parasitic related diarrhea in travellers

7/27/2019 Parasitic Related Diarrhea in Travellers

1/5782 Rprd f AustRAliAn FAmily PhysiciAn Vol. 41, no. 10, octobeR 2012

clinical

Parasitic causes of prolongeddiarrhoea in travellersDiagnosis and management

Andrew Slack

t q f f w rga

a Cryptosporidiumparvumr rprda

a prd a a

a gg ad dag p a a

dff r r a. Arav,

rga a Strongyloidesa a

f q fr w

ga a ag.

udrg a f f a f va prva, k

f ara f, a pd.

nvr, a prvd w

ravr awar f rk ad a avd

pa f.

Diagnosis

A w a dag pr, g w a

p r fg ad ar

(v, arar, ) f darra a

w a pr f d r .

Aad p a xprd gv

f pra ad d d pr

f fvr, /rgr ad jad. or pra

f r ad pa xaa ar

ggd Table 1 ad Table2.1,3,4

Investigations

t r f arar vga wfd:

fr, df aga ag f

darra, ad d, da rd

d a aara r rd drdr.

Fr g d vv g ffr p d pa.

ida, d frd r qd

p, d f dvr

arar ad a pr pad d

aa-a ad-fra (sAF) fxav. t

d kp a r prar rar

a rfrgrad. mp

ar warrad a ra v ad

dr f ra pra f

Diarrhoea remains the largest infectious risk

posed to the traveller while abroad or on their

return home. A large percentage is due to

bacterial infections such as enterotoxigenic

Escherichia coli and resolve within days of onset.

A small percentage of the travelling population

will have prolonged symptoms that may disrupt

either a long term holiday or a return to normal

activities when they are at home.

Prgd darra (pa dfd a >14 da) r

13% f ravr w darra.1 of f

a, prza f wd a fr

ajr f a.2

Dra f a f pr darra

fw a fra f r, xaa,

argd arar vga ad, vr rar,

dag agg r vav g a

p.

Background

Prolonged infectious diarrhoea in the returning traveller is generally caused by

protozoal and occasionally by helminth parasites.

Objective

This article provides a framework for the diagnosis, management and prevention

of the diseases that cause persistent diarrhoea in the traveller.

Discussion

A large proportion of disease is caused by Giardia lamblia, Cryptosporidiumparvum andEntamoeba histolytica. However, given the ease of travel with

comorbid conditions such as human immunodeficiency virus, there is an

expanding list of organisms that can cause persistent diarrhoea. An awareness of

the likely aetiological agents and their clinical features enables a more effective

diagnosis and management of the patients condition using an appropriate

antiparasitic agent. Prevention strategies need to be initiated before travel and

should consist of simple but memorable advice. Noninfectious causes of diarrhoea

should be considered as diarrhoea can be a prominent feature of conditions such

as hyperthyroidism or coeliac disease.

Keywords

diarrhoea; travel; intestinal diseases, parasitic; diagnosis, differential


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clinicalParasitic causes of prolonged diarrhoea in travellers diagnosis and management

Rprd f AustRAliAn FAmily PhysiciAn Vol. 41, no. 10, octobeR 2012 783

a pag g ad. if p ar

d d d w a

rva f 23 da w, w rapr

arar rrg w a ap. ta

g ad, mdar rr fr

fa rp r ad v (mcs)

ad w fa rp fr va, ad

para (ocP) a 7 da prd. if a rd ap

rqrd, a prd f 7 da ap

fr a ap fr ocP a rqd.

Kwg apa f g

arar pra, a a p

gd wa adda g a dd

ak a dag. Fr a, z

aa ar avaa fr g

fr Giardia lamblia, C. parvumad Entamoebahistolytica. spa a ar rqrd fr

dag f rprda. Pra a

ra (PcR) g fr pag ar

k r avaa fr.

Clostridium difficileg warrad

w av rvd rad pr a

r. ca r dr w

arar r va dad a

rq fr a faa rr g.

