Tropical Infections Review — John Greene, MD

okay we’re going to talk today about tropical infections and travel related infections so every year there’s about 15 million travelers over see half of them go to develop countries most get no sound advice and many do not take proper prophylaxis so we’re gonna try to understand the pitfalls when traveling sound advice to travelers and what are your hazards and what are your resources so here are some facts about 70% of people report some health problems while traveling 8% actually will seek medical care overseas half a percent will actually need emergency care which is about 15,000 and one in a hundred thousand will die why traveling and what is the role of infect season all of this so what are the threats well obviously there’s jetlag lack of oxygen DVDs airplane travel taxicabs notorious trauma that’s one of the biggest ones diarrhea dysentery hepatitis A typhoid from eating the food and water bites mosquitos and animal bites our issues crime is another one and revolution so access to travelers risk you want to get a typical history pregnancies important what’s your prior immunization your allergies all those are questions to ask now all of these diseases are potential there but the risk is low for most of them higher for others so you have to decide what’s the risk of this and should I prevent it and how so hepatitis A is the most common infection so of all the things you should get vaccinated for hepatitis E is available and so that is the most important vaccinations malaria is number two there’s over a thousand cases in the US per year there’s no vaccine so you have to take prophylaxis hepatitis B depends on your duration of travel and if you’re becoming sexually active in the country you’re going to all of these are questions on whether Hep B vaccination is necessary one in a thousand I fight fever rare but does occur one in 3,000 cholera also very rare depends on when you go and if there’s outbreaks like the Haiti outbreak yellow fever and Japanese encephalitis have incredibly bad morbidity mortality associated with it so even though they’re rare if you get it it’s not a good outcome so vaccinations are possible less exotic infections easily preventable obviously tetanus diphtheria polio measles rubella the flu shot and strep pneumo these are all questions on traveling should I get these vaccines somewhat preventable is traveler’s diarrhea or there’s ways you can do that taking cipro is not necessarily recommended refax min is a way of doing it a lot of people I know though do take cipro in case they get sick but there’s no data that says that’s helpful and of course you can come back with a cold which is probably quite common Arthropoda salt I like that name bug bites okay malaria can be obtained dengue chikungunya fever you should all know that it’s the dengue lookalike yellow fever Japanese encephalitis West Nile virus filariasis actually you would have to live there for a year and get thousands of mosquito bites to get elephantiasis or filariasis so you could get it but not likely okay continuing on that Leishmania with sand flies uncle circa as the black flies sleeping sickness does occur and travelers the tsetse fly water exposure if you go swimming in the rivers or the lakes justice’ myiasis can occur leptospirosis that’s a big one the venture vacations amoebic encephalitis you can get that in Florida Texas Georgia so you don’t have to travel but it does occur in other countries stinging jellyfish corals etc drowning does occur specially with alcohol intoxication other threats altitude sickness deep vein thrombosis heat stroke and exhaustion drowning Psych illnesses and stress and no way to pay for medical care unless you bought insurance when you traveled this is an old slide but it brings up the idea if you were traveling to Thailand what would be your number one concern diarrhea would dominate then respiratory than malaria hepatitis interesting gonorrhea was up there too this is a nice way of looking at probability the

most common thing you’re gonna get is diarrhea followed by malaria and a cold or rest or illness and malaria is only if you went to West Africa as far as that higher risk and then notice Hep A and then you get dengue and then it really starts dropping so the chances of you getting meningococcal meningitis is extremely low compared to the other things so what are the common causes of fever after tropical travel the first thing everyone thinks of is malaria you should also think of respiratory diarrhea gangee typhoid Rickettsia is those are very frequently forgotten Rickettsia illnesses you have to know what they are around the world interesting you can break it down into what if you get a fever with a short incubation within a week of travel there’s a whole lot of things what if your fever occurs a month later well there’s another thing to think about what about if your fever occurred over three months after your return so you know depending on when your fever occurred your differential may change so if you look at some of the ways of looking at the world global poverty is blown up in Africa and Asia prompt prominently the global wealth we all know is in Europe United States and Asia Japan India has a lot of wealth and then where do all the tourists want to go well they like to go to Mexico US Europe is big and parts of Asia are also big all right and then where are all the people using up the water us is a big water use alors and what about where’s the resources the Amazon River in South America is very large and how much rainfall interesting Africa gets a lot as does South America and if you look at infections you can break them down into when people die in different countries there’s low income middle come and high income and you can break them down into the young the middle age and the elderly so if you look at Africa for example kids dying from zero to four dominating