Helminthic infections

- Helminths are pathogenic or parasitic worms. They include roundworms

(nematodes), flukes (trematodes), or tapeworms (cestodes). Most helminths
begin life when the eggs or larvae are eliminated in the feces or urine of
humans. They are then transmitted to the oral cavity by contaminated foods or
hands. Because children tend to be careless about washing their hands before
eating or tend to suck their thumbs, it makes them prone to these infections.

Roundworms (ascariasis)
- Ascaris lumbricoides are generally asymptomatic infections but when there is an
extensive parasite load, malnutrition and gastrointestinal symptoms result.
- With an incubation period of 8 weeks, the nurse must obtain a history of travel
to underdeveloped countries. The roundworm parasite lives in the intestinal
tract. Larvae, which hatch from the ingested eggs, penetrate the intestinal wall
and enter the circulation. From there, they may migrate to any body tissue.
- Children develop a loss of appetite and nausea and vomiting. Intestinal
obstruction may occur from a mass of roundworms in the intestine. Ascariasis
can be prevented by the sanitary disposal of feces to prevent contamination of
the soil.
- There are several treatment options:
- (a) a single dose of albendazole with food,
- (b) nitazoxanide twice a day for 3 days, or
- (c) a single dose of ivermectin (off-label use and not to be used in children less
than 15 kg)

Hookworms
- Hookworm infections tend to be asymptomatic and are more common in children
living in tropical climates with poor sanitation. Hookworm eggs, like roundworm
eggs, are found in human feces.
- They enter children’s bodies through the skin and then migrate to the intestinal
tract, where they attach themselves onto the intestinal villi and suck blood from
the intestinal wall to sustain themselves. Abdominal pain which is colicky in
nature, nausea, and diarrhea with marked eosinophilia can be a presenting sign
4 to 6 weeks after exposure.
- If a great number of hookworms are present, severe anemia may result.
- Treatment is with albendazole (albenza), mebendazole (vermox), and pyrantel
pamoate (pin x) are effective.
 - Children may also need therapy for the anemia.

Enterobiasis (pinworms)
- Pinworms are small, white, threadlike worms that live in the cecum. After
ingestion of the egg either by ingestion or breathing, the mature worms develop
over a period of 2 months in the cecum. The mature female pinworm then
migrates out of the anus to deposit eggs on the skin in the anal and perianal
region.
- The movement of the worms causes the anal area to itch, and the child will
awaken at night crying and scratching. Some of the eggs are then carried from
the child’s fingernails to the mouth. After being ingested, they hatch in the child’s
intestinal tract, and the cycle is repeated (cdc, 2016f).
- The worms are large enough that they can be seen if the child’s buttocks are
separated. Pressing a piece of cellophane tape against the anus and then
inspecting it under a microscope will generally reveal pinworm eggs.
- Treatment is with a single dose of mebendazole (vermox) or pyrantel pamoate
(antihelminthic). Underclothing, bedding, towels, and nightclothes should be
washed before reuse. In addition, all family members need to be treated for
pinworm infestation because the worms are easily transmitted from person to
person. Teach children to avoid nail biting and to wash their hands before food
preparation or eating to avoid transfer of pinworm eggs and to prevent this type
of infection.

Protozoan infections
- Protozoa are unicellular organisms. They absorb fluid through their cell
membrane and can move from place to place by pseudopod, flagella, or cilia
action. They are most pathogenic in the gastrointestinal, genitourinary, and
circulatory systems. Some protozoa reproduce by simple binary fission, whereas
other forms have complex life cycles. They have the ability to form cysts or
surround themselves with a membrane, which makes them resistant to
destruction.

Giardiasis
 - Giardia lamblia, a flagellated protozoa, is the most common intestinal parasitic
infection in the united states with transmission occurring from ground water
contamination and untreated surfaces that are contaminated.
- The peak of the disease occurs in the early summer through the fall.
Transmission occurs through the fecal–oral route and occurs from fecal
contaminated water and stool. Transmission can occur from person to person or
from person to animal. The child ingests the cysts of the organism, and the cysts
develop in the intestine into the mature form of the organism. Ingestion of as
little as 10 cysts has been associated with illness. It is contagious as long as the
infected person still has excreted cysts.
- The disease can be asymptomatic or, in symptomatic people, associated with
diarrhea, weight loss, abdominal cramps, bloating, and weight loss. The
diagnosis is made through dfa assays as well as specific eia with dfa being the
recommended test by the cdc.
- According to the 2015 red book, metronidazole (flagyl), nitazoxanide (alinia,
nizonide), and tinidazole (tindamax) are the drugs of choice in pediatric patients,
with metronidazole being the least expensive.
- Nitazoxanide is approved over 1 year of age, whereas tinidazole is approved over
3 years of age. Treatment of asymptomatic carriers is not recommended for well
children living in a household with well people.
- Prevention measures include hand washing for more than 20 seconds, improved
sanitation at day care, adequate chlorination of pool and drinking water, and
camping water decontamination.

Fungal infections
- Fungi are larger than bacteria; some are unicellular (yeasts), but generally, they
are multicellular (molds). Deep mycoses invade internal organs. Respiratory
transmission is by the inhalation of spores. Subcutaneous mycoses invade the
skin, subcutaneous tissue, and bone. Infections usually occur from introduction
of the fungi into a wound. Superficial mycoses invade only the hair, skin, or nails.

Superficial fungal infections

- Four superficial fungal infections seen frequently in children are tinea cruris,
pedis, capitis, and corporis.

Tinea cruris
 - Tinea cruris (jock itch) is a brownish to erythematous, well-demarcated patch on
the groin, inner thighs, and scrotum. The patch can sometimes have central
clearing and may have a papular or vesiculopapular border. The area is pruritic
and may result from moisture, close-fitting garments, and obesity. The
incubation period is from 1 to 3 weeks. Local application of an antifungal agent
for 4 to 6 weeks is needed, and the use of corticosteroids in the area should be
avoided.
Tinea pedis
- Tinea pedis (athlete’s foot) produces pruritic, pinpoint vesicles with fissuring
between the toes and on the plantar surface of the foot. It is treated with
antifungal agent such as clotrimazole (lotrimin).
Tinea capitis
- Tinea capitis is a dermatophytic fungal infection of the scalp which can present
one of four ways: (a) a patchy alopecia with short 2 to 4 mm broken-off hair
shafts, (b) a well demarcated scaling erythematous patch in circular area, (c) a
yellow crusting, perifollicular erythema of scalp which has heavy hair loss, or (d)
a kerion or boggy circular area of hair loss which is the result of an inflammatory
response to the fungus. The child must be treated with oral antifungal such as
griseofulvin (gris-peg) or terbinafine (lamisil) and topical shampoo such as
selenium sulfide (selsun shampoo), ketoconazole (nizoral shampoo), and
ciclopirox (loprox shampoo) applied two to three times a week.
- Adolescents should be cautioned not to consume alcohol while taking any oral
antifungal medications as they are metabolized by the liver and can cause
nausea and vomiting. Safety of the drug during pregnancy is not established.
Caution children to avoid strong sunlight during griseofulvin therapy because
photosensitivity may occur.
Tinea corporis
- Tinea corporis is a superficial, well-demarcated, mildly erythematous, ring-like
infection of the epidermal layer of the skin characterized by slightly scaly central
clearing and raised papular borders. It starts as a papular lesion and spreads
over several days. It is called ringworm due to its circular shape.
- The incubation period is 1 to 3 weeks. The lesions are confused with granuloma
annulare and nummular eczema. Topical antifungal treatment should be applied
to the affected area for 1 week following complete clearing of the lesion.