Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Ridding Children of Common Worm Infections Richard B. Tudor To cite this article: Richard B. Tudor (1975) Ridding Children of Common Worm Infections, Postgraduate Medicine, 58:7, 115-122, DOI: 10.1080/00325481.1975.11714227 To link to this article: https://doi.org/10.1080/00325481.1975.11714227
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• In the United States, the most common worm infections in children are due to the nematodes Enterobius vermicularis (pinworm) and Ascaris lumbricoides (roundworm). Infection by Trichuris trichiura (whipworm) is infrequent and is seen in the semitropical are as. Trichinosis is far Jess corn mon th an it was before federal legislation prohibiting the feeding of raw garbage to swine was enacted. Tapeworm infection in children is seldom seen. Viscerallarva migrans, a fairly important disease of children (but very difficult to diagnose), is seen occasionally. It is caused by Toxocara canis or T cati, the dog or cat roundworm. 1 Many of the Vietnamese children who have recently arrived in the United States have been found to have helminthic, protozoal, or bacterial diseases. The most common bacterial infections fou nd in these children and the ir contacts are acute intestinal infections by Shigel/a, Escherichia coli, and Salmonella. Also common are malaria and infections with Giardia lamblia, Entamoeba histolytica, Pneumocystis carinii, and hepatitis A virus. When a Vietnamese child has symptoms suggesting one of these infectious diseases, stool examination for ova and parasites plus examination of a blood smear for evidence of malaria is mandatory. especially if the spleen is enlarged.
pediatries RIDDING CHILDREN OF COMMON WORM INFECTIONS Richard B. Tudor, MD University of Minnesota Medical School Minneapolis
Worm infections in children are still with us in spite of greatly improved sanitation in the United States. lndoor flush toilets, paved streets, high living standards, and the like have not eliminated these parasites.
Plnworms
Symptoms-The most common manifestation of pinworm infection is itching around the anus occurring especially at night when the female worms crawl out of the cecum and colon ~nd lay eggs in the anal skin folds. There may be no specifie symptoms, however, or an infected child may appear tired and may have dark circles under the eyes due to Jack of sleep. Sorne infected children have abdominal pain with vomiting. while others may be irritable and hyperactive. Occasionally the worms may fill and block the intestinal lumen, especially in the region of the cecum. Appendicitis due to obstruction by pinworms has been reported. Pinworms can travel through the female urethra, carrying E coli into the urinary bladder and causing urinary tract infection in young girls. 2 • 3 Transmission-Pinworms are passed from hand to mouth. Contamination of clothes and the home environment with ova Ieads to spread of infection to siblings and other family members. The ova are commonly found on bedclothes, mattresses, and pajamas used by infected persons and have been found on ceilings, door surfaces, tabletops. and doorknobs. Large numbers of ova often can be found on bathroom toilets, sinks, and walls. •
Vol. 58 • No. 7 • Decermer 1975 • POSTGRADUATE MEDICINE
115
"Our beat hope for control [of vlscerallarva mlgrans] lies ln prevention.''
Diagnosis-Ordering a stool examination for ova when pinworm infection is suspected is a common error. The results often will be negative, because the worms deposit eggs outside the body. The most efficient way to find the eggs is to obtain material for microscopie examination from the perianal area. A practical way to do this is to collect the material on clear cellophane tape. Parents should be instructed to check the child's anus at night for pinworms, using a flashlight, if the child appears restless. Treatment-Ordinary washing of bedding will usually kill the pinworm eggs. 1 advise parents to put drawstrings at the waist and bottoms of the child's pajamas, and 1 sornetimes advise the wearing of gloves at night to avoid direct contact of fingers with perianal skin. Frequent hand washing and fingernail scrubbing are essential, and the nails should be kept very short. Toilets and bathroom sinks and walls should be cleaned frequently by vigorous scrubbing. Carpeting in the home or school may be contaminated by eggs. lt is best to treat the entire family at one time even if only one me rn ber is infected. 2 The three most useful drugs for treatment of pinworm infection are pyrantel pamoate (Antiminth), pyrvinium pamoate (Povan), and piperazine citrate (Antepar). 2 • 4 • 5 A newer drug, mebendazole (Vermox), is suggested for treatment not only of pinworm infection but also of whipworm, roundworm, or hookworm infection. Pyrantel pamoate will not stain teeth, stools, clothing, or toilet seats. lt is available as a caramel-flavored oral suspension containing the equivalent of 50 mg of pyrantel base per milliliter. lt is given in a single dose of l ml of the suspension for each l 0 lb of body weight, ie, l tsp (5 ml) for a 50-lb child. This corresponds to Il mg of pyrantel base per kilogram or 5 mg for each pound of weight. The maximal total dose is l gm. When prescribing pyrvinium pamoate, the physician should advise the family and the child that this agent will turn the stools a bright red. The tablets should be swallowed whole so as not to stain teeth. Use of the drug is contraindicated in aspirin-sensitive individuals, such as sorne asthmatics, because of cross-sensitivity to the tartrazine in the tablet coating. Pyrvinium pamoate is available in
116