followed by East Mediterranean Southeast Asia when you get into fifteen to fifty nine year olds again Africa’s dominating Europe and Southeast Asia if you look at low-income countries the top killers are pneumonia heart attacks diarrhea AIDS stroke then TB neonatal infections malaria and prematurity if you look at high-income countries the only infection is pneumonia at number four all of the others are non infectious diseases and then when you look at the disability-adjusted life years if you kill the young you tend to have a high disability adjusted life year than if you died of a stroke at 80 so obviously pneumonia diarrhea HIV are killing young people so they have high levels of disability adjusted life years and then another way of looking at the map of all the killers you can see how people die half of them die over 60 but the young 0 to 4 there’s a large piece of the pie of people dying at that age and high-income countries 0 to 14 year olds don’t die very common whereas in Africa 45% of deaths are of 0 to 14 so there’s a major discrepancy there and then if you look at age of death again Africa dominating versus the high-income and then if I look at extremes here by sex you can see injuries males are more likely to die of an injury female overall they’re fairly common and then when you look at different things broken down between males and females interesting cardiovascular was in females infections a little bit more in males and cancer a little bit more in males unintentional injuries highly in males over females and then when you look at child mortality you can see in Africa for example the top killers are diarrhea pneumonia mer malaria and perinatal conditions so that’s what they’re dying of primarily and then if you broke it down into countries by death in the child deaths you can see by the illustration of people that Africa is dominating with HIV malaria pneumonia notice that measles is also a big killer that’s a big area of concern and then when we say we have neonatal deaths what are they really dying of they’re dying of prematurity birth asphyxiation neonatal infections diarrhea neonatal tetanus 3.4%

so these are all preventable kind of things or some of them are so you can see that’s a big concern and then when you look at cause of death between high income countries and lower you can see Africa has a lot more communica land nutritional deaths than say high-income countries and then another way of looking at it in Africa you can see injuries HIV and other infectious parasitic disease maternal nutritious nutritional conditions dominating if you meant things out in two years of life loss so if you lose young people you have a high amount of years of life lost as opposed to an elderly person so you can see Africa Southeast Asia’s on the exact opposite extreme of high-income Americas and then again if you look at diseases if you die of pneumonia diarrhea HIV neonatal conditions it’s different than when you died of stroke and heart attacks at an old age when you’re considering years of life lost and then years of life disability and disability adjusted life years you could see in Africa those numbers are quite disproportional to the rest of the world and when you look at burden of disease by broad categories again Africa the communica maternal perinatal nutritional is way over represented followed by eastern Mediterranean in Southeast Asia and then when you look at age distribution of diseases between high and low middle income you can see that when you get to that 0-4 piece of the pie dramatic differences in even in the 5 to 14 and when you look at the leading cause of death in the middle years okay you can see that again where do they put most of the illnesses they’re putting a lot of stress on psychiatric illnesses HIV is getting a lot of attention TB and then as they keep going down you’re getting a lot of Psych issues are becoming a world problem they’re working on and then you look at burden of disease and women HIV TB especially in Africa neuropsych conditions injuries maternal nutritional conditions again high in Africa and then burden of injuries disability-adjusted life years poisoning Falls fires they’re cooking right in their house fires falling into the fire suicide violence war you can see that in some places they’re quite high depending on how you look at the piece of the pie this is a interesting is that what is the predictions for 2020 and 2030 they’re predicting that malaria deaths TB and HIV will drop and stroke heart attacks and cancers are going to grow higher as people’s health improves and another way of looking at it is projections not dramatic changes for high-income for low income there’s some pretty dramatic changes going on at these projections hold true and then who knows why diarrhea is gonna go from number two to out of the top 20 rotavirus vaccine right so diarrhea is gonna drop dramatically pneumonia and other infections will go down things like diabetes COPD those are gonna increase stroke heart attacks by 2030 now if we think of HIV you’ve all seen the map sub-saharan Africa Southeast Asia dominate some countries like Haiti Central America you can see a lot of HIV rates if you follow the HIV epidemic you would know that it was on the increase and the 90s and by the 2000s it started to level off and when you look at prevalence of HIV you can see sub-saharan Africa has the highest amount of HIV if you were to look at a map where is all your HIV Africa India in Southeast Asia dominates the world people dying of HIV the same places are quite heavily represented where do physicians want to work well unfortunately Africa is highly underrepresented so there’s a major physician shortage in Africa everybody wants to come to the United States to work or in Europe and China Japan and India have a lot of physicians and then when you look at HIV you have to look at children orphaned by AIDS all of these are questions that have been addressed because who’s taking care of these people usually the family is if you look at the numbers Southeast Asia and you

