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Central Nervous System Altered Mentation, Meningitis, Coma, Focal Signs of Lesion and Seizures

Altered Mentation

Acute psychiatric illness

Any acute febrile illnesses: e.g., malaria, meningitis, pneumonia, typhoid fever.

Bartonellosis (Oroya fever) (South America/Andes Mountains): Bartonellosis is a gram negative bacterial systemic infection with Bartonella bacilliformis, which is transmitted by sandflies. Infection is characterized by insidious onset of fever, malaise, headache, myalgia; or in other cases, acute onset high fever, chills, drenching sweats, lymphadenopathy, hemolytic anemia, liver involvement and altered consciousness. Essential features are fever, progressive hemolytic anemia, generalized lymphadenopathy, and exposure to sandflies. Salmonellosis is a common complication of bartonellosis. Nodular (and often ulcerated) lesions occur one to three months after the onset of illness. Treatment is with penicillin, tetracycline, streptomycin, or chloramphenicol.

Hemorrhagic fevers (HFs): See full discussion of HFs. The major HFs include hemorrhagic fever with renal syndrome, hantavirus pulmonary syndrome, South American HFs, Lassa HF, Marburg and Ebola HFs, Kyasanur Forest HF, Omsk HF, Crimean-Congo HF, Chikungunya fever, dengue fever and HF, and Rift Valley fever (distribution is noted in the full discussion). The viral hemorrhagic syndrome (VHS) results from widespread increased permeability of microvasculature. Depending on the severity of vascular instability and decrease in platelet function, presentation may range from mild to severe illness; and hemorrhagic manifestations are not always apparent. A common course of illness begins with an abrupt onset of fever, myalgia, cutaneous flushing, and conjunctival suffusion. Within several days, the patient's condition worsens to include syncope, photophobia, headache, hyperesthesia, abdominal pain, nausea/vomiting, anorexia, and prostration. Treatment is primarily supportive, except that Lassa fever, South American HFs, and possibly Crimean-Congo HF and Rift Valley HF may be treated with a slow infusion of IV ribavirin.

Hemorrhagic fevers, South American : See full discussion of HFs, including Junin HF (Argentina), Machupo HF (Bolivia), and other HFs: Incubation in South American HFs ranges from 7-14 days. South American HFs are characterized by the gradual onset of fever, myalgia, and signs and symptoms as described above under general signs and symptoms. Thrombocytopenia, bleeding, and neurological dysfunction (confusion, tremors, and cerebellar signs) are common in South American HFs. Treatment is supportive and also includes IV ribavirin as discussed in the full discussion of hemorrhagic fevers.

Malaria: See full discussion (Tropical Africa, Asia, South and Central Americas; East China, Middle East): Malaria is caused by the protozoas Plasmodium falciporum, P. vivax, P. ovale, and P. malariae and is transmitted by mosquito bite, parenteral injection, or congenitally. Malaria is usually characterized by sudden onset of high fever, sweating, chills, uncontrollable shaking, headache, and splenomegaly. Fever tends to wax and wane in 48-72 hour cycles, though cycles may be irregular, especially with infection by P. falciporum. Onset may also be insidious, with less dramatic symptoms such as fever, headache, dyspnea, abdominal pain, nausea, diarrhea, myalgias, and splenomegaly. P. falciporum may cause parasitemia resulting in a life-threatening condition characterized by hemolysis, jaundice, anemia, acute renal failure, and hemoglobinuria. Cerebral malaria, also life-threatening, is characterized by gradual onset of severe headache, drowsiness, delerium, and coma. Seizures may also occur and are most common in children. P. faciporum causes death in as many as 25% of untreated cases. Treatment depends on the organism, immune status of the patient, and severity of the attack. Oral chloroquine is a mainstay of treatment except for infection with chloroquine-resistant P. falciporum. P. falciporum presents the greatest challenge because of severity of attacks as well as the existence of multidrug (especially chloroquine)-resistant strains. Combination drug treatment is common, e.g., mefloquine combined with artesunate for multidrug-resistant strains as described in the full discussion.

