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March 2010

March 2010

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ISSN 1391-0736
 The Sri Lanka
Prescriber
 The Sri Lanka Prescriber
is sponsored bythe State Pharmaceuticals Corporation of Sri Lankaas a service to the medical profession
.
March 2010; Volume 18, No. 1 Toxocariasis1Management of chronic constipation in children3 Treating dementia6Management of psoriasis11Self-assessment questions14
CONTENTS
 
 The Sri Lanka
Prescriber
Editors
Professor Anoja Fernando
 
MBBS, FRCP, BA
Professor Gita Fernando
 
MBBS, FRCP, FCCP
Professor Colvin Goonaratna
 
MBBS, FRCP, FRCPE, FCCP, PhD, DSc
Editorial Board
Chinta Abayawardana
 
Diploma in Pharmacy
Dr Anuja Abayadeera
MBBS, FRCA, MD
Dr Nanda Amarasekara
 
MBBS, MD, FRCP, FCCP, FRACP
Dr Shamya de Silva
 
MBBS, DCH, MD
Dr Ranjan Dias
MBBS, MS, FRCS
Dr Priyadarshani Galappatthy
 
MBBS, MD, MRCP, DMT
Professor Laal Jayakody
 
MBBS, MRCP, PhD
Dr A M O Peiris
 
BDS, FDSRCPS, FFDRCS
Dr Hemamali Perera
 
MBBS, MRCPsych, MD
Professor Harshalal Seneviratne
 
MBBS, FRCOG, DM
Professor Anura Weerasinghe
 
MBBS, MD, FRCP, DCH, DTM&H, PhD, FCCP
Copies of the
Sri Lanka Prescriber
and inquiries from M. P. Kuruppu,Deputy General Manager, Marketing, and Ms Sujathi Jayaratne,Promotional Manager (Telephone 2421833), State PharmaceuticalsCorporation, P. O. Box 1757, 75, Sir Baron Jayathilake Mawatha,Colombo 1.Price per copy Rs 50.00 (students Rs 25.00). Personal callers mayalso obtain copies from the Departments of Pharmacology atthe Medical Faculties in Colombo, Galle and Sri Jayewardenepura.
Published by
Department of PharmacologyFaculty of Medicine271, Kynsey Road, Colombo 8, Sri Lanka. Telephone: +94 11 2695300 Ext 315E-mail: phrm_cmb@hotmail.com
and
State Pharmaceuticals Corporation75, Sir Baron Jayathilake Mawatha, Colombo 1. Telephones +94 11 2320356-9Fax: +94 11 447118E-mail: prmanager@spc.lk Web site: www.spc.lk
Printed by
Ananda Press82/5, Sri Ratnajothi Saravanamuttu Mawatha,Colombo 13. Telephone: +94 11 2435975E-mail: anpress@sltnet.lk
(
Secretary to Board and member
)
Cover picture
 The standardization of pharmaceuticals
(About 1883)
Seldom did two preparations of 19th-century vegetable drugshave the same strength. Dr. Albert B. Lyons developedmethods of accurate assay. Messrs. Parke and Davisrecognized the importance of his work, began marketing of standardized medicines.
One of a series:
A History of Pharmacy in Pictures,
presented by Parke, Davis& Company.George A. Bender, Director ©1956 Robert A. Thom, Artist
 
1
Sri Lanka Prescriber, Vol. 18, No. 1, 2010
 Toxocariasis is a zoonotic helminthic infection ohumans caused by the dog roundworm (
 Toxocara canis
)or cat roundworm
(Toxocara cati)
. Humans are acci-dental hosts, usually infected by ingestion of embryonatedeggs from contaminated sources. H. C. Wilder was thefirst to describe toxocariasis in humans, when hepublished a paper in 1950 describing ocular granulomasin patients thought to have retinoblastomas. Toxocariasis is a worldwide infection. Seroepide-miological surveys show a 2-5% positive rate in healthyadults from urban western countries and 14-37% in ruralareas. In tropical countries, surveys show a positive rateof 63% in Bali, 86% in Saint Lucia (West Indies), and92% in La Reunion (French Overseas Territories, IndianOcean).
Clinical presentation
Most cases of 
 Toxocara
infection are asymptomatic,especially in adults. When symptoms do occur, they arethe result of migration of second stage
 Toxocara
larvaethrough the body. Three syndromes o
 Toxocara
infection are generallyrecognised.
In children, covert toxocariasis is a mild,subclinical, febrile illness. Symptoms includecough, difficulty sleeping, abdominal pain,headaches, and behavioural problems. Exami-nation may reveal hepatomegaly, lymphadenitis,and wheezing.
Visceral larva migrans is caused by the migrationof larvae through the internal organs of humansand the resulting inflammatory reaction. Aconstellation of symptoms develops, includingfatigue, anorexia, weight loss, pneumonia, fever,cough, bronchospasm, abdominal pain, headaches,rashes, and, occasionally, seizures. Examinationmay reveal hepatomegaly, lymphadenitis, andwheezing. Occasionally, pleural effusionsdevelop. Chronic urticaria has been described.Severe cases can lead to myocarditis orrespiratory failure.
Ocular larva migrans, which is caused by larvalmigration into the posterior segment of the eye,tends to occur in older children and young adults.Patients may present with decreased vision, redeye, or leukokoria (white appearance of thepupil). Granulomas and chorioretinitis can be
Toxocariasis
observed in the retina, especially at the macula.Unilateral visual loss, retinal fibrosis, retino-blastoma, and retinal detachment occur. Serumantibodies to
 Toxocara
are often absent or presentin low titres.Because the anti-
 Toxocara
immunoglobulin-positivepopulation is much higher than the prevalence of clinicaltoxocariasis, most patients are thought to have subclinicalinfection.
 Transmission
 Transmission o
 Toxocara
to humans is usually throughingestion of infective eggs. Both
 Toxocara
 
canis
and
 Toxocara cati
eggs require a long incubation period outsideof a host before becoming infective, so fresh eggs cannotcause toxocariasis. Many objects and surfaces canbecome contaminated with infectious
 Toxocara
eggs.Flies can act as mechanical vectors for
 Toxocara
, butmost infections occur without a vector. In tropicalcountries eggs can mature to the infective stage after 2weeks outside of a host.
 Toxocara
eggs can remaininfectious for years, as they are very resistant to theeffects of chemicals, as well as changes in temperature.
Diagnosis
Diagnosis of toxocariasis is difficult becauseconfirmation of infection requires demonstration of larvaeby biopsy. Clinicians use serologic testing (eg, enzyme-linked immunosorbent assay [ELISA] and immunoblot)to infer diagnosis.
Laboratory studies
 The diagnosis of toxocariasis requires a highindex of suspicion and depends on serologictesting.
Peripheral blood eosinophilia is the mostimportant finding; however, it may be absent inpatients with ocular or covert toxocariasis.
Serum total IgE: Patients with toxocariasis oftenhave a marked increase in total IgE levels.
ELISA with
 Toxocara
excretory-secretoryantigen (TES-Ag)
{
An elevated anti-TES-Ag IgE level indicatesacute infection or progressive inflammationcaused by toxocariasis.

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