Prpra d d ak fr f

d w dffra, r/vr

f , ad adda r d

ak fr Strongyloidesad f apprpra.

i pa w a fvr: d r, k

ad f fr aara ad rr

da ra/c-rav pr (esR/cRP)

a arkr f faa.1,3,4

Giardia lamblia

Giardia lamblia(a kw a G. duodenalisr

G. intestinalis) aga

ag f pr darra. i a a wrdwd

dr pa ad rag

fd ara f w aa. i a fd

57% f ud sa ad 1530% f d ara.5,6 Gv

dr ad prva, Giardia

k pag f ravr.

tra va faara r r va

g f aad war r

rraa ad pa r. i parar

prva dr ad w av x w

. l a aqrd rg

fd aa.

sp f Giardiaf d

darra, aa, fa, f g gra

, ag/d ad, ,

aa, arxa ad vg. t gra

ar a r f a aarpv a a appar

fara ag.6

P-Giardiaf, aa df

; a pr fr vra wk afr

ra. t pa d ward a

pa f a ra p-ra

ad a pra rpr a ra ag

dgv ad d rvr a

fw wk.7

Dag f Giardiaf va

rp f w prpara g fr

r va a ra d. sv ad

pf f d dpd

rp ad p. Giardia

ag z aa av gagrag ppar w arar ad av

a pf ad v apprag grar

a 90%.8,9 tra f garda ad r

rga w Table 3.

Cryptosporidium parvum

Cryptosporidium parvum d

ad prza pag

ravr. lk Giardia, a a wrdwd

dr w prad rak rrg

dvpd r a w a d

f dvpg r.10,11 trav

a Aa, parar ida, aad

w gr ra f rav rad f.

Cryptosporidium a war ad fd-

r pag; p f f

d ada pa, fag, fa,

arxa, fvr, aa ad wg .12

Cryptosporidiumf ar gra

f g w a da dra f 510

da.12 hwvr, a pad

pr ad raa darra

w a df vr/aqrddf dr (hiV/AiDs) r r

prg da.

Dag prfrd g a dfd

ad-fa a f prrvd . sar

Giardia, aa ar w avaa

ad av prvd v vr rp.1

Cryptosporidium aad w a

pf rra w dr a a

r p 40% f pa.12

Tble 1. Key history poits i the retured trveller with dirrhoe

How long have the symptoms been occurring? What is the nature and character

of the stool? Have you noticed any other changes with your bowel habit (eg.

abdominal distension or tenesmus)?

What were your bowels like previously?

Had you previously had episodes of this type of stool?

Have you ever been investigated for any gastrointestinal disease (eg. inflammatorybowel disease, coeliac disease, bowel cancer or irritable bowel syndrome)?

Do you have any medical conditions? Do you know your HIV status?

What medications have you been taking? Have you taken antibiotics in the past 2

months?

What about vaccinations/malaria prophylaxis?

Travel history is very important. Ask the patient to bring in their itinerary so

nothing is missed. Systematically go through the patients journey when, where

and what they did. Look for potential risks or behaviours regarding eating, drinking

or exposure

Tble 2. Physicl exmitio i the ptiet with persistet dirrhoe

Assess hydration status with a large volume of diarrhoea comes a loss of total

body water and subsequent hypovolaemia

Assess nutritional status malabsorptive diarrhoea could result in loss of muscle

mass, fat wasting or vitamin deficiencies

General physical examination look for localising signs that may indicate a

contributing disease such as malaria (hepatosplenomegaly) or a noninfective

disease such as hyperthyroidism (tachycardia, tremor)


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Parasitic causes of prolonged diarrhoea in travellers diagnosis and managementclinical

784 Rprd f AustRAliAn FAmily PhysiciAn Vol. 41, no. 10, octobeR 2012

w darra hiV/AiDs pa.22 if

av a fd p

pa r a mx, Arga

ad ngr.21 A I. belli, f a

prf war darra ad aadwg . D f rga

va pa ag f fxd ap ad

gra prfrd w hiV/

AiDs. R f a g

arrvra rap a aw ara f

rga.