Meningitis, chronic and recurrent, is common worldwide, often as a complication of communicable diseases caused by a variety of pathogens as follows: (1) Bacterial causes include incompletely treated suppurative meningitis, parameningeal infection, Lyme disease, mycobacterium tuberculosis, syphilis; and less commonly actinomycosis brucellosis, leptospirosis, nocardial infection, and Whipple's disease. (2) Fungal infections with the potential to cause meningitis include aspergillosis, blastomycosis, cryptococcus, coccidiomycosis, candidiasis, histoplasma, and sporotrichosis. (3) Protozoal causes include toxoplasmosis and trypanosomiasis. (4) Helminthic causes include angiostrongyliasis, cysticercosis, gnathostomiasis, and trichinosis. (5) Viral causes include echoviral infections, herpes, HIV, lymphocytic choriomeningitis, and mumps. Viral or aseptic meningitis is characterized by sudden onset of fever and signs and symptoms of meningeal involvement (headache, neck stiffness, irritability/malaise, and sometimes rash and nausea and vomiting (from Chin, 2000; Koroshetz & Swartz, 1998).

Meningoencephalitis is relatively common worldwide and in some cases occurs as a complication of communicable diseases. Viruses are the most common pathogen, especially enteroviruses, but also arboviruses, herpesviruses, and other pathogens in illnesses including African trypanosomiasis, amebiasis, angiostrongyliasis, candidiasis, Chagas' disease, cryptococcosis, cytomegalovirus, dengue fever, hemorrhagic fevers, herpes, listeria, toxoplasmosis, and others. Young age and immunocompromise increase the risk of meningoencephalitis.

Relapsing fevers (Louse-borne relapsing fever [LBRF] is a public health problem primarily in the highlands of Ethiopia; while tick-borne relapsing fever [TBRF] has a much wider distribution): RFs are spirochetal infections with Borrelia sp. (gram negative helical bacteria) and are characterized by recurrent episodes of fever and apyrexia. Manifestations of both LBRF and TBRF are sudden-onset of fever, chills, headache, tachycardia, nausea and vomiting, arthralgia, myalgias, and petechial rashes. Hepatosplenomegaly is common and confusion may occur. Conjunctival injection, epistaxis, cough, and slight hemoptysis may also occur. Symptoms last for 3-10 days, when there is a crisis (>fever and severity of other symptoms), followed by recovery and relapse in about 7-14 days. There are one to two relapses in untreated LBRF and three to ten relapses in untreated TBRF. LBRF is treated with a single dose of oral erythromycin, tetracycline, doxycycline or chloramphenicol; or single parenteral dose of the preceding medications or penicillin G. TBRF is treated with a seven day course of the same medications. Jarisch-Herxheimer reactions to treatment are common (acute febrile reaction with headache and myalgia).

Syphilis, tertiary

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Meningitis

Malaria: See full discussion (Tropical Africa, Asia, South and Central Americas; East China, Middle East): Malaria is caused by the protozoas Plasmodium falciporum, P. vivax, P. ovale, and P. malariae and is transmitted by mosquito bite, parenteral injection, or congenitally. Malaria is usually characterized by sudden onset of high fever, sweating, chills, uncontrollable shaking, headache, and splenomegaly. Fever tends to wax and wane in 48-72 hour cycles, though cycles may be irregular, especially with infection by P. falciporum. Onset may also be insidious, with less dramatic symptoms such as fever, headache, dyspnea, abdominal pain, nausea, diarrhea, myalgias, and splenomegaly. P. falciporum may cause parasitemia resulting in a life-threatening condition characterized by hemolysis, jaundice, anemia, acute renal failure, and hemoglobinuria. Cerebral malaria, also life-threatening, is characterized by gradual onset of severe headache, drowsiness, delerium, and coma. Seizures may also occur and are most common in children. P. faciporum causes death in as many as 25% of untreated cases. Treatment depends on the organism, immune status of the patient, and severity of the attack. Oral chloroquine is a mainstay of treatment except for infection with chloroquine-resistant P. falciporum. P. falciporum presents the greatest challenge because of severity of attacks as well as the existence of multidrug (especially chloroquine)-resistant strains. Combination drug treatment is common, e.g., mefloquine combined with artesunate for multidrug-resistant strains as described in the full discussion.

