Answers

1. D. Trichinosis should be suspected in a patient who has any of the cardinal features of periorbital edema, myositis, fever, and eosinophilia. Infection is acquired after consumption of inadequately cooked pork, bear, or walrus infected with viable larvae. Stool examination does not contain the eggs of the parasite but may contain larvae. Muscle biopsy from a tender, swollen muscle (preferably deltoid or gas-trocnemius) may establish the diagnosis, but a negative biopsy does not exclude this infection, especially in light parasitemias. Suramin is not used in trichinosis. Although thiabendazole is effective, mebendazole is the drug of choice, and frequently steroids are also used for severe symptoms.

2. E. TPE is caused by microfilariae in the lungs and hyperimmune responsiveness to bancroftian or malayan filariasis. Paroxysmal respiratory symptoms may fluctuate in severity. Eosinophilia, almost always present, is usually very high, and the absence of microfilariae in the blood does not rule out TPE. A presumptive clinical diagnosis can be made by response to therapy without a lung biopsy. Diethylcarbamazine for 14 days is an effective therapy that can be repeated if symptoms persist. The role of ivermectin in TPE has not been established.

3. D. In the United States intestinal helminths produce mild disease with nonspecific findings. Piperazine or pyrantel pamoate may be used for the treatment of ascariasis. Mebendazole is an effective drug to be taken for 3 days. Thiabendazole is not used in this condition but is used commonly in strongyloidiasis. Albendazole at a single dose of 400 mg is the preferred mode of therapy. It is a convenient agent for mass treatment programs that target school children in endemic areas.

4. C. Albendazole (approved by the U. S. Food and Drug Administration for this indication) has a 90% efficacy rate in neurocysticercosis. The initial therapy of parenchymal disease with seizures should focus on symptomatic treatment with anticonvulsants. However, while destroying the cyst, albendazole may result in a profound parenchymal brain reaction and in severe neurological defects or retinal damage (i.e., loss of vision and optic neuritis) in eye lesions. Corticosteroids should be given concomi-tantly in these situations. In ventricular disease with obstructive hydrocephalus, surgery with shunting can be helpful. Treatment with niclosamide or prazi-quantel should be considered later to eliminate the adult tapeworm in the gut and prevent further reinfection. Neither piperazine nor thiabendazole is effective in this indication.

5. A. D. latum, the fish tapeworm acquired from consumption of raw fish in endemic areas, is best treated with praziquantel or niclosamide. Ivermectin is effective for filarial infections, especially O. volvulus. Albendazole, although highly effective in some tapeworm infections, is not used in fish tapeworm infections. Vitamin B12 deficiency is due to the parasite competing with the host for the vitamin, sometimes absorbing 80% of ingested amounts. Patients may develop megaloblastic anemia and mild to severe central nervous system manifestations (subacute combined degeneration of spinal cord). Mild B12 deficiency should be treated with vitamin injections in addition to specific drug therapy. Piperazine, a roundworm treatment, is not used for this indication.

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