Pus and Parasites

At home, ear infections and hypertension and diabetes are the bread and butter of primary care. Here it´s abscesses and parasites. As a consequence, the Oxford Handbook of Tropical Diseases has become one of my best friends. I carry it with me and snack on it throughout the day. In the evenings, I snuggle up with it for more filling entrees about the diagnosis and treatment of various parasitic infections, as well as the “big three”: HIV, TB, and malaria.

Mozambique exceeds even Bethel in the number and size of nasty abscesses that we have to incise and drain. Not very appetizing work.

Parasites are rampant: the medical school here did a survey in the barrio next door and found that 40 to 80 percent of residents are colonized by each of the common parasites: tapeworms, ascariasis, giardia, etc. Though a diagnosis of pinworms sends shockwaves through American middle class communities, here they are an expected part of life. While the thought of carrying a colony of worms around in your belly may be discomforting, most of the time they cause little or no symptoms. When the number of parasites gets large, though, they can contribute to anemia, fatigue, failure to thrive, and a host of other complications. We routinely de-worm the kids when they come in with swollen bellies and vague GI complaints, or anemia and poor weight gain.

One curiousity is called "larva cutaneous migrans". This little worm enters the skin through barefeet, then crawls around just beneath the surface leaving a serpentine trail. It eventually dies, or pops out of the skin, but in the meantime it causes a lot of itching. A good reason to wear shoes when you visit Africa. ~

Schistosomias is another, more severe infection: this promiscuous parasite lives half it´s life cycle in snails, and the other half in people. People contract it when they spend time in fresh water: the parasite penetrates the skin, enters blood vessels, migrates to the liver, and matures to an adult. Then they set up residence in various locales in the body,depending on the particular subspecies. One type, schistosomiasis haemotobium (save that for your next game of SCRABBLE), favors the bladder, another, the liver, spleen and intestines. The disease is very common, not in Beira, but in many other areas of Mozambique( and all over Africa) Many of the patients here are from those areas, and I have seen a half dozen patients with various forms of the disease.

Yesterday, I saw a young man, about 24 years old, from the region called Zambezia, who likely had schistosomiasis. (The Zambezi river is the largest river around, and drains a huge area of Zimbabwe, Zambia and Botswana). He complained of pelvic pain, and bloody urine. Another, patient of similar age had abdominal pain, and blood in his stool. A third, older adult male had developed a distended abdomen from fluid collection (ascites) which occurred because the infection caused scarring in his liver that prevents blood flowing back to the heart (portal hypertension). In spite of their disease, they all appeared relatively vigorous and well nourished (in contrast to the HIV and TB and malaria patients, who look ill). All of these people were easily treated with Praziquantal in a single dose. I am curious to see them back after treatment to see how they respond.

Lest you get too complacent , schistosomiasis is a cousin to this parasite that causes “swimmers itch” that we Zimmer´s experience when we swim in Great Pond in Maine every summer. The difference is that that particular flavor of parasite lives alternately in snails and ducks. We humans are accidental hosts, and the parasite dies after penetrating the skin rather than enjoying a long and prosperous life in our liver.

Rather than posting a picture of a disgusting parasite, I put a photo of a beachside fishing village about 20 miles north of here. We biked to it yesterday. Nice spot!