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Parasitology II: Arthropods & vector-borne parasites Mark K. Huntington, MD Ph. D FAAFP Sioux Falls Family Medicine Residency and University of South Dakota

Where we’re going… • Bugs of medical importance • Vector-borne parasites

Simplistic Intro to Medical Entomology

Misc. arthropods • • Flies Mosquitoes Fleas Lice Mites Ticks Bugs

Flies and mosquitoes • Feed on you – Fly larvae • myiasis

[Deleted – patient with myiasis] [Deleted – closeup of myiasis]

[Deleted – close-up of nasal myiasis]

[Deleted – occular myiasis (retina)] [Deleted – occular myiasis (anterior chamber)]

[Deleted – photo of xenotherapy patient] Therapeutic applications [Deleted – photo of xenotherapy patient] (Xenotherapy)

Flies and mosquitoes • Feed on you – Fly larvae • myiasis – Adults • Anticoagulants (allergens) – Dermatitis – Research interests • Some come by day, some by night – Significance as vectors

Fleas and Lice • • Fleas live off, but leap on to feed. Lice live on, but may rub off[Deleted – photo of Cause pruritic dermatitis flee] More than a nuisance… – Bubonic plague [Deleted – photo of lice] – Typhus – Etc.

Mites and ticks ►Demodex ►Sarcoptes ►Dermacentor § Vector for RMSF ►Ixodes § Vector for Lyme § also Babesia [Deleted – photomicrograph of mite] [Deleted – photomicrograph of scabies] [Deleted – photos of ticks]

Bugs • Reduvius [Deleted – photo of assassin bug] • Cimex [Deleted – photo of bedbug]

Bedbugs • NOT vectors [Deleted – photos of bedbug stages, debris from • Feed on human blood at all stages bedbug infestation, patient with bedbug bites] • Cannot bait to exterminate

Vector-borne parasites Protozoa Helminths • Leishmaniasis – Sand fly (various) • Trypanosomiasis – African – tsetse fly (Glossina) – Chagas – reduviid bug • Babesiosis – Tick (Ixodes) • Malaria – Mosquito (Anopheles) • Onchocerciasis – Black fly (Simulium) • Loiasis – Deer fly (Chrysops) • Elephantiasis – Mosquito (various) • Flukes – Snail (various)

Vector-borne protozoa

Babesiosis • Of minor medical importance • [Deleted – photomicrograph of blood Vector: Ixodes tick (like Lyme disease) smear] – Often co-existent with other tick-borne infections • Intra-erythrocytic (like malaria)

Leishmaniasis

[Deleted – lifecycle]

[Deleted – histology of lesion]

“Dry” lesion [Deleted – photo of patient]

Lymphatic spread [Deleted – photo of patient]

Disseminated cutaneous [Deleted – photo of patient]

“Wet” lesion [Deleted – photo of patient]

[Deleted – diagram of LRV 1 and leishmaniasis pathogenesis]

“Espundia” [Deleted – photo of patient]

Kala azar [Deleted – photo of patient]

Post-kala azar dermatitis [Deleted – photo of patient]

[Deleted – epidemiological maps]

Key points • Vector-borne (sand fly) • There are cutaneous, mucocutaneous, and visceral forms • Treatments are fairly toxic

Chagas’ Disease

[Deleted – epidemiological map]

[Deleted – multiple images, including life cycle, photomicrographs of various stages, and photograph of Ramano’s sign]

Infection 2 -3 weeks Acute Fever, Malaise Asymptomatic Lymphatic activity Parasitemia Cardiac malfunction Latent (years) Chronic Cardiomyopathy Megasyndromes

[Deleted – photo of cardiomyopathy at autopsy]

[Deleted – photo of megacolon at autopsy]

Key points • Vector-borne (reduviid bug) • Pathology is immune-mediated • Leading cause of heart failure in endemic regions • Associated eponym: Romaño’s sign

African trypanosomiasis

[Deleted – multiple images, including life cycle, photomicrographs of various stages, and photograph of Winterbottom’s sign]

[Deleted – photo of patient]

[Deleted – epidemiologic map]

Key points • Vector-borne (Tse tse fly) • Associated eponym: Winterbottom’s sign • Diffuse CNS findings

Vector-borne helminths Filarial worms Schistosomiasis Paragonimiasis

Onchocerciasis

[Deleted – multiple images over multiple slides, including life cycle, photomicrographs of various stages, patients with nodules, patients with occular manifestations, dermatological manifestions, and histology of lesions]

