Parasitic Infection

Parasitic infections are common throughout the world but until recently differences between effects on women and men have not been studied. Due to the increase in international travel and the immigration of people from tropical areas to more developed countries, physicians are likely to see an increase in tropical disease with both common and uncommon presentations.

Pretravel advice for women should include a risk assessment as to potential exposure to parasitic disease. Knowledge about how a particular disease might affect

WOMEN'S HEALTH AND TRAVEL Table 24.12 Potential effects of parasitic infection on reproduction

Parasites

Impaired fertility

Failure to carry to term

Fetal infection

Protozoans

Entamoeba histolytica x

Giardia lamblia x

Leishmania spp x

Plasmodium spp x

Trypanosoma spp x

Toxoplasma gondii Pneumocystis carinii

Intestinal nematodes

Ascaris lumbricoides x

Enterobius vermicularis (pinworm) x

Trichuris trichiura (whipworm) Hookworm x

Extraintestinal nematodes

Strongyloides stercoralis x

Trichinella spiralis x

Filaria spp x

Trematodes

Schistosoma spp x

Clonhorchis sinensis x

Paragonimus westermani

Cestodes

Echinococcus spp x

Taenia spp x

Adapted from Lee RV (1988) Medical Complications During Pregnancy (eds GN Burrow and TF Ferris). WB Saunders, Philadelphia; and Manuel, Elaine C. Jong and Mcmullen Russel (eds) (1995) Travel and Tropical Medicine, p. 156. WB Saunders, Philadelphia.

her long-term fertility or pregnancy outcome might make a difference to a traveler's compliance with preventative measures or bring about a change in itinerary so as to avoid the risk of exposure (Table 24.12).

After travel, women should be asked about travel history if they have recurrent gynecological symptoms or are in the process of an infertility workup or breast-mass evaluation. Parasitic worms such as Ascaris spp. amd Enterobius vermicularis have been found on Pap smear results. Amebiasis can result in ulcerating lesions and unusual vaginal disharge in some cases (Hammill, 1989). Breast masses are not always malignant: they can be parasitic in a woman with the appropriate travel history (Sloan et al, 1996; Perez et al, 1997).

Parasitic infection as the only or concomitant cause of infertility in Caucasian women is rare to date; however, with the burgeoning increase in travel for work and play, parasitic causes of infertility will increase. Parasitic infections may be found in unusual places if there is an index of suspicion. An interesting case of microfilariae in follicular fluid was recently described in a case report (Goverde et al., 1996). The case involved an infertile woman undergoing in vitro fertilization. Her infertiliy was presumed to be due to Chlamydia trachomatis but moving microfilariae of Mansonella perstans were found in the aspirated follicular fluid during the in vitro fertilization procedure. The woman was also found to have schistosomal infection. Although the authors do not believe a case similar to this has been reported, it is probably because microfilariae and other parasites have not been looked for routinely in the female genital tract.

Thus, physicians evaluating women immigrants or world travelers for infertility and other gynecologic problems should consider parasitic infections in the differential diagnosis (Balasch et al., 1995). Clinicians evaluating pregnant women should also review past travel history during their prenatal visit owing to the risk of an accelerated course of some tropical diseases during pregnancy and/or congenital transmission.

Parasitic diseases in women may have effects on fertility, during pregnancy and throughout the life stages as a result of a variety of mechanisms (Stray-Pedersen, 2000).

The infecting parasite may cause anatomic or functional changes in the genital tract so that conception or implantation does not occur, owing to scarring and inflammation of the fallopian tubes or infiltration of the uterine lining. The parasitic infection may be severe enough to affect maternal health adversely during pregnancy, to the point that pregnancy termination is required. The parasites may infect and cross the placenta

Table 24.13 Tropical parasitic infections: issues specific to women

Parasite/Infection

Issues specific to women

Prevention

Treatment

Intestinal nematodes

Ascariasis

Enterobiasis (pinworm)

Hookworm

Ancylostoma duodenalis Necator

Strongylodiasis

Tissue nematodes

Wucheria bancrofti

Brugia malayi

Trichinella spiralis

Trematodes

Schistosomiasis (Female genital schistosomiasis, FGS)

Adult worms can invade the female genital tract and cause tubo-ovarian abscess, pelvic pain and infertility

Pinworms can migrate and ascend the genital tract causing vaginitis and pelvic inflammatory disease Pregnancy can exacerbate the symptoms of vaginitis and pruritus vulva

Can cause severe anemia, causing intrauterine growth retardation during pregnancy

Hyperinfection can occur during pregnancy due to immunosuppression Lactation is contraindicated until after treatment as larvae may be passed in milk to infant

Adult worms inhabit lymphatics and regional lymph nodes. Acute and chronic inflammation can lead to obstruction of the lymphatics and edema of the breast, vulva and pelvic organs

Adverse effect on fertility and lactation Elephantitis of vulva may obstruct labor and necessitate C-section Pregnancy may exacerbate edema and chyluria

May be associated with hydramnios Microfilaria can invade placenta and fetus

May disrupt menstrual cycle

May cause abortion, premature labor, stillbirth

? Intrauterine infection

The female genital may be infected with eggs of S. mansoni and S. haematobium Acute and chronic inflammation of the fallopian tubes and ovaries can lead to salpingitis, infertility, ectopic pregnancies

Lesions of the cervix, vagina, vulva may ulcerate and be painful with intercourse

May facilitate transmission of HIV from infected men to uninfected women May need surgery prior to vaginal delivery

Schistosomiasis may affect the placenta and the fetus; however, there is no evidence of growth retardation or preterm delivery to date No evidence that pregnancy accelerates the development or increases the severity in the mother

Food and water precautions

Good personal hygiene

Do not walk barefoot

Do not walk barefoot

Avoid mosquito bites

Avoid mosquito bites

Avoid eating pork, boar or bear

Avoid water, infested areas

Pyrantel pamoate

Treat in pregnancy only if severe infection

Mebendazole

Albendazole

Mebendazole

Albendazole

Pyrantel pamote

Treat only if severe infection

Mild cases treat with iron, vitamins, protein Severe cases pyrantel pamoate 11 mg _i kg daily for 3 days

Postpone treatment in asymptomatic women until after delivery Severe infection thiabendazole, ivermectin

Treatment should be avoided until after delivery; diethylcarbamazine

Treatment should be avoiled until after delivery; diethylcarbamazine

Pyrantel pamoate active against ingested larve Once tissue invasion need thiabendazole

Praziquantel

May treat if necessary during pregnancy

WOMEN'S HEALTH AND TRAVEL Table 24.14 Indications for treatment of intestinal nematodes during pregnancy

Parasite

Infective state

Mode of transmission

Adult habitat

Indications for prescription in pregnancy

Enterobius vermicularis

Egg

Ingestion

Cecum

None

(pinworm)

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