Meningitis, chronic and recurrent, is common worldwide, often as a complication of communicable diseases caused by a variety of pathogens as follows: (1) Bacterial causes include incompletely treated suppurative meningitis, parameningeal infection, Lyme disease, mycobacterium tuberculosis, syphilis; and less commonly actinomycosis brucellosis, leptospirosis, nocardial infection, and Whipple's disease. (2) Fungal infections with the potential to cause meningitis include aspergillosis, blastomycosis, cryptococcus, coccidiomycosis, candidiasis, histoplasma, and sporotrichosis. (3) Protozoal causes include toxoplasmosis and trypanosomiasis. (4) Helminthic causes include angiostrongyliasis, cysticercosis, gnathostomiasis, and trichinosis. (5) Viral causes include echoviral infections, herpes, HIV, lymphocytic choriomeningitis, and mumps. Viral or aseptic meningitis is characterized by sudden onset of fever and signs and symptoms of meningeal involvement (headache, neck stiffness, irritability/malaise, and sometimes rash and nausea and vomiting (from Chin, 2000; Koroshetz & Swartz, 1998).

Meningoencephalitis is relatively common worldwide and in some cases occurs as a complication of communicable diseases. Viruses are the most common pathogen, especially enteroviruses, but also arboviruses, herpesviruses, and other pathogens in illnesses including African trypanosomiasis, amebiasis, angiostrongyliasis, candidiasis, Chagas' disease, cryptococcosis, cytomegalovirus, dengue fever, hemorrhagic fevers, herpes, listeria, toxoplasmosis, and others. Young age and immunocompromise increase the risk of meningoencephalitis.

Naegleria infection (Worldwide): Naegleria fowleri (a protozoal) infection is the cause of amebic meningoencephalitis, which currently is rare. There are two forms: (1) acute and often fatal CNS infection in otherwise healthy persons and (2) granulomatous infection in immunocompromised persons. Meningoencephalitis is also related to other illnesses. See meningoencephalitis above.

Toxocariasis (Worldwide): Toxocariasis is the most common visceral larva migrans and is due to infection with the tissue nematode (roundworm) toxocara canis or T. cati. Toxocariasis is most common among children who eat feces-contaminated dirt. Most infections are small load and asymptomatic except for mild eosinophilia. Heavy worm loads, decreased immune competence, and other factors may lead to malaise, fever, cough and wheezing, hepatomegaly, anorexia, and weight loss. Ocular toxocariasis also occurs and usually leads to decreased vision. For symptomatic infections, the treatment of choice is diethylcarbamazine 6 mg/kg/day po tid for 10 days. Asymptomatic infections are not necessary to treat.

Trichinosis (trichinella) (Worldwide): Trichinosis is a nematode (roundworm) infection with Trichinella sp. from ingestion of meat that contains cysts, especially undercooked pork or meat from a carnivore. Infection ranges from light and asymptomatic to heavy and life-threatening. Manifestations vary according to the life cycle of the worms: Initially there is malaise, nausea, cramping abdominal pain, and diarrhea. Gastrointestinal symptoms are followed in 1-6 weeks by fever, eosinophilia, periorbital and facial edema, conjunctivitis, dysphagia, dyspnea, cough, myalgia, and muscle spasms. Complications include meningitis and other neurological disorders, myocarditis, pneumonia, and nephritis. The current treatment of choice is mebendazole 300 mg po tid for 10 days (sometimes with prednisone to control symptoms).