tablets and as an oral suspension. The suspension contains the equivalent of l 0 mg of pyrvinium per milliliter, and each tablet con tains the equivalent of 50 mg. Dosage is 5 mg of pyrvinium pamoate for each kilogram of body weight. For each 10 kg (22lb), l tsp (5 ml) of suspension or l tablet may be given in a single dose. If necessary, the dose may be repeated in two or three weeks. The dosage of piperazine citrate is l tsp (0.5 gm) of the syrup for each 15 lb of body weight, up to a maximum of 5 tsp (2.5 gm) for a child weighing more than 68Ib, given once a day for seven days. The course may be repeated if necessary in one week. After anthelmintic treatment is started, 1 frequently prescribe once- or twice-daily application of oxytetracycline (Terramycin) ointment on the fingertips and around the anus for four to six weeks. Roundworms
Second in frequency to the pinworm as a cause ofworm infection in the United States is the common roundworm. 1 • 3 Adult ascarides are large (15 to 40 cm long), cylindrical worms with blunt ends which lie in the lumen of the jejunum. A female lays about 200,000 eggs a day. Symptoms-Symptoms of roundworm infection are varied. Fever, cough, and wheezing may occur as the larvae pass through the lungs, or abdominal symptoms may appear with return of the worms to the intestinal tract. Bowel obstruction, appendicitis, or biliary tract obstruction, with Iiver abscess, may ensue. Transmission-The eggs are qui te resistant to drying and cold and may remain viable in the soil for long periods. Contri!mting to a massive buildup is continued fecâl pollution, especially by children, near farmhouses, fields, schools, and playing areas. Eggs or larvae hatched after about two weeks' incubation in soil are usually carried to new hosts on the fingers of children playing in the contaminated area. Swallowed ova hatch in the upper part of the small intestine. The larvae penetrate the intestinal wall and eventually reach the lungs via the blood or lymphatics. Larvae migrating up the bronchi and trachea to the epiglottis are swaÏiowed and return to the jejunum. 3 - 7
POSTGAADUATE MEDICINE • December 1975 • Vol. 58 • No. 7
....
Richard B. Tudor Dr. Tudor is clinical instructor in pediatries, University of Minnesota Medical School, Minneapolis.
Diagnosis-An infected child or a parent may notice the passage of a roundworm severa! centimeters long from the bowel and may report this to a doctor. Even if the worm has been flushed down the toilet, a description of it as being "like an angleworm" is helpful in diagnosis. If the worm is collected and brought to the physician, the diagnosis can be made easily. Occasionally, diagnosis is made by direct microscopie examination of fecal emulsion for ova. Treatment-The simplest treatment for ascaris infection is administration of pyrantel pamoate. Dosage is the same as that used for pinworm infection. Single doses give a highly satisfactory cure rate. 4 • 5 • 8 Piperazine citrate also is effective in a dosage of75 mg/kg given on each of two successive days. Mebendazole, 25 mg/kg twice daily for two days, is also used in treatment of roundworm infection. If hookworm infection is also present, the ascariasis should be treated first because tetrachloroethylene, used in treatment of hookworm infection, will cause the ascarides to migrate. Hookworms
Hookworm disease is usually seen in children older than children with pinworm or roundworm infection. It is commonly caused by Ancylostoma duodenale or Necator americanus and in the United States occurs mostly in the Gulf states and the southeastem Atlantic region. Symptoms-The classic manifestations are iron-deficiency anemia and hypoalbuminemia due to chronic intestinal blood loss. (The worms feed on blood.) Gastrointestinal symptoms such as vague epigastric distress, pica, and typical ulcer pain may occur.
118
During invasion of exposed skin by larvae, there may be an erythematous maculopapular rash and edema with pruritus. The lesions are most common between the. toes and have been termed "ground itch. " 3 • 5 Young children with this disease often have extreme anemia with cardiac insufficiency and anasarca, whereas older children may show retarded physical, mental, and sexual development. Asymptomatic hookworm infections, however, outnumber symptomatic infections. Transmission-Human beings are infected by penetration of the skin by infective larvae in soi!. The larvae reach blood vessels and are carried to the lungs. They move up the respiratory tract, are swallowed, and finally attach themselves to the small intestine. Diagnosis-Diagnosis by stool examination for larvae is very difficult. Stool specimens must be examined within a few hours after passage or may be held in special parasitic containers available from state boards of health. Eosinophilia is common in infected persons and is usually moderate but may be severe (up to 50%). Finding occult blood in the stool is a tip-off to search for hookworm larvae. Treatment-The drug of choice for treatment of infection with A duodenale is biphenium hydroxynaphthoate (Alcopara). 5 Dosage is one 5-gm packet of granules for a child weighing less than 50 lb or a 5-gm packet given twice in one day ( 10 gm) for a larger child or adult. Food should be withheld for two hours after the drug is administered. 5 Administration of a single dose of tetrachloroethylene, 0.1 ml/kg of body weight up to a total not exceeding 5 ml, is an older form of treatment. The drug is given in early moming on an empty stomach. The patient should not eat for four hours afterward but may have liquids. As tetrachloroethylene frequently causes nausea, vomiting, and dizziness, most physicians now prescribe biphenium hydroxynaphthoate or mebendazole instead. The dosage of mebendazole is 1 tablet of lOO mg twice a day for three days. Alternative agents include pyrvinium pamoate suspension and thiabendazole (Mintezol). Thiabendazole is available as chewable 500-mg tablets or as a suspension containing 500 mg/tsp. Dosage for a child is 25 mg/kg. Thiabendazole is also effective
