosts for swimmer's itch-causing parasites. CuSO4 is still sometimes applied specifically to areas of lakes where swimmer's itch severity is high. It is unclear whether targeted application of chemical molluscicides like CuSO4 is effective for controlling swimmer's itch. Previous research has found that the larval stage of the parasites responsible for swimmer's itch are released from infected snails and are concentrated by onshore and alongshore winds, and thus, may not be affected by such focused applications. In this study, we evaluated the impact of targeted CuSO4 application to a specific recreational swimming area in a lake in Michigan. We measured the effect on snail populations, as well as on the presence/abundance of swimmer's itch-causing parasites using qPCR. Ultimately, while CuSO4 was confirmed to significantly reduce populations of snails within the treatment area, it was found to have no significant impact on swimmer's itch-causing parasites in the water, likely due to the free-swimming larval stages (cercariae) moving into the treatment area from surrounding regions.

Parasitic Skin Infections for Primary Care Physicians.

The 2 epidermal parasitic skin infections most commonly encountered by primary care physicians in developed countries are scabies and pediculosis. Pediculosis can be further subdivided into pediculosis capitis, corporis, and pubis. This article presents a summary of information and a review of the literature on clinical findings, diagnosis, and treatment of these commonly encountered parasitic skin infestations.

Real-time PCR and sequencing assays for rapid detection and identification of avian schistosomes in environmental samples.

Cercarial dermatitis, also known as swimmer's itch, is an allergenic skin reaction followed by intense itching caused by schistosome cercariae penetrating human skin. Cercarial dermatitis outbreaks occur globally and are frequently associated with freshwater lakes and are occasionally associated with marine or estuarine waters where birds reside year-round or where migratory birds reside. In this study, a broadly reactive TaqMan assay targeting 18S rRNA gene (ribosomal DNA [rDNA]) sequences that was based on a genetically diverse panel of schistosome isolates representing 13 genera and 20 species (the 18S rDNA TaqMan assay) was developed. A PCR assay was also developed to amplify a 28S rDNA region for subsequent sequencing to identify schistosomes. When applied to surface water samples seeded with Schistosoma mansoni cercariae, the 18S rDNA TaqMan assay enabled detection at a level of 5 S. mansoni cercariae in 100 liters of lake water. The 18S rDNA TaqMan and 28S rDNA PCR sequencing assays were also applied to 100-liter water samples collected from lakes in Nebraska and Wisconsin where there were reported dermatitis outbreaks. Avian schistosome DNA was detected in 11 of 34 lake water samples using the TaqMan assay. Further 28S rDNA sequence analysis of positive samples confirmed the presence of avian schistosome DNA and provided a preliminary identification of the avian schistosomes in 10 of the 11 samples. These data indicate that the broadly schistosome-reactive TaqMan assay can be effective for rapid screening of large-volume water samples for detection of avian schistosomes, thereby facilitating timely response actions to mitigate or prevent dermatitis outbreaks. Additionally, samples positive by the 18S rDNA TaqMan assay can be further assayed using the 28S rDNA sequencing assay to both confirm the presence of schistosomes and contribute to their identification.

Avian schistosomes and outbreaks of cercarial dermatitis.

Cercarial dermatitis (swimmer's itch) is a condition caused by infective larvae (cercariae) of a species-rich group of mammalian and avian schistosomes. Over the last decade, it has been reported in areas that previously had few or no cases of dermatitis and is thus considered an emerging disease. It is obvious that avian schistosomes are responsible for the majority of reported dermatitis outbreaks around the world, and thus they are the primary focus of this review. Although they infect humans, they do not mature and usually die in the skin. Experimental infections of avian schistosomes in mice show that in previously exposed hosts, there is a strong skin immune reaction that kills the schistosome. However, penetration of larvae into naive mice can result in temporary migration from the skin. This is of particular interest because the worms are able to migrate to different organs, for example, the lungs in the case of visceral schistosomes and the central nervous system in the case of nasal schistosomes. The risk of such migration and accompanying disorders needs to be clarified for humans and animals of interest (e.g., dogs). Herein we compiled the most comprehensive review of the diversity, immunology, and epidemiology of avian schistosomes causing cercarial dermatitis.

[Demodex folliculorum and demodex brevis]. / Demodex folliculorum i demodex brevis.

