FACULTY OF MEDICINE UNIVERSITY OF ALEXANDRIA

ARTHROPODS AS AN ETIOLOGICAL CAUSE OF SKIN DISEASE

SEMESTER 3 (2011/2012) TUTOR: DR. SHEREEN MOSALLEM STUDENT ID NUMBER: (10-2) 241-250
1

GROUP MEMBERS:
10-2-241-NAWAR NADHRAH BINTI ABDUL WAHID 10-2-242-NUR AFIQAH AUNI BINTI ZAWAWI 10-2-243-NUR AFIQA BINTI ROSLAN 10-2-244-NUR AKMA BINTI ZAINAL SHAHROM 10-2-245-NURUL IMAN BINTI ZULKEFLI 10-2-246-NURUL AQMAR BINTI MOHD SUHAIMI 10-2-247-NURUL BAINUN BINTI AHMAD SHAFRI 10-2-248- NURULZIANI IZZATI BINTI MOKHTAR 10-2-249- NURUL SHAZWANI BINTI SAARI 10-2-250-NURUL ATIQAH BINTI SAHMAH

Contents:
1. Introduction..4 2. Objectives...........5 3. Introduction of Arthropods.6-9 4. Scabies....10-12 5. Tungiasis....13-15 6. Chiggers Disease...16-19 7. Plica Polonica..20-23 8. Vagabonds Disease...24-27 9. Phthirus Pubis...28-35 10. Cutaneous Myiasis..36-39 11. Fleas, Mosquito and Ticks Bites40-46 12. Arthropods as Vector, Transmitting Skin Disease....47-51 13.Conclusion....52 14.References....53-57
3

Introduction :
Etiologic agents are those microorganisms and microbial toxins that cause disease in humans and include bacteria, bacterial toxins, viruses, fungi, rickettsiae, protozoans, and parasites. These disease-causing microorganisms may also be referred to as infectious agents. Arthropods and other organisms that transmit pathogens to animals (including humans) are called vectors. Etiologic agents, vectors, and materials containing etiologic agents are recognized as hazardous materials. Materials containing etiologic agents are regularly transported from one location to another by common land and air carriers. Arthropods as an etiological agent can cause many skin disease such as scabies by sarcoptes scabei, tungiasis by female ectoparasitic Tunga penetrans flea, Vagabonds disease by body lice, and many others. Skin disease occur mainly by bite and when direct contact with the arthropods. We must know how the mode of its transmission to avoid it.

Objectives :
At the end of this, students will be able to: 1. To study the arthropods that can caused the skin disease 2. Understanding how the arthropods caused the skin disease 3. To know the symptoms of the diseases and the way to treat them

INTRODUCTION TO ARTHROPODS

10-2-242 NAWAR NADHRAH BINTI ABDUL WAHID

INTRODUCTION OF ARTHROPODS AS AN ETIOLOGICAL CAUSE (AGENT) OF SKIN DISEASE Some people nowadays are not aware that some of the arthropods can play a significant part as disease producing organisms such as the crustacea, arachnida and some insecta like the mosquitoes or the bugs. In addition to their importance in etiological cause (agent) they also helps in the transmission or vectors of various pathogens to man. HOW THE ARTHROPODS CAUSE A DISEASE? 1.Through the presence of the parasite in the tissue(the adult or any developmental stages), the tissues can causes myiasis as such in the presence of larvae higher diptera and they can also cause scabies in the development of sarcoptes scabies(itch mite) producing tunnel in the skin. 2.Through the toxins and venom that had been introduced into the skin by biting or stinging which either will cause local or systemic effects 3.Allergic reactions: due to injection of the saliva in the skin by concentrating highly antigenic material or by the parasite bodies themselves. 4.Entomophobia: a fear of arthropods can be extremely important as it causes of severe neurosis.[1] CLASSIFICATION OF ARTHROPODS I. II. III. Class crustacea : crabs, prawns, and copepods (crustacea is not a causative agent but it is a transmitting vector) Class arachnida :scorpions, spiders,ticks, and mites Class insecta or hexapoda : fleas, lice, bugs, mosquitoes, and flies

Class Crustacea They are microscopic and aquatic organisms which inhabit both the fresh and salt water bodies including lakes, ponds and temporary pools. They are more commonly found in still water than in the running streams.[2] Characteristic morphology : They have a pyriform body, which is divided into an anterior broad cephalothorax and a narrow four segmented abdomen. The last abdominal segment is biforked with bristles. They have two pairs of antennae and five pairs of swimming legs.[3] Copepods are crustacean of medical importance. They include the genera Diaptomas and Cyclops.[4]

Figure 1.0-Crabs(crustacean) Class Arachnida They are land arthropods adults of which possess four pairs of legs and have no antenna. Their bodies shows fusion between the different parts.[5] This class includes two orders of medical importance: 1) Scorpionida:-

Figure 2:- Scorpion ( the body is divided into fused cephalothorax and segmented abdomen)

2) Acarina :- Ticks and mites (all the body segments are fused together with any apparent segmentation)

(Figure 3.0:- ticks)

(figure 4.0:- Mites)

8

Size Cuticle Body hairs mouth parts Hypostome

TICKS Large thick and leathery absent strong, well developed teeth exposed and large

MITES Small thin and membranous presents poorly developed

unarmed, hidden, small

Class Insecta This is the largest and most important class of arthropods Four orders of medical importance:-order anoplura(lice) -order hemiptera(bugs) -order siphonaptera(fleas) -order dipteral(flies and mosquitoes) Characteristics morphology:-

Fiqure 5.0 :- Insecta Head:- carries mouth parts adapted for blood sucking or lapping and a pair of long or short antennae[6] Thorax:- Carries three pairs of legs with or without one pair of wings and made up of three segments;[7] 1)prothorax 2)mesothorax 3)metathorax Abdomen:- divided into several segments. The last segments are modified into sexual organs.[8]

SCABIES

10-2-242 NUR AFIQAH AUNI BINTI ZAWAWI

10

DEFINITION Scabies is an contagious skin disease marked by intense itching, inflammation and red papules. It is cause by tiny mites called Sarcoptes scabiei. It gets its name from Latin word scabere which means to scratch. It is specific skin parasite causing severe itching among overcrowded poor population or poor hygienic condition.[4] CAUSATIVE AGENT Sarcoptes scabiei is a small arthropode belong to class Arachnida, order Acarina. It is rounded or oval in shape. Its also unsegmented with four pairs of legs and its tegument is covered with hairs or bristles. [1]

Sarcoptes Scabiei

MODE OF TRANSMISSION Scabies is transmitted by skin to skin contact (direct contact) with an infected person that gives the mites time to crawl from one person to another. Shared personal items, such as bedding or towels, may occasionally be to blame. Scabies can pass easily between family members or sexual partners. It is not likely to spread through a quick handshake or hug because it cannot jump or fly but it crawls very slowly. The life cycle starts when an adult female in contact with skin. It penetrates the horny layer of the skin and keeps on burrowing in the epidermis, resulting in the formation of tunnels. It can slice skin with its sharp front legs and mouthparts and takes about 30 minutes to burrow into the skin then laying eggs. It lays 2-3 eggs per day for two month and then it dies. The larvae will hatch in 3-10 days and move on the skin and then mature into adult mites. The adult mites live 3-4 weeks in the hosts skin.[1][4]

