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admin | What Cures Bv | 21.12.2013
This week at Infection Landscapes I will cover onchocerciasis, which is more commonly known as "river blindness" for reasons that will shortly become clear. The symbiotic relationship between this helminth and a bacterium constitutes another critical, and fascinating, component to the worm's life cycle.
Black flies occupy a fascinating ecology, which conforms to specific features of the landscape even though they are widely distributed throughout the world.
The larvae further develop into pupae under the water and finally emerge from the water as adults in a bubble of air. Lymphadenopathy presents as the microfilariae locate in lymph nodes, with pronounced nodules commonly developing at these sites. There is increasing evidence that the potent inflammatory response stimulated by the microfilariae is due to O. Accordingly, in endemic areas, infection transmission is associated with residential or occupational distance to flowing rivers and streams in mountainous terrain.
These features of black fly ecology and subsequent landscape of transmission make vector control an extraordinarily difficult, and largely unfeasible, approach to the prevention of onchocerciasis.
More generally, de-worming campaigns do offer some hope, even for regional elimination of onchocerciasis. A rash is the abnormal change in the skin and this change affects the texture, color and appearance of the skin. Itching is an unpleasant feeling in the human body that causes the reflex or desire to scratch.  Research has proved that itching has a number of similarities to pain but their behavioral response patterns are different. Rashes can be of two types, they could either induce an itching sensation or they might be non itchy rashes. Infants often suffer from itchy rash due to infection, dry skin or as a result of overactive glands in the infant.  Itchy rashes in infants can be petechial rash which are serious and require immediate medical attention or they can be erythematous rash which are usually not as serious as the petechial rashes.
Certain childhood diseases cause red itchy spots in children and this condition is known as Exanthem. Itchy rashes are a common cause of worry during the last five weeks of pregnancy when the stretching of the skin is the greatest; however this condition clears with delivery.
Many a times itchy rashes also appears s itchy red bumps and this could be due to various causes such as insect bites, acne, razor bumps, presence of a foreign object in the skin, side effects of various drugs, infection, immune deficiency or as a reaction to external stimuli. Itchy nevuses is another type of itchy rash that is a chronic condition where in the delimited rash appears on the mole or macule of the affected individual.
Itchy rashes also appear as itchy scaling patches in case of fungal infections and genetic disorder.
In severe cases itchy rashes are characterized by itchy red patches that have blisters, crusts or are scaling.  Some of these conditions are severe sunburn, photosensitivity, sever cellulitis, shingles, cold sore, eczema, impetigo, paronychia, scabies, paget disease, pompholys and more. Other than the above mentioned conditions, itchy rashes could also be an indicator of other internal diseases. When checked, Shutterstock's safe search screens restricted content and excludes it from your search results. In the past, diaper contact dermatitis was usually localized to moist peri-genital and peri-anal skin locations.
Presentation of pityriasis that shows the typical "Christmas tree" dermatone distribution on the back but more extensive rash on the arms and legs.
Post treatment with antibiotics for MRSA and antifungal for tinea capitus, this child's inflammation has markedly improved but the child will likely still have patches of permanent alopecia due to severe damage to the hair follicles. Palmoplantar keratoderma is a chronic condition manifesting in early childhood with marked thickening of the skin of the palms and soles and areas of rash on body pressure points and sites of recurrent friction.
Acanthosis and circular lesions of superficial fungal infection complicate atopic dermatitis with hyperpigmented patches on his shoulders in this overweight youth with insulin resistance. The helminth causing this infection is vector-borne, adding further complexity to its transmission dynamics. Onchocerciasis is caused by Onchocerca volvulus, which is a nematode, and transmitted to humans by Simulium black flies. Wolbachia is a genus of bacteria that commonly infects many species of insects, and a few species of nematodes. Much like most adult mosquitoes, the males subsist on plant juices alone while females also seek out the blood of vertebrate hosts. Onchocerciasis pathogenesis is due to the microfilariae and the Wolbachia that infect them. In minor, low volume infections, the infection may be entirely subclinical, but can also present with mild itching or discoloring of the skin. Interestingly, there are geographic differences in the lymphatic sites that are most often involved. However, because the microfilariae can invade any structure in the eye, pathology can also derive from damage to the posterior eye, including the retina and optic nerve.
