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cases occurring in South America, Europe, Africa, China and Australia. Humans become infected by eating
aquatic plants (especially watercress) grown in water contaminated with feces from infected animals or
humans (night soil). Most human infections are mild, although heavy infections can result in extensive liver
damage. Even without treatment, many patients will have no symptoms. If flukes lodge in the extrahepatic
biliary ducts, right upper quadrant (RUQ) abdominal pain may occur.
Subjective: Symptoms
In moderate-to-severe infections: Diarrhea, RUQ abdominal pain (biliary colic), weakness, malaise and night
sweats, fever, jaundice.
Focused History: Have you noted a fever? Have you noticed pain in your right upper abdomen? (typical
symptoms; right upper quadrant pain occurs as worms migrate to the liver) How long ago were you in South
America, Europe, Africa, China or Australia? (Symptoms usually occur at least 12 weeks after ingestion of
the eggs)
Objective: Signs
Using Basic Tools: Palpation: Hepatomegaly and splenomegaly
Using Advanced Tools: Lab: O & P of stool to identify Fasciola eggs.
Assessment: Travel to an endemic area is critical for considering the diagnosis.
Differential Diagnosis: cholecystitis/cholangitis and clonorchiasis (see sections).
Plan:
Treatment: Bithionol 30-50 mg/kg per day in 3 divided doses on alternate days for a duration of 10-15 days
(available from the Centers for Disease Control and Prevention). An alternate: triclabendazole (Fasinex)
10 mg/kg once.
Patient Education
General: Avoid improperly prepared food (particularly aquatic plants in endemic areas).
Medications: Bithionol can cause photosensitivity and gastrointestinal symptoms.
Follow-up Actions
Evacuation/Consultation Criteria: Evacuate unstable patients and those unable to complete the mission.
Consult infectious disease specialist or internist.
Zoonotic Disease Considerations
Principal Animal Hosts: Cattle, sheep, and other large ruminants
Clinical Disease in Animals: Cattle – asymptomatic; sheep – distended painful abdomen, anemia, and
sudden death
Probable Mode of Transmission: Ingestion of contaminated greens
ID: Filariasis (Elephantiasis)
LTC Glenn Wortmann, MC, USAIntroduction: Filariasis refers to infection by one of several nematodes found in the tropics and subtropics
(see Onchocerciasis and Loiasis in Skin chapter). Lymphatic-dwelling nematodes are discussed here.
They are transmitted by mosquitoes and cause three similar conditions: Bancroftian Filariasis (Wuchereria
bancrofti), Malayan or Brugian Filariasis (Brugia malayi) and Timorean Filariasis (B. timori). Adult worms live
in the lymphatics and release microfilaria, which can take up to a year to appear in the blood after infection,
thus making diagnosis difficult.
Subjective: Symptoms
Early symptoms can include swollen lymph nodes (especially in the groin), headache and fever. Long-