Sandbox Jyostna

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• Filariasis Return to Top

• Filariasis

• 1. Lymphatic filariasis- Wuchereria bancrofti, Brugia malayi Brugia timori::* 2. Cutaneous filariasis- Onchocercia volvulus, Loa loa

• Onchocerciasis Return to Top

• Onchoceria volvulus cutaneous filariasis (river blindness) treatmentGilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.

• Preferred regimen: Ivermectin Single dose of 150 mcg/kg po; repeat q6-12months until asymptomatic.
• Alternative regimen: If Ivermectin fails, consider Suramin.
• Note (1): Onchocercia and Loa loa may both be present. Check peripheral smear; if Loa loa microfilaria present, treat onchocercia first with Ivermectin before Diethylcarbamazine (DEC) for Loa loa.
• Note (2): Retreatment for microfilaremia often necessary q6-12 months as demonstrated by repeat blood smear or antigen testing.
• Note (3): Do not use Diethylcarbamazine (DEC) in Onchocerca volvulus due to increased risks of precipitating blindness.
• Treatment of endosymbiont Wolbachia (bacteria) may help clear infection
• Preferred regimen: Doxycycline 100 mg qd or bid for 6-8 wks in lymphatic filariasis although effect may be more important for co-infecting pathogens such as Wuchereria or Onchocerca than loaloa.

• Loiasis Return to Top

• Loa loa cutaneous filariasis (eyeworm disease) treatmentGilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.::* Preferred regimen: Diethylcarbamazine (DEC) escalation recommended to reduce reactions on day 1-50 mg, day 2-50 mg tid, day 3-100 mg tid, Days4-21, 8-10mg/kg/day in 3 divided dose::* Alternative regimen: Albendazole 200mg po bid for 21 days::: Note: If concomitant onchocercia Loa loa, treat oncho first. Ifover 5,000 microfilaria/mL of blood, Diethylcarbamazine (DEC) can cause encephalopathy. Might start with albendazole for few days with or without steroids, then Diethylcarbamazine (DEC).

• Wuchereria bancrofti Return to Top

• Wuchereria bancrofti lymphatic filariasis (elephantiasis) treatment::* Preferred regimen (1): Scaled dose Diethylcarbamazine (DEC) escalation recommended to reduce reactions on day 1-50 mg, day 2-50 mg tid, day 3-100 mg tid, Days 4-14, 2 mg/kg q8h for total of 72 mg over 14 days. (Diethylcarbamazine(DEC) 2 mg/kg PO tid for 12 days (may be accompanied by systemic reaction to dying worms,local reactions include lymphadenitis, transient lymphedema)).::: Note: Corticosteroids or antihistamines may be needed to treat allergic reactions that develop as a consequence of dying microfilariae.

• Preferred regimen (2): Albendazole 400 mg PO single dose regimen AND (Ivermectin 200 mcg/kg PO OR Diethylcarbamazine 6mg/kg) may reduce or suppress microfilariae; however, this will not affect adultworms.::: Note (1): Most symptoms with Wuchereria bancrofti are due to the adultworm.::: Note (2): Retreatment for microfilaremia often necessary q6-12 months as demonstrated by repeat blood smear or antigen testing.::: Note (3): Do not use Diethylcarbamazine (DEC) in Onchocerca volvulus due to increased risks of precipitating blindness.

Note (4): Skin snip technique is skin snips can be obtained using a corneal scleral punch, or more simply a scalpel and needle. The sample must be allowed to incubate for 30 minutes to 2 hrs in saline or culture medium, and then examined for microfilariae that would have migrated from the tissue to the liquid phase of the specimen. ::: Note (5): Site of infection:::: 5.1 General: filarial fever includes fever, chills, malaise during acute or recurrent episode.