and and sub-saharan Africa are dominating if you look at the countries with the highest HIV rates you can see all of them are in South our sub-saharan Africa and when you look at the map again most of the adults and children come from those two parts of the world children dying of HIV say locations very high numbers a number of children living with HIV again sub-saharan Africa and Southeast Asia dominates and newly infected children the numbers also high in those areas and then how many children are dying less than 15 high numbers in Africa and Southeast Asia and if you look at different parts of the world at clinics you can see different changes over time like in India you can see changes in the clinics where IV drug users may come and then over time in Thailand there’s maybe some leveling off of the epidemic and if you look at the Philippines you can also see changes in the epidemic over time Bangladesh Pakistan when you look at Ukraine the IV drug use is very high in Russia and Ukraine and Eastern Europe so that’s driving the epidemic at high levels and then Latin America you can see countries in Latin America with different levels of HIV looking at different populations and then how many HIV infections occur per day these numbers change every year but you can see that it’s quite high even in children and then globally how many HIV deaths are occurring in children these are some of the numbers you can get from the UN AIDS group people living with hiv/aids death and then a regional statistics even in North America you can look at them from every country on your own well when they look at HIV rates they look at neonatal antenatal clinics women attending you can see leveling off in some countries HIV is decreasing if you look at the female-to-male breakdown HIV is very high in the female population overseas the male and you can see that a lot of the countries are represented in sub-saharan Africa 15 to 24 year old children with HIV is declining and children dying of HIV is declining and the number of adults and deaths due to AIDS globally has declined after a peak and one of the big reasons are the availability of antiretroviral therapy the more that that’s being used in an area the death rate is dropping number of people getting HIV and low and middle-income over the world you can see dramatic increases and when you look at coverage you see some countries don’t do a very good job and others are doing a much better job so you can look at it based on countries now that’s HIV from a global perspective what about tuberculosis where is most of the tuberculosis in the world sub-saharan Africa India Southeast Asia Russia and interesting Brazil and if you want to know from where is all the TB Africa and Asia dominates in Eastern Europe and if you want to know what’s the top 10 TB infected countries all of them are in sub-saharan Africa and malaria that’s another epidemic to be concerned about whereas most your malaria all of them in our in Africa except India is on the map so we got three major illnesses sub-saharan or Africa is dominating this is your malaria distribution where the Equator is so you can see a lot of malaria and those areas and there’s a lot of interesting articles about how epidemics meet each other like the TB epidemic meets the HIV epidemic which meets the malaria epidemic and how does that affect it you get a lot of resistance of malaria chloroquine in all of these countries here so you have to use non chloroquine drugs when people die of malaria where are they at Africa is dominating majorly when you look at World Health Organization working on malaria eradication they have different levels of control versus in all of those areas and this is the estimated incidence you can see Africa Papa New Guinea has a lot of malaria

sub-saharan Africa again an estimated malaria per thousand population so if you think of malaria remember the bad one is falciparum the one that can get into your liver and be delayed is 5x and Ovalle and remember the red cells may rupture all at once and giving you the classic fever pattern most of the time they rupture intermittently and your fevers all the time but once you get into a pattern you might get qwerty and quotient malaria vivax of a liter and malaria and quarts and malaria and then you need to know Plasmodium no less ci that’s going to be on your board so here’s a fever pattern giving you the different bugs and what it may eventually work its way to so the periodicity of malaria fevers so the classic malaria is fevers chills dominating headache muscle pain you may have a liver spleen a third of the time enlarged and even nausea and vomiting is there for falciparum you can die within 48 hours so that’s a major problem and in most cases that we see tend to be South suprem which is the most deadly one and you can’t count on chloric and work in even in Haiti there’s some chloroquine resistance going on if you’re a parasitic knee is over five percent there’s a greater mortality so this is a typical view of what a falciparum malaria patient would look like and of course you come in anemic as well as the hemolysis given you this jaundice Blackwater fever your urine is black from the hemolysis so that’s why they call it Blackwater fever if you develop cerebral malaria almost guaranteed you will die especially if not treatment more common in kids and you may have brain damage if you survive and you may have seen so this is the brain with falciparum malaria where the bug is sludging in the capillaries of the brain this is a kid with a zipper of malaria you get low glucose which is a challenge you get severe anemia incredibly low hemoglobins you go into a RDS your kidneys fail low sodium you may have a low temperature and pregnancy is a big issue with malaria and