Dracunculiasis is infection with Dracunculus medinensis, a nematode worm. It is caused by drinking water containing water fleas (Cyclops species) that have ingested Dracunculus larvae. Pathophysiology Dracunculiasis is caused by drinking water containing water fleas (Cyclops species) that have ingested Dracunculus larvae. The acidic environment of the stomach and duodenum kills the copepods. The larvae are subsequently released in the stomach or small intestine and penetrate the mucosa to mate and mature in the abdomen or retroperitoneal space approximately 60-90 days after initial infection. The maturation stage can last for up to 1 year, and, during this time, the adult male probably dies because only the female worm is recovered from symptomatic patients. After maturation is complete, the female Dracunculus reaches a length of up to 1 m (with a thickness of only 1-2 mm) and slowly migrates from the GI tract into subcutaneous tissue, usually to a location in the lower extremity. The female worms move through the person's subcutaneous tissue, causing intense pain, and eventually emerge through the skin, usually at the feet, producing edema, a blister and eventually an ulcer, accompanied by fever, nausea, and vomiting. If they come into contact with water as they are emerging, the female worms discharge their larvae, setting in motion a new life cycle. Free-living larvae can survive only 3 days without a host; they become infective after 2 weeks (2 molts) within the host copepod. Epidemiology United States Dracunculiasis is rarely imported to the United States. Two cases have been reported since 1995, both occurring in individuals from Sudan. International In 1986, more than 3.5 million people in 20 countries were infected with guinea worm. At the end of 2004, all of Asia was free of the disease. Sporadic cases have been noted in Australia and North America in African immigrants during the period 2000-2005. Since 2006, only sporadic cases have been reported in African nations. From 2007-2008, indigenous infections were limited to focal areas of four countries in sub-Saharan Africa: Sudan, Ghana, Mali, and Niger. Currently, guinea worm disease remains endemic in 3 countries: Sudan, Mali, and Ethiopia and fewer than 1,800 cases were reported in the world in 2010. The most prominent hot spot for guinea worm disease is South Sudan, which harbors 94% of current cases. Treatment The mainstay of treatment is the extraction of the adult worm from the patient using a stick at the skin surface and wrapping or winding the worm a few centimeters per day. Because the worm can be as long as one meter in length, full extraction can take several days to weeks. This slow process is required to avoid breakage and leaving behind a portion of the worm. Each day, the affected body part is immersed in a container of water to encourage more of the worm to come out. The wound is cleaned and gentle traction is applied to the worm to slowly pull it out. Pulling stops when resistance is met to avoid breaking the worm. The worm is wrapped around a stick to maintain some tension on the worm and encourage more of the worm to emerge. Topical antibiotics are applied to the wound to prevent secondary bacterial infections and the affected body part is then bandaged with fresh gauze to protect the site. These steps are repeated every day until the whole worm is successfully pulled out. Analgesics, such as aspirin or ibuprofen, are given to help ease the pain of this process and reduce inflammation.