Demodex are cosmopolitan mites occurring in many species of mammals. Two morphologically distinct Demodex species parasitize on humans: Demodexfolliculorum (Simon, 1842) and Demodex brevis (Akbulatova, 1963). Until recently, these species have been regarded as commensals; now they are considered as parasitic organisms. In people, Demodex spp. can be found mainly in the sebaceous glands of the skin (mainly in the area of the forehead, cheeks, nose, behind ears and neck), in hearing aids, and on the scalp, covered with hair. Infection with demodex happens through direct contact with infected bed linen, towels, creams and other cosmetics. Despite the high prevalence of Demodex spp. in the human population, symptoms of demodecosis are not common, and can be found mainly in people with weakened immune systems due to aging or a number of diseases.

Risk factors associated with clinical dermatophilosis in smallholder sector cattle herds of Zimbabwe at the Amblyomma variegatum and Amblyomma hebraeum interface.

A cross-sectional study was conducted to investigate factors for clinical dermatophilosis herd-level positivity in smallholder dip tanks from Gokwe (Chemawororo, Gwanyika), Kwekwe (Koronika) and Chegutu (Chivero), Zimbabwe, between September 2013 and April 2014. A total of 185 herds were clinically examined for disease and tick infestation. Data on herd and potential herd level risk factors were collected using a structured questionnaire. A herd was classified as clinically positive if an animal satisfied any of the following criteria: small lesions characterised by hairs clumping like a small paint brush, clear exudative circumscribed lesions with scabs of at least 1 cm in diameter and confluent progressive exudative scab lesions affecting significant parts of the animal's body. Amblyomma variegatum and Amblyomma hebraeum ticks were identified in situ with further laboratory confirmation. The potential herd-level risk factors for clinical dermatophilosis were tested using multiple logistic regression with herd infection status (positive, negative) being the binomial outcome and risk factors being predictors. Of the herds examined, clinical bovine dermatophilosis was detected in 45 % (84/185, 95 % confidence interval (CI) 38.2, 52.6 %) of the herds. The herd prevalence ranged from 6.9 % (95 % CI 0.00, 16.7) to 56.7 % (95 % CI 43.8, 69.6) with Chivero and Chemawororo dip tanks recording the lowest and highest prevalence, respectively. Herds infested with A. variegatum were associated with higher odds (OR = 6.8, 95 % CI 1.71, 27.10) of clinical dermatophilosis while the association was not significant (p > 0.05) in A. hebraeum-infested herds. A history of having bought cattle (OR = 3.5, 95 % CI 1.09, 11.12) compared to not buying was associated with increased herd clinical positivity status. It was concluded that management practices aimed at movement and tick control would help reduce the prevalence of clinical dermatophilosis in cattle herds.

In the clinic. Common cutaneous parasites.

This issue provides a clinical overview of Common Cutaneous Parasites focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Approaches towards DNA vaccination against a skin ciliate parasite in fish.

Rainbow trout (Oncorhynchus mykiss) were immunized with plasmid DNA vaccine constructs encoding selected antigens from the parasite Ichthyophthirius multifiliis. Two immobilization antigens (I-ags) and one cysteine protease were tested as genetic vaccine antigen candidates. Antigenicity was evaluated by immunostaining of transfected fish cells using I-ag specific mono- and polyclonal antibodies. I. multifiliis specific antibody production, regulation of immune-relevant genes and/or protection in terms of parasite burden or mortality was measured to evaluate the induced immune response in vaccinated fish. Apart from intramuscular injection, needle free injection and gene gun delivery were tested as alternative administration techniques. For the I-ags the complement protein fragment C3d and the termini of the viral haemorrhagic septicaemia virus glyco(G)protein (VHSV G) were tested as opsonisation and cellular localisation mediators, respectively, while the full length viral G protein was tested as molecular adjuvant. Expression of I-ags in transfected fish cells was demonstrated for several constructs and by immunohistochemistry it was possible to detect expression of a secreted form of the Iag52B in the muscle cells of injected fish. Up-regulations of mRNA coding for IgM, MHC I, MHC II and TCR ß, respectively, were observed in muscle tissue at the injection site in selected trials. In the spleen up-regulations were found for IFN-γ and IL-10. The highest up-regulations were seen following co-administration of I-ag and cysteine protease plasmid constructs. This correlated with a slight elevation of an I. multifiliis specific antibody response. However, in spite of detectable antigen expression and immune reactions, none of the tested vaccination strategies provided significant protection. This might suggest an insufficiency of DNA vaccination alone to trigger protective mechanisms against I. multifiliis or that other or additional parasite antigens are required for such a vaccine to be successful.