11

CLINICAL PICTURE Vesiculation of the skin and severe pruritis will apparent in the patients skin. It crawls in the webs of the inter-digital spaces, flexor aspect of the arm, elbows, axillae, groin, breast, umbilicus, shoulder, back and buttocks. The mites deposit minute fecal pellets that provoke vesiculations of the skin and severe itchy. It is intensified by warmth and perspiration of the affected area. Increased body warmth at night will activate the mite to secrete acidic secretion which can cause intensifies the irritation. Secondary bacterial infection and pustules formation will complicate the lesion.[1][4] TREATMENT Scabies will not go away on its own. Before apply any treatment, should thoroughly scrubbed all over the infested region by using soap and warm water using lifa to open the tunnel and expose the mite to the drug action. After that, rubbed with acaricidal lotion such as Eurax. It is efficient mite killer and inhibits mite growth. Treatment should repeated daily for 5 successive days. Sterilized patients clothes and bed sheet by boiling during treatment. All family and close contacts should be treated at the same time and avoid contact with infected persons. Treatment must be thorough and simultaneous.[1][4]

12

TUNGIASIS

10-2-243 NUR AFIQA BINTI ROSLAN

13

ORGANISM Tungiasis is an inflammatory skin disease caused by infection of the female ectoparasitic Tunga penetrans flea. It also has many names, being known in various locations as the chigoe flea, jigger, nigua or sand flea. It found in the tropical parts of Africa, the Caribbean, Central and South America, and India. Tunga penetrans is the smallest flea in the world, measuring 1mm across. It is also known in Latin America as the nigua and bicho de pie. Painful infections with T penetrans can cause significant morbidity. [6]

Tunga Penetrans MODE OF TRANSMISSION Fleas live in warm, dry soil and sand of beaches, stables, and stock farms. It will invade unprotected skin. The most common site of involvement is the sole of feet, interdigital spaces, and below the toe nails. The flea has limited jumping ability. Both the male and the non fertilized female flea feed intermittently on warm-blooded hosts. Once impregnated, however, the female flea anchors herself to the skin by using biting mouthparts and burrows into the epidermis. Because the process is painless, a keratolytic enzyme may be involved. The flea expands, often reaching 1 cm in diameter. The head is down into the upper dermis feeding from blood vessels, while the caudal tip of the abdomen is at the skin surface, often forming a punctum or an ulceration. The flea breathes through this opening. In many cases, this is described as a white patch with a black dot. Over 1-2 weeks, more than 100 eggs, which fall to the ground, are individually released from this exposed orifice. Afterwards, the flea dies and is slowly sloughed by the host. The eggs hatch on the ground in 3-4 days, go through larval and pupal stages and become adults in 2-3 weeks. The complete life cycle lasts approximately 1 month. [5]

SYMPTOMS AND SIGNS The pain, swelling, inflammation as well as severe pruritis can occur. In the centre one can observe black dots. If it is not treated it can lead to secondary infections such as tetanus or gangrene. The death may occur due to secondary infection. The single flea present in the early stage 2 and redness hardly occurs. The pain is not so tense and itching can occur. It occurs due to response as a result of immune. It also shows irritation. In 3rd stage feces can also be seen. Increase in itching, present a black nodule and surrounded by a white halo in the stretched skin. Pain is severe during night and the nodules are present on the foot when the person walks.
14

There is the release of egg and secretion by water. The flea may lead the formation of abscess. In this cases severe ulcers are common. In severe pain the patient is not able to walk properly. [7]

Tungiasis TREATMENT The disease is self-limiting, at least when exposure to the parasite is limited, management is mostly confined to treatment. Due to the secondary infection that can cause serious medical issues, the recommended course of action upon diagnosis is surgical extraction of the flea followed by the application of a topical antibiotic. Care should be taken to avoid tearing the flea during the extraction procedures as severe inflammation will result. The same will occur if part of the flea is left behind. Sterile equipment should always be used, as contaminated instruments could act as mechanical vectors for pathogens to enter the body. There is no drug effective against embedded fleas. Oral niridazole, oral ivermectin and topical ivermectin and metrifonate have been somewhat successful, but not enough to be significant. For secondary infections, trimethoprim, sulfamethoxazole, metronidazole, amoxicillin, (with/without clavulanate) have been used successfully, though these treat only the secondary infections. Successful topical treatments also include cryotherapy and electrodesiccation of the lesion. The T. penetrans flea can also be suffocated using occlusive petrolatum. Even without treatment, the burrowed fleas will die within five weeks and are naturally sloughed off as the skin sheds. [6][7]

Extraction of the flea

15

CHIGGERS DISEASE

10-2-244 NUR AKMA BINTI ZAINAL SHAHROM

16

WHAT ARE CHIGGERS DISEASE ? Chiggers are the juvenile form (larvae) of a certain type of mite of the family Trombiculidae. Mites are arachnids (like spiders and ticks). Chiggers are found throughout the world. They most commonly live in forests, grassy fields, gardens, parks, and in moist areas around lakes or rivers. Most of the larvae that cause chigger bites are found on plants that are relatively close to the ground surface, because they require a high level of humidity for survival. During the wet season, chiggers are usually found in tall grass and other vegetation. During dry seasons, chiggers are mostly found underneath brush and shady areas.[9] GROSS MORPHOLOGY Chiggers are barely visible to the naked eye (their length is less than 1/150th of an inch). They are red in color and may be best appreciated when clustered in groups on the skin. The juvenile forms have six legs, although the (harmless) adult mites have eight legs.[10] CHIGGERS LIFE CYCYLE The larvae, commonly called chiggers, are about 0.170.21 mm (0.0070.008 in) in diameter, normally light red, covered in hairs, and move quickly relative to size. There is a marked constriction in the front part of the body in the nymph and adult stage. The eggs are round in shape. Chiggers come in 3 stages: the deutovum, unfed larva, and engorged larva. Once in the egg, the larvae is enclosed in a membrane in addition to the eggshell.They are now called deutovum. After hatching, the unfed larvae migrate to the highest area and wait for a host. The larval stage is the only parasitic stage of the mite's life cycle. They are parasites to many animals. About 30 of the many species in this family, in their larval stage, attach to various animals, including amphibians, reptiles, birds, and mammals, and feed on skin. The larva remains attached to a suitable host for 3 to 5 days before dropping off to begin its nymph stage. [11]

17

Picture of Chigger Eggs, Larvae, Nymph, and Adult

HOW DO CHIGGERS BITES HUMAN? Chigger mites infest human skin via areas of contact with vegetation, such as pant cuffs or shirt sleeves and collars. They migrate on the skin in search of an optimal feeding area. A common myth about chiggers is that they burrow into and remain inside the skin. This is not true. Chiggers insert their feeding structures into the skin and inject enzymes that cause destruction of host tissue. Hardening of the surrounding skin results in the formation of a feeding tube called a stylostome. Chigger larvae then feed upon the destroyed tissue. If they are not disturbed (which is rarely the case because of they cause substantial itching) they may feed through the stylostome for a few days. The chigger's mouth and feeding structures are delicate and are best able to penetrate the skin at areas of wrinkles, folds, or other areas of skin that are thin. Most bites occur around the ankles, the crotch and groin areas, behind the knees, and in the armpits. Barriers to migration on the skin such as belts may be one reason that chigger bites also commonly occur at the waist or at other areas where their migration is prevented by compression from clothing.[12]

18

Picture of how chiggers bite human SYMPTOMS OF CHIGGERS BITES

Picture of Chiggers bites

A chiggers bite itself is not noticeable. After the chigger has begun to inject digestive enzymes into the skin (usually after about 1-3 hours), symptoms typically begin.

