History

Fact Explanation
Limb pain Dracunculiasis is an infection of the nematode Dracunculus medinensis, which is also referred as the guinea worm. This disease is progressing toward global eradication and now has been reporting only from 3 endemic countries, namely Sudan, Mali, and Ethiopia. The human encounter the disease by drinking water contaminated by water fleas (Cyclops species) which have ingested the Dracunculus larvae. They penetrate the intestinal mucosa and become mature in abdomen or retroperitoneal space. Then 1 meter long adult worm migrates to the subcutaneous tissue of the lower limb. As the worm moves through the subcutaneous layer, it causes severe pain for the human host. [1,2,3,4,5,6]
Skin rash When the adult worm migrates along the subcutaneous tissue, it triggers an allergic reaction. Blisters are formed. The leg become erythematous and swollen due to obliterated venous return. These skin changes are accompanied by fever, nausea, and vomiting. [1,2,3,4]
Emerging worms The worm eventually emerges through the skin usually at the feet. As it emerges, the blisters are erupted and the worm releases a collection of larvae-containing fluid. [3,4,5,6]
Ulcer The site of the worm began to emerge usually develop in to an ulcer. The ulcer grows as the worm continuously comes out of the host's leg. [2,4,6]
References
  1. GULANIKAR A. Dracunculiasis: two cases with rare presentations. J Cutan Aesthet Surg [online] 2012 Oct, 5(4):281-3 [viewed 31 July 2014] Available from: doi:10.4103/0974-2077.104918
  2. CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC). Imported dracunculiasis--United States, 1995 and 1997. MMWR Morb Mortal Wkly Rep [online] 1998 Mar 27, 47(11):209-11 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9551880
  3. GREENAWAY C. Dracunculiasis (guinea worm disease). CMAJ [online] 2004 Feb 17, 170(4):495-500 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14970098
  4. CHOUBISA SL, VERMA R, CHOUBISA L. Dracunculiasis in tribal region of southern Rajasthan, India: a case report. J Parasit Dis [online] 2010 Oct, 34(2):94-6 [viewed 31 July 2014] Available from: doi:10.1007/s12639-010-0017-0
  5. KOREVAAR DA, VISSER BJ. A worm emerging from the foot. Neth J Med [online] 2012 Oct, 70(8):375-9 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23065987
  6. FABIANSEN C, HARBOE ZB, CHRISTENSEN V. Dracunculiasis in South Sudan. Am J Trop Med Hyg [online] 2010 May, 82(5):757 [viewed 31 July 2014] Available from: doi:10.4269/ajtmh.2010.09-0681

Examination

Fact Explanation
Fever Fever is a rare presentation and if present, is attributed to inflammatory reaction triggered by the adult worm. [1,2,3,4]
Leg tenderness When the worm migrate along the subcutaneous layer, it causes severe inflammation. The leg becomes intensely tender. [2,3,4]
Rash The emerging site around the feet usually become edematous and erythematous. This is followed by blister formation. [3,4,5,6]
Emerging adult worm Identification of the worm head is within an ulcer is diagnostic [1,2,4,6]
Ulcer The emerging site becomes an ulcer eventually. The ulcer may become secondarily infected as the worm takes time to complete the emigration. [2,3,5]
References
  1. GULANIKAR A. Dracunculiasis: two cases with rare presentations. J Cutan Aesthet Surg [online] 2012 Oct, 5(4):281-3 [viewed 31 July 2014] Available from: doi:10.4103/0974-2077.104918
  2. CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC). Imported dracunculiasis--United States, 1995 and 1997. MMWR Morb Mortal Wkly Rep [online] 1998 Mar 27, 47(11):209-11 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9551880
  3. GREENAWAY C. Dracunculiasis (guinea worm disease). CMAJ [online] 2004 Feb 17, 170(4):495-500 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14970098
  4. KOREVAAR DA, VISSER BJ. A worm emerging from the foot. Neth J Med [online] 2012 Oct, 70(8):375-9 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23065987
  5. FABIANSEN C, HARBOE ZB, CHRISTENSEN V. Dracunculiasis in South Sudan. Am J Trop Med Hyg [online] 2010 May, 82(5):757 [viewed 31 July 2014] Available from: doi:10.4269/ajtmh.2010.09-0681
  6. CHOUBISA SL, VERMA R, CHOUBISA L. Dracunculiasis in tribal region of southern Rajasthan, India: a case report. J Parasit Dis [online] 2010 Oct, 34(2):94-6 [viewed 31 July 2014] Available from: doi:10.1007/s12639-010-0017-0

Differential Diagnoses

Fact Explanation
Filariasis Filariasis is a parasitic disease that is caused by thread-like roundworms belonging to the Filarioidea type. These are spread from by blood-feeding black flies and mosquitoes. Lymphatic filariasis is caused by the worms Wuchereria bancrofti, Brugia malayi, and Brugia timori. These worms occupy the lymphatic system, including the lymph nodes; in chronic cases, these worms lead to the disease elephantiasis which is characterized by edema with thickening of the skin and underlying tissues. Elephantiasis mainly affects the lower extremities. [1]
References
  1. CHANDY A, THAKUR AS, SINGH MP, MANIGAUHA A. A review of neglected tropical diseases: filariasis. Asian Pac J Trop Med [online] 2011 Jul, 4(7):581-6 [viewed 31 July 2014] Available from: doi:10.1016/S1995-7645(11)60150-8

