Post on 07-Apr-2018
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Called infestation and not infection because there is noproduction of antigen-antibody to fight these worms
50% of children have associated protein energymalnutrition and vitamin deficiencies
Indian J of Peds, Dec.; 1959, JN Pohowalla, SD Singh:most common infestations were ascariasis andthreadworms.Trichuris trichiura and H. nana were found insmall numbers. Hookworm infrequent
Mainly caused by contaminated food and water. Poorhygiene, lack of cleanliness, bare foot walking,undercooked foods and contact with infected environment-lands which is contaminated with human and animalexcreta are the few other causes
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Three groups of helminths:
Nematodes (roundworm),
Trematodes (flukes) &
Cestodes (tapeworm)
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Pinworm, Threadworm
Intense itching at perianal area {esp. at night} oftenthe first sign. Scraching the perianal skin predisposesto 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 atcommencement of itching
Dx: Stool R/M: Eggs present only in 5%, Hypoallergic
adhesive tape: Scotch Tape Test
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Autoinfection & Retrograde infection
Easily spread, the clinician must decide whether totreat all close contacts
Worms will die in intestines within 6 wks & if no neweggs 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 areNOT destroyed], Piperazine [> 3 months] 2 doses 2weeks apart; risk of neurotoxicity
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Soil TransmittedHelminths:roundworm,hookworm,whipworm.
Cant completelife cycle inhumans, requiresoil for maturationof fertilized egg
More commonwith poorsanitation
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Ascaris lumbricoids, affects up to 90% of persons insome tropical regions
Look similar to earthworms, up to 30 cm
Hyperinfection
PEM, night blindnessAscaris Pneumonia[Loefflers syndrome]: Sputum
may contain larvae
Wandering Ascaris appendicitis, obstructivejaundice, acute pancreatitis, peritonitis, hepatic abscess
Ectopic Ascariasis: may be vomited up or come outthrough mouth or nose, may cause suffocation whilethrough respiratory passage: Stress (fever, illness,
anesthesia), some antihelminths predispose!
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May present with fever, hepatomegaly, urinaryretention, vomiting, etc.
Cephalad migration
Dx: Stool R/M: Eggs, also in BileCBC: Eosinophilia in early stage of invasion, if in
intestinal phase s/o associated strogyloidosis ortoxocariasis
Barium Study: String like shadow because of contrast
ingestion by worms (within 4 6 hrs)
US Abdomen: Biliary obstruction
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Tx: Single dose*: Albendazole, mebendazole,ivermectin
Partial/complete I.O. [Heavy worm load]: Piperazine 75mg/kg/d (max. 3.5 gm/d) through NG tube. If NOT
available, conservative management (NG suction, IVF,electrolyte correction) may result in resolution ofobstruction, at which point any of three* drugs can begiven!
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
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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 alongthe path of larva. Resembles Larva Currens by
Strongyloides. {Last only weeks}
Nutritional deficiencies esp. Iron. HencePica/Allotriophagy
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Fecal blood loss is proportionate to the worm burden.Protein loss albumin, edema, ascites
Dyspepsia, epigastric tenderness simulating pepticulcer, Constipation, steatorrhoea
Stool R/M: Occult blood, Characteristic hookwormeggs, concentration method better yield
Tx: 1st correct anemia if severe
Albendazole, Mebendazole, Pyrantel pamoate
Repeat Stool examination suggested after 2 wks,retreated if positive
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Trichuris Trichiura
Resides in Cecum, ascending colon, appendix
Mostly asymptomatic
Heavy load anemia, hypoproteinemia, growthretardation, dysentery, rectal prolapse, epigastric pain,abdominal distention
Frequently with other helminths, 3 9 yrs
Dx: Stool, eosinophilia minimal
Tx: Mebendazole, Albendazole ( 3 days for heavyinfection)
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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% mortalityeven with Tx
Dx: Stool: Larva, Duodenal fluid microscopy
Tx: Ivermectin (200 g/kg/d) for 1-2 days, 7 10 daysfor Hyperinfection syndrome. Thialbendazole,
Albendazole 3 days
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Toxocara canis (dog roundworm), T. cati (catroundworm)
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 childwith 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
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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 withpraziquantel. Nitazoxanide.
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Passage of worms in stools/vomitusPerianal itch PinwormBare foot walk hookworm, strongyloidosis,
cutaneous larva migrans
Pica toxocara (Visceral larva migrans)Child care centre pinworm, giardia, cryptosporidiaPersistent 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 humanexcreta ascariasis, trichiuris
Rectal prolapse Trichiuris
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Soil contaminated with dog/cat feces or animalcontact Toxocara
Iron deficiency anemia NOT responding to Irontherapy Hookworm infestation
Recurrent Abdominal Pain [RAP]: 3 episodes over 3months, severe enough to affect daily activity
Eosinophilic Pneumonitis (Lffler's syndrome):rounded infiltrates; a few millimeters to severalcentimeters in size. Infiltrates may be transient &intermittent, clearing after several weeks. If seasonaltransmission of the parasite seasonal pneumonitiswith eosinophilia in previously infected and sensitizedhosts: Ascaris, Hookworm, Strongyloides, Atopic,
Hypersensitivity pneumonitis
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Cough:
Ascarisis
Hookworm infestation
Strongyloidosis
Visceral larve migrans [H/O Pica]; Chronic cough,often paroxysmal & worse at night; wheezing &irritability. Fever, leucocytosis, eosinophilia &hepatomegaly.