Pronounced itching is the most common symptom. The area of the bite may be reddened, flat, or raised; sometimes it resembles a pustule or blister. The itch is due to the presence of the stylostome and usually is most intense within 1-2 days after the bite. The itching persists for several days, and complete resolution of the skin lesions can take up to two weeks.[12]

TREATMENT OF CHIGGERS BITES Treatment for chigger bites is directed toward relieving the itching and inflammation. Calamine lotion and corticosteroid creams may be used to control itching. Oral antihistamines, such as diphenhydramine (Benadryl), may also be used for symptom relief.[12]

19

PLICA POLONICA

10-2-245 NURUL IMAN BINTI ZULKEFLI

20

PLICA POLONICA Polish plait (also known as Plica polonica in Latin) is a formation of hair. It can be viewed as a hairstyle similar to dreadlocks or a hair disease. [13] The Polish plait or Plica polonica usually results from deficient hair care. Uncombed hair becomes irreversibly entangled, forming a matted and sticks together in clumps, malodorous(having an unpleasant smell) and encrusted(having a hardened crust as a covering) or sticky moist mass. [13][14][15][16] Other reference also stated that the disease of Plica Polonica also known as Plica Neuropathica which have the same characteristic but is uncommon condition. [15]

Picture of matted entangled hair from the collection of the library of Warsaw [17]

A polish plait in the Museum of Faculty of Medicine, Medical College Jagiellonian University, Kakow, Poland.

Example of picture of person with Plica polonica disease with entangled hair.

21

HISTORY The Polish plait was quite common in past centuries when hair care was largely neglected. It affected mostly the peasantry, but was not unusual among higher social classes. The most notable person in history said to be afflicted with it was King Christian IV of Denmark (1577 1648). His plait had the form of a pigtail hanging from the left side of his head, adorned with a red ribbon. His courtiers were said to have adopted the hairstyle in order to flatter the king Due to superstitious beliefs, the Polish plait used to be particularly common in Poland, hence its English and Latin name. Similarly, in German it is called Weichselzopf, or Vistula plait, after a river in Poland. Initially, the plait was treated as an amulet, supposed to bring good health. For this reason people not only allowed it to develop, but even encouraged it. Spreading fat on their hair and wearing wooly caps even in summer were common practices. In the early 17th century people began to believe plaits were an external symptom of an internal illness. A growing plait was supposed to take the illness "out" of the body, and therefore it was rarely cut off; in addition, the belief that a cut-off plait could avenge itself and bring an even greater illness discouraged some from attacking it. It was also believed that casting a magic spell on someone could cause that person to develop a Polish plait, hence also the name "elflock" was used in English. These convictions were so widespread and strong that many people lived their whole lives with a Polish plait. A plait could sometimes grow very long even up to 80 cm. Polish plaits could take various forms, from a ball of hair to a long tail. Plaits were even categorized in a quite sophisticated way; there were plaits "male" and "female", "inner" and "outer", "noble" and "fake", "proper" and "parasitical". A British diarist and Samuel Johnson's friend, Hester Thrale, in her book Observations and reflections made in the course of a journey through France, Italy, and Germany, describes a Polish plait she saw in 1786 in the collection of the Elector of Saxony in Dresden: "the size and weight of it was enormous, its length four yards and a half [about 4.1 m]; the person who was killed by its growth was a Polish lady of quality well known in King Augustus's court." In the second half of the 19th century some intellectuals waged a war against superstition and lack of hygiene among the peasantry. Many plaits, often to the horror of their owners, were cut off. In Western Galicia, it was Professor Jzef Dietl who made a particular effort to examine and treat Polish plaits. He organized an official census of people suffering from the disease, which spawned rumors that plaits would be taxed. Those rumors were said to have helped eradicate the Polish plait in the region. A huge, 1.5-meter long, preserved Polish plait can be seen in the Museum of the Faculty of Medicine (Medical College, Jagiellonian University) in Krakw. The Polish word for the Polish plait, kotun, is now used figuratively in Poland to denote an uneducated person with an old-fashioned mindset.[13]

22

SYMPTOMS The following are some of the symptoms of Plica Polonica: Sometimes large head of hair, made of a hard impenetrable mass of keratin fibers permanently cemented together with dried pus, blood, old lice egg-casings and dirt.[13] Inflamed scalp with bad odour.[5][16] It may be associated with damage to sections of the cuticle(the hair-shafts tough protective outer layer) hereby exposing a moist sticky cortex to which other similarly effected hair shafts adhere.[15]

CAUSES It is a type of condition, as a result of various pathological processes such as certain fungal diseases, eczema and also accompanied with lice infestation (pediculosis) and lead to inflammation of the scalp. [13][14]

Pediculus humanus (lice)

Risk factors responsible: i) Diseased hair shafts ii) Hair with natural kinks. iii) Shampoos used and water quality (affects cuticle leaves cortex exposed). iv) Poor hair care and grooming techniques. v) Lice infestation, chemical exposure The condition may follow an acute infestation with pediculus capitis.[15] TREATMENTS The disease may be easily prevented by standard hygienic practices, such as: Washing combing of the hair cutting the affected hair[13]

23

VAGABONDS DISEASE

10-2-246 NURUL AQMAR BINTI MOHD SUHAIMI

24

DEFINITION Vagabonds disease is another type of skin disease and its name is originate from Paris. Vagabonds disease is a condition of pigmentation of the skin caused by long continued exposure, uncleanliness, and especially by scratch marks and other lesions due to the presence of body lice. [23] Vagabonds disease is also known as Vagrants disease or parasitic melanoderma which is the darkening or discoloration of the skin caused by chronic scratching of the bites of the body louse. CAUSATIVE AGENT Vagabonds disease is caused by body lice. There many type of body lice. For example : a) Pediculosis humanus corporis (body louse) b) Phthirus pubis (pubic louse) c) Pediculosis humanus humanus (head louse)

Pediculosis humanus humanus [31]

Pediculosis humanus corporis [32]

