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associated protein energy malnutrition and vitamin deficiencies Indian J of Peds, Dec.; 1959, JN Pohowalla, SD Singh: most common infestations were ascariasis and threadworms.Trichuris trichiura and H. nana were found in small numbers. Hookworm infrequent Mainly caused by contaminated food and water. Poor hygiene, lack of cleanliness, bare foot walking, undercooked foods and contact with infected environmentlands which is contaminated with human and animal excreta are the few other causes
Three groups of helminths: Nematodes (roundworm), Trematodes (flukes) & Cestodes (tapeworm)
Pinworm, Threadworm Intense itching at perianal area {esp. at night} often the first sign. Scraching the perianal skin predisposes to infection impetigo, eczematous lesions Persistent infection anorexia, weight loss, nocturnal enuresis, irritability, insomnia, appendicitis (2%) Hx: H/O passage of small whitish worms in stools, gravid females may be visible in perianal area at commencement of itching Dx: Stool R/M: Eggs present only in 5%, Hypoallergic adhesive tape: Scotch Tape Test
Autoinfection & Retrograde infection Easily spread, the clinician must decide whether to treat all close contacts Worms will die in intestines within 6 wks & if no new eggs are swallowed, no new worms will replace them, measures applied for 6 wks Tx: Albendazole, Mebendazole. Tx may be repeated (2 to 4 times) after 7 14 days for reinfestation [ova are NOT destroyed], Piperazine [> 3 months] 2 doses 2 weeks apart; risk of neurotoxicity
Soil Transmitted Helminths: roundworm, hookworm, whipworm. Cant complete life cycle in humans, require soil for maturation of fertilized egg More common with poor sanitation
Ascaris lumbricoids, affects up to 90% of persons in some tropical regions Look similar to earthworms, up to 30 cm Hyperinfection PEM, night blindness Ascaris Pneumonia [Loefflers syndrome]: Sputum may contain larvae Wandering Ascaris appendicitis, obstructive jaundice, acute pancreatitis, peritonitis, hepatic abscess Ectopic Ascariasis: may be vomited up or come out through mouth or nose, may cause suffocation while through respiratory passage: Stress (fever, illness, anesthesia), some antihelminths predispose!
May present with fever, hepatomegaly, urinary retention, vomiting, etc. Cephalad migration Dx: Stool R/M: Eggs, also in Bile
CBC: Eosinophilia in early stage of invasion, if in intestinal phase s/o associated strogyloidosis or toxocariasis
Barium Study: String like shadow because of contrast ingestion by worms (within 4 6 hrs) US Abdomen: Biliary obstruction
Tx: Single dose*: Albendazole, mebendazole, ivermectin Partial/complete I.O. [Heavy worm load]: Piperazine 75 mg/kg/d (max. 3.5 gm/d) through NG tube. If NOT available, conservative management (NG suction, IVF, electrolyte correction) may result in resolution of obstruction, at which point any of three* drugs can be given! Surgery: to relieve intestinal or biliary obstruction (ERCP), or for volvulus or peritonitis 20 to perforation Repeat Stool examination suggested after 3 wks, retreated if positive
Necator americanus or Ancylostoma duodenale Acquired through skin, walking bare foot Ancylostoma Dermatitis or Ground Itch: at the site of entry. Pruritic maculopapular rash. Lasts 1 2 wks.
Fecal blood loss is proportionate to the worm burden. Protein loss albumin, edema, ascites Dyspepsia, epigastric tenderness simulating peptic ulcer, Constipation, steatorrhoea Stool R/M: Occult blood, Characteristic hookworm eggs, concentration method better yield Tx: 1st correct anemia if severe Albendazole, Mebendazole, Pyrantel pamoate Repeat Stool examination suggested after 2 wks, retreated if positive
Trichuris Trichiura Resides in Cecum, ascending colon, appendix Mostly asymptomatic Heavy load anemia, hypoproteinemia, growth retardation, dysentery, rectal prolapse, epigastric pain, abdominal distention Frequently with other helminths, 3 9 yrs
STH, autoinfection 1/3rd asymptomatic Larva Currens, Lofflers syndrome & GI symptoms like ascaris Marked eosinophilia Hyperinfection syndrome in immunocompromised: Pulmonary + GI CNS S/s with Sepsis: 25% mortality even with Tx
Toxocara canis (dog roundworm), T. cati (cat roundworm) Preschool child with Pica or exposure to dogs S/S: Fever, cough, wheeze, pulmonary infiltration, hepatomegaly, endophthalmitis Recurrent ARI, low grade fever. Marked eosinophilia Dx: suggested by the finding of eosinophilia in a child with hepatomegaly or other signs of the disease, especially with a history of exposure to puppies Dx: ELISA for toxocara antibodies, larva in tissues Tx: Albendazole/Mebendazole 5 days, DEC 21 days
Dwarf tapeworm Resides in jenunum S/S: Nonspecific abdominal pain, poor appetite Dx: Eggs on microscopy of stool
Passage of worms in stools/vomitus Perianal itch Pinworm Bare foot walk hookworm, strongyloidosis, cutaneous larva migrans Pica toxocara (Visceral larva migrans) Child care centre pinworm, giardia, cryptosporidia Persistent eosinophilia with/without IgE: tissue invasion May be the only clue to helminthiasis! Ida because of chronic blood loss/bloody diarhrea Trichuris (whipworm) Ground grown vegetables contaminated with human excreta ascariasis, trichiuris Rectal prolapse Trichiuris
Soil contaminated with dog/cat feces or animal contact Toxocara Iron deficiency anemia NOT responding to Iron therapy Hookworm infestation Recurrent Abdominal Pain [RAP]: 3 episodes over 3 months, severe enough to affect daily activity Eosinophilic Pneumonitis (Lffler's syndrome): rounded infiltrates; a few millimeters to several centimeters in size. Infiltrates may be transient & intermittent, clearing after several weeks. If seasonal transmission of the parasite seasonal pneumonitis with eosinophilia in previously infected and sensitized hosts: Ascaris, Hookworm, Strongyloides, Atopic, Hypersensitivity pneumonitis
Visceral larve migrans [H/O Pica]; Chronic cough, often paroxysmal & worse at night; wheezing & irritability. Fever, leucocytosis, eosinophilia & hepatomegaly.