5.2 Lymph:localized lymphadenitis, may be painful(red,warm) or painless, unilateral or bilateral groin swelling. May be due to adult worm or complicating bacterial infection.:::: 5.3 Derm:pruritus,dermatitis,subcutaneous nodules. :::: 5.4 Genital:scrotal or vulvar swelling/ hydrocele; may be able to visualize adult W.bancrofti worm by ultrasound. :::: 5.5 Extremities:unilateral or bilateral swelling, acute or chronic. May be extreme (classic elephantiasis) or mild. May be associated with recurrent bacterial cellulitis (abrupt onset of redness ,fever). :::: 5.6 Lungs:tropical pulmonary eosinophilia (miliary pattern on CXR, nocturnal paroxysmal cough, wheezing, accompanied by marked eosinophilia, responds to DEC, usually amicrofilaremic). :::: 5.7 Renal: chyluria, hematuria (rupture of dilated lymphatics into urinary excretory system). May see weightloss, hypoproteinemia, lymphopenia, anemia.

5.8 Musculoskeletal:acute monoarthritis (knee>ankle) which responds to DEC, tenosynovitis (rare), thrombophlebitis (rare).::: Note (6):::: Diagnosis 1.serological-antigen detection by commercially available card test ; IgG4 antibody (not filaria species specific and may cross react with other helminths);:::: Diagnosis 2.special maneuvers DEC provocative days test (induce microfilaremia with dose of DEC); polymerase chain reaction.:::: Diagnosis 3.skin snips (detect Onchocerca volvulus, Mansonella streptocerca). Ultrasonography can detect adult W.bancrofti worms in scrotal lymphatics.

• Treatment of endosymbiont Wolbachia (bacteria) may help clear infection:::* Preferred regimen: Doxycycline 100 mg qd or bid for 6-8 wks in lymphatic filariasis although effect may be more important for co-infecting pathogens such as Wuchereria or Onchocerca than loaloa.

• Brugia malayi Return to Top

• Brugia malayi, Brugia timori lymphatic filariasis (elephantiasis) treatment::* Preferred regimen (1): Scaled dose Diethylcarbamazine (DEC) escalation recommended to reduce reactions on day 1-50 mg, day 2-50 mg tid, day 3-100 mg tid, Days 4-14, 2 mg/kg q8h for total of 72 mg over 14 days. (Diethylcarbamazine(DEC) 2 mg/kg PO tid for 12 days (may be accompanied by systemic reaction to dying worms,local reactions include lymphadenitis, transient lymphedema)).::: Note: Corticosteroids or antihistamines may be needed to treat allergic reactions that develop as a consequence of dying microfilariae.

• Preferred regimen (2): Albendazole 400 mg PO single dose regimen AND (Ivermectin 200 mcg/kg PO OR Diethylcarbamazine 6mg/kg) may reduce or suppress microfilariae; however, this will not affect adultworms.::: Note :::: Diagnosis 1.serological-antigen detection by commercially available card test ; IgG4 antibody (not filaria species specific and may cross react with other helminths);:::: Diagnosis 2.special maneuvers DEC provocative days test (induce microfilaremia with dose of DEC); polymerase chain reaction.:::: Diagnosis 3.skin snips (detect Onchocerca volvulus, Mansonella streptocerca). Ultrasonography can detect adult W.bancrofti worms in scrotal lymphatics.

• Echinococcus granulosus (hydatid disease) treatment

• Preferred regimen: Percutaneous aspiration-injection-reaspiration (PAIR) and Albendazole.Before & after drainage:Albendazole ≥60 kg, 400 mg PO bid or <60 kg, 15 mg/kg per day divided bid, with meals. Then: Puncture (P) & needle aspirate (A) cyst content. Instill (I) hypertonic saline (15–30%) or absolute alcohol, wait 20–30 min, then re-aspirate (R) with final irrigation.

Note: Continue Albendazole for 28 days Cure in 96% as comp to 90% patients with surgical resection

• Echinococcus multilocularis (alveolar cyst disease) treatment

• Preferred regimen: Albendazole ≥60 kg, 400 mg PO bid or <60 kg, 15 mg/kg per day divided bid, with meals.

Note (1): Albendazole efficacy not clearly demonstrated, can try in dosages used for hydatid disease.