Trypanosomiasis (African) or African sleeping sickness (Tropical Africa): Trypanosomiasis is caused by protozoal parasites, Trypanosoma brucei rhodesiene or T b gambiense, transmitted by bite of the tsetse fly. T b rhodesiene infections are more virulent than T b gambiense; and in the former, patients experience three stages of illness (trypanosomal chancre, hemolymphatic, and meningoencephalitic) as opposed to two stages in the latter (trypanosomal chancre and meningoencephalitic) with significantly milder symptoms. The painful trypanosomal chancre (3-10 cm) appears about two days after the bite and lasts 2-4 weeks. The hemolymphatic stage is characterized by high fevers lasting several days, with symptom-free periods of days to weeks. Less common manifestations of this stage are severe headache, malaise, arthralgia, lymphadenopathy, circinate rash, pruritis, and hepatosplenomegaly. Weight loss and debilitation also occur, and myocarditis may develop. The meningoencephalitic stage is characterized by progressive apathy, nighttime insomnia and daytime somnolence, anorexia, retarded speech, extrapyramidal signs (tremors, fasciculations, choreiform movements, and Parkinsonian-like appearance), and finally, coma and death. Treatment is complex and toxic, and depends on the infecting organism and stage of illness. Among the medications currently in use are suramin, melarsoprol, pentamidine, eflornithine, and corticosteroids.

Coma

Encephalitis (see Arbovirus encephalitis): Causes of encephalitis among refugees and immigrants include arborvirus infections (mosquito or tick-borne - especially cerebral malaria), trypanosomiasis, relapsing fever, trichinosis, cysticerosis, toxocariasis, and angiostrongyliasis. Arbovirus encephalitis (Worldwide - according to specific disease): The most important (highest case- fatality rates) arbovirus or arthropod-borne encephalitides are (1) Japanese encephalitis (JE), which is found throughout Asia and the Pacific; (2) Murray Valley (MV), which is found in Australia and New Guinea; and (3) eastern equine encephalomyelitis (EEE), which is found in the Americas and Caribbean. Severe infections are usually characterized by acute onset of fever, meningeal signs (headache, stiff neck, irritability, nausea and vomiting, delirium, >vital signs), tremors, convulsions, and stupor progressing to coma. Treatment is primarily supportive.

Malaria (cerebral): See full discussion (Tropical Africa, Asia, South and Central Americas; East China, Middle East): Malaria is caused by the protozoas Plasmodium falciporum, P. vivax, P. ovale, and P. malariae and is transmitted by mosquito bite, parenteral injection, or congenitally. Malaria is usually characterized by sudden onset of high fever, sweating, chills, uncontrollable shaking, headache, and splenomegaly. Fever tends to wax and wane in 48-72 hour cycles, though cycles may be irregular, especially with infection by P. falciporum. Onset may also be insidious, with less dramatic symptoms such as fever, headache, dyspnea, abdominal pain, nausea, diarrhea, myalgias, and splenomegaly. P. falciporum may cause parasitemia resulting in a life-threatening condition characterized by hemolysis, jaundice, anemia, acute renal failure, and hemoglobinuria. Cerebral malaria, also life-threatening, is characterized by gradual onset of severe headache, drowsiness, delerium, and coma. Seizures may also occur and are most common in children. P. faciporum causes death in as many as 25% of untreated cases. Treatment depends on the organism, immune status of the patient, and severity of the attack. Oral chloroquine is a mainstay of treatment except for infection with chloroquine-resistant P. falciporum. P. falciporum presents the greatest challenge because of severity of attacks as well as the existence of multidrug (especially chloroquine)-resistant strains. Combination drug treatment is common, e.g., mefloquine combined with artesunate for multidrug-resistant strains as described in the full discussion.

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Focal Signs of Lesion and Seizures

Amebiasis: See full discussion (Worldwide): Amebiasis is an amebic gastrointestinal infection (sometimes affecting other systems) that may be asymptomatic, chronic, or acute. Symptoms may include abdominal pain, diarrhea (with blood), weight loss, dehydration. Systemic dissemination is usually to the liver, but may also involve the brain, heart (pericarditis), lungs, and genitalia. Invasive amebiasis is treated with metronidazole and colonization without symptoms is treated with paromomycin or iodoquinol.