25

Phthirus pubis cause Vagabonds disease at pubic of women [33] MODE OF TRANSMISSION Human lice have the potential to transfer from person to person very quickly. The head louse spreads from an infested person to others during direct contact and indirectly when infested items such as hats, scarves, coats, combs, and brushes are shared. School-age children are at risk because they are more likely to share such items, especially under crowded conditions. The pubic louse typically spreads between human partners during sexual intercourse and other intimate contact. Spread of pubic lice via infested bedding and toilet seats can occur, but is not common because pubic lice die within a few hours once they are off a human host. The body louse spreads during direct contact with infested people or indirectly when infested clothing is shared. Body lice also spread when they leave a person with a high fever and crawl across a surface to infest a nearby individual. Again, the body louse is capable of rapidly building very high numbers and infesting large numbers of people living in conditions that are associated with disasters such as war, hurricanes, and earthquakes when humans are crowded together without access to clean clothes, clean bedding, and periodic bathing.[28]

Body lice at the pubic area

26

TREATMENT Body lice mainly live in clothing. Destroy or carefully wash infected clothing in hot water (at least 130 degrees F), then machine dry using a hot cycle. Your doctor may also recommend a prescription cream or wash containing permethrin, malathione, or benzyl alcohol. However, hygiene and washing clothes, bedding, and towels are most important and are usually enough.[27]

This cream is use to treat this Vagabonds disease

27

PHTHIRUS PUBIS

10-2-247 NURUL BAINUN BINTI AHMAD SHAFRI

28

GENERAL DISCRIPTION Phthirus Pubis also known as Crab Louse or Pubic lice, are parasitic insects commonly known for infesting human pubic hair. The species may also live on other areas, they may occasionally be found on other coarse body hair, such as hair on the legs, armpits, moustache, beard, eyebrows, or eyelashes. Pubic lice infestation is found worldwide and occurs in all races, ethnic groups, and levels of society. Animals do not get or spread pubic lice..Humans are the only known hosts of this parasite They feed exclusively on blood.[34][35] MORPHOLOGY The lice are 1.5 2.0 mm in length and nearly as broad as long. The adult has a crab shaped body, a rectangular head, and three pairs of legs. The front pair of leg is much more slender and has smaller claws than the other two pairs. The characteristically large claws are located on the middle hind legs. [36] LIFE CYCLE From egg laying to formation of the adult, is about 17 25 days. The female lay about 30 eggs during her life. The eggs (nits) are cemented to hair, and hatch within 6 8 days. The nymph undergoes three molts within two weeks. The life span of the adult is about 1 month.[4] It undergoes incomplete metamorphosis, which means the newly hatched larvae in this type of development resembles the adult. But, it is smaller in size and gradually increase in size by successive moulting.[37] CLASSIFICATION The infestation with pubic lice is called phthiriasis pubis, while infestation of eyelashes with pubic lice is called phthiriasis palpebrarum.[35] TRANSMISSION Pubic lice usually are spread through sexual contact and are most common in adults. Pubic lice found on children may be a sign of sexual exposure or abuse. Occasionally, pubic lice may be spread by close personal contact or contact with articles such as clothing, bed linens, or towels that have been used by an infected person. A common misunderstanding is that pubic lice are spread easily by sitting on a toilet seat. This would be extremely rare because lice cannot live long away from a warm human body and they do not have feet designed to hold onto or walk on smooth surfaces such as toilet seats.[34]

29

SIGNS AND SYMPTOMS The main symptom is itching, usually in the pubic-hair area, resulting from hypersensitivity to louse saliva, which can become stronger over two or more weeks following initial infestation. In some infestations, a characteristic grey-blue or slate coloration appears at the feeding site, which may last for days.Furthermore, Visible nits (lice eggs) or crawling lice. [34][35]

DIAGNOSIS (EXAMINATION & TEST) A pubic lice infestation is diagnosed by finding a "crab" louse or egg (nit) on hair in the pubic region or, less commonly, elsewhere on the body (eyebrows, eyelashes, beard, mustache, armpit, perianal area, groin, trunk, scalp). Pubic lice may be difficult to find because there may be only a few. Pubic lice often attach themselves to more than one hair and generally do not crawl as quickly as head and body lice. If crawling lice are not seen, finding nits in the pubic area strongly suggests that a person is infested and should be treated. If you are unsure about infestation or if treatment is not successful, see a health care provider for a diagnosis. Persons infested with pubic lice should be investigated for the presence of other sexually transmitted diseases. Lice and nits can be removed either with forceps or by cutting the infested hair with scissors (with the exception of an infestation of the eye area). A magnifying glass or a stereomicroscope can be used for the exact identification. If lice are detected in one family member, the entire family needs to be checked and only those who are infested with living lice should be treated.[34][35] TREATMENT Crab lice can be treated with permethrin 1% cream rinse and pyrethrins. They can be used for this purpose and are the drugs of choice for pregnant or lactating women. These agents should be applied to the affected areas and washed off after 10 minutes. Shaving off or grooming any hair in the affected areas with a fine-toothed comb is necessary to ensure full removal of the dead lice and nits. Resistance of pubic lice to pyrethroids must be, if at all, very rare. A second treatment after 10 days is recommended. It is also crucial to make sure that all the bed sheets are changed. The sheets used before the first application of the treatment must be put away in a plastic bag, without air and well shut. They should be left alone for 15 days before washing to avoid the reproduction and survival of lice eggs that may have been left on the sheets and lead to reinfestation. Pubic lice on the eyelashes can be treated with a permethrin formulation by applying the solution to the infested hair with an applicator. Lindane shampoo (1%), a pediculicide, although banned in more than 50 countries, is approved by the U.S. Food and Drug Administration(FDA) as safe and effective when used as directed for
30

the second-line treatment of pubic lice ("crabs"). While serious side effects have been reported, they are considered to be rare and have almost always resulted from misuse of medication, such as excessive application and oral ingestion. To minimize this risk, Lindane medications are now dispensed in small single-use bottles. The Centers for Disease Control and Prevention (CDC) notes that Lindane should not be used immediately after a bath or shower, and it should not be used by persons who have extensive dermatitis, women who are pregnant or lactating or children aged under two years. The FDA similarly warns against use in patients with a history of uncontrolled seizure disorders and premature infants, and recommends cautious use in infants, children, the elderly, and individuals with other skin conditions (e.g., atopic dermatitis, psoriasis) and in those who weigh less than 110 lbs (50 kg).[35][38][1] How to treat pubic lice infestations: (Warning: See special instructions for treatment of lice and nits on eyebrows or eyelashes. The lice medications described in this section should not be used near the eyes.) 1. Wash the infested area; towel dry. 2. Carefully follow the instructions in the package or on the label. Thoroughly saturate the pubic hair and other infested areas with lice medication. Leave medication on hair for the time recommended in the instructions. After waiting the recommended time, remove the medication by following carefully the instructions on the label or in the box. 3. Following treatment, most nits will still be attached to hair shafts. Nits may be removed with fingernails or by using a fine-toothed comb. 4. Put on clean underwear and clothing after treatment. 5. To kill any lice or nits remaining on clothing, towels, or bedding, machine-wash and machine-dry those items that the infested person used during the 2-3 days before treatment. Use hot water (at least 130F) and the hot dryer cycle. 6. Items that cannot be laundered can be dry-cleaned or stored in a sealed plastic bag for 2 weeks. 7. All sex partners from within the previous month should be informed that they are at risk for infestation and should be treated. 8. Persons should avoid sexual contact with their sex partner(s) until both they and their partners have been successfully treated and re-evaluated to rule out persistent infestation. 9. Repeat treatment in 9-10 days if live lice are still found. 10. Persons with pubic lice should be evaluated for other sexually transmitted diseases (STDs).

