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Called infestation and not infection because there is no production of antigen-antibody to fight these worms 50% of children have

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.

Bronchopneumonia & eosinophilia: Less w.r.t. Ascaris


Creeping Eruption or Larva Migrans: Due to A. braziliense & A. carinum Reddish itchy papule along the path of larva. Resembles Larva Currens by Strongyloides. {Last only weeks} Nutritional deficiencies esp. Iron. Hence Pica/Allotriophagy

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

Dx: Stool, eosinophilia minimal


Tx: Mebendazole, Albendazole ( 3 days for heavy infection)

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

Dx: Stool: Larva, Duodenal fluid microscopy


Tx: Ivermectin (200 g/kg/d) for 1-2 days, 7 10 days for Hyperinfection syndrome. Thialbendazole, Albendazole 3 days

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

Tx: Niclosamide is 1st choice. Reinfection, treat with praziquantel. Nitazoxanide.

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

Cough: Ascarisis Hookworm infestation Strongyloidosis

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

Vulvovaginitis: Pinworm Ascariasis Trichuriasis (whipworm)

Blood in Stools:
Hookworm Trichuriasis (whipworm) Others

Predominant intestinal parasites


Intestinal entry and maturation

Intestinal entry, disease elsewhere


Larval stage leaves the gut

Skin entry, gut manifestations


Mature stage enters the gut

Skin entry, disease elsewhere


Dissemination Failure to complete life cycle

Intestinal worms:
ascaris lumbricoides trichuris trichiuria taenia saginata enterobius vermicularis

Intestinal protozoans:
giardia lamblia cryptosporidium parvum entamoeba histolytica

Intestinal entry, disease elsewhere


acquired toxoplasmosis hydatid disease (echinococcus) cysticercosis (taenia solium) visceral larva migrans (Toxocara canis) trichinosis (trichinella spiralis)

Skin entry, intestinal manifestations


Hookworm Strongyloides Schistosoma mansoni

Skin entry, localized disease Leishmaniasis Filariasis Skin entry, disease by dissemination Malaria Trypanosomiasis Schistosomiasis

Ingestion of cysts, oocysts or ova


Cryptosporidium Giardia Amoebiasis

Entry of larvae or oncospheres

Site of adult stage or disease


Intestine

Toxoplasmosis Visceral larva migrans


Ascaris Trichuris Enterobius

Trichinella Ingested

Disseminated

Hookworm Strongyloides through skin

Intestine

Symptoms
Abdominal pain & Distension

Parasite
Giardia Cryptosporidium Amoebiasis Ascaris, hookworm, taenia Giardia Cryptosporidium Strongyloides Amoebiasis Trichuris Hookworm Trichuris

Diarrhoea +/- malabsorption

Diarrhoea with Blood loss

Tenesmus, Prolapsed rectum

Symptom
Anaemia

Mechanism
Blood loss

Parasite
Amoebiasis Hookworm Trichuris S mansoni Giardia Diphyllobothrium Heavy infestation

Malabsorption

Malnutrition

Symptom

Mechanism

Parasites

Skin rash

Papulovesicular Creeping eruption Peri-anal rash and pruritus Pulmonary migration

Hookworm Strongyloides Enterobius

Respiratory symptoms

Ascaris Hookworm Strongyloides Toxocara

Symptom

Mechanism

Parasite
Ascaris Ascaris Ascaris

Intestinal obstruction Worm bolus Appendicitis Jaundice, biliary colic Prolapsed rectum Obstruction Biliary obstruction

Tenesmus, weight loss

Trichuris

Intestinal perforation Transmural necrosis and peritonitis

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

Concerns related to adverse effects:


Bone marrow suppression: Agranulocytosis, aplastic anemia, granulocytopenia, leukopenia, and pancytopenia have occurred leading to fatalities (rare); Discontinue if clinically significant decreases in counts Transaminase elevations: Reversible elevations. Discontinue if LFT elevations are >2 times the upper limit of normal; may consider restarting (with frequent monitoring of LFTs) when hepatic enzymes return to pretreatment values. Rarely jaundice or cholestasis Even in long-term therapy of cystic hydatid disease and neurocysticercosis, well tolerated by most patients Liver function tests should be monitored during protracted albendazole therapy, and the drug is not recommended for patients with cirrhosis

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