PARASITES
Charles Sheard, M.D.
Rhett Drugge, M.D.
Stamford, Connecticut
Scabies | Pediculosis Pubis |
Fleas | Bedbugs |
Sand Fleas | Larva Migrans |
Pediculosis Corporis | Pinworms |
Pediculosis Capitis |
Scabies Sarcoptes scabiei
This is probably one of the most common parasitic infections,
usually spread by bodily contact, though other contaminated
objects can also infect. There is severe itching, usually worse
at night, with lesions (mostly excoriated burrows) on the
fingerwebs, volar wrists, buttocks, penis, axillary folds and
around the nipples in women.
Diagnosis
Diagnosis is confirmed by curettage of a burrow followed by KOH microscopy of the arthropod, its scat
or eggs. This technique is often unyielding leaving clinical
judgement to rule in half of cases. Inquiry as to the source of
infection can be an important clinical correlate. Such personal
contacts should be evaluated and treated for scabies to avoid
reinfection.
Treatment
Treatments such as Kwell lotion given twice daily for 3 days,
then repeated weekly for 3 weeks, Eurax cream or lotion (Geigy)
twice a day, and the old-fashioned remedy of 10% sulfur ointment
applied at night for four nights in a row and washing it off in
the morning are effective. The best treatment is benzyl benzoate.
Benzyl benzoate 25% emulsion applied from the neck down after a
hot bath while the skin is still damp, and then left on, is
effective if repeated nightly for three nights when the bedding
is changed and fresh clothing is worn in the morning. Treatment
should be repeated once, a week later. Particular attention
should be paid to body folds. If hands are washed, the emulsion
should be reapplied for 24-hour contact. Permethrin, a
crysanthenum derivative applied neck down, left overnight and
repeated in a week is sufficient when combined with hot water
laundry of linen. Permethrins have not the neurotoxicity which
characterizes lindane, especially in infants with a high surface
to mass ratio and highly permeable skin. Norwegian scabies is a
crusted variant featuring thousands of organisms in
neurologically impaired or immunologically suppressed
individuals, whereas a normal scabies infestation is by fewer
than 20 organisms. A single dose of methotrexate is curative in
Norwegian scabies.
Fleas (Siphonoptera)
Plague, rickettsiae and murine typhus are probably transmitted by
rodent fleas. Most flea bites seen in this country are from dog
and cat fleas, who lay their eggs in floor cracks, rugs or in
dust or other debris. Fleas can go without seeking food for long
periods of time, and larvae in a rug can take up to a year to
reach the adult stage, so infestations can be stubborn (life cycle). Diagnosis is made by seeing
three or four bites in a straight line, evenly spaced, or wheals
with a pinpoint central hemorrhagic puncta on the ankles, or
legs. Another way to detect the presence of fleas in a house is
to wear white socks, sit in the dark, then turn on the light
suddenly and see the fleas on the socks.
Treatment
Flea powers dusted on the animal or a flea collar, plus spraying
the rugs and animals' sleeping places with Raid are necessary.
Occasionally naphtha crystals are needed to deinfest a rug.
Better yet, all the rugs should be sent out to be cleaned, and
repellants should be worn on the ankles. Shuffling across a floor
with flypaper leggings will catch many leaping fleas. Black Flag
is a good killer spray.
Sand Fleas (Tunga
penetrans)
Sand fleas are burrowing insects indigenous to South
America, the West Indies and Africa producing shallow lesions
usually around the great toenail but in general on the lower
extremities. The fleas gradually engorge themselves with blood as
they burrow and should be removed carefully with a flat needle.
The lesions are referred to as chigo itch (no relation to
chiggers). Good solid shoes usually prevent this.
Pediculosis (Lice, Anoplura)
Pediculosis
Corporis
The lice live in clothing; the nits hatch in 9 days and must
feed within 24 hours. The adult lives about 30 days and is a
vector for relapsing fever and typhus. Diagnosis is made by
seeing parallel linear scratch marks on the shoulders, back,
buttocks and thighs, sparing the face and hands, with small red
puncta and an urticarial eruption. In long-standing cases
(vagabonds' disease), enlarged regional lymph nodes and a
peculiar melanoderma not unlike Addison's disease are features.
Treatment
Historically in large populations, 10% DDT in talc blown into
the clothing was used to deinfest; otherwise hot soap-and-water
baths and sterilization of the clothing, including bedding, in an
autoclave or oven (hotter than 160 F) is satisfactory.
Pediculosis
Capitis
Blacks are immune to this infestation of the scalp hair.
Characteristically the nape of the neck is excoriated, itchy and
may be impetiginized and crusted with a bad odor. The nits can be
seen attached to the hair, firmly. They have a
characteristic fluorescence when tested with Wood's light
(white). This pediculosis is more common in children than in
adults.