31

Special instructions for treatment of lice and nits found on eyebrows or eyelashes:

If only a few live lice and nits are present, it may be possible to remove these with fingernails or a nit comb. If additional treatment is needed for lice or nits on the eyelashes, careful application of ophthalmic-grade petrolatum ointment (only available by prescription) to the eyelid margins 2-4 times a day for 10 days is effective. Regular Vaseline* should not be used because it can irritate the eyes if applied.[34]

SIDE NOTES The constant scratching and digging can cause the skin to become raw, and secondary infections may develop. Can be prevented by, Avoid sexual or intimate contact with infected people. If you are sexually active, use safe sex practices to avoid getting lice. Good personal hygiene is always recommended. If possible, avoid trying on bathing suits while you are shopping. However, if you must try them on, be sure to wear your underwear. This may prevent transmission.[36] Epidemiology of Phthirus Pubis, Current worldwide prevalence has been estimated at 2 percent of two human populations, accurate numbers are difficult to acquire, because pubic lice infestations are not considered a reportable condition by many governments, and many cases are self-treated or treated discreetly by personal physicians. Although any part of the body may be colonized, crab lice favour the hairs of the genital and peri-anal region. Especially in male patients, pubic lice and eggs can also be found in hair on the abdomen and under the armpits as well as on the beard and mustache, while in children they are usually found in eyelashes.[35]

32

Microscopic picture of the phthirus pubis [39]

Life cycle of the pubis louse [38]

Sketch picture of The Crab Louse[40]

33

Life Cycle and mode of transmission [38]

34

Left to right : Pubic lice in genital area - Pubic lice on abdomen - Pubic lice on the eyelashes[34] Below: Treatment of the pubic lice [41]

35

CUTANEOUS MYIASIS

10-2-248 NURULZIANI IZZATI BINTI MOKHTAR

36

DEFINITION Cutaneous myiasis is an infestation of the skin by developing larvae (maggots) of a variety of fly species (myia is Greek word for fly) within the arthropod order Diptera(two-winged adult flies) . The larvae feed on the host's dead or living tissue, body substances, or ingested food.[43][44]

Infestation of the skin by developing larvae

(up) larvae of higher Diptera (down) fly species of Higher Diptera

There are three main types of skin infestation by fly larvae:

Furuncular (pimple- or boil-like) myiasis Wound myiasis Migratory myiasis

The disorders vary depending on the species of fly involved. Infestation usually occurs in tropical countries. People in the United States who have myiasis usually have recently arrived from or visited a tropical country.[47]

37

CAUSATIVE AGENT As mentioned, the cause for myiasis is the infestation of humans tissue or organ with the larvae of the Diptera order of fly species. More than a hundred species of Diptera have been reported to cause human myiasis. Some of the most important are as follows:

Dermatobia hominis (human botfly) causes furuncular myiasis. Cordylobia anthropophaga also causes furuncular myiasis. Cochliomyia hominivorax (America) and Chrysomyia bezziana (Africa, Australia, Asia) both cause wound myiasis. Lucilia, Sarcophaga, Calliphora also cause wound myiasis. Hypoderma bovis (infested cattle) and Gasterophilus intestinalis(infested horses) both cause creeping (migratory) myiasis.[46]

MODE OF TRANSMISSION For example, human botfly that cause furuncular myiasis. The adult fly resembles a bumblebee; it is short lived and survives for little more than a week. It does not feed and is infrequently seen. The life cycle of the botfly is unique, as the female, egg-bearing fly attaches her eggs to the abdomen of a blood-sucking arthropod (means of transportation known as phoresy), usually a mosquito (although 40 other species of insects and ticks have been reported). When the mosquito takes a blood meal from a warm-blooded animal, the local heat induces the eggs to hatch and drop to the skin of the host and enter painlessly through the bite of the carrier or some other small trauma.

Mature larva of the Dermatobia hominis fly;rows of hooks apparent on its tapered body.

Furuncular myiasis

Once deposited in the skin, the larvae start out as small and fusiform and later become pyriform to ovoid as they reach full development at lengths of 15-20 mm. They are encircled by several rings of spines. Eventually, if the cycle is unperturbed, larvae emerge from the host in 67 weeks and drop to the ground, where they pupate to form flies in 2-3 weeks.[43]

38

Wound myiasis occurs when fly larvae infest open wounds in a living host. Mucous membranes (e.g. oral, nasal, and vaginal membranes) and body cavity openings (e.g. in or around the ears and eye socket) can also be affected. Flies may be dispersed by prevailing winds, and infection is often acquired while resting outside during the day or may result from trauma.[43][44]

Wound myiasis affecting the scalp

Creeping (or migratory) cutaneous myiasis may be caused when there is exposure to infested cattle or in those who work with horses.[46] . Less often, the flies lay eggs directly on people. Larvae do not stay in one spot. They burrow under the skin, causing itchy lesions that may be mistaken for cutaneous larva migrans[45]

Condition of creeping eruption

TREATMENT 1. Removal of these larvae then treating the lesion. 2. If deeply deated larvae, an attempt must be made to remove the larvae and the wound should be backed with antibiotic. 3. Stimulate larvae to leave the wound in furuncular myiasis by application of Vaseline. [1]

Removal of the larva with firm sustained pressure

39

FLEAS, MOSQUITO AND TICKS BITES

10-2-249 NURUL SHAZWANI BINTI SAARI

40

FLEAS BITES
Fleas are small, blood sucking insects that do not have wings which are very harmful for both humans and pets. They have a flat shaped body and a piercing mouth with sharp jaws. They survive on the blood sucked out from humans and animals. When they pierce their mouth into human skin, an anticoagulant present in their saliva gets injected into the blood which prevents the blood from clotting. This enables them to keep sucking blood from the human body until their thirst is quenched. Basically, flea bites symptoms show up because of the harmful anticoagulant that causes adverse skin reactions. [49] SYMPTOMS Symptoms often begin suddenly (within hours). Flea bites in human several times because they have tendency to move around restlessly over human body. This gives rise to clusters of small and red bumps. Hives Itching (can be severe, and may be all over or just where the rash is located) Rash with small bumps that itch and may bleed o Located on the armpit or fold of a joint (at the elbow, knee, or ankle) o The amount of skin affected increases over time (enlarging skin rash or lesion) or the rash spreads to other areas o When pressed the area turns white (blanches to touch) Skin folds, such as under the breasts or in the groin may be affected (intertrigo) Swelling only around a sore or injury [48][49] TREATMENT Treatment for early relief from the symptoms: 1) wash the affected spot properly with antiseptic soap and cold water to disinfect them (Never use hot or warm water on them as it can increase the itchy feeling) 2) Apply ice. Wrap up a few ice cubes in a clean piece of cloth and apply it on the flea bites. This will have a soothing effect on the itchy bites, and the swelling can also be controlled to a certain extent. 3) To bring down the skin irritation, over the counter 1% hydrocortisone creams can also be applied. 4) However, if these home treatments fail to show any effect, then the doctor should be consulted. Generally, they prescribe oral antihistamine medicines to check the skin allergic reaction and calamine lotion for topical application on the itchy bites.

