1. 1 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Dr. Huntington has indicated he has no relevant financial relationships to disclose.

2. 2 Additional Disclaimer This lecture was amply illustrated with breathtaking images – those that were selected because of their ability to make even a calloused trauma surgeon squirm! Alas, collected from myriad sources over more than a quarter of a century of teaching parasitology, copyright attribution and permission could not be established and obtained. While the Fair Use clause of the US Copyright Law permits a teacher to use small portions of a work to illustrate a point in a lecture, their reproduction in this database is generally considered to be outside the limits of the Fair Use intent. That is certainly the AAFP’s position. Too bad; guess you should have been here in person! “The 1961 Report of the Register of Copyrights on the General Revision of the U.S. Copyright Law cites examples of activities that courts have regarded as fair use: “quotation of excerpts in a review or criticism for purposes of illustration or comment; quotation of short passages in a scholarly or technical work, for illustration or clarification of the author’s observations; use in a parody of some of the content of the work parodied; summary of an address or article, with brief quotations, in a news report; reproduction by a library of a portion of a work to replace part of a damaged copy; reproduction by a teacher or student of a small part of a work to illustrate a lesson; reproduction of a work in legislative or judicial proceedings or reports; incidental and fortuitous reproduction, in a newsreel or broadcast, of a work located in the scene of an event being reported.” (emphasis added) http://www.copyright.gov/fls/fl102.html

3. Mark K. Huntington, MD PhD FAAFP Sioux Falls Family Medicine Residency and University of South Dakota Parasitology II: Arthropods & vector-borne parasites

4. Where we’re going… Bugs of medical importance Vector-borne parasites

5. Simplistic Intro to Medical Entomology

6. Misc. arthropods Flies Mosquitoes Fleas Lice Mites Ticks Bugs

7. Flies and mosquitoes Feed on you –Fly larvae myiasis

8. [Deleted – patient with myiasis] [Deleted – close- up of myiasis]

9. [Deleted – close-up of nasal myiasis]

10. [Deleted – occular myiasis (retina)] [Deleted – occular myiasis (anterior chamber)]

11. Therapeutic applications (Xenotherapy) [Deleted – photo of xenotherapy patient]

12. Flies and mosquitoes Feed on you –Fly larvae myiasis –Adults Anticoagulants (allergens) –Dermatitis –Research interests Some come by day, some by night –Significance as vectors

13. [Deleted – photo of flee] [Deleted – photo of lice] Fleas live off, but leap on to feed. Lice live on, but may rub off Cause pruritic dermatitis More than a nuisance… –Bubonic plague –Typhus –Etc. Fleas and Lice

14. Mites and ticks ► Sarcoptes ► Ixodes  Vector for Lyme  also Babesia ► Dermacentor  Vector for RMSF ► Demodex [Deleted – photomicrograph of mite] [Deleted – photomicrograph of scabies] [Deleted – photos of ticks]

15. Bugs Reduvius Cimex [Deleted – photo of assassin bug] [Deleted – photo of bedbug]

16. NOT vectors Feed on human blood at all stages Cannot bait to exterminate Bedbugs [Deleted – photos of bedbug stages, debris from bedbug infestation, patient with bedbug bites]

17. Vector-borne parasites Protozoa Leishmaniasis –Sand fly (various) Trypanosomiasis –African – tsetse fly (Glossina) –Chagas – reduviid bug Babesiosis –Tick (Ixodes) Malaria –Mosquito (Anopheles) Helminths Onchocerciasis –Black fly (Simulium) Loiasis –Deer fly (Chrysops) Elephantiasis –Mosquito (various) Flukes –Snail (various)

18. Vector-borne protozoa

19. Babesiosis Of minor medical importance Vector: Ixodes tick (like Lyme disease) –Often co-existent with other tick-borne infections Intra-erythrocytic (like malaria) [Deleted – photomicrograph of blood smear]

20. Leishmaniasis

21. [Deleted – lifecycle]

22. [Deleted – histology of lesion]

23. “Dry” lesion [Deleted – photo of patient]

24. Lymphatic spread [Deleted – photo of patient]

25. Disseminated cutaneous [Deleted – photo of patient]

26. “Wet” lesion [Deleted – photo of patient]

27. [Deleted – diagram of LRV1 and leishmaniasis pathogenesis]

28. “Espundia” [Deleted – photo of patient]

29. Kala azar [Deleted – photo of patient]

30. Post-kala azar dermatitis [Deleted – photo of patient]

31. [Deleted – epidemiological maps]

32. Key points Vector-borne (sand fly) There are cutaneous, mucocutaneous, and visceral forms Treatments are fairly toxic

33. Chagas’ Disease

34. [Deleted – epidemiological map]

35. [Deleted – multiple images, including life cycle, photomicrographs of various stages, and photograph of Ramano’s sign]

36. Infection Chronic CardiomyopathyMegasyndromes Latent (years) Acute Fever, Malaise AsymptomaticLymphatic activity Parasitemia Cardiac malfunction 2-3 weeks

37. [Deleted – photo of cardiomyopathy at autopsy]

38. [Deleted – photo of megacolon at autopsy]