As such, communities in close proximity to moving water are at high risk in topographically varied areas of endemicity. As described above, vector control of onchocerciasis is too difficult to achieve success at the population level. While conditions such as goose bumps, roseola, skin tags and warts are non itchy, conditions such as bumpy hives, folliculitis and acne are itchy in nature. Petechial itchy rashes may be caused by meningococcal infection, enterovirus infection, or due to tight clothing or even due to forceful coughing or vomiting. Exanthem is often coupled with headaches, high fever and malaise and is caused by bacteria or virus infection or as reaction to the toxin of these viruses or bacteria or as an immune reaction. Irritation caused due to alkaline saliva is one of the most common causes for itchy rashes around the mouth. During the last three months of pregnancy, pregnant women will notice itchy bumpy reddish rashes on the stretch marks on the abdomen and this condition is known as Polymorphic eruption or Polymorphous Eruption of Pregnancy.
These itchy red bumps may or may not be painful depending on the conditions and each condition has to be treated separately depending on the cause of the itchy rashes.
Some of these conditions are Nodular prurigo where in a number of itchy red nodules that has a warty surface appears on the limbs, Erythema nodosum which affects the lower legs, forearms or thighs and is characterized by raised red patches on the skin caused due to Tuberculosis or as a side effect to certain drugs. Some of these conditions are mild sunburn, hives, Angioedema, Scombroid fish poisoning, Pityriasis rosea, Amyloidosis, Granuloma annulare and Dermatomyositis. Fungal infections are associated with scaly areas and they can infect the feet, groin, body or scalp and are mostly caused due to ringworm infection. At times contact with certain plants such as chrysanthemum or even nettle can sure itchy rashes with blisters. In the case of skin cancers which could be squamous or basal cell carcinoma and melanoma tend to appear as ulcers on the skin. These conditions are mostly caused due to fungal infections, sexually transmitted diseases, clogging of sweat glands, cyst, lice and more.
This condition is called as Onychomycosis which causes the ends of the nail to turn white or yellow and causes the nail to become fragile.
Some of the diseases that have itchy rashes as one of their symptoms are liver diseases, Chron’s disease, kidney disease, Celicac disease, Chemochromatosis, Schistosomiasis, Lymphomatoid granulomatosis, drug induced jaundice and more. Superficial inflammatory conditions such as diaper dermatitis, seborrhea, tinea versicolor, and pityriasis alba are common conditions which frequently result in hypopigmentation that resolves over a period of a few months. Contact Dermatitis:Contact dermatitis to a metal fastener on a pair of jeans that has produced hyperpigmented papules coalescing to a plaque on this child's abdomen. Chicken Pox (Varicella) This child has hyperpigmented macules scattered over her body from chicken pox.
Superficial LacerationA superficial laceration has produced hypopigmentationwith surrounding hyperpigmentation in this patient. Atopic DermatitisThis teen has severe pigmentary changes from inadequately treated atopic dermatitis. This child has a patch of nummular eczema, with coalescing papules around the pilar opparatus (located just below the nipple on the chest).
Lichenification:This child with severe atopic dermatitis illustrates the tendency of children with dark skin to develop very unsightly lichenification where they have a chronic dermatosis and puritis.
Although they are often seen in the lumbosacral and gluteal areas they are not limited to those regions. Transient Neonatal Pustular MelanosisThe hyperpigmented macules and vesicles seen on the face and neck of this newborn infant are characteristic of transient neonatal pustular melanosis (TNPM).

They can often be confused with herpes simplex, but usually can be distinguished on clinical grounds. Timea corporis - Classic Presentation:Tinea corporis is extremely common in children of all ethnic backgrounds, but sometimes may have a different appearance in children with dark skin.
Tinea Corporis without Erythema:Tinea corporis often presents without any erythema in children with dark skin as is illustrated in this photo. Tinea Corporis at HarilineTinea corporis at the hairline, which goes into the scalp, needs to be treated systemically with oral anti-fungal agent such as griseofulvin. Herald Patch of Pityriasis RoseaThis lesion looks very similar to tinea corporis but actually is a herald patch seen at the onset of pityriasis rosea.
Pityriasis Rosea - Classic PresentationThe oval shaped plaques of confluent scaling papules, distributed along the dermatomes, are characteristic of pityriasis rosea in children. Pityriasis Rosea - inverse distribution on armsChildren with dark skin often present with an inverse distribution of lesions in pityriasis rosea.