POSTGAADUATE MEDICINE • Dec:ember 1975 • Vd. 58 • No. 7
against pinworm, roundworm, and whipworm infections. VIsceral Larva Mlgrans (Toxocarlasls)
Visceral larva migrans is a human infection with T canis or T cati, intestinal roundworms of dogs and cats. It is also occasionally reported in association with ascariasis. 9 Symptoms-Common presenting symptoms are fever, sometimes accompanied by profuse sweating, and enlargement and tendemess of the liver. The larvae migrate freely in body tissues, causing hemorrhage, necrosis, eosinophilia, and granuloma formation. 5 • 10 Splenomegaly, skin rash, recurrent pneumonitis (Loffler's type), and ophthalmitis may occur with severe infections. Associated ophthalmitis usually occurs in patients older than 4 years who do not have eosinophilia, hyperglobulinemia, or liver enlargement. This infection should be considered in any child with hepatomegaly. The most common ophthalmic lesions as. sociated with visceral larva migrans in volve the posterior segment of the eye and are oftwo types. One is an eosinophilic abscess causing total retinal detachment, extensive vitreous exudate, and Joss of vision (usually total and permanent). Less common is a localized fibrous tumor with little or no retinal detachment and with a relatively clear vitreous. With the fibrous tumor, vision is only partly destroyed and may be recovered if the eye is not removed. In many cases the abscess or tumor arouses suspicion of retinoblastoma and is identified only after the eye is removed. Keratitis and iritis also may occur. Transmission-Eggs deposited in soil in dog and cat feces become infective after two to three weeks' incubation. Children 1 to 4 years of age are the most likely to be infected, especially if they have the dirt-eating habit. When the ova are swallowed, the larvae hatch in the intestine, pass through the intestinal wall, and wander through the viscera. They pass first to the li ver and then to other intestinal organs, where they may produce eosinophilic granulomas. These granulomas are most commonly found in the li ver and are also found in Jung, kidney, heart, striated muscle, brain, and eyeball (persona! communication wi!h Dr. R. C. Jung of Tulane University).
Vol. 58 o No. 7 o December 1975 o POSTGRADUATE MEDICINE
Diagnosis-Clinical diagnosis of visceral larva migrans may be difficult owing to the tendency for development of the syndrome in three stages. The first lasts for several weeks and is marked by eosinophilia of about 50% which may reach 90%. 9 The total leukocyte count is also elevated, sometimes exceeding 90,000/cu mm. Episodes of mild asthma or pneumonitis may occur. In the second stage, which lasts for about a month, the cardinal signs and symptoms of enlarged li ver, fe ver, pneumonia of the Loffler type, and hyperglobulinemia are present. 11 During the third stage the patient begins to show improvement, ie, fever disappears, eosinophilia decreases (although it may take one to two years to disappear), the liver becomes smaller, and serum globulin leve! decreases. Sorne liver enlargement may persist for a year or more. A standardized skin test and indirect hemagglutination and fluorescent antibody tests forT canis and T cati are available from the United States Public Health Service in Atlanta, Georgia. The antigens of ascarides and Strongyloides stercoralis may provoke considerable cross-reactivity with the antigen ofToxocara, and differentiation is sometimes difficult. 6 Elevated IgE levels have been found in the presence of the Toxocara larvae.11 Biopsy of a granulomatous lesion may disclose the Toxocara larvae. 5 Treatment-There is no proof of the efficacy of any treatment for viscerallarva migrans, as diagnosis is difficult and spontaneous improvement is common. Diethylcarbamazine citrate (Hetrazan) bas been partially effective. The usual dosage is 10 to 30 mg/kg of body
119
Pinworm (left) and roundworm (rlght) infections are the two most comrnon worm infections in children in the United States.
weight given daily (in one dose) for 14 days. Thiabendazole, 25 to 50 mg/kg/day for seven to ten days, may be helpful but the results of its use are equivocal. The best treatment in milder cases is to maintain good general health. Bronchodilators, expectorants, and antibiotics may help if asthmatic symptoms or secondary bacterial infection is present. Corticosteroids may be lifesaving in cases of severe respiratory di stress or ophthalmitis. Until we find a better way to diagnose visceral larva migrans and an effective drug to treat it, our most effective weapon against the infection is prevention through periodic administration of anthelmintics to household dogs and cats to rid them of Toxocara and through prompt cleanup of feces of pets.
Summary
The most common worm infection in children in the United States is pinworm infection. In second place is roundworm infection. Agents that are effective against these nematodes in a high proportion of cases are available. In hookworm disease, generally seen in older children, tetrachloroethylene treatment is being supplanted by use of drugs less likely to have adverse side effects. Viscerallarva mi grans is difficult to diagnose and to treat, and our best hope for control lies in prevention. • Address reprint requests to Richard B. Tudor, MD, 2545 Chicago Ave, Suite 105, Minneapolis, MN 55407.