41

5) In small children, the symptoms become more serious than in adults. Sometimes, flea bites on children may lead to serious signs of infection after a few days. Child should be taken to the doctor where they would be treated with antibiotics for the infection. Along with the treatments for the flea bites symptoms, eliminate the harmful fleas from the house. [49]

Fleas

symptom : fleas bite

MOSQUITO BITES
That lady mosquito that descended onto the arm or leg for a taste attracted to human by our heat, perspiration on the skin, body odour, and even the emissions of carbon dioxide. It stuck its sharp, thin proboscis (or mouth part) into human skin and began sucking the blood. Mosquito saliva contained proteins, digestive enzymes, and anticoagulants (the latter of which prevent your blood from clotting). Once it finished gathering nourishment, the mosquito departed (or met a deadly end via a palm or fly swatter). Some saliva remains in the wound and the proteins swimming around there are what provoke an immune response from our body. [53]

42

SYMPTOMS The first time a mosquito bites, there is no reaction. If more mosquitoes and more bites over time, our body begins to react to the proteins and enzymes and the red bumps start to appear within a day. More mosquito bites begin to produce a more immediate reaction and the swollen hive or wheal rises up within minutes instead of hours. Eventually, some of the population become immune to bites, and show no reaction when bit; others may develop a mosquito bite allergy and exhibit more severe reactions to the bites, such as blistering, bruising, extreme swelling, and prolonged itching [53] Typical signs and symptoms of mosquito bites include: [50] Soft, initially pale bumps on your skin that can become pink or red Itching The bump that results from a bite can appear immediately or may take up to two days to appear. People which is highly sensitive to mosquito bites, may have a much larger area of itching. Severe allergic reaction Rarely, a serious reaction to mosquito bites might occur, which results in swelling in the throat, significant hives and wheezing. This life-threatening condition (anaphylaxis) requires immediate medical attention. [50] TREATMENT Mosquito bite treatment starts with 1) Cleaning the area and addressing the reaction as soon as you realize you've been bitten. A simple mild soap and warm water wash is the first place to start; pat dry with a soft towel and resist the urge to rub. Scratching and rubbing will actually prolong the mosquito bite itch instead of offering (temporary) relief. You also run the risk of introducing dirt and bacteria into the open area and developing an infection. 2) Ice wrapped in a towel or an ice pack will ease a mosquito bite's swelling. Even a cold can of soda or bottled water can do in a pinch. 3) Aloe Vera gel is nature's perfect gift for treating mosquito bites. The coolness eases symptoms and forms a protective layer after application to reduce the risk of infection. Reapplication will be necessary. It's good to do another soap and water wash every few hours.

43

4) Calamine lotion or a topical anesthetic (containing pramoxine) are effective mosquito bite treatments. One percent hydro-cortisone cream alleviates itching, as well. 5) If applications to the surface of the skin don't take care of the symptoms immediately, try taking an anti-inflammatory such as ibuprofen or naproxen. This will help to reduce the swelling of the bites. 6) For more severe cases, an antihistamine such as Benedryl. Discuss with the doctor before administering the medication for this reason. If the mosquito bite does not respond to topical treatments and the skin around the area becomes warm, red and swollen, the bite may be infected. Call a medical practitioner in this case; a stronger treatment may be necessary. [53]

Symptom : Mosquito bite

female mosquito

TICKS BITES
Ticks are scientifically classified as Arachnida (which includes spiders), they are classified into two families of ticks, Ixodidae (hard ticks) and Argasidae (soft ticks), are known to transmit diseases or illness to humans. Hard ticks have a scutum, or hard plate, on their back while soft ticks do not. Ticks have a complex life cycle that includes eggs, larvae, nymphs, and adult male and female ticks. The larvae, nymphs, and adults all need blood meals. Usually, the female adult (hard tick) is the one causing the most bites as males usually die after mating. Ticks do not jump or fly. They simply reach out with their legs and grab or crawl onto a host. Although some larvae have preferred hosts, most ticks in the nymph or adult phase will attach a get a blood
44

meal from several different kinds of animals, including humans. The hard ticks tend to attach and feed for hours to days. Disease transmission usually occurs near the end of a meal, as the tick becomes full of blood. It may take hours before a hard tick transmits pathogens. Soft ticks usually feed for less than one hour. Disease transmission can occur in less than a minute with soft ticks. The bite of some of these soft ticks produces intensely painful reactions. [52] The tick bite produce toxins, secretions, or organisms in the tick's saliva transmitted through the bite that causes disease. [51] SYMPTOMS Tick bite is usually painless and remains that way even after the tick stops the blood meal and falls off of the skin. Later, the bite site may develop itching, burning, redness, and rarely, localized intense pain (some soft tick bites) in some individuals. A few individuals may be sensitive or allergic to tick bites (tick saliva secretions) and develop rash, shortness of breath, swelling, numbness, or paralysis. However, the majority of individuals with tick bites develop no symptoms, and many do not remember getting bitten. Some immediate symptoms that infrequently or rarely develop during or immediately after a tick bite may be fever, shortness of breath, weakness,vomiting, swelling, weakness or paralysis, headache, confusion, or palpitations. Individuals with these symptoms should be seen immediately by a doctor. [52] TREATMENT For all tick bites, local cleansing and antibiotic cream may be applied. If the bite area develops itching, preparations containing diphenhydramine (Benadryl) are recommended. These Benadryl compounds can be applied directly to the skin for itching or administered orally by tablets. This is usually the only treatment needed. However, treatment of the pathogens that the tick may pass to a person depends on other factors, such as the type of tick, length of time of attachment to the host, diseases in the community, and symptoms developed by the patient. Specific treatment is based on the identity of the pathogen transmitted. For example, oral antibiotics may be prescribed for some diseases. With more significant symptoms, antibiotics may need to be given intravenously and the patient may need to be hospitalized. The best approach to treatment is to diagnose which pathogen has been transmitted to the patient (for example, Borrelia species of bacteria) and then use the specific treatment to reduce or kill the pathogen. [51]

45

Symptom : Tick Bite

Tick

46

ARTHROPODS AS VECTOR, TRANSMITTING SKIN DISEASE

10-2-250 NURUL ATIQAH BINTI ABU SAHMAH

47

LYME DISEASE Also referred as Borreliosis, Banwarth Syndrome. 1. Vector: Hard ticks (Class Arachnida) 2. Causative organism: Borrelia burgdorferi (B. burgdorferi); a spirochete 3. Mode of infection: by the bite of the hard tick [1]

[54] Spirochete of B.burgdorferi (left) and female tick as vector (right) 4. Signs and Symptoms: Bulls-eye-rash at the site of tick bite. It expands with time reaching 30cm in diameter. Later, it produces problems in the joints, heart and nervous system.