Angiostrongyliasis (Caribbean, Southeast Asia, Pacific Islands): Angiostrongyliasis includes several distinct nematode (roundworm) infections caused by Angiostrongylus sp. as follows. (1) Nematode (rat lungworm) infection with A. cantonensis that often is subclinical. Larvae migrate to the CNS and may cause eosinophilic meningoencephalitis. Symptoms may include severe headache (most common symptom), stiff neck, low grade fever, nausea, vomiting, abdominal discomfort, paresthesias of trunk and extremities, and other neurologic signs, including unilateral facial paralysis. The disease is usually self-limiting. Treatment is supportive, and includes corticosteroids, spinal taps, and analgesics. Antihelminthics are not used because of host reaction to dead worms in the CNS. (2) Nematode infection with A. costaricensis of the gastrointestinal tract with cutaneous, intestinal, and pulmonary manifestations (related to the nematode life cycle in the host body); and in some cases, hyperinfection syndrome. Cutaneous manifestations include edema, inflammation, and pruritis. Intestinal manifestations include abdominal and flank pain, fever, malaise, anorexia, nausea, vomiting, and weight loss. Pulmonary manifestations include cough, rales, wheezing, low grade fever, and hemoptysis. Hyperinfection syndrome includes severe pulmonary, cardiac, neurologic symptoms, progressing to septicemia and death. Treatment includes supportive therapy and glucocorticoids; and in some cases ivermectin or thiabendazole or albendazole.

Botulism (Worldwide): Botulism is a severe food poisoning resulting from ingesting the neurotoxin produced by Clostridium botulinum in canned or preserved foods (such as those produced under unsanitary conditions and imported). Symptoms include abdominal pain, vomiting, and CNS disturbances.

Cryptococcosis (U.S., Australia, tropical Asia, Africa, South America): Cryptococcosis is a yeast (Cryptococcus neoformans) infection beginning in the lungs and spreading to the CNS and thus resulting in meningitis and in some cases, disseminated disease. Immunocompromised persons are at increased risk. Treatment is with amphotericin B alone or in combination with flucytosine. Mild cases may be treated with fluconazole; and fluconazole is also used for maintenance therapy.

Cysticercosis (tapeworm cysts) and cysticercosis (Worldwide, but endemic in certain areas): Tapeworm or cestode infections result from the ingestion of Taeniasis sp. eggs, often found in undercooked meat or excreted proglottids (segments) of the adult tapeworm. Depending on the species, adult tapeworms reach a length of eight meters and live as long as 25 years. The beef tapeworm (Taeniasis saginata) usually causes gastrointestinal discomfort and weight loss. Awareness of infection often is through discovery of proglottids in the stool. Manifestations of intestinal infection with the pork tapeworm (Taeniasis solium) are similar to those of the beef tapeworm. However, ingestion of food that is fecally contaminated with T. solium eggs results in cysticercosis. The symptoms of cysticercosis are caused by the presence of cysticeri (encapsulated larvae) and the resulting inflammatory reaction or space-occupying lesions. The incubation period is as long as five years. Manifestions are most commonly varied neurologic problems, including fever, headache, CVA, hydrocephalus, seizures, and other symptoms of increased intracranial pressure. Visual manifestations may be from increased intracranial pressure or a cyst in the eye. Cysts are also found in subcutaneous and muscle tissue. Treatment of intestinal tapeworms is with a single dose of praziquantel 5-10 mg/kg. Treatment of cysticercosis is with albendazole 5 mg/kg po tid for 8-30 days or praziquantel 20 mg/kg po tid for 14 days. Therapy may increase symptoms, in which case dexamethasone helps reduce distress. Also see echinococcosis and hymenolepiasis.

Diphtheria (Worldwide): Diphtheria is an acute upper respiratory infection caused by virulent strains of the toxin-producing gram positive bacillus, Cornybacterium diphtheriae. Symptoms include fever, serosanguinous nasal discharge, sore throat, and gray pseudomembrane in the pharynx, nasopharynx, and/or trachea. Complications include respiratory tract obstruction, pneumonia, peripheral neuritis, and/or myocarditis. Immunization is essentially universal among younger people in the U.S., but some refugees and immigrants may not be immunized. Treatment includes (1) diptheria antitoxin within 48 hours of onset (after testing for sensitivity to antitoxin); (2) procaine penicillin G 600,000 units IM bid for 14 days (150,000 units/kg/day IV for 10 days for pediatric patients) or erythromycin 500 mg parenterally or po qid; (3) bedrest and supportive care; and (4) isolation until secretions are noncontagious. With some differences in regime, carriers are also treated.