References 1. Center for Disease Control advises on health status of Vietnamese orphans. ln Communicable Disease Newsletter. Minneapolis, Minnesota Department of Health, May 1975. vol 2. no. 3 2. Crowder M. Harlin VK, Sinacore J, et al: Seminar on intestinal parasitic problems of school age children. Infect Dis 5:1,4,8.9, Dec 1974 3. Most H, Shookhoff HB: Helminthic infections. In Forum on Infection. Clinicat Vie~s From Research and Practice. New York, Biomedical Information Corp, 1975, vol 2, no. 1 4. Biagi F: Intestinal parasites. ln Conn HF (Editor): Current Therapy. Philadelphia, WB Saunders Co, 1975, pp 42-45 5. Plorde JJ: Intestinal nematodes. In Wintrobe MM, Thom GW. Adams RD, et al (Editors): Harrison's Principles of Internai Medicine. Ed 7. New York, McGraw-Hill Book Co. 1974, pp 1035-1042
~"~eadysource COMMON WORM
1'
INFECTIONS
AUDIOVISUALS
DO
Medical Parasltology (2 full-color filmstrips totaling 100 frames; 9-page booklet) (Markell, Voge) Source: WB Saunders Co, 218 W Washington Sq, Philadelphia, PA 191 05 Cost: $32.50 A Close Look at Helminthe (80 si ides, tape cassette) Source: Roerig Division, Pfizer lnc, 235 E 42nd SI, New York. NY 10017, Attn Ms Katen
6. Faust EC, Rus1oell PF, Jung RC (Editors): Craig & Faust's Clinicat Parasitology. Ed 8. Philadelphia, Lea & Febiger, 1970 7. Juniper K Jr: Parasitic diseases of the intestinal tract. ln Paulson M (Editor): Gastroenterologic Medicine. Philadelphia, Lea & Febiger, 1969 8. Handbook of Microbial Therapy. Med Lett Drugs Ther 14:1-64, 21 Jan 1972 9. Burton IF, Hould FL: Visceral larva migrans syndrome caused by humanAscaris lumbricoides. Harper Hosp Bull 239, Jul-Aug 1960 10. Beaver PC, Snyder CH, Carrera GM, Dent JH, Lafferty JW: Chronic eosinophilia due to viscerallarva migrans. Pediatries 9:7. 1952 Il. Rosenberg EB, Whalen GE, Bennich H: Increased circulating IgE in a new parasitic disease-human intestinal capillariasis. N Engl J Med 283:1148, 19 Nov 1970
0
Treatlng Plnworm Infection Treatlng Roundworm Infection New York: Roerig Division, Pfizer lnc, 1973 (AvaHable from Roerig representative or by direct request to the company at 235 E 42nd St, New York, NY 10017, Attn Ms Katen) Harrlson's Prlnclples of Internai Medicine (ed 7) (Wintrobe et al, editors) pp 1033-1045 New York: McGraw-Hill Book Co. 1974
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Medical Parasltology(ed 3) (Markell, Voge) Philadelphia: WB Saunders Co, 1971
Plnworm Infestation Pediatries Digest. Sep 1975, pp 13-16
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PRESCRIBING INFORMATION Antiminth (pyrantel pamoate) Oral Suspension Actions. Antiminth (pyrantel pamoate) bas demonstrated anthelmintic activity against Enterobius vermicularis (pinworm) and Ascaris lumbri· coides (roundworm). The anthelmintic action is probably due to the neuromuscular blocking property of the drug. Antiminth is partially absorbed after an oral dose. Plasma levels of unchanged drug are low. Peak levels (0.05-0.13JLg/ml.) are reached in 1-3 hours. Quantities greater than 50% of administered drug are excreted in feces as the unchanged form, whereas only 7% or less of the dose is found in urine as the unchanged form of the drug and its metabolites. Indications. For the treatment of ascariasis (roundworm infection) and enterobiasis (pinworm infection). Warnings. Usage in Pregnancy: Reproduction studies have been performed in animais and there was no evidence of propensity for harm to the fetus. The relevance to the human is not known. There is no experience in /regnant women who have receive this drug. Precautions. Minor transient elevations of SGOT have occurred in a small percentage of patients. Therefore, this drug should be used with caution in patients with pre-existing liver dysfunction. Adverse Reactions. The most frequently encountered adverse reactions are related to the gastrointes· tinal system. Gastrointestinal and hepatic reac· tions: anorexia, nausea, vomiting, gastralgia, abdominal cramps, diarrhea and tenesmus, transient elevation of SCOT. CNS reactions: headache, dizziness, drowsiness, and insomnia. Skin reactions: rashes. Dosage and Administration. Children and Adults: Antiminth Oral Suspension (50 mg. of pyrantel base/ ml.) should be administered in a single dose of Il mg. of pyrantel base per kg. of body weight (or 5 mg./ lb.); maximum total dose 1 gram. This corresponds to a simplified dosage regimen of 1 cc. of Antiminth per 10 lb. of body weight. (One teaspoonful = 5 cc.) Antiminth (pyrantel pamoate) Oral Suspension may be administered without regard to ingestion of food or time of day, and purging is not necessary prior to, during, or after therapy. lt may be taken with milk or fruit juices. How Supplied. Antiminth is available as a pleasant tasting caramelflavored suspension which contains the equivalent of 50 mg. pyrantel base per ml., sup~ed ill 60 cc. bot· des and Unitcups of 5 cc. in packages of 12.