[55] Bulls eye rashes on the skin

Lyme disease has 3 stages: 1. Early localized stage with skin inflammation 2. Early disseminated stage with heart and nervous system involvemet such as palsies and meningitis 3. Late stage with motor and sensory nerve damage, brain inflammation and arthritis.

48

5. Diagnosis: The disease is diagnosed by the patients clinical signs and the presence of Lyme antibodies in patients blood. [56]

EPIDEMIC TYPHUS 1. Vector: Lice or also known as body louse. (Class Insecta or Hexapoda)

[57] Body louse as vector causing epidemic typhus 2. Causative organism: Rickettsia prowazekii (R. prowazekii) 3. Mode of infection: Faeces of infected lice containing the rickettsia, contaminate skin abrasion, conjunctiva and mucous membrane. Inhalation of dried faeces containing the rickettsia Crushing of insects on skin [1] 4. Signs and symptoms: Rash that begins on body trunk (stomach, chest and back) and spread to all parts of body except palms and soles. Bleeding into the skin (petichae) Delirium Hypotension Death (10%-60%) [58]

49

Diffuse petechial rash (left), rose spots-like skin lesion (middle), classical typhus rash (right) 5. Diagnosis Many tests can be done to diagnose the disease such as identification of bacterial genus and species by PCR testing of skin biopsy of skin rash. [59][60]

CLINICAL MANIFESTATION

DESCRIPTION Vector: Phlebotomous fly (sandflies) Causative organism: Leishmania lutzomyia

Mucocutaneous leishmaniasis that causes disfigurement of nasal septum, lips and palate (bone is not affected)[63]

Disease: Mucocutaneous Leishmaniasis

Vector: Cyclops (copepode) Causative organism: Dracunculus medinensis (nematode) From left: D. medinensis emerging from the blister and a method to extract the aforementioned nematode [64] Disease: Dracunculasis

50

Vector: Culex quinquefasciatus (mosquito) Causative organism: Wuchereria bancrofti From left: Left leg elephantiasis and microscopic picture of W. bancrofti [6] Disease: Bancrofti Lymphatic Filariasis or Elephantiasis

Vector: Chrysops silacea and Chrysops dimidiata (fly) Causative agent: Loa loa (blood dwelling nematode) Disease: Loiasis

From left: A loa loa crossing the conjunctiva and a Calabar swelling [7]

Vector: Simulium damnosum (blackflies) Causative organism: Onchocerca volvulus Disease: Onchocerciasis

From left: Onchocerciasis nodule and cataract formation lead to river blindness disease [68]

Vector: Mansonia annulifera (mosquito) Causative organism: Brugia malayi From left: Brugian lymphatic filariasis and lymphangitis [69] Disease: Brugian Lymphatic Filariasis or Elephantiasis
51

Conclusion:
Numerous species of arthropods play a role in human disease. The medical significance of various species of arthropods relates to their blood suckling habit producing venomous and toxic, which cause skin disease. Cutaneous symptoms, including blistering and contact dermatitis, allergic reaction and secondary infection, are some common symptom of the skin disease. Thus, we must keep a healthy environment for a better hygiene to prevent any of arthropods causing disease.

52

REFERENCES 1) Infection and Immunity Module 8 Semester 3, faculty of Medicine, University of Alexandria, Page 46-62 2) Crabs, retrived from http://www.enchantedlearning.com/subjects/Crab.shtml, date accessed: 13th December 2011 3) Dust mites, retrived from http://health.allrefer.com/health/insect-bites-or-stingsmite.html, date accessed: 13th December 2011 4) Sarcoptes Scabiei-Scabiei, retrieved from http://www.parasitesinhumans.org/sarcoptes-scabiei-scabies.html, date accessed : 16th December 2011 5) Tungiasis, retrieved from http://emedicine.medscape.com/article/231037overview#a0156, date accessed : 13th December 2011 6) Tungiasis, retrieved from http://en.wikipedia.org/wiki/Tungiasis, date accessed : 13th December 2011 7) Tungiasis, retrieved from http://www.privatehealth.co.uk/diseases/skindisorders/tungiasis/ date accessed : 13th December 2011 8) Symptoms and sign of tungiasis, retrieved from http://www.alldiseases.org/what-is-atungiasis/ date accessed : 13th December 2011 9) What are Chiggers?, retrieved from : http://www.medicinenet.com/chiggers_bites/article.htm date accessed : 19th December 2011 10) Gross Morphology, Chiggers Life Cycle, retrieved from
http://en.wikipedia.org/wiki/Trombiculidae date acceesed : 19th December 2011 11) How Do Chiggers Bite Human? , retrieved from http://www.medicinenet.com/chiggers_bites/article.htm date accessed : 19th December 2011 12) Symptoms of Chiggers Bites, Treatment of chigger Bites, retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002309/ date accessed : 19th December 2011

13) Polish plait, retrieved from : http://en.wikipedia.org/wiki/Polish_plait, date of accessed: 16th December 2011 14) Polish plait, retrieved from http://encyclopedia2.thefreedictionary.com/Plica+Polonica, date of accessed: 16th December 2011. 15) Polish plait, retrieved from http://www.mindheal.org/plica_polonica.html, date of accessed: 16th December 2011. 16) Polish plait, retrieved from http://www.stevens-trichology.com/plica-polonica.htm, date of accessed: 16th December 2011.
53

17) Plica polonica, retrieved from http://www.wilanowpalac.pl/plica_polonica_or_the_polish_koltun.html, date of accessed: 16th December 2011. 18) Vagabonds Disease, retrieved from . http://www.merriamwebster.com/medical/vagabond's%20disease date accessed : 16th December 2011 19) Vagabonds Disease, retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1948743/ date accessed : 16th December 2011 20) Top Ten Professional Vagabonds Disease, retrieved from http://www.nullhypothesis.co.uk/science//item/top_ten_professional_vagabonds_disease date accessed : 16th December 2011

21) Vagabonds Disease, retrieved from

http://www.healthdiscussions.org/hd/index.php?t=Vagabond's+disease date accessed : 16th December 2011 22) Pediculosis Corporis, retrieved from http://en.wikipedia.org/wiki/Pediculosis_corporis date accessed : 16th December 2011

23) Vagabonds Disease, retrieved from

http://www.ailments.com/2236/Vagabonds_Disease.html date accessed : 16th December 2011 24) Recognize Body Lice Symptoms, retrieved from http://www.wikihow.com/Recognize-BodyLice-Symptoms date accessed : 16th December 2011 25) Bilogial Peculiarities and Medical Importance of the Lice, retrieved from http://ezinearticles.com/?Bilogial-Peculiarities-and-Medical-Importance-of-the-LiceFamily&id=4694384 date accesed : 16th December 2011 26) Parasiti Melanoderma, retrieved from http://dictionary.reference.com/browse/parasitic+melanoderma date accessed : 16th December 2011 27) Body Lice, retrieved from http://health.nytimes.com/health/guides/disease/bodylice/overview.html date accessed : 16th December 2011 28) Louse,retrieved from http://extension.entm.purdue.edu/publichealth/insects/louse.html date accessed : 16th December 2011 29) Vagabonds Disease, retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1948743/pdf/procrsmed00442-0038a.pdf date accessed : 16th December 2011 30) Body Lice, retrieved from http://www.livingwithbugs.com/body_lice.html date accessed : 16th December 2011 31) Vagabonds Disease, retrieved from http://www.google.com/imgres?q=vagabond%27s+disease&hl=en&safe=active&sa=X&gbv=2 &biw=1366&bih=624&tbm=isch&tbnid=vSa4u0QAkbDRLM:&imgrefurl=http://quizlet.com/37 15244/e3-parasite-vs-disea date accessed : 16th December 2011

