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Enterobius Vermicularis (Pinworm)

Prashanth Rawla; Sandeep Sharma.
Author Information

Last Update: December 30, 2018.

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Introduction
Enterobius vermicularis, also called pinworm, is one of the most common nematode
infections in the world. Originally, E. vermicularis was named Oxyuris
vermicularis. Humans are the only natural host for this infection. Transmission occurs in
people who are living in crowded environments and usually occurs within families. The
worms are tiny, thread-like, and whitish. The worm is named after the characteristic pin-like
tail present on the posterior part of female worms.[1][2]
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Etiology
Infection most commonly occurs in children, but any individual is susceptible to E.
vermicularis infection. People from tropical climates and school-aged children are the most
vulnerable. Infection is caused by ingestion of the pinworm eggs. Route of infection is most
commonly through the fecal-oral route.[3]
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Epidemiology
The male to female infection frequency is 2 to 1. However, a female predominance of
infection is seen in those between the ages of 5 and 14 years. It most commonly affects
children younger than 18 years of age. It is also commonly seen in adults who take care of
children, institutionalized children. Center for Disease Control and Prevention data indicates
that there about 40 million people estimated to have been infected in the United
States. Transmission can occur via contact with contaminated clothes, bedding, personal care
products, and furniture. Fecal-oral is the most common mode of transmission. Rarely,
transmission can occur via inhalation mode when eggs are inhaled and then subsequently
swallowed.
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Pathophysiology
Enterobius vermicularis is an organism that primarily lives in ileum and cecum.
Once E.  vermicularis eggs are ingested, they take about 1 to 2 months to develop into adult
worms which happens in the small intestine. These do not usually cause any symptoms when
confined to the ileocecal area. The female adult worms and ova migrate to the anal area
mostly at night time and deposit thousands of eggs in the perianal area. This migration
causes a lot of itching and pruritus. Eggs hatch near the anal area causing itching, scratching
and this causes perianal pruritus. This leads to contamination of the fingers and results in
ingestion of the eggs (autoinfection) and restarting of the life cycle of the worm.
Occasionally, the larvae migrate back into the rectum and to the small intestine and begin the
life cycle (retro infection).
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History and Physical

Infection is usually benign, and about a third of the patients are asymptomatic. The most
common symptoms associated with pinworm infestation is perianal itching. Perianal
erythema may be seen due to the itching and scratching. Sometimes a superficial bacterial
infection can occur at the scratching sites resulting in erythema and warmth. Persistent
itching can cause disturbances in sleep and may lead to insomnia. Female genitourinary
infections have also been reported in the literature. Water diarrhea has been reported in some
patients. Sometimes abdominal pain and other serious complications like appendicitis can
occur due to worms blocking the lumen in the appendix or lead to inflammation around the
appendix.[4] Sometimes tiny thread-like worms may be visible to the naked eye in the
perianal area.
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Evaluation
Enterobius can be diagnosed through a cellophane tape test or pinworm paddle test where
an adhesive tape-like material is applied to the perianal area and then examined under a
microscope. The examination might reveal characteristic ova which are 50 by 30 microns in
size and have a flattened surface on one side or may reveal the worms. Female worms are
around 8 to 13 mm long while male worms are 2 to 5 mm long. The examination is usually
done early morning for higher diagnostic yield. If the examination is negative for five
consecutive mornings, then the diagnosis is ruled out. Stool examination is not helpful in the
diagnosis of E. vermicularis as they are only occasionally excreted in the stool
usually. Sometimes analysis of the stool specimen is recommended to rule out other causes.
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Treatment / Management
Treatment consists of the following antihelminthic medications:
Albendazole: Given on an empty stomach, a 400-mg, one-time dose followed by a repeat
dose in 2 weeks
OR
Mebendazole: A 100-mg, one-time dose followed by a repeat dose in two weeks
OR
Pyrantel Pamoate:  Available over the counter in the United States; Dose of 11 mg/kg up
to a maximum 1 gm given 2 weeks apart
Other medications which have been used to treat enterobiasis are ivermectin and piperazine,
although the latter has lower efficacy and higher toxicity.[5]
Enterobiasis can cause recurrent reinfection, so treating the entire household,
whether symptomatic or not is recommended to prevent recurrence.
Treatment of Enterobius infection in pregnancy should be reserved for patients who have
significant symptoms. In pregnant patients, pyrantel pamoate is preferred over other
medications.
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Differential Diagnosis
 Pruritus ani
 Pruritus vulvae
  Atopic dermatitis
 Perirectal abscess
 Cellulitis
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Toxicity and Side Effect Management

