Albendazole in Pediatrics

8/4/2019 Albendazole in Pediatrics

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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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Albendazole in Pediatrics