you may get dehydrated quite easily now vivax ovalle remember this one gets into the liver so you have to use prime McQuinn and you can still die of this one but it usually is not as deadly as falciparum okay and then malaria tends to be a mild disease low levels of parasites remember it affects the kidneys and gives you the Mariana fright us and nephrotic syndrome and then this one is guaranteed on your boards which is a macaque monkey malaria is now getting into humans called no less CI and it looks just like malaria except the parasite burden can be as high as falciparum making it more deadly than malaria and it may be confused with malaria the good news is you can actually use chloroquine for it so how do you diagnose it you do a thin and fixed smear and you want to do looking for the parasites as well as the morphology and this is how to do those smears and then this would be multiple parasite rings obviously a falciparum multiple parasites likely a falciparum nowadays we have rapid dig detection kits we can do a quick little blood test and determine if you are positive for certain malaria so here’s a falciparum here’s a vivax so you can do this and it’s quite cheap so you can take it with you go into a malaria endemic area and check people by finger stick if they have malaria now mullerian pregnancies a whole topic in and of itself because they’re immunosuppressed they get a severe course they get complicated Asians miscarriages and how do you treat malaria which ones are safe which ones should you avoid when you’re pregnant so these are major questions when treating malaria in pregnancy so this is falciparum multiple red cells parasitize that’s about a 30% Paris the tinea that’s the classic banana shaped comida site which is only found with falciparum that’s what you want to look for that is a child with cerebral malaria as is this and there’s the brain sludging with the malaria now that’s a mirror’s Oh light and you’re looking for shufflers dots those little red dots or shufflers dots so you know that’s vivax ovalle and that is the nephrotic syndrome from

plasmodium malariae okay and Plasmodium malaria it looks like the planet Saturn with a band across it and this is your red cells on scanning electron micrograph female izing so how do you control malaria well you can get rid of the mosquitoes you can vaccinate but there is none readily available they’re still working on that and of course you can take prevention therapy your chances of malaria are as low as one in 10,000 in Central America to as high as one in 30 in the Oceania area and sub-saharan Africa so your risk depends on where you go malaria is the most common etiology diagnosed in returning travels with a fever its highest in sub-saharan Africa and then Asia America falciparum is most common and usually they did not take chemo prophylaxis or they didn’t take it correctly so these are all the drugs you can take for chemo prophylaxis our favorite is Malarone followed by doxycycline followed by mefloquine and if you go to Haiti you can use chloroquine and then of course using repellents are very important so that will prevent dengue yellow fever malaria etc and avoiding the mosquitoes and some people even sleep in insecticide impregnated nets that’s another integral part so you want to make sure you have the deep preparation de et has the most effective way of getting rid of the mosquitoes now the chances of you getting meningococcal meningitis is rare but there is a belt in Africa where epidemics occur you could get it during the dry season there or during the Hajj pilgrimage to Saudi Arabia so this would be a brain infected with meningococcal meningitis with the meningeal enhancement petechial / perk and di see pattern with ultimately purpura fulminant requiring amputation of the hands and feet and that is the location where meningitis is most likely to be acquired excuse me with mass gatherings and vaccinations art are required or recommended by the way besides meningococcus there’s also strep pneumonia meningitis is occurring in the meningitis belt of Africa so here’s the Africans lining up for their vaccinations when there are big-time meningitis outbreaks and it occurs during the harmattan when the Sahara Desert for two to three months blows all this sandy stuff and dries out your nasal pharynx and this is what the air and the eye sight would look like for several months so you can understand how things would dry out easy in your nasal pharynx now another illness breakbone fever okay and that would be rut dengue right so dengue is traveling along the equator spread by 80s a [ __ ] died the same as yellow fever so this would be your dengue kind of map and remember there’s four Cyril types if you get infected the second time of the difference zero type you can get dengue hemorrhagic fever there’s about a hundred million cases a year most people are actually asymptomatic however the illness becomes more severe in cute as an adult’s as opposed to children the mortality is low but it’s still there with dengue especially with the hemorrhagic fever so here’s your 80s a jib time mosquito and some people say your fever pattern may look like a saddle sort of off and on to febrile of a febrile for one to three days headaches the breakbone fever do the bat the backache the joint pain the rash the eye pain nausea vomiting you may get vascular permeability changes the capillaries are fragile so you get these petechiae and then you can have rapid deterioration with dehydration and then ultimately GI bleeding can occur as you start to get very easily able to breathe to bleed and due to the hemorrhagic manifestations you may get large ecchymosis versus the small to Tiki eye and then that sandpaper kind of rash is dengue and there’s the petechiae especially downstream from a tourniquet net is used as the tourniquet test sign with petechiae developing after you put on the tourniquet so the diagnosis is a clinical diagnosis eventually you can get back your antibody or PCR test and then there is no treatment except supportive care and don’t give them

