Ronald C. Neafie

Old world leishmaniasis: an emerging infection among deployed US military and civilian workers.

Many veterans of Operation Iraqi Freedom are now returning to the United States after potential exposure to leishmaniasis. In the past year, large numbers of leishmaniasis cases of a magnitude not encountered in the United States since World War II have challenged clinicians in both the military and the civilian sectors. Many Reserve and National Guard troops were deployed to Iraq and are now back in their communities. Hundreds of leishmaniasis cases, which were managed by a few practitioners initially, permitted further appreciation of the epidemiology and diagnostic and treatment options for Old World leishmaniasis. We describe the current situation, with on-the-ground experience, complimented by a literature review, and we provide a practical list of options for the clinician likely to encounter this parasitic infection in the coming months and years.

Case 4. The first fatal Baylisascaris infection in humans: an infant with eosinophilic meningoencephalitis.

Baylisascaris procyonis, the ascarid of raccoons, causes a characteristic, rapidly fatal eosinophilic meningoencephalitis with ocular involvement in many naturally and experimentally infected aberrant hosts, including monkeys. Warnings that humans are potentially susceptible to the devastating infection have been issued, but an instance in humans has not been recognized. This report describes a boy who died from an eosinophilic meningoencephalitis, which mimicked B. procyonis infection in monkeys. The causative agent was not identified during life. Autopsy showed a systemic larval ascarid infection with massive involvement of the brain. The size and anatomy of the larvae in histologic sections were identical to those recorded for B. procyonis. The larvae were indistinguishable from the B. procyonis larvae observed in histologic sections of experimentally infected monkeys. An indirect immunofluorescence test was positive for B. procyonis. Exposure to raccoon feces was highly likely. The evidence suggests that this is the first recognized B. procyonis infection in humans. Prudent avoidance of exposure to raccoon feces is indicated.

Liesegang Rings in Tissue: How to Distinguish Liesegang Rings from the Giant Kidney Worm, dioctophyma renale

Liesegang rings (LRs) are periodic precipitation zones from supersaturated solutions in colloidal systems. They are formed by a process that involves an interplay of diffusion, nucleation, flocculation or precipitation, and supersaturation. Examples include LRs of calcium carbonate in oolitic limestone (in nature), LRs of silver chromate in gelatin (in vitro), and LRs of glycoprotein in pulmonary corpora amylacea (in vivo). Here we describe LRs in lesions from 29 patients—mostly lesions of the kidney, synovium, conjunctiva, and eyelid. The LRs formed in cysts, or in fibrotic, inflamed, or necrotic tissue. The LRs in this study varied greatly in shape and size, measuring 7-800 μm. Special stains and energy-dispersive radiographic analysis or scanning electron microscopy revealed that some LRs contained calcium, iron (hemosiderin), silicon, and sulfur. Some pathologists have mistaken LRs for eggs, larvae, or adults of the giant kidney worm, Dioctophyma renale. D. renale is a large blood-red nematode that infects a variety of fish-eating mammals, especially mink. Fourteen documented infections of humans have been recorded, usually with adult worms expelled from the urethra. The adult worms are probably the largest helminth to parasitize humans. Eggs of D. renale are constant in size (60-80 μm × 39-47 μm), contain an embryo, and have characteristic sculpturing of the shell. Liesegang rings should not be mistaken for eggs, larvae, or adults of D. renale, or for any other helminth.

Cutaneous botryomycosis in a patient with acquired immunodeficiency syndrome

A patient with acquired immunodeficiency syndrome presented with multiple pruritic papules and nodules over the trunk and extremities. Biopsy specimens from two of these lesions contained granules within abscesses of the papillary dermis. There were numerous gram-positive cocci within the granules. Culture of one lesion failed to produce growth. A mouse inoculated with tissue from a lesion revealed no evidence of sepsis or organ involvement. The skin lesions showed no obvious response to systemic antimicrobial therapy but gradually resolved after treatment had been discontinued. Such lesions should be clinically distinguished from other cutaneous manifestations of acquired immunodeficiency syndrome, such as Kaposis sarcoma.

Mucosal leishmaniasis in Brazil.

The clinical diagnosis and laboratory identification of Leish‐mania brazilicnsis braziliensis, a parasitic disease affecting the upper aerodigestive tract, is difficult. A retrospective computer‐assisted analysis of patient records was done after examination of 58 patients with mucosal leishmaniasis in an endemic area of L. braziliensis braziliensis in Bahia, Brazil during January 1987. Biopsies of clinically active and clinically inactive mucosal patients were examined for parasites using routine hematoxylin and eosin histopathology and a new technique for rapid detection of Leishmania amastigotes using a genus‐specific indirect immunofluorescent assay.

Diagnosis of Strongyloides stercoralis in a peritoneal effusion from an HIV-seropositive man. A case report.

BACKGROUND Strongyloides stercoralis, a nematode parasite in humans with free-living and autoinfective cycles, is often an asymptomatic infection of the upper small intestine. If the host becomes immunocompromised, autoinfection may increase the intestinal worm burden and lead to disseminated strongyloidiasis. The parthenogenetic adult female larvae can remain embedded in the mucosa of the small intestine for years, producing eggs that develop into either rhabditiform, noninfective larvae or filariform, infective larvae. Manifestations of dissemination occur when the filariform larvae penetrate the intestinal wall and migrate into the blood. Pulmonary involvement is common, and the central nervous system may be affected. Blood eosinophilia is typical, and gram-negative sepsis from enteric bacteria may occur. Much less commonly described is invasion of the peritoneal cavity with peritoneal effusion. CASE A 49-year-old man who came to the United States from Liberia 4 years earlier presented with sudden onset of severe abdominal distention, generalized weakness and marked pedal edema. Diagnostic paracentesis showed numerous filariform larvae of S stercoralis. Stool examination confirmed the presence of both rhabditiform and filariform larvae. Subsequently the patient was found to be HIV seropositive, with a CD4 lymphocyte count of 59. CONCLUSION Early detection of S stercoralis may alter the often-fatal course of infection. The present case is the second reported one in the English-language literature of the diagnosis of S stercoralis in ascitic fluid.

Microsporidial Myositis and The Acquired Immunodeficiency Syndrome (AIDS): A Four-Year Follow-Up

Excerpt To The Editor:In 1985, Ledford and colleagues (1) reported the first case of a patient with the acquired immunodeficiency syndrome (AIDS) with myositis secondary to a microsporidial infecti...

UNUSUAL CUTANEOUS INFECTIOUS AND PARASITIC DISEASES

The cutaneous manifestations of thirteen unusual infections and parasitic diseases are described. Their geographic distribution, morphologic features of the causative organism, histopathologic changes, criteria for diagnosis, and treatment are included.

Dracunculiasis of the Orbit and Eyelid: Light and Electron Microscopic Observations of Two Cases

Dracunculiasis, an infection caused by the nematode parasite, Dracunculus medinensis, usually affects the skin and subcutaneous tissue. The authors studied two cases of dracunculiasis involving the orbit and eyelid in African children. In the first case, the patient presented with proptosis and the clinical diagnosis was Burkitts lymphoma. In the second patient, the eyelid lesion was diagnosed as a dermoid cyst. Histopathologically, the orbital lesion showed a degenerated and partially calcified worm within a large intraconal abscess. The eyelid lesion contained a well-preserved gravid female worm filled with larvae. The results of transmission and scanning electron microscopic studies are discussed.

Disseminated infection caused by Sparganum proliferum in an AIDS patient

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