ROeRIGe A division of Plizer Pharmaceuticals New York. New York 10017
122
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Ridding Children of Common Worm Infections Richard B. Tudor To cite this article: Richard B. Tudor (1975) Ridding Children of Common Worm Infections, Postgraduate Medicine, 58:7, 115-122, DOI: 10.1080/00325481.1975.11714227 To link to this article: https://doi.org/10.1080/00325481.1975.11714227
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
• In the United States, the most common worm infections in children are due to the nematodes Enterobius vermicularis (pinworm) and Ascaris lumbricoides (roundworm). Infection by Trichuris trichiura (whipworm) is infrequent and is seen in the semitropical are as. Trichinosis is far Jess corn mon th an it was before federal legislation prohibiting the feeding of raw garbage to swine was enacted. Tapeworm infection in children is seldom seen. Viscerallarva migrans, a fairly important disease of children (but very difficult to diagnose), is seen occasionally. It is caused by Toxocara canis or T cati, the dog or cat roundworm. 1 Many of the Vietnamese children who have recently arrived in the United States have been found to have helminthic, protozoal, or bacterial diseases. The most common bacterial infections fou nd in these children and the ir contacts are acute intestinal infections by Shigel/a, Escherichia coli, and Salmonella. Also common are malaria and infections with Giardia lamblia, Entamoeba histolytica, Pneumocystis carinii, and hepatitis A virus. When a Vietnamese child has symptoms suggesting one of these infectious diseases, stool examination for ova and parasites plus examination of a blood smear for evidence of malaria is mandatory. especially if the spleen is enlarged.
pediatries RIDDING CHILDREN OF COMMON WORM INFECTIONS Richard B. Tudor, MD University of Minnesota Medical School Minneapolis
Worm infections in children are still with us in spite of greatly improved sanitation in the United States. lndoor flush toilets, paved streets, high living standards, and the like have not eliminated these parasites.
Plnworms
Symptoms-The most common manifestation of pinworm infection is itching around the anus occurring especially at night when the female worms crawl out of the cecum and colon ~nd lay eggs in the anal skin folds. There may be no specifie symptoms, however, or an infected child may appear tired and may have dark circles under the eyes due to Jack of sleep. Sorne infected children have abdominal pain with vomiting. while others may be irritable and hyperactive. Occasionally the worms may fill and block the intestinal lumen, especially in the region of the cecum. Appendicitis due to obstruction by pinworms has been reported. Pinworms can travel through the female urethra, carrying E coli into the urinary bladder and causing urinary tract infection in young girls. 2 • 3 Transmission-Pinworms are passed from hand to mouth. Contamination of clothes and the home environment with ova Ieads to spread of infection to siblings and other family members. The ova are commonly found on bedclothes, mattresses, and pajamas used by infected persons and have been found on ceilings, door surfaces, tabletops. and doorknobs. Large numbers of ova often can be found on bathroom toilets, sinks, and walls. •
Vol. 58 • No. 7 • Decermer 1975 • POSTGRADUATE MEDICINE
115
"Our beat hope for control [of vlscerallarva mlgrans] lies ln prevention.''
Diagnosis-Ordering a stool examination for ova when pinworm infection is suspected is a common error. The results often will be negative, because the worms deposit eggs outside the body. The most efficient way to find the eggs is to obtain material for microscopie examination from the perianal area. A practical way to do this is to collect the material on clear cellophane tape. Parents should be instructed to check the child's anus at night for pinworms, using a flashlight, if the child appears restless. Treatment-Ordinary washing of bedding will usually kill the pinworm eggs. 1 advise parents to put drawstrings at the waist and bottoms of the child's pajamas, and 1 sornetimes advise the wearing of gloves at night to avoid direct contact of fingers with perianal skin. Frequent hand washing and fingernail scrubbing are essential, and the nails should be kept very short. Toilets and bathroom sinks and walls should be cleaned frequently by vigorous scrubbing. Carpeting in the home or school may be contaminated by eggs. lt is best to treat the entire family at one time even if only one me rn ber is infected. 2 The three most useful drugs for treatment of pinworm infection are pyrantel pamoate (Antiminth), pyrvinium pamoate (Povan), and piperazine citrate (Antepar). 2 • 4 • 5 A newer drug, mebendazole (Vermox), is suggested for treatment not only of pinworm infection but also of whipworm, roundworm, or hookworm infection. Pyrantel pamoate will not stain teeth, stools, clothing, or toilet seats. lt is available as a caramel-flavored oral suspension containing the equivalent of 50 mg of pyrantel base per milliliter. lt is given in a single dose of l ml of the suspension for each l 0 lb of body weight, ie, l tsp (5 ml) for a 50-lb child. This corresponds to Il mg of pyrantel base per kilogram or 5 mg for each pound of weight. The maximal total dose is l gm. When prescribing pyrvinium pamoate, the physician should advise the family and the child that this agent will turn the stools a bright red. The tablets should be swallowed whole so as not to stain teeth. Use of the drug is contraindicated in aspirin-sensitive individuals, such as sorne asthmatics, because of cross-sensitivity to the tartrazine in the tablet coating. Pyrvinium pamoate is available in
116