aspirin steroids are controversial but nobody has jumped on the bandwagon wholeheartedly and then of course we have Blackwater vomit so that’s yellow fever right so yellow fever also spread by the 80s a [ __ ] died and there is a live vaccine you can get for that however if you’re over 65 it can be dangerous people have died from it so you may have to make sure you have no comorbid problems if you’re over 65 notice yellow fever seems to spare Asia and it’s mostly in the Americas and Africa and if you want to no matter most of your cases are occurring you can see it’s in Africa and South America with a few cases in the Caribbean and Central America and then yellow fever is found in the jungle but it’s making its way into the suburbs and the cities and then of course we have another mosquito-borne illness which is Japanese encephalitis this one gives you those correo athetoid movements which are characteristic of Japanese encephalitis and that’s spread by the Culex Anopheles mosquito and the vaccine is inactivated so you can get your je vaccine and it stretches from India to Japan by the way who needs a je vaccine is a whole topic in and of itself if you’re going near a pig farm out in the country in those areas you need a je vaccine if you’re not you have to really think about what’s my risk okay so for the board someone’s going to be going to a pig farm out in those areas that say je vaccine because it likes to cycle around the farm animals and the humans are incidental hosts so that’s where you’re gonna find the most mosquitoes with the je and then the most these mosquitoes breed and all these areas so they try to eradicate standing water now who knows what she’s doing she’s treating bed nets right with insecticide it lasts about a year it cost $1 and you put your bed net up and it keeps all the mosquitoes away hopefully which spread all the diseases that we just mentioned so bed nets are big deals in fact they actually track children that slept under bed nets whether they were treated or not you can see which countries do a good job and which ones do a bad job using the bed nets now if you get into life cycles the one thing you want to remember is which malaria goes to the liver the answer is the vivax ovalle so that one needs the primary red cell erythro genic cycle but it needs the prime McQuinn for the liver phase otherwise you get a relapse by the way you can have falciparum and vivax at the same time so we treated one guy who had definite falciparum and he relapsed two or three months later so he probably also was co-infected with vivax or Ovalle so remember falciparum the most dangerous can go to the brain pulmonary edema kidney failure why do you get such high parasite emia infects all ages of red cells that’s why and then that’s the cases where Africans 75% of African children account for the mortality of that we used to have a lot of it in the US and of course now it’s people who travel to other countries remember falciparum has no liver stage and banana shaped comida site remember the five expo valley the shufflers dots the low pear settimia it likes the liver and an infects red cell so that’s why that are young not the middle or older ones that’s why you get lower pairs to tinea don’t forget malaria has the banned form the nephrotic syndrome blue area to fry this the low parasite level and it only infects the old red cells and then these symptoms include even as much as COFF where we don’t think of malaria and then the signs include large liver spleen anemia and coma and then the thin and fixed smear travel to an endemic area when you want to compare the four falciparum vivax ovalle malaria remember the liver stage for vivax ovalle we don’t tend to separate vivax oro valley and then what is a poor prognosis hi Paris the tinea seizures coma low glucose acidosis all of these things are bad news and higher mortality and then when you look at the actual forms notice shuffler dots are vivax Ovalle and then the banana shaped Camino site is falciparum when you’re studying the difference we don’t recommend that you

fumigate your house like this but this is one way to get rid of mosquitoes and then of course remember the deep in the amount of teeth concentration you’ll get these are all the products you can use for insect repellents and the deep percent 10% is recommended and don’t give it to kids because they can have problems with absorption and then people actually assess how well these drugs work for malaria prevention how convenient they are how much cost how low you tolerate them I told you that Malarone Doxie mefloquine chloroquine those are the sort of ones you want to use now those are the common stuff this is the stuff you don’t think about so here’s a guy who went to Africa and he’s got this classic fever pattern and it’s peripheral smear show squiggly line so what does he have he has relapsing fever Borelli OSIS right tick-borne versus louse borne so relapsing fever you can get this in your travels we’ve seen that where the Borrelia gets into the body through a big bite whereas a louse usually would be affecting homeless people people in refugee camps and you want to look for those spirochetes in the peripheral blood and they can have all kinds of multi organ system treatment as penicillin or doxycycline now what do you get with your skin and soft-tissue in the tropics what is that rash tinea corporis and you see that a lot and the dogs and cats running around so the humans can get it from the pets and then you can get tinea capitis now if you get an aberrant granulomatous response to tinny in your beard or your scalp we call that what a carrion so a carrion is a dermatophyte infection of the scalp of beard with an aberrant immune response and may get secondary bacterial