Note (2): Wide surgical resection only reliable treatment; technique evolving

• Neurocysticercosis treatment (NCC)

• 1 Larval form of Taenia solium

• Preferred regimen: Treat Taenia solium intestinal tapeworms, if present, with Praziquante l5-10 mg/kg PO for 1 dose for children & adults.

• 2 Parenchymal neurocysticercosis

• Preferred regimen: Patients body weight of ≥60 kg,Albendazole 400mg bid with meals or Patients body weight of 60 kg,Albendazole 15 mg/kg per day in 2 divided doses (max. 800 mg/day) AND Dexamethasone 0.1 mg/kg per day with or without anti-seizure medication] all for 8-30 days

Note : “Viable” cysts by CT/MRI Meta-analysis: treatment associated with cyst resolution, decreased seizures, and decreased seizure recurrence.

• Alternative regimen: (Praziquantel 100 mg/kg per day in 3 div. doses PO for 1 day, then 50 mg/kg/d in 3 doses and [[Dexamethasone]} ANDDexamethasone 0.1mg/kg per day with or without anti-seizure medication) all for 29 days.

Note (1): Albendazole associated with 46% decrease in seizures.

Note (2): Praziquantel less cysticidal activity.

Note (3): Steroids decrease serum levels of [[Praziquantel].

Note (4): NIH reports Methotrexate at ”20 mg/wk allows a reduction in steroid use.

• 3 Degenerating cysts

• Preferred regimen: Patients body weight of ≥60 kg,Albendazole 400mg bid with meals or Patients body weight of 60 kg,Albendazole 15 mg/kg per day in 2 divided doses (max. 800 mg/day) AND Dexamethasone 0.1 mg/kg per day with or without anti-seizure medication] all for 8-30 days

Note (1): Treatment improves prognosis of associated seizures.

Note (2): For dead calcified cysts, no treatment indicated

• 4 Subarachnoid neurocysticercosis

• Preferred regimen: (Patients body weight of ≥60 kg,Albendazole 400mg bid with meals or Patients body weight of 60 kg,Albendazole 15 mg/kg per day in 2 divided doses (max. 800 mg/day) AND Dexamethasone 0.1 mg/kg per day with or without anti-seizure medication] all for 8-30 days) AND shunting for hydrocephalus.

Note: Without shunt, 50% died within 9 years.

• 5 Intraventricular neurocysticercosis

• Preferred regimen: Albendazole AND dexamethasone AND perhaps neuroendoscopic removal if obstruction of CSF circulation

• Sparganosis (Spirometra mansonoides) treatment

• Preferred treatment: Surgical resection or ethanol injection of subcutaneous masses

Note: Source for Spirometra mansonoides larval cysts is frogs/snakes

• Body lice

• Pediculus humanus, corporis treatment

• Preferred regimen (1): Success with Ivermectin in home shelter with 12 mg PO on days 0, 7, & 14
• Preferred regimen (2): Treat clothing with 1% Malathion powder OR 0.5% Permethrin powder.

Note (1): No drugs for the patient.

Note (2): Organism lives in and deposits eggs in seams of clothing. Discard clothing; if not possible treat clothes with 1% Malathion powder OR 0.5% Permethrin powder.

• Head lice

• Pediculus humanus, capitis treatment

• Preferred regimen: Permethrin 1% lotion apply to shampooed dried hair for 10 min.; repeat in 9-10 days OR Malathion 0.5% lotion (Ovide) apply to dry hair for 8–12hrs, then shampoo. 2 doses 7-9 days apart.
• Alternative regimen: Ivermectin 200 μg/kg PO once; 3 doses at 7 day intervals reported effective. Malathion 0.5% lotion report that 1–2 20-minutes applications 98% effective.

Note (1):Malathion in alcohol is potentially flammable.

Note (2): Permethrin success in 78%.

Note (3): Extra combing of no benefit.

Note (4): Resistance increasing.No advantage to 5% permethrin.