Echinococcosis (Hydatid disease): See full discussion (Most of the world; endemic in South America, North Africa, Middle East, Southern Europe - especially in areas where sheep are raised). Echinococcosis or hydatid disease is a tapeworm infection that often is asymptomatic, especially in the lengthy early stages. Echinococcus embryos trapped in various organs (especially the liver or lung) develop into hydatid cyst(s), which grow and eventually cause dysfunction according to the function or area of the organ(s). Surgical excision of the cyst remains the treatment of choice. Albendazole is given pre and post-operatively. Drug treatment includes albendazole or mebendazole or praziquantel - all with poor cure rates.

Gnathostomiasis (China, Japan, Southeast Asia, Pacific Islands): Gnathostomiasis is a tissue nematode (roundworm) infection with Gnathostoma spinigerum following ingestion of undercooked fish or fowl. Initial symptoms are nausea, vomiting, right upper quadrant abdominal pain, hepatomegaly, fever, and eosinophilia; followed 2-4 weeks later by diffuse painless, pruritic subcutaneous swelling which may migrate, wax and wane, or appear as serpiginous. Swelling is due to migration of the immature worm, and usually is found on an arm or leg, but may also occur in the eyelid (with associated ocular symptoms) or may also affect visceral organs. Eosinophilic myeloencephalitis occurs when the worm migrates along a large nerve trunk resulting in nerve root pain, paralysis, severe headache, and/or signs of cerebral hemorrhage. Treatment includes surgical removal + albendazole 400 mg po for 21 days (not FDA approved and not highly effective).

Hemorrhagic fevers, South American : See full discussion of HFs, including Junin HF (Argentina), Machupo HF (Bolivia), and other HFs: Incubation in South American HFs ranges from 7-14 days. South American HFs are characterized by the gradual onset of fever, myalgia, and signs and symptoms as described above under general signs and symptoms. Thrombocytopenia, bleeding, and neurological dysfunction (confusion, tremors, and cerebellar signs) are common in South American HFs. Treatment is supportive and also includes IV ribavirin as discussed in the full discussion of hemorrhagic fevers.

HIV/AIDS: HIV/AIDS is found world-wide, and is especially common in sub-Saharan Africa, Southeast Asia, and India. Heterosexual transmission is common in these areas. Readers are referred to the CDC and other current sources of information (See links).

Lyme disease (North America, Europe, Asia): Lyme borreliosis is a tick-borne spirochete, and though Lyme disease often considered (in the U.S.) as a North American illness, is also found in Europe and Asia. There also are similar tick-borne illnesses. Lyme disease occurs in three stages: (1) Early localized infection is characterized by erythema migrans, i.e., papule or macule expanding to large annular lesion with clearing center or center that becomes indurated or necrotic. (2) Early disseminated infection is characterized by fever with chills, secondary (and smaller) lesions, headache, stiff neck, myalgias, arthralgias, and malaise and fatigue; other neurological signs, and sometimes cardiac problems may also develop. (3) Late persistent infection is characterized by the development of arthritis, chronic synovitis, and other musculoskeletal problems. Central and peripheral nervous system disorders also occur, as well as skin lesions such as acrodermatitis chronicum atrophicans which presents as discoloration and swelling of a distal extremity progressing to a condition resembling localized scleroderma. Diagnosis of Lyme disease is based on exposure and presence of specific symptoms (erythema migrans + at least one late manifestion + laboratory confirmation - usually antibodies by ELISA). Treatment is with oral antibiotics (doxycycline or amoxicillin or cefuroxime axetil or erythromycin for 10-60 days, depending on severity/extent of illness) or, if neurological involvement, with IV antibiotics.

Meningoencephalitis is relatively common worldwide and in some cases occurs as a complication of communicable diseases. Viruses are the most common pathogen, especially enteroviruses, but also arboviruses, herpesviruses, and other pathogens in illnesses including African trypanosomiasis, amebiasis, angiostrongyliasis, candidiasis, Chagas' disease, cryptococcosis, cytomegalovirus, dengue fever, hemorrhagic fevers, herpes, listeria, toxoplasmosis, and others. Young age and immunocompromise increase the risk of meningoencephalitis.