The large patches on the right leg appeared first and were initially thought to be tinea corporis. Lichen Nitidus vs Lichen StriatusThis child has a line of skin colored papules stretching from the upper thigh to the ankle.
Pityriasis AlbaThe hypopigmented patches on this child's left cheek is characteristic of pityriasis alba. For unknown reasons, tinea capitis is much more prevalent in the United States in African American children than in children of other races. The current epidemic of this illness often presents with a seborrheic-like scaling in the absence of alopecia.
The lesions are less erythematous on the background of darker skin but typical "burrows" can be seen from the mite under the skin and secondary infection causes impetigo lesions where the child scratches their skin. Tinea Versicolor - hyperpigmentedThese lesions are examples of the hyperpigmented variation of tinea versicolor. Tinea Versicolor - HypopigmentedThe name tinea versicolor refers to the variable coloration of lesions. Pseudofolliculiltis BarbaePseudofolliculitis barbae is a foreign body reaction that occurs when arcuate hairs curve upon themselves and re-penetrate the skin. Hypopigmentation from Tretinoin (Retin A) UseThis teen's acne improved with Retin A, but hypopigmentation developed on the cheeks where it was applied more densely.
Henna and contact DermatitisThis East African girl developed a severe contact dermatitis with itching at the site of an elaborate skin decoration with henna. Coining in a ChildCoining is a common healing practice used among Asian patients within the United States. Coining TechniqueThe lesions seen in coining are produced by rubbing a warm oil or Tiger Balm on the skin and firmly abrading the skin with a coin or special instrument as is illustrated in this photo. Circular Burns from Traditional HealingPatterned circular scars around the umbilicus in this East African child were produced by traditional treatments for illness. Circular Burns on ScalpThese circular lesions were produced by traditional burning treatments in an East African boy.
ScarringThese diagonal scars at the top of the buttocks were from cuts made in the skin by the grandmother of this East African child "to help her walk" when she was about 9 months of age.
As the second leading infectious cause of blindness in the world, onchocerciasis is also associated with a large burden of disease, particularly in sub-Saharan Africa.
These ubiquitous bacteria can engage either parasitic or symbiotic relationships with their hosts. When the larvae emerge from the eggs they remain submerged and anchor themselves to fixed objects, typically rocks, in the bed of the lotic environment. The adult worms are effectively sealed off from the host's immune system in their subcutaneous nodules.
For example, in the Americas the lymph nodes of the head and neck are more frequently affected, whereas in sub-Saharan Africa the femoral and inguinal lymph nodes are more commonly affected. As mentioned above, these bacteria are necessary catalysts to the larval development of this helminth in the black fly.
However, transmission is not exclusive to these sites because some Simulium species have broad flight ranges that extend well beyond (up to 40 miles for some species) their reproductive sites. Currently, prevention and control strategies, primarily led by the African Programme for Onchocerciasis Control (APOC) and Onchocerciasis Elimination Program for the Americas (OEPA), employ therapeutic and prophylactic administration of ivermectin, which is very effective against filarial helminths, but cannot be administered to individuals who are infected with Loa loa nematodes as it causes severe reactions in the host that can lead to extensive secondary disease. The difficulty in addressing this issue seems immense given the improbability of effective vector control.
Some of the diseases that cause red itchy spots are chicken pox, which causes rashes over the face and the trunk, Measles, which casus itchy rashes on the trunk, face, limbs and mouth accompanied with cough. Scalp ringworm infection is also responsible for itchy rashes coupled with scaly skin and hair loss. This condition is also known as PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy) and is often noticed during the first pregnancy as the abdomen is the tightest at this stage. Some of these itchy red bumps are even gender specific such as Perioral dermatitis, which causes scaly rashes around the eyes and mouth in women and Grover’s disease which almost always appears only in men who are unwell and over 50 and is characterized by the pimple like red bumps appearing on the back and chest.
Psoriasis causes itchy rashes due to genetic disorder and it affects the knees, elbows, genital area, scalp and other parts of the body. Gravitational eczema often appears on the lower legs of a person suffering from thrombosis or venous diseases. While dandruff and scalp ringworm are the main culprits for itchy rashes on the scalp, ringworm infection of the beard and fungal infection of the groin and inner thighs causes itchy rashes on beard and groin.