tablets and as an oral suspension. The suspension contains the equivalent of l 0 mg of pyrvinium per milliliter, and each tablet con tains the equivalent of 50 mg. Dosage is 5 mg of pyrvinium pamoate for each kilogram of body weight. For each 10 kg (22lb), l tsp (5 ml) of suspension or l tablet may be given in a single dose. If necessary, the dose may be repeated in two or three weeks. The dosage of piperazine citrate is l tsp (0.5 gm) of the syrup for each 15 lb of body weight, up to a maximum of 5 tsp (2.5 gm) for a child weighing more than 68Ib, given once a day for seven days. The course may be repeated if necessary in one week. After anthelmintic treatment is started, 1 frequently prescribe once- or twice-daily application of oxytetracycline (Terramycin) ointment on the fingertips and around the anus for four to six weeks. Roundworms
Second in frequency to the pinworm as a cause ofworm infection in the United States is the common roundworm. 1 • 3 Adult ascarides are large (15 to 40 cm long), cylindrical worms with blunt ends which lie in the lumen of the jejunum. A female lays about 200,000 eggs a day. Symptoms-Symptoms of roundworm infection are varied. Fever, cough, and wheezing may occur as the larvae pass through the lungs, or abdominal symptoms may appear with return of the worms to the intestinal tract. Bowel obstruction, appendicitis, or biliary tract obstruction, with Iiver abscess, may ensue. Transmission-The eggs are qui te resistant to drying and cold and may remain viable in the soil for long periods. Contri!mting to a massive buildup is continued fecâl pollution, especially by children, near farmhouses, fields, schools, and playing areas. Eggs or larvae hatched after about two weeks' incubation in soil are usually carried to new hosts on the fingers of children playing in the contaminated area. Swallowed ova hatch in the upper part of the small intestine. The larvae penetrate the intestinal wall and eventually reach the lungs via the blood or lymphatics. Larvae migrating up the bronchi and trachea to the epiglottis are swaÏiowed and return to the jejunum. 3 - 7
POSTGAADUATE MEDICINE • December 1975 • Vol. 58 • No. 7
....
Richard B. Tudor Dr. Tudor is clinical instructor in pediatries, University of Minnesota Medical School, Minneapolis.
Diagnosis-An infected child or a parent may notice the passage of a roundworm severa! centimeters long from the bowel and may report this to a doctor. Even if the worm has been flushed down the toilet, a description of it as being "like an angleworm" is helpful in diagnosis. If the worm is collected and brought to the physician, the diagnosis can be made easily. Occasionally, diagnosis is made by direct microscopie examination of fecal emulsion for ova. Treatment-The simplest treatment for ascaris infection is administration of pyrantel pamoate. Dosage is the same as that used for pinworm infection. Single doses give a highly satisfactory cure rate. 4 • 5 • 8 Piperazine citrate also is effective in a dosage of75 mg/kg given on each of two successive days. Mebendazole, 25 mg/kg twice daily for two days, is also used in treatment of roundworm infection. If hookworm infection is also present, the ascariasis should be treated first because tetrachloroethylene, used in treatment of hookworm infection, will cause the ascarides to migrate. Hookworms
Hookworm disease is usually seen in children older than children with pinworm or roundworm infection. It is commonly caused by Ancylostoma duodenale or Necator americanus and in the United States occurs mostly in the Gulf states and the southeastem Atlantic region. Symptoms-The classic manifestations are iron-deficiency anemia and hypoalbuminemia due to chronic intestinal blood loss. (The worms feed on blood.) Gastrointestinal symptoms such as vague epigastric distress, pica, and typical ulcer pain may occur.
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During invasion of exposed skin by larvae, there may be an erythematous maculopapular rash and edema with pruritus. The lesions are most common between the. toes and have been termed "ground itch. " 3 • 5 Young children with this disease often have extreme anemia with cardiac insufficiency and anasarca, whereas older children may show retarded physical, mental, and sexual development. Asymptomatic hookworm infections, however, outnumber symptomatic infections. Transmission-Human beings are infected by penetration of the skin by infective larvae in soi!. The larvae reach blood vessels and are carried to the lungs. They move up the respiratory tract, are swallowed, and finally attach themselves to the small intestine. Diagnosis-Diagnosis by stool examination for larvae is very difficult. Stool specimens must be examined within a few hours after passage or may be held in special parasitic containers available from state boards of health. Eosinophilia is common in infected persons and is usually moderate but may be severe (up to 50%). Finding occult blood in the stool is a tip-off to search for hookworm larvae. Treatment-The drug of choice for treatment of infection with A duodenale is biphenium hydroxynaphthoate (Alcopara). 5 Dosage is one 5-gm packet of granules for a child weighing less than 50 lb or a 5-gm packet given twice in one day ( 10 gm) for a larger child or adult. Food should be withheld for two hours after the drug is administered. 5 Administration of a single dose of tetrachloroethylene, 0.1 ml/kg of body weight up to a total not exceeding 5 ml, is an older form of treatment. The drug is given in early moming on an empty stomach. The patient should not eat for four hours afterward but may have liquids. As tetrachloroethylene frequently causes nausea, vomiting, and dizziness, most physicians now prescribe biphenium hydroxynaphthoate or mebendazole instead. The dosage of mebendazole is 1 tablet of lOO mg twice a day for three days. Alternative agents include pyrvinium pamoate suspension and thiabendazole (Mintezol). Thiabendazole is available as chewable 500-mg tablets or as a suspension containing 500 mg/tsp. Dosage for a child is 25 mg/kg. Thiabendazole is also effective