54

32) Vagabonds Disease, retrieved from

http://www.google.com/imgres?q=vagabond%27s+disease&hl=en&safe=active&sa=X&gbv=2 &biw=1366&bih=624&tbm=isch&tbnid=bczDsop3pjWDPM:&imgrefurl=http://drkaae.com/Me dicalEntomology/Chapte date accessed : 16th December 2011 33) Vagabonds Disease, retrieved from http://images.search.yahoo.com/images/view;_ylt=A0PDoX2w4uhONHgAdtKJzbkF;_ylu=X3oD MTBlMTQ4cGxyBHNlYwNzcgRzbGsDaW1n?back=http%3A%2F%2Fimages.search.yahoo.com% 2Fsearch%2Fimages%3F_ad date accessed : 16th December 2011

34) Phthirus pubis, Retrieved from http://www.medicinenet.com/pubic_lice_crabs/article.htm Date accessed : 19 December 2011 35) Phthirus pubis. Retrieved from http://en.wikipedia.org/wiki/Crab_louse Date accessed : 19 December 2011 36) Phthirus pubis. retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000841.htm Date accessed : 19 December 2011. 37) Phthirus Pubis, retrieved from http://www.atlas.or.kr/atlas/alphabet_view.php?my_codeName=Phthirus%20pubis Date accessed : 19 December 2011 38) Complete Life cycle. retrieved from http://www.allstop.com/images/diagrams/lifecycle-pubic-louse-diagram.gif Date accessed : 19 December 2011 39) Cycle and Mode of transmission. retrieved from http://dpd.cdc.gov/dpdx/images/ParasiteImages/MR/Phthiriasis/Phthiriasis_LifeCycle.gif Date accessed : 19 December 2011 40) Microscopic picture of Phthirus Pubis, retrieved from http://www.rightdiagnosis.com/phil/html/pubic-lice/4077.html date accessed : 19th December 2011 41) Sketched picture of Phthrius pubis. Retrieved from http://www.bumblebee.org/invertebrates/Anoplura.htm Date accessed : 19 December 2011 42) Treatment of Crab Louse Diagram, retrieved from http://www.omnimedicalsearch.com/conditions-diseases/pubic-lice.html date accessed : 19th December 2011 43) Myiasis, retrieved from http://emedicine.medscape.com/article/1491170-overview#showall
date accessed : 18th December 2011 44) Cutaneous Myiasis, retrieved from http://dermnetnz.org/arthropods/myiasis.html date accessed : 18th December 2011

55

45) Cutaneous Myiasis, retrieved from

http://www.merckmanuals.com/home/skin_disorders/parasitic_skin_infections/cutaneous_m yiasis.html date accessed : 18th December 2011 46) Myiasis Clinical Presentation, retrieved from http://emedicine.medscape.com/article/1491170-clinical#showalldate accessed : 18th December 2011 47) Cutaneous Myiasis, retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20883399 date accessed : 18th December 2011

48) Fleas, retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/001329.htm date accessed: 10th December 2011 49) Flea Bites Symptom, retrieved from: http://www.buzzle.com/articles/flea-bitessymptoms.html date accessed :10th December 2011 50) Mosquito Bites, retrieved from: http://www.mayoclinic.com/health/mosquitobites/DS01075/DSECTION=symptoms date accessed : 10th December 2011 51) Ticks, retrieved from: http://www.emedicinehealth.com/ticks/article_em.htm date
accessed : 10th December 2011

52) Ticks, retrieved from: http://www.medicinenet.com/ticks/article.htm date accessed :

10th December 2011

53) Mosquito Bites-Treatment and Prevention, retrieved from: http://shakarama.nubpages.com/hub/treating.Mosquito-Bites date accessed : 10th
December 2011 54) Todars Online Textbook of Bacteriology, Kenneth Todar, PhD, retrieved from http://textbookofbacteriology.net/Lyme.html, date accessed: 13 December 2011

55) Image reprinted with permission from eMedicine.com, 2008 (left), CDC/ James Gathany (right), MedicineNet.com, retrieved from
http://www.medicinenet.com/script/main/art.asp?articlekey=110181 date accessed :13th December 2011 56) PubMed Health, Us National Library of Medicine, retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002296/, date accessed: 13 December 2011 57) Typhus , MedicineNet.com, retrieved from http://www.medicinenet.com/typhus/article.htm , date accessed: 13 December 2011 58) Typhus, Medline Plus, National Library of Medicine, National Institute of Health, retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/001363.htm, date accessed: 13 December 2011 59) Ricketssial disease, Postgraduate Medical Journal, retrieved from http://pmj.bmj.com/content/76/895/269.full, date accessed: 13 December 2011 60) Epidemic typhus Imported from Algeria, Centers for Disease Control and Prevention, retrieved from, http://wwwnc.cdc.gov/eid/article/5/5/99-0515_article.htm, date accessed: 13 December 2011 56

61) Parasites, Leishmaniasis, Centre for Disease Control and Prevention, retrieved from: http://www.cdc.gov/parasites/leishmaniasis/ , date accessed: 26 December 2011 62) Cutaneous leishmaniasis, Journal of American Academy of Family Physicians, retrieved from: http://www.aafp.org/afp/2004/0315/p1455.html, date accessed: 26 December 2011 63) Mucocutaneous leishmaniasis, Stanford University, retrieved from: http://www.stanford.edu/class/humbio103/ParaSites2006/Leishmaniasis/Mucocutaneous.ht m, date accessed: 26 December 2011 64) Dracunculiasis, World Health Organization, retrieved from: http://www.who.int/topics/dracunculiasis/en/, date accessed: 26 December 2011 65) Chagas-Heart Disease, Frontiers in Bioscience, retrieved from: http://www.bioscience.org/2003/v8/e/948/fulltext.asp?bframe=figures.htm&doi=yes, date accessed: 26 December 2011 66) Filariasis, Medscape Reference, retrieved from: http://emedicine.medscape.com/article/217776-overview#showall, date accessed: 26 December 2011 67) Loiasis, Stanford University, retrieved from: http://www.stanford.edu/class/humbio103/ParaSites2006/Loiasis/Index.html, date accessed: 26 December 2011 68) Onchocerciasis, Medscape Reference, retrieved from: http://emedicine.medscape.com/article/224309-overview, date accessed: 26 December 2011 69) Brugia Malayi, Stanford University, retrieved from: http://www.stanford.edu/group/parasites/ParaSites2009/JuliaLiebner_Brugiamalayi/JuliaLieb ner_Brugiamalayi.htm, date accessed: 26 December 2011

57