A Wandering Missionary's Burden: Persistent Fever and Progressive Somnolence in a Returning Traveler.

Human African trypanosomiasis incidence has declined, but diagnosis remains difficult, especially in nonendemic areas. Our patient presented with fever, progressive lethargy, and weight loss for 5 months and had previously traveled to Ghana and Cameroon but had not been to areas with recently reported African trypanosomiasis. Extensive workup was negative, except for lymphocytic pleocytosis in cerebrospinal fluid; ultimately, a bone marrow aspiration revealed necrotizing granulomatous inflammation with 2 trypanosomes discovered on the aspirate smear, consistent with Trypanosoma brucei. The patient was treated with combination nifurtimox and eflornithine with full recovery.

Human Intestinal Parasite Burden and Poor Sanitation in Rural Alabama.

Hookworm infection affects 430 million people worldwide, causing iron deficiency, impaired cognitive development, and stunting in children. Because of the environmental conditions needed for the hookworm life-cycle, this parasite is endemic to resource-limited countries. Necator americanus was endemic in the southern United States before improvement of sewage disposal systems and eradication programs. With continued poverty, poor sanitation, and an environment suitable for the hookworm life-cycle in some regions of the southern United States, a current prevalence study using modern molecular diagnostics is warranted. Lowndes County, Alabama, was chosen as the study site given previous high hookworm burdens, degree of poverty, and use of open-sewage systems. Participants were interviewed, and stool, serum, and soil samples were tested for nine intestinal parasites using a multiparallel quantitative real-time PCR (qPCR) and enzyme-linked immunosorbent assays. We found that, among 24 households, 42.4% reported exposure to raw sewage within their home, and from 55 stool samples, 19 (34.5%) tested positive for N. americanus, four (7.3%) for Strongyloides stercoralis, and one (1.8%) for Entamoeba histolytica. Stool tested positive for N. americanus contained low levels of parasite DNA (geometric mean 0.0302 fg/µL). Soil studies detected one (2.9%) Cryptosporidium species, and Toxocara serology assay detected one (5.2%) positive in this population. Individuals living in this high-risk environment within the United States continue to have stool samples positive for N. americanus. Gastrointestinal parasites known to be endemic to developing countries are identifiable in American poverty regions, and areas with lower disease burden are more likely to be identified by using qPCR.