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Genitourinary

Sexually transmitted diseases should always be considered. Cultural or other issues may confound history, examination, and diagnosis. Rape is a common occurance of war and in some refugee camps; and many women will be unable to disclose this information - especially in front of others, such as a translator.

Enterobiasis or Pinworm infection (Worldwide; most common helminthic infection in Western Europe and U.S.): Enterobiasis is a nematode infection of the intestinal tract caused by Enterobius vermicularis eggs which are ingested via contaminated food or soiled hands. Manifestations/associated problems include perianal pruritis, vulvovaginitis in prepubertal girls, and secondary enuresis and urinary tract infection. Treatment is with mebendazole single dose of 100 mg po, repeated in 2 weeks or albendazole single dose of 400 mg po, repeated in 2 weeks (Not FDA approved for this use).

Filariasis: See full discussion (Distribution given below). The filarial parasites are tissue-dwelling roundworms whose microfilarial (mf) larvae are transmitted by several species of mosquitos or flies. The most problematic forms of filariasis are (1) Bancroftian filariasis and Malayan filariasis (much of the tropical and subtropical world between the Tropics of Cancer and Capricorn) which involve the lymphatic system and result in elephantiasisis and in some cases, chyluria, i.e., chyle (lymph and triglyceride in an emulsion) in the urine caused by obstruction between intestinal lymphatics and thoracic duct leading to rupture of renal lymphatics into renal tubules; (2) loiasis or loa loa (tropical Africa) in which worms live in subcutaneous tissue; and (3) Onchocerciasis (tropical Africa and to a lesser extent Central and South America) which causes river blindness and skin disorders. Treatment in most cases is effective only against the mf, hence the infection continues and repeated treatment (with ivermectin and/or DEC) may be necessary.

Granuloma inguinale or Donovanosis (Tropics, especially Southern India, Southern Africa, Pacific Islands, Papua, New Guinea, Caribbean Islands): Granuloma inguinale is a sexually transmitted disease caused by Calymmatobacterium granulomatous and characterized by an initial papule on the penis or labia. The papule ulcerates and develops into a painless granulomatous (beefy red and friable) raised area that spreads. Secondary anaeorobic infections are common and result in pain and foul-smelling drainage. Extension to the inguinal region may produce swelling similar in appearance to bubos. Early lesions of granuloma inguinale may be mistaken for syphilis, ulcerative stages mistaken for lymphogranuloma venereum, and the granulomatous tissue may be mistaken for carcinoma. Treatment is with TMP/SMX, azithromycin, tetracyclines, or newer quinolones.

Schistosomiasis or Bilharzia: See full discussion (Numerous areas of the world, especially Africa and Asia with variants and locations noted in the full discussion). Schistosomiasis is caused by Schistosoma sp. and encompasses several syndromes, not all of which are evident in all infected persons. Initial symptoms may include a pruritic, papular rash - most commonly in persons who do not live in endemic areas. Acute schistosomiasis (Katayama fever) occurs in primary infection 1-2 months after exposure to heavy parasite loads. Symptoms may include fever of several weeks duration, headache, urticaria, cough, hepatosplenomegaly, lymphadenopathy, diarrhea, and eosinophilia. Hematuria and dysuria occur in some infections. Symptoms tend to gradually diminish over several months, but may intensify as more eggs are deposited. Chronic hepatosplenic schistosomiasis is a consequence of eggs retained in tissue and prolonged infection - usually > 10 years duration. The liver may be large or small and firm with nodularity. Portal hypertension, splenomegaly, or esophageal or gastric varices may occur. Hematemesis and splenomegaly are common presenting symptoms, with normal liver function. Periportal fibrosis and portal hypertension is associated with glomerulonephritis (proteinuria, renal failure) and pulmonary hypertension (cor pulmonale). Granulomatous tissue in the bowel results in bloody diarrhea. The last (chronic) stage varies according to species, with some species primarily affecting the liver and intestines, and one species affecting primarily the urinary tract. In general, patients with chronic schistosomiasis tend to present in developed countries with lethargy, colicky abdominal pain, mucoid/bloody diarrhea, or dysuria and hematuria. Salmonella infection concurrent with schistosomiasis is common and is resistant to treatment unless the schistosomiasis is also treated. Complications include progression of liver, kidney, or other organ dysfunction for many years after transmission has been interrupted - especially with heavy infection and re-exposure. Central nervous system lesions occur, but rarely. Treatment is according to species: For S. haematobium and S. mansoni, praziquantel 20/kg po bid for one day; for S. japonica and S. mekongi, praziquantel 20/kg po tid for one day are the treatments of choice. S. mansoni may also be treated with oxamniquine in a single po dose (with food) of 15 mg/kg. S. haematobium in North and East Africa may be treated with metrifonate 7.5-10 mg/kg every other week for a total of 3 doses.

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