Dermatologic manifestations of HIV in Africa.

Dermatologic disease is common in HIV-infected individuals, and clinicians caring for patients with HIV infection or AIDS in Africa are routinely confronted with skin problems in their patients. Scarce access to dermatologic specialty care and limited educational resources describing the unique clinical characteristics of HIV-related skin disease can make diagnosing and treating skin diseases a challenge in Africa. This article describes common HIV-related dermatologic conditions in Africa and their differential diagnoses and includes treatment strategies that are likely to be available locally. It is not meant to be comprehensive but rather to serve as a practical resource to aid practitioners by providing images of common conditions and describing distinctive clinical presentations of common conditions.

Morgellons in dermatology.

Delusional parasitosis (DP) is the most frequent delusional disorder in dermatology. In DP there is a fixed belief of a usually skin-related invasion or infestation by a number of alleged infectious species (usually parasites and bacteria), whose identity has varied over the decades. Since 2002 worldwide an increasing number of patients have complained of unverifiable fibers and filaments in or on the skin, associated with numerous nonspecific complaints (arthralgias, altered cognitive function and extreme fatigue). This entity has been named "Morgellons disease" by the patients themselves, although medical evidence for its existence is lacking. As an example, we discuss a 55-year-old woman who complained of Morgellons disease and was treated as if she had DP. Currently the delusional assumption of infestation with Morgellons should be considered as a new type of DP with some kind of inanimate material. We therefore recommend in case of DP including Morgellons the use of the broader term "delusional infestation".

Improved general health of international adoptees, but immunization status still insufficient.

We studied the demographic and clinical data from 495 adopted children seen between January 2002 and January 2007 to evaluate the medical condition and immunization status of international adoptees. The data of children from Chinese origin (53.5%) were compared to children arriving from other countries. Medical problems requiring treatment were present in 42.8% of the children. Parasitic gastrointestinal infection (22.0%) and skin abnormalities (22.4%) were diagnosed most often. Hepatitis B (1.2%) and tuberculosis (1%) were documented in some children; HIV, hepatitis C, and syphilis were not seen in any of the children. Antibody levels against diphtheria and tetanus were insufficient in about half of all children, particularly in those from China. In conclusion, most adoptive children had a good general health, with only a few having major medical problems. Many adoptive children had an inadequate immunization status.

Efficacy of in-feed probiotics against Aeromonas bestiarum and Ichthyophthirius multifiliis skin infections in rainbow trout (Oncorhynchus mykiss, Walbaum).

AIMS: The aim of this study was to assess the efficacy of in-feed probiotics as a preventive measure against skin infections caused by Aeromonas bestiarum and Ichthyophthirius multifiliis (Ich) in rainbow trout. METHODS AND RESULTS: Fin rot was induced in fish by intradermal injection with 0.1 ml volumes containing 10(5) cells per ml A. bestiarum at the base of the dorsal fin. Ich infections resulted from immersion in Ich-contaminated water. Each probiotic was administered orally [10(8) cells per g feed for GC2 (Aeromonas sobria) and 10(10) cells per g feed for BA211 (Brochothrix thermosphacta)] for 14 days. Results showed that, after challenge with A. bestiarum, probiotics GC2 and BA211 led to 76% and 88% survival, respectively, in contrast to 22% survival for controls. Fish fed with probiotic GC2 had 100% survival after challenge with Ich compared with 2% for probiotic BA211 and 0% for controls. Analysis of innate immune responses revealed that probiotic GC2 promoted higher phagocytic activity, whereas probiotic BA211 led to enhanced respiratory burst activity. CONCLUSION: Of the two probiotics examined, GC2 was more effective in protecting against both fin rot and Ich. Each probiotic appeared to stimulate different pathways within the innate immune system. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first demonstration that probiotics can protect fish against surface infections. Furthermore, this is the first time a probiotic has been shown to protect against a eucaryotic pathogen, namely I. multifiliis.

Amblyomma variegatum in cattle in Marie Galante, French Antilles: prevalence, control measures, and infection by Ehrlichia ruminantium.