In such cases, itchy rashes often disappear, when the treatment for the internal diseases are successful. The papules will resolve with corticoid steroid treatment and removal of contact with metal, but the hyperpigmentation will last for months. These lesions can be prevented by appropriate vaccination of children 12 months and over with the varicella vaccine. This superficial inflammation usually resolves with temporary hypopigmentation at the site of lesions over 6 to 8 weeks. This lichenification and hyperpigmentation is very slow to resolve even with regular treatment with topical steroids. Intrauterinely acquired herpes infection can present with vesicles and pustules at birth, but most of these infants have intrauterine growth retardation and microcephaly. This is a typical lesion of tinea corporis: an annular shaped lesion with raised margins, clearing in the center and some erythema.
The lesions may be more difficult to see in children with darker skin pigmentation and as noted earlier, often have a more papulofollicular appearance.
Rather than appearing on the trunk, as in the prior photo, they primarily are distributed on the arms and legs as is illustrated in this photo. It usually does not respond to topical steroids and resolves without treatment over a period of months, but the duration of lesions is variable.
Fifteen percent of African Americans who visited an outpatient clinic for non-dermatological reasons were found to be infected in a recent study.
This non-inflammed presentation leads to delayed diagnosis and spread within the household. The plaques and patches are slightly raised, usually circular, often on the neck and upper face, but commonly on the chest, back, and under the breasts in adolescent girls. This creates pustules and papules as illustrated on the back of the head of this young man who has shaved his scalp. The hypopigmentation resolved with shortening the duration of Retin A application to 2 hours and adding an oral antibiotic to prevent the inflammatory lesions. This is commonly seen with tight hair braids or tuffs and is found in individuals from many different ethnic backgrounds. Initially they were confused with alopecia from tinea capitis but the history indicated that they had been produced by a traditional treatment for chronic ear infection.
Scars are also common on the face as cosmetic and religious decoration in many African groups. Like coining, cupping is done to release wind from the body and thereby restore balance and health. In the case of the Wolbachia-Onchocerca-Simulium triad, an extraordinarily complex symbiosis has evolved wherein O.

The females are day biters and host preferences differ by Simulium species, as does their geographic range.
The microfilariae, on the other hand, are in direct contact with blood and tissue and, thus, with the host's immune system. Early infection usually presents with a tearing, irritated conjunctivitis, often with a hypersensitivity to light.
However, these bacteria produce potent molecules that are proinflammatory to the human host. The vast majority of these occur in sub-Saharan Africa, however, there are small localized areas of endemicity in Central America and in the warm, moist, yet mountainous altitudes of northern South America. Therefore, while risk of infection is certainly concentrated at the reproductive sites of fast moving water, the overall endemicity is typically more diffuse, and geographic risk more extensive, than the narrow corridor delineated by the waterway. For example, a person suffering from severe psoriasis will suffer from itchy rash condition where as an individual suffering from mild psoriasis may not feel the urge to itch. Erythematous itchy rashes could be caused due to eczema, viral skin rash, diaper rash, thrush, measles and  heat rash. Some of the other diseases that cause this red itchy spots condition are Fifth disease, hand foot and mouth disease, Hepatitis B, Roseola infantum, scarlet fever and more. While most of these conditions are associated with certain infections, allergic reaction or other internal diseases, the casues of some of these conditions remains unknown. Fox-Fordyce disease is another disease that causes itchy rashes in the armpits or groins due to the clogging of sweat glands in young women between the age of 13 to 35 years.
It is a very common practice in many ethnic groups to do ear piercing in early infancy which may help to avoid keloid formation. Compared to a bruise they are more uniform in skin color, their borders are better defined, there is no induration or tenderness and they are stable over time.
They are more common in term infants and are almost always seen at birth or soon after birth. Perinatally acquired herpes infection usually does not present with vesicles until day of life 5 - 17. The lesions of lichen striatus appear similar to those of lichen nitidus, but have a linear distribution.
Early treatment of acne, when it is mild, is important to prevent the long lasting hyperpigmentation and scars. The alopecia can be permanent if there are large areas that are not recognized and treated appropriately by loosening the traction on the hairs.