Blastocystis hominis

Blastocystis hominis a rga a r

rvr r f pag,

gv a apa arrag a

wd d. lkw, d av d

aa w p a darra,

ag, ada pa ad xv fa.

i pr a k dar a

xpr r rga a rrd. Wr

Blastocystisa ad ad a

p ar pr, a ra f ra

warrad.23,24

Strongyloides

W a a f pr

darra, Strongyloidesra a rgaa a g r q

fd. Rk far d rav d

ara, g aad war r a

w fd , a rg arf

rav. A r r f ar a

apa, a pr w darra,

rara ad ada pa. cr f

pa w a dad df

d g d rrd , rga

aa, ad d pfa rqd fr

g arar.15

Cyclospora cayetanensis

Cyclosppora cayetanensis a da rgad mx, ha, Pr ad npa. i

k a fd rrdg r. i

a fd ud sa, pa

prd fd fr d r.16

ca far f Cyclosporaf

d darra, arxa, aa, fa,

fag, rapg, fvr ad wg .

Darra a a p 3 wk ad pa

pa av 515 w pr da,

wvr, apa f ar p.

ha df vr pa pa

av r vr da, w rad wg

ad gr dra f darra.10 Dag

dfd ad fa ag f fxd

ap.17

Isospora belli

Isospora bellia fd prda

prd ravr rp,

pa w hiV/AiDs r r aqrd

t- df,13 a a fd

p ravr.19,20 i a

prf ad war darra. i a fd fa r f fd,

dag a pr pr ra

k.21 ia ra AiDs pa da

a f ra ar gr dvpg

r.

Microsporidium

Enterocytozoonbieneusiad Encephalitozoon

intestinalisar pag aad

Entamoeba histolytica

Entamoeba histolytica aav ag

f aa. i a rga a a

pad darra da ad vav

da a vr a. E. histolytica g a a f ad

p 100 000 da ppa wr

d. t ajr f f r

cra ad s Ara, Afra ad ida

. t rk ravr parad

a d f rga.14

t ajr f pa w av

apa r w v da w a grada

f darra w grad ada

dr. Fvr a aad w

a da. m ad/r d a

pr f rga pra w wa

ad a a daag.

ivav da, pfa vr a,

ar rar; p d fvr, aa ad

rg ppr qadra pa. Pra, prarda

r pra da g d

x f vr a. iagg f vr,

g rad r pd grap (ct)

ag, d arar a.

cfra f dag f d

apra.15

Dag f E. histolytica rp pr, w v ragg fr 3050%

v w pa ag q ar d.

svra r pag Entamoebap

r E. histolytica, akg dff

rr df. cra aa

ar avaa ad av prvd v

ad pf pard rp. t

aa ar r prfrd a faa

p, k Giardia/Cryptosporidium

Tble 3. Tretmet optios for etiologicl gets of persistet dirrhoe

Organism First line Alternative agents Reference

Giardia lamblia Metronidazole or tinidazole Paromomycin, mebendazole,

albendazole and nitazoxanide*

28, 29

Cryptosporidium parvum Supportive therapy. Restitution of immunity with CD4+ >200 12

Entamoeba histolytica Metronidazole, tinidazole paromomycin (invasive disease)* 15, 29

Cyclospora cayetanensis Trimethoprim + sulfamethoxazole Ciprofloxacin 29Isospora belli Trimethoprim/sulfamethoxazole 21

Microsporidium Supportive therapy. Restitution of immunity with CD4+ >200 22

Blastocystis hominis Metronidazole or tinidazole Trimethoprim + sulfamethoxazole 23, 24

Strongyloides stercoralis* Albendazole Ivermectin 25, 26

* Specialist advice should be sought before the institution of therapy wherever possible


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clinicalParasitic causes of prolonged diarrhoea in travellers diagnosis and management

Rprd f AustRAliAn FAmily PhysiciAn Vol. 41, no. 10, octobeR 2012 785

rapaa ad htlV-1 a pa r

Strongyloidesprf dr, w

a a g ra.25,26

srg fr pr f Strongyloides

rrd ravr w pr darra

r w pa warrad gv a

-f p. crr rg

d d agar pa r r rg.

