5-40
standing cases may present with lymphedema (which causes swollen legs [elephantiasis], scrotum, breasts,
genitalia, etc). Tropical pulmonary eosinophilia is a complication of filarial infection associated with intermittent
nocturnal asthma, fever and interstitial lung disease.
Focused History: Have you had repeated episodes of swollen lymph nodes? (recurrent lymphadenitis is
typical) How long have/did you lived in this/that area? (Most of the chronic complications of filariasis occur in
long-term residents of endemic areas.)
Objective: Signs
Using Basic Tools: Intermittent fever and swollen lymph nodes. Chronic infection results in the swelling
associated with elephantiasis.
Using Advanced Tools: Lab: Giemsa stained thick and thin blood smears may reveal microfilariae.
Assessment:
Diagnose by examining a blood smear for the presence of microfilariae. Most microfilariae are active at night,
but many in SE Asia are best detected between 10 am and 2 PM. The presence of retrograde lymphadenitis
is also helpful.
Differential Diagnosis - lymphadenitis may also be seen with acute bacterial or viral infections.
Plan:
Treatment:
Primary: Ivermectin 200-400 mcg/kg as a single dose may be used.
Alternate: Diethylcarbamazine citrate (DEC) 6 mg/kg daily x 2 weeks.
NOTES: Drugs only clear the microfilaria, not all adult worms. Relapses are common and may respond
to repeated treatment.
Patient Education
General: Avoid insect bites
Activity: As tolerated
Diet: As tolerated
Medications: Occasional gastrointestinal side effects. DEC can have generalized side effects, requiring
pain relief and steroids.
Prevention and Hygiene: Avoid insect bites
No Improvement/Deterioration: Return for evaluation
Follow-up Actions
Return evaluation: As needed
Consultation Criteria: Failure to improve
ID: Giardiasis
LTC Glenn Wortmann, MC, USAIntroduction: Giardiasis is a common water-borne cause of diarrhea throughout the world. It is transmitted by
fecal contamination of food or water. Treating water with chlorine may not kill Giardia cysts, especially if the
water is cold. Incubation period is 3-25 days, with an average of about one week.
Subjective: Symptoms
Diarrhea (often prolonged), abdominal cramps, bloating
Focused History: Have you had watery diarrhea? (common for giardiasis) Do you taste rotten eggs when
you burp? (sulfuric belching is often noted) How long have you been experiencing diarrhea? (can extend
for months)