Naegleria fowleri (a protozoal) infection is the cause of amebic meningoencephalitis, which currently is rare. There are two forms: (1) acute and often fatal CNS infection in otherwise healthy persons and (2) granulomatous infection in immunocompromised persons. Meningoencephalitis is also related to other illnesses. See meningoencephalitis above.

Poliomyelitis (Primarily on the Indian subcontinent and Africa - "on the verge of worldwide eradication" [Chin, 2000]): Poliomyelitis is caused by an enterovirus and in the great majority of cases, infection is asymptomatic. The types of symptomatic poliomyelitis are: (1) Abortive poliomyelitis is characterized by self-limited fever, headache, sore throat, nausea, vomiting, diarrhea, and constipation. (2) Nonparalytic poliomyelitis is characterized by meningeal signs (e.g., headache, stiff neck, irritabilty, nausea, vomiting), muscle spasms, and the constitutional signs noted under abortive poliomyelitis. (3) Paralytic poliomyelitis may develop during the febrile stage of illness. There are two types of paralytic poliomyelitis: (1) Spinal involves weakness or paralysis of muscles ennervated by spinal nerves. Bulbar involves weakness or paralysis of muscles ennervated by cranial nerves IX and X, as well as respiratory and vagal centers. Development of paralysis is decreased by strict bedrest. Treatment otherwise, is supportive.

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.

Tapeworms and cysticercosis: See Cysticercosis above. Also see echinococcosis and hymenolepiasis.

Tetanus (Worldwide): Tetanus is a neurological disorder caused by the neurotoxin elaborated by the ubiquitous soil-dwelling anaerobic bacillus Clostridium tetani. Infection occurs as a result of introduction of Clostridium spores into wounds. Early manifestations are stiffness of the neck and jaw (lockjaw), dysphagia, and irritability. Pain and tingling at the wound site, followed by regional fasciculations may also be presenting symptoms. Progression includes trismus (jaw muscle spasms), facial muscle rigidity, life-threatening airway /pulmonary muscle spasms, and neck, back, and abdominal muscle spasms, and tonic convulsions. Treatment is in an acute care facility and includes antibiotic therapy, antitoxin, and neurological, pulmonary, and other supportive care - often in a critical care unit. Illness does not confer immunity, hence immunization is included in treatment.

Trematodes, lung-dwelling cause paragonimiasis (Asia, Latin America, Africa): Paragonimus sp. are lung-dwelling (as well as other sites) trematodes. Infection is most frequently linked with ingestion of incompletely cooked or pickled shellfish. Paragonimiasis may persist for many years and thus present as acute or chronic illness - though chronic is the more common. Acute illness may include fever, cough, pleural effusion, and hepatosplenomegaly. Chronic paragonimiasis is characterized by cough, dyspnea, hemoptysis, brown-flecked sputum, and pleuritic chest pain. X-ray shows (depending on length of illness) diffuse or segmented infiltrates, nodules, cavities, ring cysts, and/or pleural effusions. Extrapulmonary infections may manifest with abdominal pain, diarrhea, and CNS symptoms. Treatment is with praziquantel 25 mg/kg tid for two days.

Trichinosis (trichinella) (Worldwide): Trichinosis is a nematode (roundworm) infection with Trichinella sp. from ingestion of meat that contains cysts, especially undercooked pork or meat from a carnivore. Infection ranges from light and asymptomatic to heavy and life-threatening. Manifestations vary according to the life cycle of the worms: Initially there is malaise, nausea, cramping abdominal pain, and diarrhea. Gastrointestinal symptoms are followed in 1-6 weeks by fever, eosinophilia, periorbital and facial edema, conjunctivitis, dysphagia, dyspnea, cough, myalgia, and muscle spasms. Complications include meningitis and other neurological disorders, myocarditis, pneumonia, and nephritis. The current treatment of choice is mebendazole 300 mg po tid for 10 days (sometimes with prednisone to control symptoms).

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