We report Marie Galante as one of the Caribbean islands most heavily infested by the tropical bont tick (TBT) Amblyomma variegatum which is associated with two major diseases of ruminants: heartwater and dermatophilosis. In 2005, a survey was undertaken to assess the prevalence of TBT infestation in cattle, the prevalence of Ehrlichia ruminantium infection in TBTs, and the tick control measures implemented by livestock owners. A random sample of 195 cattle herds out of 1885 recorded on the island was investigated by thoroughly counting adult ticks on each animal and filling a questionnaire. A randomly collected sample of 136 TBTs was tested for infection by E. ruminantium by pCS20 nested PCR. Cattle herd prevalence (hp) was 73.8% for infestation by at least one TBT, 17.9% for infestation by at least one engorged female TBT, and 8.2% for clinical dermatophilosis. Cattle individual prevalence was 42.3% for infestation by at least one TBT, 6.6% for infestation by at least one engorged female TBT, and 2.2% for clinical dermatophilosis. The minimum, maximum and average numbers of TBTs per infested animal were, respectively 1, 108 and 11.5. Prevalence of TBT infection by E. ruminantium was 19.1%. No significant difference in herd prevalence was found among parishes or among ecological zones. For cattle owners treating against ticks (97.9% of all owners), all used aspersion of amitraz and herd prevalence was significantly different among those treating every 1-2-week (hp=69.6%, n=148), and less often than every 2-week (hp=88.6%, n=35) (P=0.031). Of the 42 herd subunits treated less than 4 days before the survey, 27 (64%) were infested with at least one TBT, and 6 (14%) with at least one engorged female TBT. These results indicate a high level of TBT infestation in Marie Galante, the inefficacy of tick treatments currently performed, and the need for an improved tick control strategy. Persisting high levels of infestation in Marie Galante threaten the success of on-going TBT eradication programs in the Caribbean because TBT can spread through migrating birds and trade of animals or of animal hides to other islands and potentially the American continent.

Risk factors for tungiasis in Nigeria: identification of targets for effective intervention.

BACKGROUND: The parasitic skin disease tungiasis (caused by the flea Tunga penetrans) affects resource-poor communities in Latin America, the Caribbean and sub-Saharan Africa. Prevalences in endemic areas are high, and severe pathology occurs commonly. However, risk factors for infestation have never been assessed in Africa. METHODS AND FINDINGS: A cross-sectional study was conducted in Erekiti, a rural community in Lagos State (Nigeria), where tungiasis is endemic. Individuals were examined clinically for the presence of tungiasis, and a questionnaire was applied. Data from 643 individuals (86.6% of the target population) were analyzed; 252 (42.5%) were infested with T. penetrans. In the multivariate logistic regression analysis, presence of pigs on the compounds (adjusted odds ratio = 17.98; 95% confidence interval: 5.55-58.23), sand or clay floor inside houses (9.33; 5.06-17.19), and having the common resting place outside the house (7.14; 4.0-14.29) were the most important risk factors identified. The regular use of closed footwear (0.34; 0.18-0.62) and the use of insecticides indoors (0.2; 0.05-0.83) were protective against infestation. The population attributable fractions associated with tungiasis were: sand or clay floor inside the house (73.7%), resting usually outside the house (65.5%), no regular use of closed footwear (51.1%), and pigs on the compound (37.9%). CONCLUSION: The presence of tungiasis in Erekiti is determined to an important extent by a limited number of modifiable variables. Effective and sustainable intervention measures addressing these factors need to be implemented in this and other West African communities with high disease burden.

Parasitic miticidal therapy.

Parasites are a common cause of dermatological disease in the dog and cat. Knowledge of different miticidal options for the common parasitic diseases is imperative when choosing the appropriate treatment for a patient. This is especially important with the recent advent of safer and more effective antiparasitic medications. Diagnostic and therapeutic methods for Cheyletiella spp., Demodex spp., Notoedres cati, Sarcoptes scabei, and Otodectes cyanotis are discussed, with emphasis on protocols for miticidal therapies, as well as safety concerns and side effects. This information will allow the practitioner to choose the safest and most efficient treatment for parasitic skin disease in their small animal patients.

Selective mass treatment with ivermectin to control intestinal helminthiases and parasitic skin diseases in a severely affected population.

