Updated: 12/30/2018

Visceral Infections of Protozoa

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  • A 50-year-old healthcare worker presents to the emergency room after a month-long trip to India. He reports having fevers, abdominal pain, and a 5-lb weight loss over the past week. He recalls being bit by multiple types of bugs during his summer month in India. His past medical history includes gonorrheal urethritis. His social history includes having several different male sexual partners over the past year often without protection. On physical exam, there is hepatosplenomegaly. He is treated for a presumed parasitic infection, given his clinical risk factors, and tested for HIV. (Visceral leishmaniasis)
Introduction
  • Protozoa
    • single-celled eukaryotes, often parasitic, that feed on organic tissues
Infections of Protozoa
Central Nervous System
Gastrointestinal
Visceral Infections
Hematologic Infections Sexually Transmitted Diseases
  • Toxoplasma gondii
  • Naegleria fowleri
  • Trypanosoma brucei
  • Acanthamoeba
  • Giardia lamblia
  • Entamoeba histolytica
  • Cryptosporidium
  • Trypanosoma cruzi
  • Leishmania donovani
  • Plasmodium
  • Babesia
  • Trichomonas vaginalis

Trypanosoma cruzi
  • Introduction
    • clinical syndrome
      • Chagas disease
    • transmission
      • via triatomine, a type of reduviid bug (“kissing bug”)
        • painless bite that deposits feces
    • demographics
      • South America
    • risk factors
      • poor sanitation
      • tropical areas
      • immunosuppression
  • Presentation
    • acute infection
      • Romaña sign is a characteristic sign
        • unilateral periorbital swelling
      • chagoma on the skin at the site of inoculation
    • chronic infection
      • dilated cardiomyopathy
        • apical atrophy
      • megacolon
      • megaesophagus
  • Imaging
    • chest radiograph
      • cardiomegaly
    • barium swallow or barium enema
      • dilated esophagus
      • dilated megacolon
  • Studies
    • peripheral blood smear
      • trypomastigotes (motile flagellated form)
    • detection of antibodies via serology
    • detection of DNA via polymerase chain reaction (PCR)
  • Treatment
    • benznidazole or nifurtimox
      • first-line
Leishmania donovani
  • Introduction
    • clinical syndrome
      • visceral leishmaniasis (also known as kala-azar or black fever)
      • cutaneous leishmaniasis
    • transmission
      • via sandfly bites
    • demographics
      • younger children
      • mostly found in India, Bangladesh, Sudan, Ethiopia, and Brazil
    • risk factors
      • HIV/AIDS
    • prognosis
      • visceral leishmaniasis is fatal without treatment
  • Presentation
    • visceral leishmaniasis (kala-azar)
      • spiking fevers
      • weight loss
      • hepatosplenomegaly
      • abdominal pain
    • cutaneous leishmaniasis
      • skin papules that progress to nodule or ulcer
  • Studies
    • pancytopenia
    • biopsy or needle aspiration of bone marrow or skin lesions 
      • macrophages with ingested amastigotes (flagella-lacking form)
    • urine antigen testing
  • Treatment
    • amphotericin B or sodium stibogluconate
      • first-line
    • miltefosine
      • second-line
  • Complications
    • post-kala-azar dermal leishmaniasis
      • chronic skin rash with onset months to years after treatment
      • erythematous or hypopigmented polymorphic lesions throughout the body

 

 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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