infection more common in the African race how about this occurs when you’re hot and sweaty into trigonis areas satellite lesions Canada enter try go this one is jock itch though that would be to knee Icarus the scalloped borders central clearing and then this one’s not getting better with antifungals so you get out your woods lamp shine it on there and gives you coral pink fluorescence so you have what Aerith rasma caused by chronic bacterial minute issome um renamed RK no vector minute ism um treatment is a macrolide and then of course herpes can occur in the genital area these are acyclovir resistant herpes cases and perianal herpes and lip herpes usually in HIV patients now I’m still talking skin and soft-tissue what about these little holes in your feet walking with flip-flops or sandals and the flea cannot jump high so it drills into your toes and feet so what’s that called there it is laying eggs under your toenail so that’s called Tunga penetrance you can get secondary tetanus gangrene staff strep infections and look like that okay Tunga penetrance there is the flea on the bite on the biopsy of the skin and if you dig it out you can’t treat it you dig them out there’s the flea okay so Tunga penetrance it’s also found in all kinds of animals and it’s a sand flea sandy terrain if you sit in the area you can actually get it in your perineum buttocks and that’s another location you can see it heavy infestations you can get everything from gangrene to requiring amputations what if that bug bites you lays an egg under your skin and within a week something is moving under your skin and you pull out that’s a botfly blowfly you pull out a maggot so that’s called myiasis okay so here’s your life cycle of myiasis which occurs in central South America and Africa primarily and in the in Florida for example it’s mostly in cows horses and rarely in humans you can even buy medical maggots by the way put on wounds now this guy slept on a sand pile and he’s itching like crazy so what does he have and this was in the Amazon

in Brazil he has cutaneous larva migrans from the dog and cats defecating in the sand so that’s the typical squiggly line of cutaneous larva migrans and the treatment is usually ivermectin works the best or albendazole and usually it’s the feet because we’re walking in the sand especially at the beach there’s a lot of that because the dogs run around the beach there so dogs cats defecating the sand also pigs goats horses defecating and then you get there hookworms okay these are all cutaneous larva migrans and it likes around the toes it’ll go away if you don’t treat it if you take some albendazole ivermectin my been dissolve a and then this is sort of the life cycle where the filiform larva is drilling into your skin there and then when you travel if something bit you and you get this linear pattern that’s consistent with bedbugs which is Cimex lectularius they do not spread disease although they have been cultured and we’re positive for MRSA so they brings up a question of whether you could get mersa from them they like the inseams around the mattresses and in the walls so bedbugs are concerned and then surgery and other countries as well in the u.s. you can see wounds that look very nodular liposuction there was an outbreak going to Dominican Republic for cheaper liposuction breast implants cheaper surgery pedicures those all can cause nodular lesions caused by what bug the rapidly growing micro bacterium which includes fortuitous Aloni eye and abscesses and then you may encounter people that walk barefooted farming for a living they have these large draining sinus tracts and if you amputate the leg it’s eating up the leg over ten years almost and it has sulfur granules Splendor hopefully phenomenon where it meets the white cells and that’s called madura foot or mice automa could be due to up soil bacteria or a mold and it’s usually in males than females and it likes to feet more than other parts of the body 20 to 50 year old and depending on the cause you’re treated with antibiotics or antifungals and surgery you might see a lot of lumpy jaw that’s caused by what actinomycosis okay sulfur granules grandpa’s of filamentous rods molar tooth colonies so lumpy jaws occurs in horses cows and humans so that can occur in the United States but you might see it more overseas how about walking barefoot in getting this verrucas kind of pattern to your skin they’re hyper pigmentation granulomas with the medlar bodies so that would be chroma blastomycosis that’s another sub-q mycosis that you’ll encounter in patients over there and you want to look for the medlar bodies and treat it with antifungal easels usually and then the other one is a large ulcer after traumatic inoculation from a stick or soil pigmented septate of hyphy clears nicely with antifungals and that’s FeO – Aiko sees and this one is also traumatically inoculated into the sub-q tissues the dark will all DeMatteis fungi and you treat it with the easels how about this one which causes swelling of the testicles urinating pure kyle lymphatic juice and it looks like that so that would be filariasis eventually it presents with elephantiasis due to obstruction of the lymphatics and then what makes it pathogenic is a bacteria that’s a commensal and lives inside of it a symbiote what’s its name begins with a w wolbachia right and if you take doxycycline you kill the wall back eeeh so this is what LF you’d have to have thousands of mosquito bites you also get secondary strep infections which exacerbate the lymphatic obstruction so it’s a vicious cycle and multiple reasons to get ultimately elephantiasis the classic one is which rare EF Bancroft II now this is what can happen over time with elephantiasis and the treatment is usually diethyl carbonate inor ivermectin filariasis the doxycycline actually treats the prevents