Mazzotti reaction [Deleted – photo of patient] [Deleted – histology]

[Deleted – multiple images of the Onchocerciasis Control Project (WHO), images of ivermectin distribution, and clipping about eradication of transmission in certain foci using pharmacological intervention. ]

Wolbachia [Deleted – photomicrographs of Wolbachia in Onchocerca, embryogenesis] [Deleted – effect graphon of worm inflammation with and without eradication of Wolbachia] Büttner et al. Filaria Journal 2003; 2: 10 Hoerauf et al. Issues Infect Dis. 2007; 5: 31 Saint André et al. Science 2002; 295: 1892

Wolbachia • A bug (bacteria) in a worm in a bug (vector) • Role in embryogenesis for worm – No bug, no baby worms • Role in pathogenesis in human – No bug, less inflammation – Role in adverse drug reaction

Key points • Vector = black fly • Pathology due to inflammation • Wolbachia plays important role • Treatment is a success story… so far!

Loa loa

[Deleted – lifecycle]

[Deleted – photo of patient with Calabar swelling] [Deleted –close-up of worm in conjunctivae]

[Deleted – photo of surgical removal of worm from conjunctivae]

Key points • Vector = deer fly • Microfilaria circulate during the day • Associated eponym: Calabar swelling

Lymphatic filariasis

[Deleted – multiple images over multiple slides, including life cycle, photomicrographs of various stages, photomicrograph of vector passing larvae, patients with extreme elephantiasis, ultrasonograms of filaria in situ, epidemiological map, ancient woodcutting depicting elephantiasis, and histology of lesions]

Key points • Vector = mosquitoes • Microfilaria circulate at night • Physiological, not anatomic, means of pathogenesis • Wolbachia symbiotic bacteria…

A quick flashback to Onchocerca [Deleted – comic relief]

Maybe all filariae are lymphatic… [Deleted – histology of onchocerciasis nodule demonstrating worm is entirely within lymphatic endothelium]

Don’t forget! [Deleted – multiple photo of flukes (whose vectors are snails) which were discussed in GI section of this series of lectures]

So… how do you treat them? [Deleted – photo of hand full of pills]

Challenges to Interventions • • • Penetration of drug Toxicity of drug Resistance of parasite Elimination of parasite Infection vs. disease Immunization challenges

Simplistic antiparasitic primer • Leishmaniasis – antimonials, amphotericin • Amoebiasis – Metronidazole, amphotericin • Trypanosomiasis – African - Suramin - Pentamadine Melarsoprol - Eflornithine – American - Nifurtimox - • Toxoplasmosis – Pyrimethamine • Filariae – DEC, ivermectin • Platyhelminths – Praziquantel • Dracunculis • Larval migrans – Albendazole • Trichinella – Mebendazole

Simplistic antiparasitic primer • Leishmaniasis – antimonials, amphotericin • Amoebiasis – Metronidazole, amphotericin • Trypanosomiasis – African - Suramin - Pentamadine Melarsoprol - Eflornithine – American - Nifurtimox - • Toxoplasmosis – Pyrimethamine • Filariae – DEC, ivermectin • Platyhelminths – Praziquantel • Dracunculis • Larval migrans – Albendazole • Trichinella – Mebendazole

Of course, there is another rather important vector-borne parasite… [Deleted – illustration of “war on malaria” with the mosquitos looking like old German bombers during the Battle of Britain]

Questions & discussion Credits: The majority of images utilized in this presentation were retrieved via Google search and wantonly plagiarized.

Bibliography The images used in this lecture were plagiarized from the following sources: • • • Blaum & Omura’s Images in Clinical Medicine, NEJM 338: 1733 Gardiner, Fayer, & Dubey, An Atlas of Protozoan Parasites in Animal Tissues Google internet search Gutierrez’s Diagnostic Pathology of Parasitic Infections Halstead & Warren’s Diseases of Travelers and Immigrants Hunter’s Tropical Medicine and Emerging Infectious Diseases Katz, Despommier & Gwadz’s Parasitic Diseases Markell & Voge’s Medical Parasitology Peters & Gilles’s A Color Atlas of Tropical Medicine and Parasitology Reeder & Palmer’s The Imaging of Tropical Diseases J. F. Williams personal collection (And actually, a few of the pictures were mine, too. )