OBJECTIVE: To assess the short-term and long-term impact of selective mass treatment with ivermectin on the prevalence of intestinal helminthiases and parasitic skin diseases in an economically depressed community in north-east Brazil. METHODS: An intervention was carried out in a traditional fishing village in north-east Brazil where the population of 605 is heavily affected by ectoparasites and enteroparasites. The prevalence of intestinal helminths was determined by serial stool examination and the prevalence of parasitic skin diseases by clinical inspection. A total of 525 people out of a target population of 576 were treated at baseline. The majority of these were treated with ivermectin (200 microg/kg with a second dose given after 10 days). If ivermectin was contraindicated, participants were treated with albendazole or mebendazole for intestinal helminths or with topical deltamethrin for ectoparasites. Follow-up examinations were performed at 1 month and 9 months after treatment. FINDINGS: Prevalence rates of intestinal helminthiases before treatment and at 1 month and 9 months after mass treatment were: hookworm disease 28.5%, 16.4% and 7.7%; ascariasis 17.1%, 0.4% and 7.2%; trichuriasis 16.5%, 3.4% and 9.4%; strongyloidiasis 11.0%, 0.6% and 0.7%; and hymenolepiasis 0.6%; 0.4% and 0.5%, respectively. Prevalence rates of parasitic skin diseases before treatment and 1 month and 9 months after mass treatment were: active pediculosis 16.1%, 1.0% and 10.3%; scabies 3.8%, 1.0% and 1.5%; cutaneous larva migrans 0.7%, 0% and 0%; tungiasis 51.3%, 52.1% and 31.2%, respectively. Adverse events occurred in 9.4% of treatments. They were all of mild to moderate severity and were transient. CONCLUSION: Mass treatment with ivermectin was an effective and safe means of reducing the prevalence of most of the parasitic diseases prevalent in a poor community in north-east Brazil. The effects of treatment lasted for a prolonged period of time.

The impact of ivermectin treatment alone and when in parallel with Simulium neavei elimination on onchocerciasis in Uganda.

The study was conducted in August 2002 in Kigoyera parish in Kyenjojo district, where ivermectin treatment had been the strategy to control onchocerciasis since 1991 and was later supplemented with Simulium neavei control in 1995 and subsequent elimination; and in July 2003 in Kicece parish in Kamwenge district, where ivermectin treatment alone had been the strategy used to control onchocerciasis since 1991. Our objective was to examine and compare the impact of ivermectin treatment alone and when in parallel with S. neavei elimination on nodule and microfilariae carrier rates and on onchocercal dermatitis to provide baseline data that could be used to monitor the trends of microfilariae carrier rates for decision-making on when to discontinue ivermectin treatment. The combined interventions had significantly reduced onchocercal dermatitis from 34% pre-control to 2.9% (P < 0.001), microfilariae carrier rate from 88 to 7.5% (P < 0.001) and nodule prevalence from 49 to 19.2% (P < 0.001). Ivermectin treatment alone had also reduced onchocercal dermatitis prevalence from 34.2% pre-control to 9.5% (P < 0.001), the microfilariae carrier rate from 78 to 27.8% (P < 0.001) and nodule prevalence from 49.1 to 14.2% (P < 0.001). None of the children under 10 years were nodule or microfilariae carriers in both study areas. Histological examination of eight nodules extirpated from patients in Kigoyera identified five male and 12 female adult worms that were all old and alive. Five live and one dead female worms and one live male worm were identified from nodules extirpated from patients in Kicece. There was no female worm with embryogenesis from the nodules obtained from Kigoyera while two female worms from five nodules obtained from Kicece still showed a few embryos. Two female worms in each of the study area had sperms in uteri indicating that male worms were still active. Ivermectin treatment in parallel with vector elimination had a greater impact on onchocercal dermatitis and microfilariae carrier rates than ivermectin treatment alone. It would be worthwhile considering supplementation of ivermectin treatment with vector elimination in all isolated foci with S. neavei transmission to hasten the elimination of onchocerciasis as a public health and socio-economic problem in those foci.

Cutaneous myiasis due to the Tumbu fly during Operation Keeling.

Cutaneous myiasis is a temporary infestation of the skin with fly larvae (1). The following is a description of a case of cutaneous myiasis caused by the African Tumbu fly (Cordylobia anthropophaga). The clinical presentation and treatment of this infestation is discussed. A review of the Tumbu fly's lifecycle with emphasis on the prevention of the disease in the operational environment is also described.