the recurrent strep infections and it kills the wolbachia now this looks like elephantiasis as does this as does this as does that and this but it’s actually not a parasite it’s from living in a silica rich soil volcanic soil and who knows how do you prevent this you wear shoes okay so this is called po Taccone osis it’s not a full area it’s found in countries that have a lot of silica soil and it gets in through the skin so if you wear shoes you can prevent pota kony osa so it’s people walking around barefooted in that red clay kind of soil and the particles the silica get in there so how do you prevent pota cony osis shoes ok so distributing shoes is a big way to get rid of pote oconee osis and if you want to know where most of your po Taccone osis is you can see the map for yourself now what kind of worm was slated for eradication in 2000 then 2010 now 2020 this is called guinea worm okay or the thread worm you have to grab it and roll it on a stick one inch per day for 30 days and get it out if you pull it too fast you break it off you get abscesses up the leg and you stick their foot in a bucket of water to make the diagnosis come back 30 minutes later the worm will be sticking out because it knows it’s in water it’s trying to lay eggs and you grab it and then roll it on a stick so that’s called guinea worm you can see where most of it is located it’s also called the thread worm because it looks like a thread and you roll it up on a stick that’s what it would look like you can tie it with a string so it doesn’t go back in and don’t pull it too hard if you snap it off it dies then you get abscesses you can also have it up your leg and in your abdomen but mostly it’s the legs and if you stick your foot in a bucket of water it’ll come out and you grab it and you roll it on a stick until all of it eventually comes out so that’s the lifecycle of the guinea worm so how do you prevent it you filter the water so they don’t drink the copepod and tell people don’t go in the water when they have ulcers on their legs which is hard to do because every day they go to the water and they stand in the water to get their water and therefore the life cycle is easy to maintain now if you’re handling fish chickens or any other kind of seafood you get a purple violaceous cellulitis so what’s that era Sifl or a syphilis Rick rewsey Appa the– what if you’re cleaning out your fish tank refresh Mycobacterium marinum right can give you a spore autre coid pattern Mycobacterium marinum global problem how about finger nail infections right on the edge of them actually not the nail that’s called a paronychia and if it’s in the pulp space it’s called a felon so those are the terms there and then you have to drain these they’re usually staph aureus that’s a global problem you can also see of course her pet Whitlow and impetigo is a big problem in the tropics lots of impetigo when you go to the tropics that honey crusted appearance you’ll see a lot of impetigo which could be treated with topical or oral antibiotics you’ll also see a lot of punched out skin ulcers following bug bites and that’s called eczema due to group a strep eczema and then lots of fur uncle’s also occur in that hot moist environment kymmie acquired MRSA does occur in other countries but is not necessarily as high as we have here fir uncles and carbuncles so whenever uncle coalesce as you get carbuncles that look like that also this is a usually a tropical yeah problem which is paya Myositis pus in the muscle you see that in the tropics staph aureus usually the young the quads and the gluteus and then of course there’s lots of animal contact so if the cat bites you you get Pasteurella molt asada even the big cats and then the worst bites are in the fingers because of the tendon sheaths and then Pasteurella is the big one it occurs very quickly so they all get prophylaxis with cat bites dog bites you want to worry about Pasteurella and 60% but also cap the site aphasia Cana more sustained and those can be fatal and then human bites or fights with the fists eikenella and anaerobic strep and then of course monkey bites

especially around temples you want to worry about herpes B or herpes semi a and then rat bites if you get bit by a rat you can get rat bite fever which is streptobacillus moniliformis in the US and spy really a minor in Asia so those are the two causes of rat bite fever and they’re all treated with penicillin s– alligator bites leeches we want to think of air ammonius hydrophilic okay and then all bites you want to worry about rabies right so raccoons skunks coyote foxes bats in the US and if you look at the rest of the world dogs tend to dominate but there’s other animal bites including bats and others that you may see and then of course tetanus is another concern whenever you have any bite injury and that is the sardonic smile and AAPIs thought nests and this is the sardonic smile lockjaw and that is the sub terminal spore of tetanus now this is a kid in Africa who literally is not smiling he has tetanus and that is the sardonic smile this is a baby who has the umbilical cord there was the entry site for tetanus total-body AAPIs darkness this is the same kid who survived tetanus so yes you can survive tetanus and then this was a Gore from an animal so that is a high tetanus prone wound of course and then this guy here has tetanus and you put him in a dark room and you don’t open the door you don’t turn the lights on otherwise they go into spasms any stimulation so remember tetanus is a big problem a million cases 50,000 deaths are in children in the US it’s mostly the elderly because they don’t get vaccinated heroin use is a big tetanus concern it’s a motor neuron synaptic problem you get rid of the inhibitory neurons with the tetanus spasm you get the lockjaw the difficulty swallowing sensory stimulate tend to cause the spasm and the neonatal tetanus is usually from the stump putting junk around the stump or using bamboo to cut the cord and then it’s a pure