Diarrhea: Roundworms: Ascariasis: Chronic diarrhea & colicky abdominal pain Hookworm: Unformed tarry stools with heavy infestation Trichuriasis (whipworm): Rarely bloody mucoid diarrhea
Strongyloidosis (threadworm): Mucoid diarrhea, at times severe, may persist or alternate with constipation. Sometimes malabsorption syndrome & protein losing enteropathy
Blood in Stools:
Hookworm Trichuriasis (whipworm) Others
Intestinal worms:
ascaris lumbricoides trichuris trichiuria taenia saginata enterobius vermicularis
Intestinal protozoans:
giardia lamblia cryptosporidium parvum entamoeba histolytica
Skin entry, localized disease Leishmaniasis Filariasis Skin entry, disease by dissemination Malaria Trypanosomiasis Schistosomiasis
Trichinella Ingested
Disseminated
Intestine
Symptoms
Abdominal pain & Distension
Parasite
Giardia Cryptosporidium Amoebiasis Ascaris, hookworm, taenia Giardia Cryptosporidium Strongyloides Amoebiasis Trichuris Hookworm Trichuris
Symptom
Anaemia
Mechanism
Blood loss
Parasite
Amoebiasis Hookworm Trichuris S mansoni Giardia Diphyllobothrium Heavy infestation
Malabsorption
Malnutrition
Symptom
Mechanism
Parasites
Skin rash
Respiratory symptoms
Symptom
Mechanism
Parasite
Ascaris Ascaris Ascaris
Intestinal obstruction Worm bolus Appendicitis Jaundice, biliary colic Prolapsed rectum Obstruction Biliary obstruction
Trichuris
Amoebiasis
Benzimidazoles (BZAs): broad-spectrum anthelminths Thialbendazole relatively toxic, Mebendazole albendazole Albendazole is more effective than mebendazole against strongyloidiasis, cystic hydatid disease caused by E. granulosus, & neurocysticercosis Inhibit microtubule polymerization by binding to tubulin, inhibiting the microtubule-dependent uptake of glucose. Irreversible damage occurs in GI cells of the nematodes starvation, death, and expulsion by the host: selective toxicity Immobilization & death of susceptible GI parasites occur slowly, and their clearance from the GI tract may not be complete until several days after treatment!
Poorly absorbed from the GI tract Fatty meal increases absorption by two to six fold Well distributed into various tissues including hydatid cysts albendazole sulfoxide derivative. Crosses BBB; hence used in NCC In children between the ages of 12 and 24 months, the WHO recommends a reduced dose of 200 mg Transient mild GI symptoms (epigastric pain, diarrhea, nausea, and vomiting) occur in ~1% of treated individuals Allergic phenomena rarely occur and usually resolve after 48 hours
Indications
Single dose Tx of: Ancylostoma caninum, Ascaris lumbricoides (roundworm), Ancylostoma duodenale (hookworm), Necator americanus (hookworm) 3 days Tx for: Cutaneous larva migrans, Gongylonemiasis, Strongyloidosis, Taeniasis, H. Nana
Indications
Enterobius vermicularis (pinworm): 400 mg as a single dose; may repeat in 2 weeks Visceral larva migrans (toxocariasis): 800 mg/day in 2 divided doses for 5 days Whipworm* & Cutaneous larva migrans: 400 mg once daily for 3 days Clonorchis sinensis (Chinese liver fluke): 10 mg/kg for 7 days Mansonella perstans: 800 mg/day in 2 divided doses for 10 days
Indications
Hydatid Cyst (not amenable to PAIR or surgery): 15 mg/kg/d q12h (max. 800 mg/d) 28 days. May need to repeat 4 or more cycles with 15 days drug free intervals NCC: 15 mg/kg/d q12h (max. 800 mg/d) 8 28 days, started on day 3 of steroids. C.I. in ocular & spinal cysticercosis Giardiasis: 10 mg/kg/d (max. 400 mg/d) 5 days Trichinosis: 400 mg/dose 12 hrly 8 14 days + steroids for CNS or severe symptoms
School-based Deworming Interventions: WHO Periodic deworming is a feasible & effective short-term measure for the control of morbidity due to intestinal parasites Treatment without prior screening offers significant logistic & economic advantages, is recommended where presence of intestinal parasites among school-age children of over 50% The frequency of chemotherapy should be three times annually for prevalence rates exceeding 50%, or less after consideration of local circumstances
Advantages Provides safe and effective therapy against infections with GI nematodes, including mixed infections of Ascaris, Trichuris, and hookworms Single dose usually sufficient for most Albendazole is combined with either diethylcarbamazine or ivermectin in programs directed toward controlling LF