sk pa adv fr ra f

Strongyloidesf a f dd.25,26

Nonparasitic causes ofchronic diarrhoea

i pra rr a darra a

p f a r da;

a a d a rav prdd

pd. Pa w av pr darra

dp gav rg fr para

d frr vgad. Frr ag

dr ar w Table 4. Rfrra fr

pa fw p warrad w r

ad xaa ar ggv f pa

ar (. ag f w a aad w

dg, fa r f ar, ada r

ra a), faar w da, a

da r gg p xpad

vga.27

Prevention of parasitic

infections in the traveller

ma f ax fr prv f ravr

darra ra r fr prv f para

f. Table 5w adv a a gv

fr rav. t adv d ra

ad p rar a g wdd r vr

dad. A rr r a ravg a a

kark r a p-rav kg ard a p

rfr adv. Table 6prvd xap

p ag a a gv ravr.

Key points

Pr darra ravr

ad prza para.Giardia rga, fwd

Cryptosporidiumad E. histolytica.

s rp d w ag-

pf z aa gv g

v f d.

if w E. histolyticaad Strongyloides

a da a vr a a

prf dr rpv.

b ar fr pf aa df

ag gg darra afr ffv

ra.

hiV/AiD pa ar a a grar rk f

prgd f w pa da

p.

cdr para a f darra

r dffra dag, dg C. difficile

a da, faar w da a

ardra aarp.

Prv avd dag ravr

fr rav ad advg p rag

avd f, a avdg aad

war ad fd r ad vrg f.

AuthorAdrw sak mbbs, bApps(mr), jr

a ffr, Dpar f ira md, G

ca hpa, Qad. a.ak@ga..

cf f r: dard.

References1. lk DFm, R Jmb. 9: if rr

ravr. md J A 2002;177:2129.2. sa n, DP hl, Ra DJ. Ga g f

ravr darra: a rvw fr 1973

Tble 5. advice before trvel regrdig voidce of prsites

Use extra caution when travelling in areas of low sanitation and poor sewage

treatment

Consume only bottled water (make sure that the lids are sealed)

If necessary, water can be made safe by boiling, filtering or iodination/chlorination

Avoid high risk foods such as unpeeled vegetables, fruits and items washed in

untreated water

Clean hands frequently consider ethanol-based handwash

Avoid contact such as swimming in suspected contaminated lakes/rivers or other

water sources, especially where there is no sanitation the faeces has to go

somewhere, and where better to wash your bum than in the local river?

Avoid walking around in bare feet in mud or rainforest areas If HIV positive or immunocompromised, you are at a greater risk of more chronic

debilitating disease. Know your status and your CD4+/viral load before travelling

Tble 6. Simple dvice for ptiets to void dirrhoel illess

while trvellig

The ABCD of avoiding diarrhoea

A Avoid anything that may be contaminated with faecal material. Water and food

are the biggest culprits

B Bottled water is the safest option. Check seals and method of purification

C Clean and Cover: Wash hands thoroughly using an alcohol based cleanser. Cover

your feet

D Disease: if you are immunocompromised, you are at risk of a wider range of

disease. Take extra caution and tell your physician this when you get unwell so

they can look for different pathogens

Remember: its all about hands, feet and mouth when it comes to diarrhoea

Hands Wash your hands using an alcohol-based cleanser before and after toileting

and eating

Feet Parasites can burrow their way into your body: shoes are a great way to stop

this happening

Mouth Think about what you put in your mouth: is it likely to be contaminated with

unseen faeces?

Tble 4. noprsitic cusesof persistet dirrhoe i the

trveller

Coeliac disease

Clostridium difficile

Medication induced

Hyperthyroidism

Inflammatory bowel disease

Postinfectious lactase deficiency

Carbohydrate malabsorption

Colorectal cancer


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786 Rprd f AustRAliAn FAmily PhysiciAn Vol. 41, no. 10, octobeR 2012

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parasitic related diarrhea in travellers

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