Treatment
Benzyl benzoate emulsion, lindane or permethrin are
effective. A steel fine comb facilitates the cure. It is
advisable to repeat the treatment several times and ensure
cure. Sources of infestation must be removed, and family, school
mates and other acquaintances should be checked. Soaking the
combs in ammonia water for 2 hours allows the nits to be easily
removed. Hats are best discarded. Nits hatch in a week, so weekly
examination must be done. Vinegar has some dissolving effect on
the nit cement as does derosene (used 50% in mineral oil). Benzyl
benzoate is most reliable.
Pediculosis Pubis
Ordinarily the crab louse is confined to the pubic and anal hair,
but in hirsute or heavily infested patients, the chest hair, arm
and leg hair, as well as the axilla, beard and eyelashes can be
infested. These areas should be examined thoroughly on each
visit. The nits attach themselves to the hair and probably are
nourished by apocrine secretion. This disease is seen in all
classes of society, as opposed to other varieties of lice which
favor the poorer sections of the population. One hairy patient
who periodically has to make a 6-week swing through some small
towns with inferior hotels, shaves himself from head to foot
before and during his trip. Once bitten, twice shy. Undoubtedly
some people are more susceptible than others. Crab lice are
considered a sexually transmitted disease although this is not
always the case.
Treatment
Often these lice can be exasperatingly difficult to eradicate in
a clean person; treatment should be for three weeks as a rule and
threat the marital partner at the same time. Treatment with Kwell
shampoo daily and Kwell lotion, or benzyl benzoate applied twice
a week from navel to knees and elsewhere as needed, with
occasional steel combing, has been necessary despite optimistic
one-shot treatments recommended elsewhere. For eyelid
infestation, yellow oxide of mercury ophthalmic ointment 1% is
very helpful, pulling the nits off with forceps. Maculae
caeruleae (taches bleuatres), slate-gray bluish
macules 4-10 mm in diameter, are occasionally encountered on the
chest, thighs or abdomen of heavily infested patients, and they
can in general be disregarded as a vasomotor phenomenon secondary
to the material injected into the skin while the louse is dining.
Bedbugs
(Cimicidae)
This cosmopolitan disease is caused by a flat, hard 4-mm-long and
3-mm-wide insect that could survive a year in a test tube with no
food, generally lives in cracks and wooden beds or furniture or
under baseboards, wallpaper or mattress tufts, lays eggs over a
long period and has three or four generations per year. It comes
out at night to attack the sleeper and takes 10-15 minutes to
gorge. For diagnosis, the occurrence of two to five grouped and
evenly spaced lesions, usually urticarial papules at the exposed
areas, e.g., the wrist, ankle, waist and neck, with new lesions
occurring nightly either in a segment of a circle or in a
straight line, is strongly suggestive. Often others in the room
will be affected, too.
Treatment
The beds should be taken apart and all the joints sprayed
with an effective spray, as well as baseboards, mattress tufts,
floors and walls. The sprays linger for 3 to 4 months, so perhaps
spraying every few months for a year is the best way to deal with
this problem. Heating the house to 130 F with the windows closed
will also destroy the bedbugs.
Larva Migrans (Creeping Eruption)
This disease consists of irregular wandering tunnels because of
the invasion of the skin by a larval form of certain roundworms
(usually cat and dog hookworms) in the sands of the southern
United States. Cases have been contracted on New England beaches
too. Larva currens (cutaneous Strongyloides) can mimic
larva migrans, though the invasion usually is on the buttocks.
Treatment
Thiabendazole, 50 mg/kg body weight, given either all in one
dose or over 2 days, is curative. Ethyl chloride spray
refrigeration at the "head" for more than 60 seconds
used to be the treatment. The thiabendazole suspension (10%)
rubbed in locally either with or without occlusion is effective.
Pinworms
(Oxyuriasis)
This usually involves children, though parents can also be
infested. The disease manifests itself by anal itching. A
flashlight at night will occasionally demonstrate the worms, and
anal smears, if done first thing in the morning will catch ova. A
small piece of Scotch tape can be used for this purpose, stuck on
a glass slide and mailed to the provincial or state laboratory.
Treatment
Any good antibiotic will slow up the
worm either internally or externally, since it hatches its eggs
outside the anus. Pyrinium pamoate, 5-10 mg/kg body weight, given
once and repeated in a week, gives excellent results. The tablets
are superior to the liquid, which has an unpleasant oily clinging
flavor. Mebendazole, is a second choice with a single dose of 100
mg; repeat after 2 weeks. A single dose of 100 mg for children
>2 years; repeat after 2 weeks.Piperazine adipate, one
teaspoon given three times a day for a week, and Antepar, given
according to weight, are alternative treatments. Since the
infestation is continued by the fingernails transmitting eggs
from anus to mouth, obvious precautions include a nail brush,
tight shorts worn in bed at night and frequent changes of bed
linen.
This document is a resource from the
Internet Dermatology Society
Send your comments to:
Rhett Drugge, M.D.
Last Update: February 17,1997