• Myiasis

• Fly larvae treatment

• Preferred treatment (1): Occlude punctum to prevent gas exchange with petrolatum, fingernail polish, makeup cream or bacon.
• Preferred treatment (2): When larva migrates, manually remove.

Note (1): Myiasis is due to larvae of flies

Note (2): Usually cutaneous/subcutaneous nodule with central punctum.

• Pubic lice

• Phthirus pubis treatment

Preferred regimen: Pubic hair with Permethrin 1% lotion OR Malathion 0.5% lotion as for head lice

Alternative regimen: Eyelids: Petroleum jelly applied qid for 10 days OR Yellow oxide of mercury 1% qid for 14 days.

• Scabies

• Sarcoptes scabiei treatment

• 1. Immunocompetent patisent

• Preferred regimen: (Primary) Permethrin 5% cream (ELIMITE).

Note (1): Apply entire skin from chin down to and including toes with Permethrin 5% cream. Leave on 8–14hours. Repeat if itching persists for >2-4 wks after treatment or new pustules occur.

Note (2): Safe for children >2 months old.

• Alternative regimen: Ivermectin 200 μg/kg PO once. As above, second dose if persistent symptoms.

Note (1): Trim fingernails.

Note (2): Reapply to hands after hand washing.

Note (3): Pruritus may persist times 2 weeks after mites gone.

• Alternative regimen (2): Less effective is Crotamiton 10% cream, apply for 24 hours, rinse off, then reapply for 24 hours.

• 2. AIDS patients (CD4 <150 per mm3), debilitated or developmentally disabled patients

* preferred regimen (for Norwegian scabies) : Permethrin 5% cream-2 or more applications a week apart may be needed. After each Permethrin dose (days 2-7) apply 6% Sulfur in petrolatum.

Note: Apply entire skin from chin down to and including toes with Permethrin 5% cream. Leave on 8–14hours. Repeat if itching persists for >2-4 wks after treatment or new pustules occur.

• Alternative regimen: Ivermectin 200 mcg/kg PO once is reported effective; may need 2 or more doses separated by 14 days.

Note: Norwegian scabies in AIDS patients is extensive, crusted. Can mimic psoriasis and not pruritic but highly contagious—isolate.

• 5. Adenovirus treatment

• 1. In severe cases of pneumonia or post Hematopoietic stem cell transplantation

• Preferred regimen: Cidofovir 5 mg/kg/wk for 2 wks, then q 2 wks AND Probenecid 1.25 gm/M given 3hrs before cidofovir and 3 & 9 hrs after each infusion OR Cidofovir 1 mg/kg IV 3 times/wk.

• 2. For hemorrhagic cystitis

Preferred regimen : Cidofovir (5 mg/kg in 100 mL saline instilled into bladder) intravesical.

Note (1): Adenovirus is the cause of respiratory tract infections including fatal pneumonia in children and young adults and 60% mortality in transplant patients.

Note (2): Adenovirus is frequent cause of cystitis in transplant patients.

Note (3): Adenovirus 14 associated with severe pneumonia in otherwise healthy young adults .Findings include fever, decreases liver enzymes, leukopenia, thrombocytopenia, diarrhea, pneumonia, or hemorrhagic cystitis.

note (4): Cidofovir is successful in 3/8 immunosuppressed children and 8 of 10 children with post Hematopoietic stem cell transplantation. Decrease in virus load predicted response to Cidofovir.

• 3. Pink eye (viral conjunctivitis)

Note (1): Usually unilateral Adenovirus (types 3 & 7 in children, 8, 11 & 19 in adults)

Note (2): No treatment.

Note (3): If symptomatic, cold artificial tears may help.

Note (4): Highly contagious.

Note (5): Onset of ocular pain and photophobia in an adult suggests associated keratitis—rare.

• 4.Bronchitis

Infants/children (≤ age 5)

< Age 2: Adenovirus;

Note:Antibiotics indicated only with associated sinusitis or heavy growth on throat culture for S. pneumo., Group A strep, H. influenzae or no improvement in 1 week. Otherwise treatment is symptomatic.