POSTGAADUATE MEDICINE • Dec:ember 1975 • Vd. 58 • No. 7
against pinworm, roundworm, and whipworm infections. VIsceral Larva Mlgrans (Toxocarlasls)
Visceral larva migrans is a human infection with T canis or T cati, intestinal roundworms of dogs and cats. It is also occasionally reported in association with ascariasis. 9 Symptoms-Common presenting symptoms are fever, sometimes accompanied by profuse sweating, and enlargement and tendemess of the liver. The larvae migrate freely in body tissues, causing hemorrhage, necrosis, eosinophilia, and granuloma formation. 5 • 10 Splenomegaly, skin rash, recurrent pneumonitis (Loffler's type), and ophthalmitis may occur with severe infections. Associated ophthalmitis usually occurs in patients older than 4 years who do not have eosinophilia, hyperglobulinemia, or liver enlargement. This infection should be considered in any child with hepatomegaly. The most common ophthalmic lesions as. sociated with visceral larva migrans in volve the posterior segment of the eye and are oftwo types. One is an eosinophilic abscess causing total retinal detachment, extensive vitreous exudate, and Joss of vision (usually total and permanent). Less common is a localized fibrous tumor with little or no retinal detachment and with a relatively clear vitreous. With the fibrous tumor, vision is only partly destroyed and may be recovered if the eye is not removed. In many cases the abscess or tumor arouses suspicion of retinoblastoma and is identified only after the eye is removed. Keratitis and iritis also may occur. Transmission-Eggs deposited in soil in dog and cat feces become infective after two to three weeks' incubation. Children 1 to 4 years of age are the most likely to be infected, especially if they have the dirt-eating habit. When the ova are swallowed, the larvae hatch in the intestine, pass through the intestinal wall, and wander through the viscera. They pass first to the li ver and then to other intestinal organs, where they may produce eosinophilic granulomas. These granulomas are most commonly found in the li ver and are also found in Jung, kidney, heart, striated muscle, brain, and eyeball (persona! communication wi!h Dr. R. C. Jung of Tulane University).
Vol. 58 o No. 7 o December 1975 o POSTGRADUATE MEDICINE
Diagnosis-Clinical diagnosis of visceral larva migrans may be difficult owing to the tendency for development of the syndrome in three stages. The first lasts for several weeks and is marked by eosinophilia of about 50% which may reach 90%. 9 The total leukocyte count is also elevated, sometimes exceeding 90,000/cu mm. Episodes of mild asthma or pneumonitis may occur. In the second stage, which lasts for about a month, the cardinal signs and symptoms of enlarged li ver, fe ver, pneumonia of the Loffler type, and hyperglobulinemia are present. 11 During the third stage the patient begins to show improvement, ie, fever disappears, eosinophilia decreases (although it may take one to two years to disappear), the liver becomes smaller, and serum globulin leve! decreases. Sorne liver enlargement may persist for a year or more. A standardized skin test and indirect hemagglutination and fluorescent antibody tests forT canis and T cati are available from the United States Public Health Service in Atlanta, Georgia. The antigens of ascarides and Strongyloides stercoralis may provoke considerable cross-reactivity with the antigen ofToxocara, and differentiation is sometimes difficult. 6 Elevated IgE levels have been found in the presence of the Toxocara larvae.11 Biopsy of a granulomatous lesion may disclose the Toxocara larvae. 5 Treatment-There is no proof of the efficacy of any treatment for viscerallarva migrans, as diagnosis is difficult and spontaneous improvement is common. Diethylcarbamazine citrate (Hetrazan) bas been partially effective. The usual dosage is 10 to 30 mg/kg of body
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Pinworm (left) and roundworm (rlght) infections are the two most comrnon worm infections in children in the United States.
weight given daily (in one dose) for 14 days. Thiabendazole, 25 to 50 mg/kg/day for seven to ten days, may be helpful but the results of its use are equivocal. The best treatment in milder cases is to maintain good general health. Bronchodilators, expectorants, and antibiotics may help if asthmatic symptoms or secondary bacterial infection is present. Corticosteroids may be lifesaving in cases of severe respiratory di stress or ophthalmitis. Until we find a better way to diagnose visceral larva migrans and an effective drug to treat it, our most effective weapon against the infection is prevention through periodic administration of anthelmintics to household dogs and cats to rid them of Toxocara and through prompt cleanup of feces of pets.
Summary
The most common worm infection in children in the United States is pinworm infection. In second place is roundworm infection. Agents that are effective against these nematodes in a high proportion of cases are available. In hookworm disease, generally seen in older children, tetrachloroethylene treatment is being supplanted by use of drugs less likely to have adverse side effects. Viscerallarva mi grans is difficult to diagnose and to treat, and our best hope for control lies in prevention. • Address reprint requests to Richard B. Tudor, MD, 2545 Chicago Ave, Suite 105, Minneapolis, MN 55407.