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Diarrhea:
Roundworms:
Ascariasis: Chronic diarrhea & colicky abdominal pain
Hookworm: Unformed tarry stools with heavyinfestation
Trichuriasis (whipworm): Rarely bloody mucoiddiarrhea
Strongyloidosis (threadworm): Mucoid diarrhea, attimes severe, may persist or alternate with constipation.Sometimes malabsorption syndrome & protein losingenteropathy
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Vulvovaginitis:
Pinworm
Ascariasis
Trichuriasis (whipworm)
Blood in Stools:
Hookworm
Trichuriasis (whipworm)
Others
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Predominant intestinal parasitesIntestinal entry and maturation
Intestinal entry, disease elsewhere
Larval stage leaves the gut
Skin entry, gut manifestationsMature stage enters the gut
Skin entry, disease elsewhereDissemination
Failure to complete life cycle
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Intestinal worms:ascaris lumbricoides
trichuris trichiuria
taenia saginataenterobius vermicularis
Intestinal protozoans:giardia lamblia
cryptosporidium parvumentamoeba histolytica
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Intestinal entry, disease elsewhereacquired toxoplasmosis
hydatid disease (echinococcus)
cysticercosis (taenia solium)visceral larva migrans (Toxocara canis)
trichinosis (trichinella spiralis)
Skin entry, intestinal manifestationsHookworm
Strongyloides
Schistosoma mansoni
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Skin entry, localized disease
Leishmaniasis
FilariasisSkin entry, disease by dissemination
Malaria
Trypanosomiasis
Schistosomiasis
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Ingestion ofcysts, oocysts
or ova
Entry of larvaeor oncospheres
Site of adultstage or disease
CryptosporidiumGiardia
Amoebiasis
Intestine
ToxoplasmosisVisceral larvamigrans
Trichinella Ingested Disseminated
Ascaris
Trichuris
Enterobius
HookwormStrongyloides
through skin
Intestine
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Symptoms Parasite
Abdominal pain & Distension GiardiaCryptosporidium
Amoebiasis
Ascaris, hookworm, taenia
Diarrhoea +/- malabsorption GiardiaCryptosporidium
Strongyloides
Diarrhoea with Blood loss Amoebiasis
Trichuris
Hookworm
Tenesmus, Prolapsed rectum Trichuris
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Symptom Mechanism Parasite
Anaemia Blood loss
Malabsorption
Malnutrition
AmoebiasisHookworm
Trichuris
S mansoni
Giardia
Diphyllobothrium
Heavy infestation
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Symptom Mechanism Parasites
Skin rash Papulovesicular
Creeping eruptionPeri-anal rash and
pruritus
Hookworm
StrongyloidesEnterobius
Respiratory
symptoms
Pulmonary
migration
Ascaris
Hookworm
Strongyloides
Toxocara
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Symptom Mechanism Parasite
Intestinal obstruction
Appendicitis
Jaundice, biliary
colic
Prolapsed rectum
Intestinal perforation
and peritonitis
Worm bolus
Obstruction
Biliary obstruction
Tenesmus, weight
loss
Transmural necrosis
Ascaris
Ascaris
Ascaris
Trichuris
Amoebiasis
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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 thenematodes starvation, death, and expulsion by thehost: selective toxicity
Immobilization & death of susceptible GI parasites occurslowly, and their clearance from the GI tract may not becomplete until several days after treatment!
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Poorly absorbed from the GI tractFatty meal increases absorption by two to six fold
Well distributed into various tissues including hydatidcysts albendazole sulfoxide derivative. Crosses BBB;hence used in NCC
In children between the ages of 12 and 24 months, theWHO recommends a reduced dose of 200 mg
Transient mild GI symptoms (epigastric pain, diarrhea,
nausea, and vomiting) occur in ~1% of treatedindividuals
Allergic phenomena rarely occur and usually resolveafter 48 hours
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Concerns related to adverse effects:Bone marrow suppression: Agranulocytosis, aplastic anemia,
granulocytopenia, leukopenia, and pancytopenia have occurredleading 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 considerrestarting (with frequent monitoring of LFTs) when hepatic enzymesreturn to pretreatment values. Rarely jaundice or cholestasis
Even in long-term therapy of cystic hydatid disease andneurocysticercosis, well tolerated by most patients
Liver function tests should be monitored during protractedalbendazole therapy, and the drug is not recommended for patientswith cirrhosis
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IndicationsSingle 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
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IndicationsEnterobius 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 oncedaily for 3 days
Clonorchis sinensis (Chinese liver fluke): 10 mg/kg for 7
days
Mansonella perstans: 800 mg/day in 2 divided doses for10 days
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IndicationsHydatid Cyst (not amenable to PAIR or surgery): 15
mg/kg/d q12h (max. 800 mg/d) 28 days. May need torepeat 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 & spinalcysticercosis
Giardiasis: 10 mg/kg/d (max. 400 mg/d) 5 daysTrichinosis: 400 mg/dose 12 hrly 8 14 days + steroids
for CNS or severe symptoms
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School-based Deworming Interventions: WHO
Periodic deworming is a feasible & effective short-termmeasure for the control of morbidity due to intestinalparasites
Treatment without prior screening offers significantlogistic & economic advantages, is recommended wherepresence of intestinal parasites among school-agechildren of over 50%
The frequency of chemotherapy should be three timesannually for prevalence rates exceeding 50%, or lessafter consideration of local circumstances
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Advantages
Provides safe and effective therapyagainst infections with GI nematodes,
including mixed infections of Ascaris,Trichuris, and hookworms
Single dose usually sufficient for most
Albendazole is combined with eitherdiethylcarbamazine or ivermectin inprograms directed toward controlling LF
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