clinical diagnosis you usually will not culture the tetanus out and you want to give the immune globulin around the wound at least half of it and the tetanus toxoid as well and what people usually can have complications are broken bones autonomic instability lourenço spasm and with respiratory failure and then another thing you can get from traveling of course this one is college student Sarika let’s leche mania from the noseeums sandfly and you could see that in a nodular ulcerative phase from two types of sandflies depending on where you are in the world that’s Leishmania mexicana from chicka-chicka Leros ear likes to bite the ears that’s called a spoon dia it likes the nose okay les mania brasiliensis and then of course visceral leche mania likes to give you a big liver spleen involves the bone marrow so those are the three types of Leishmania you can see most of the cutaneous Central South America Mediterranean and Middle East and you can see some countries have a lot of Leishmania more so than others when you start looking at maps of where is Leishmania this is kala azar Leishmania Donavan i interesting there’s association with dogs and humans living together so that there may be some Leishmania correlation there and then visceral is Brazil Sudan India and Bangladesh primarily risk-factor contact with dogs chickens horses and poor hygiene all of these may increase risk and then bone marrow biopsy will ultimately show you the a master goat in the bone marrow with the Chi NIDA Plast and the nucleus as you can see here can eat aplastic leus that’s allege mania proven diagnosis so remember the phlebotomist sandfly and the treatment is stupid gluconate Ambus ohm and asel z’ and again trying to prevent the bug bite biting you may prevent the Leishmania and then other things that are very common in other countries more so in the u.s. is scabies likes the end step of the foot and the kids between the fingers the breast area the groin the waist antecubital fossa this is what scabies would look like there’s the bug the egg in the stool and that’s what it would look like under scanning electron

micrograph where the scabies like and then with immune suppressed a IV cancer patients that’s Norwegian or crusted scabies very contagious crusted scabies very contagious with billions of organisms and then finally head and neck infections you see a lot of parvo b19 there’s an outbreak now around the world going on slap cheek you can also see erysipelas both here in the US and abroad it looks like lupus lupus spares the nasolabial fold erysipelas does not so remember era syphilis is the lupus look-alike and then if you’re in contact with water anywhere in the world even in our own state with conjunctival hemorrhage and jaundice with renal problems you want to think of what leptospirosis the bad one is it duro hemorrhagic um this one isn’t arrogance it doesn’t just require rat urine any animal urine getting into the soil and into the water can give you leptospirosis also known as wiles disease it’s a worldwide problem and it’s a problem with adventure vacations it survives in the kidney excreted in the urine for over six months and ultimately it becomes a multi-system disease almost like a vasculitis the treatments are penicillin or doxycycline up to 10% mortality with Wyles disease and remember you almost get a intravascular bleeding kind of vasculitis pathology there so you can even get autoimmune uveitis from it but the symptoms are very broad including fevers and headaches kidney disease liver and then neurologic there’s a specific leptospirosis called Fort Bragg fever that occurred in an outbreak given you some unusual constellation of symptoms and the diagnosis is by usually serology and of course clinical would be done first and then don’t forget the penicillin or doxycycline for seven days and the mortality is usually low except for the wiles disease and the liver renal dysfunction is a problem don’t forget second most common infectious cause of blindness is banca circ Isis river blindness this guy’s from Benin and so you can see it’s in Africa central South America and the World Health Organization’s trying to eradicate it the most common cause of blindness worldwide is due to trachoma okay and this is what your eyelids would look like with trachoma and eventually you cause trichiasis and the scarring pulls the hair down and it rubs against the eye and this is where trachoma is very common globally so how would you prevent trachoma what which signs would you put up about this one wash your face prevent trachoma so it’s spread by flies not sexually transmitted disease it’s a different strain so wash your face is the big push get the flies off so remember trachoma is one of the major causes of blindness globally and giving the village as if from Ison and coming back and giving it three to four months later can totally eradicate it from a village here’s another thing that likes to crawl across your eye a worm so that’s low aloha there’s the extraction of it bitten by a black fly and there’s the low aloha fill area looking worm spread by that cry sobs fly at the top the bite and that’s what it would look like and then finally contact lenses what are the three infections with contact lenses there was an outbreak with Renu contamination so this one is Pseudomonas that’s the number one number two is that’s still the Pseudomonas number two is this amoeba which is called a can–the amoeba and then number three what’s the fungus called Fusarium and the famous outbreak was Fusarium with contact lenses so those are the three eye infections Pseudomonas a can’t amoeba Fusarium and then end up the Mitas usually following eye surgery anywhere in the world gram positives dominate than a few gram negatives in yeast and that’s called what hypo peon pus in the eye right hypo peon thank you for your attention and hopefully you’ll be more familiar with infections in your travels