39. Key points Vector-borne (reduviid bug) Pathology is immune-mediated Leading cause of heart failure in endemic regions Associated eponym: Romaño’s sign

40. African trypanosomiasis

41. [Deleted – multiple images, including life cycle, photomicrographs of various stages, and photograph of Winterbottom’s sign]

42. [Deleted – photo of patient]

43. [Deleted – epidemiologic map]

44. Key points Vector-borne (Tse tse fly) Associated eponym: Winterbottom’s sign Diffuse CNS findings

45. Vector-borne helminths Filarial worms Schistosomiasis Paragonimiasis

46. Onchocerciasis

47. [Deleted – multiple images over multiple slides, including life cycle, photomicrographs of various stages, patients with nodules, patients with occular manifestations, dermatological manifestions, and histology of lesions]

48. Mazzotti reaction [Deleted – photo of patient] [Deleted – histology]

49. [Deleted – multiple images of the Onchocerciasis Control Project (WHO), images of ivermectin distribution, and clipping about eradication of transmission in certain foci using pharmacological intervention.]

50. Wolbachia Büttner et al. Filaria Journal 2003;2:10 Hoerauf et al. Issues Infect Dis. 2007;5:31 Saint André et al. Science 2002;295:1892 [Deleted – photomicrographs of Wolbachia in Onchocerca, effect on worm embryogenesis] [Deleted – graph of inflammation with and without eradication of Wolbachia]

51. Wolbachia A bug (bacteria) in a worm in a bug (vector) Role in embryogenesis for worm –No bug, no baby worms Role in pathogenesis in human –No bug, less inflammation –Role in adverse drug reaction

52. Key points Vector = black fly Pathology due to inflammation Wolbachia plays important role Treatment is a success story… so far!

53. Loa loa

54. [Deleted – lifecycle]

55. [Deleted – photo of patient with Calabar swelling] [Deleted –close-up of worm in conjunctivae]

56. [Deleted – photo of surgical removal of worm from conjunctivae]

57. Key points Vector = deer fly Microfilaria circulate during the day Associated eponym: Calabar swelling

58. Lymphatic filariasis

59. [Deleted – multiple images over multiple slides, including life cycle, photomicrographs of various stages, photomicrograph of vector passing larvae, patients with extreme elephantiasis, ultrasonograms of filaria in situ, epidemiological map, ancient woodcutting depicting elephantiasis, and histology of lesions]

60. Key points Vector = mosquitoes Microfilaria circulate at night Physiological, not anatomic, means of pathogenesis Wolbachia symbiotic bacteria…

61. A quick flashback to Onchocerca [Deleted – comic relief]

62. Maybe all filariae are lymphatic… [Deleted – histology of onchocerciasis nodule demonstrating worm is entirely within lymphatic endothelium]

63. Don’t forget! [Deleted – multiple photo of flukes (whose vectors are snails) which were discussed in GI section of this series of lectures]

64. So… how do you treat them? [Deleted – photo of hand full of pills]

65. Challenges to Interventions Penetration of drug Toxicity of drug Resistance of parasite Elimination of parasite Infection vs. disease Immunization challenges

66. Simplistic antiparasitic primer Leishmaniasis –antimonials, amphotericin Amoebiasis –Metronidazole, amphotericin Trypanosomiasis –African - Suramin - Pentamadine - Melarsoprol - Eflornithine –American - Nifurtimox - Benznidazole Toxoplasmosis –Pyrimethamine Filariae –DEC, ivermectin Platyhelminths –Praziquantel Dracunculis Larval migrans –Albendazole Trichinella –Mebendazole

67. Simplistic antiparasitic primer Leishmaniasis –antimonials, amphotericin Amoebiasis –Metronidazole, amphotericin Trypanosomiasis –African - Suramin - Pentamadine - Melarsoprol - Eflornithine –American - Nifurtimox - Benznidazole Toxoplasmosis –Pyrimethamine Filariae –DEC, ivermectin Platyhelminths –Praziquantel Dracunculis Larval migrans –Albendazole Trichinella –Mebendazole

68. Of course, there is another rather important vector-borne parasite… [Deleted – illustration of “war on malaria” with the mosquitos looking like old German bombers during the Battle of Britain]

69. Questions & discussion Credits: The majority of images utilized in this presentation were retrieved via Google search and wantonly plagiarized.

70. Bibliography The images used in this lecture were plagiarized from the following sources: Blaum & Omura’s Images in Clinical Medicine, NEJM 338:1733 Gardiner, Fayer, & Dubey, An Atlas of Protozoan Parasites in Animal Tissues Google internet search Gutierrez’s Diagnostic Pathology of Parasitic Infections Halstead & Warren’s Diseases of Travelers and Immigrants Hunter’s Tropical Medicine and Emerging Infectious Diseases Katz, Despommier & Gwadz’s Parasitic Diseases Markell & Voge’s Medical Parasitology Peters & Gilles’s A Color Atlas of Tropical Medicine and Parasitology Reeder & Palmer’s The Imaging of Tropical Diseases J.F. Williams personal collection (And actually, a few of the pictures were mine, too.)