References 1. Center for Disease Control advises on health status of Vietnamese orphans. ln Communicable Disease Newsletter. Minneapolis, Minnesota Department of Health, May 1975. vol 2. no. 3 2. Crowder M. Harlin VK, Sinacore J, et al: Seminar on intestinal parasitic problems of school age children. Infect Dis 5:1,4,8.9, Dec 1974 3. Most H, Shookhoff HB: Helminthic infections. In Forum on Infection. Clinicat Vie~s From Research and Practice. New York, Biomedical Information Corp, 1975, vol 2, no. 1 4. Biagi F: Intestinal parasites. ln Conn HF (Editor): Current Therapy. Philadelphia, WB Saunders Co, 1975, pp 42-45 5. Plorde JJ: Intestinal nematodes. In Wintrobe MM, Thom GW. Adams RD, et al (Editors): Harrison's Principles of Internai Medicine. Ed 7. New York, McGraw-Hill Book Co. 1974, pp 1035-1042
~"~eadysource COMMON WORM
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INFECTIONS
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Medical Parasltology (2 full-color filmstrips totaling 100 frames; 9-page booklet) (Markell, Voge) Source: WB Saunders Co, 218 W Washington Sq, Philadelphia, PA 191 05 Cost: $32.50 A Close Look at Helminthe (80 si ides, tape cassette) Source: Roerig Division, Pfizer lnc, 235 E 42nd SI, New York. NY 10017, Attn Ms Katen
6. Faust EC, Rus1oell PF, Jung RC (Editors): Craig & Faust's Clinicat Parasitology. Ed 8. Philadelphia, Lea & Febiger, 1970 7. Juniper K Jr: Parasitic diseases of the intestinal tract. ln Paulson M (Editor): Gastroenterologic Medicine. Philadelphia, Lea & Febiger, 1969 8. Handbook of Microbial Therapy. Med Lett Drugs Ther 14:1-64, 21 Jan 1972 9. Burton IF, Hould FL: Visceral larva migrans syndrome caused by humanAscaris lumbricoides. Harper Hosp Bull 239, Jul-Aug 1960 10. Beaver PC, Snyder CH, Carrera GM, Dent JH, Lafferty JW: Chronic eosinophilia due to viscerallarva migrans. Pediatries 9:7. 1952 Il. Rosenberg EB, Whalen GE, Bennich H: Increased circulating IgE in a new parasitic disease-human intestinal capillariasis. N Engl J Med 283:1148, 19 Nov 1970
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Treatlng Plnworm Infection Treatlng Roundworm Infection New York: Roerig Division, Pfizer lnc, 1973 (AvaHable from Roerig representative or by direct request to the company at 235 E 42nd St, New York, NY 10017, Attn Ms Katen) Harrlson's Prlnclples of Internai Medicine (ed 7) (Wintrobe et al, editors) pp 1033-1045 New York: McGraw-Hill Book Co. 1974
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Medical Parasltology(ed 3) (Markell, Voge) Philadelphia: WB Saunders Co, 1971
Plnworm Infestation Pediatries Digest. Sep 1975, pp 13-16
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PRESCRIBING INFORMATION Antiminth (pyrantel pamoate) Oral Suspension Actions. Antiminth (pyrantel pamoate) bas demonstrated anthelmintic activity against Enterobius vermicularis (pinworm) and Ascaris lumbri· coides (roundworm). The anthelmintic action is probably due to the neuromuscular blocking property of the drug. Antiminth is partially absorbed after an oral dose. Plasma levels of unchanged drug are low. Peak levels (0.05-0.13JLg/ml.) are reached in 1-3 hours. Quantities greater than 50% of administered drug are excreted in feces as the unchanged form, whereas only 7% or less of the dose is found in urine as the unchanged form of the drug and its metabolites. Indications. For the treatment of ascariasis (roundworm infection) and enterobiasis (pinworm infection). Warnings. Usage in Pregnancy: Reproduction studies have been performed in animais and there was no evidence of propensity for harm to the fetus. The relevance to the human is not known. There is no experience in /regnant women who have receive this drug. Precautions. Minor transient elevations of SGOT have occurred in a small percentage of patients. Therefore, this drug should be used with caution in patients with pre-existing liver dysfunction. Adverse Reactions. The most frequently encountered adverse reactions are related to the gastrointes· tinal system. Gastrointestinal and hepatic reac· tions: anorexia, nausea, vomiting, gastralgia, abdominal cramps, diarrhea and tenesmus, transient elevation of SCOT. CNS reactions: headache, dizziness, drowsiness, and insomnia. Skin reactions: rashes. Dosage and Administration. Children and Adults: Antiminth Oral Suspension (50 mg. of pyrantel base/ ml.) should be administered in a single dose of Il mg. of pyrantel base per kg. of body weight (or 5 mg./ lb.); maximum total dose 1 gram. This corresponds to a simplified dosage regimen of 1 cc. of Antiminth per 10 lb. of body weight. (One teaspoonful = 5 cc.) Antiminth (pyrantel pamoate) Oral Suspension may be administered without regard to ingestion of food or time of day, and purging is not necessary prior to, during, or after therapy. lt may be taken with milk or fruit juices. How Supplied. Antiminth is available as a pleasant tasting caramelflavored suspension which contains the equivalent of 50 mg. pyrantel base per ml., sup~ed ill 60 cc. bot· des and Unitcups of 5 cc. in packages of 12.
ROeRIGe A division of Plizer Pharmaceuticals New York. New York 10017
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