When applied to the fingertips, black henna has been found to interfere with measurement of oxygen saturation from a fingertip. It is also used with a wide variety of febrile illnesses as well as stress related symptoms in adults such as headaches, muscle aches and pain, low energy. The child complained that this cupping, done by a grandmother hurt, but that it did not hurt when done by mother.
Fully formed microfilariae are released from gravid adult females in an infected human host. As such, the microfilariae are capable of stimulating a potent inflammatory response in the host, which leads to disease. As the microfilariae die, these bacteria are released and subsequently interact with the human immune system, thus leading to the inflammatory responses associated with onchocerciasis. It seems as if many of these infections share the same conditions in terms of occurring in resource poor, hard to reach areas, and whose treatments could result in resistance if not done properly. Adequate topical corticosteroids, oral antihistamines and moisturizing agents to prevent itching, and early recognition and treatment of secondary bacterial skin infection can help prevent this cosmetically disfiguiring change in pigment. Although pustules are present and a culture may show bacteria, it is not necessary to treat with antibiotics. Treatment consists of avoiding a close shave, shaving with an electric razor and applying a depilatory chemical cream. Benzoyl peroxide which is commonly used in over the counter acne preparations, is a bleaching agent and produces lightened skin color with overuse.
However, some patints with contact dermatitis who have subsequently had patch tests with lawsone, the active ingredient in henna, have not shown a reaction. The practice produces linear petechiae and ecchymosis on the chest and back which resolve over several days.
When a susceptible Simulium black fly takes a blood meal from this infected human host, the fly ingests the microfilariae with the blood.
Without this bacterial infection, the helminth larvae cannot develop and their life cycle is arrested.
In high volume infections, the itching can be so severe that it renders those affected physically disabled and can sometimes even result in suicide. This stage of infection is probably an inflammatory response similar to that induced in the skin. In fact, antibiotic treatment to eliminate the Wolbachia from the microfilariae has been associated with a drastic reduction in blindness among the chronically infected even without clearance of the helminths.
Excoriated acne, impetigo, varicella, lupus, infected atopic dermatitis, contact dermatitis, and scars from burns, lacerations and abrasions are common conditions which cause long-lasting hyperpigmentation.
This child developed many other skin colored papules over the trunk during the next few months. The patches tend to be more prominent in the summer and fall as the child's normal skin tans and gets darker with the sunlight exposure whereas the affected areas remain paler. In newborn infants there is enough transcutaneous absorption of the active agent in henna, lawsone (a potent oxidizing agent), to produce hemolysis of red blood cells and indirect hyperbilirubinemia. This suggests that there are other unetermined ingredients in henna powders which are allergens. Upon reaching the gut of the fly, the microfilariae pass out of the gut and migrate to the thoracic flight muscles, where they proceed with their first (J1) and second (J2) larval stages of development. With chronic infection, onchodermatitis can be quite taxing on the skin, with a general thickening and hardening and subsequent development of a "lizard skin" appearance. When they were biopsied the histopathology of the lesions was found to be characteristic of lichen nitidus.
The presence of the lesions usually indicate that the child was very sick at one time and western medical treatment was not available or had not been effective.
J2 larvae migrate to the saliva of the fly where they further develop into the infectious third stage larvae (J3).
Depigmentation is also common in chronic infections wherein the skin can take on a leopard-like appearance. However, a sclerosing keratitis develops among those with chronic infection, which is common in areas of high endemicity.
Informing the parents to anticipate hypo-pigmentation as a part of the natural healing process helps to improve compliance with topical treatment. However, it may produce intense inflammation which can result in hyperpigmented patches on the face that are very slow to resolve or hypopigmentation as in the case above.
It is useful for the provider to ask about how the child was ill at the time they received the treatment. When the black fly with infectious J3 larvae takes a blood meal from a susceptible human host, these larvae enter the bite wound and migrate to subcutaneous tissues, where they form nodules and undergo their final developmental stage into adult worms. Stronger forms of tretinoin (0.1% cream) have been used to successfully lighten post inflammatory hyperpigmentation from acne in adults with 40 weeks of nightly treatment.
After mating, females produce an average of 700 eggs per day over the course of their adult lives, which average 8 to 10 years.
Each microfilaria produced can live for an average of 1 to 2 years before it dies, giving these organisms ample time to encounter another black fly and carry on through the life cycle.
The graphic below, produced by the Centers for Disease Control and Prevention (CDC) is a nice depiction of the life cycle of O.

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