Pyrantel pamoate can cause adverse effects like nausea, vomiting, anorexia, abdominal
cramps, diarrhea. It should be avoided in children younger than 2 years of age. Mebendazole
and albendazole should be avoided in the first trimester of pregnancy and children younger
than 1 year of age. Pregnant patients should consult their doctors before initiating any
therapy.
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Prognosis
Prognosis following a pinworm infection is excellent. Patients are recommended to follow up
with their physicians after completion of the treatment to make sure they do not have any
reinfection. Is symptoms recur then testing and treatment as above should be re-initiated.
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Complications
Occasionally a superficial bacterial infection can occur at the scratching sites due to
intense perianal pruritus. Other complications reported are female genitourinary infections
like vulvovaginitis, urinary tract infection in young girls. Appendicitis has also been reported
as a consequence of longstanding pinworm infestation.
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Deterrence and Patient Education

Patients should be educated on the need to maintain hygiene and wash their hands regularly
to prevent the spread of infection and reinfection. Family members should recognize the
signs and symptoms of pinworm infection early and should make sure that they get
appropriate medications to treat it.
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Pearls and Other Issues

Preventive strategies recommended are:
1. Washing hands regularly, particularly before eating, after changing diapers
 2. Taking a bath early in the morning to prevent egg contamination should be
encouraged in at-risk patients.
3. Trimming of fingernails should be encouraged.
4. Children should be advised to avoid sucking their fingers and touching their
perianal area.
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Enhancing Healthcare Team Outcomes

Enterobius vermicularis infection is usually treated by the primary care physician or family
physician. If having any difficulty in treating then the patient may be referred to specialists
like an infectious disease or parasitologists. Pharmacists have a role in explaining to the
patients the side effects of these medications used to treat pinworms as one of the
drugs. Pyrantel pamoate is available over the counter in the United States. School nurses
should also be aware of the manifestations of pinworm infection to prevent their spread in
the schools and daycares.[6]
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Questions
To access free multiple choice questions on this topic, click here.

Figure
Head, Enterobius Vermicularis, Pinworm. Contributed by Centers for Disease Control and
Prevention (Public Domain)
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References
1.
Cook GC. Enterobius vermicularis infection. Gut. 1994 Sep;35(9):1159-62. [PMC
free article] [PubMed]
2.
Dahlstrom JE, Macarthur EB. Enterobius vermicularis: a possible cause of
symptoms resembling appendicitis. Aust N Z J Surg. 1994 Oct;64(10):692-
4. [PubMed]
3.
 Wang S, Yao Z, Hou Y, Wang D, Zhang H, Ma J, Zhang L, Liu S. Prevalence of
Enterobius vermicularis among preschool children in 2003 and 2013 in Xinxiang
city, Henan province, Central China. Parasite. 2016;23:30.[PMC free article]
[PubMed]
4.
Yang CA, Liang C, Lin CL, Hsiao CT, Peng CT, Lin HC, Chang JG. Impact of
Enterobius vermicularis infection and mebendazole treatment on intestinal
microbiota and host immune response. PLoS Negl Trop Dis. 2017
Sep;11(9):e0005963. [PMC free article] [PubMed]
5.
Ashford RW, Hart CA, Williams RG. Enterobius vermicularis infection in a
children's ward. J. Hosp. Infect. 1988 Oct;12(3):221-4. [PubMed]
6.
Markell EK. Intestinal nematode infections. Pediatr. Clin. North Am. 1985
Aug;32(4):971-86. [PubMed]
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