Investigations - for Diagnosis

Fact Explanation
Full blood count Full blood count may show leucocytosis. Parasitic infestation is characterized by high degree of eosinophilia. [1,2,3]
Serum immunoglobulin levels IgG or IgE is elevated depending on the stage of infestation. [2,4]
Radiography Lower extreme X-ray may prove useful in identification of calcified worms. This is incase when surgery is considered [2,3,4]
References
  1. KOREVAAR DA, VISSER BJ. A worm emerging from the foot. Neth J Med [online] 2012 Oct, 70(8):375-9 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23065987
  2. CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC). Imported dracunculiasis--United States, 1995 and 1997. MMWR Morb Mortal Wkly Rep [online] 1998 Mar 27, 47(11):209-11 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9551880
  3. GREENAWAY C. Dracunculiasis (guinea worm disease). CMAJ [online] 2004 Feb 17, 170(4):495-500 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14970098
  4. CHOUBISA SL, VERMA R, CHOUBISA L. Dracunculiasis in tribal region of southern Rajasthan, India: a case report. J Parasit Dis [online] 2010 Oct, 34(2):94-6 [viewed 31 July 2014] Available from: doi:10.1007/s12639-010-0017-0

Management - General Measures

Fact Explanation
Prevention Guinea worm disease can be transmitted only by drinking contaminated water, and can be completely prevented through two relatively simple measures. Preventing people from drinking contaminated water containing the Cyclops copepod (water flea), which can be seen in clear water as swimming white specks and preventing people with emerging Guinea worms from entering water sources used for drinking are those basic measures. [1,2,3]
References
  1. CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC). Imported dracunculiasis--United States, 1995 and 1997. MMWR Morb Mortal Wkly Rep [online] 1998 Mar 27, 47(11):209-11 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9551880
  2. CHOUBISA SL, VERMA R, CHOUBISA L. Dracunculiasis in tribal region of southern Rajasthan, India: a case report. J Parasit Dis [online] 2010 Oct, 34(2):94-6 [viewed 31 July 2014] Available from: doi:10.1007/s12639-010-0017-0
  3. GREENAWAY C. Dracunculiasis (guinea worm disease). CMAJ [online] 2004 Feb 17, 170(4):495-500 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14970098

Management - Specific Treatments

Fact Explanation
Manual extraction of the worm This is done by wrapping or winding the worm at the skin surface using a stick few centimeters per day. Controlled submersion of the affected area in a bucket of water will causes the worm to discharge many of its larva, making it less infectious. The water is then discarded on the ground far away from any water source. Water will reduce the burning pain of the leg as well. Controlled traction will prevent the worm from getting broken during the process. This extraction will take hours to weeks. If facilities are available the worm also can be excised surgically. [1,2,3,4,5,6]
Topical antibiotics Are used to prevent secondary bacterial infections which is crucial because such infections significantly increases the morbidity in otherwise benign disease. [2,3,4,5]
Analgesics Analgesics such as aspirin or ibuprofen, can be used to help reduce swelling and pain. [2,3,4]
Antihelminthic drugs Usage of antihelminthic therapy is debatable as it has been found to result in infection of the areas other than the lower extremity owing to aberrant migration of worms, Still, use of metronidazole or thiabendazole may make extraction easier. [1,5,6]
References
  1. GULANIKAR A. Dracunculiasis: two cases with rare presentations. J Cutan Aesthet Surg [online] 2012 Oct, 5(4):281-3 [viewed 31 July 2014] Available from: doi:10.4103/0974-2077.104918
  2. KOREVAAR DA, VISSER BJ. A worm emerging from the foot. Neth J Med [online] 2012 Oct, 70(8):375-9 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23065987
  3. CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC). Imported dracunculiasis--United States, 1995 and 1997. MMWR Morb Mortal Wkly Rep [online] 1998 Mar 27, 47(11):209-11 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9551880
  4. GREENAWAY C. Dracunculiasis (guinea worm disease). CMAJ [online] 2004 Feb 17, 170(4):495-500 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14970098
  5. CHOUBISA SL, VERMA R, CHOUBISA L. Dracunculiasis in tribal region of southern Rajasthan, India: a case report. J Parasit Dis [online] 2010 Oct, 34(2):94-6 [viewed 31 July 2014] Available from: doi:10.1007/s12639-010-0017-0
  6. FABIANSEN C, HARBOE ZB, CHRISTENSEN V. Dracunculiasis in South Sudan. Am J Trop Med Hyg [online] 2010 May, 82(5):757 [viewed 31 July 2014] Available from: doi:10.4269/ajtmh.2010.09-0681