Case Conference

February 1, 2011Geronimo RE, Go CM, Go CK, Go F, Go MR

JOP, 4 y/o, male

CC: ANAL PRURITUS

History of Present Illness

3 Days •Pruritus in anal region – at night•No consult, no medications

1 Day •Persistence of symptoms – awakened him at night

CONSULT

Review of Systems• General: No fever, no weight loss• Skin: No rashes• Respiratory: No dyspnea, no cough• Cardiovascular: No chest pain• Gastrointestinal: No abdominal pain, no diarrhea, no

constipation• Musculoskeletal: No limitation of movements• Genitourinary: No dysuria, no hematuria• Endocrine: No heat/cold intolerance• Hematologic: No bleeding tendencies• Nervous: No seizures

Developmental History

• At par with developmental age• Emergence of primary teeth• No incontinence, toilet trained, no head

banging, phobias, night terrors, sleep disturbances

24 Hour Food Recall

•1 serving of biscuit•1 serving of bread

breakfast

•1 servings of rice•1 serving of vegetables

lunch

•noneSnack

•1 serving of chicken•2 serving of rice

Dinner

Recommended Energy & Nutrient Intake

CHO CHON FAT Calories1 servings of chicken

28 45 73

3 servings of rice 180 36 27 243

1 serving of biscuit

60 12 9 81

1 serving of bread

60 12 9 281

1 serving of vegetables

20 8 28

TOTAL 450 gms CHO 88 gms CHON 90gms FAT 706 kcal

• RENI: 1410 kcal ACI: 49 %

Immunization

• Unrecalled• Claimed to be complete

Past Medical History

• Parasitic infection– 3 y/o– Unrecalled medication– Local health center

Family Profile and HistoryMember Age/Sex Educational

AttainmentOccupation Health

StatusFather 28/M 2nd yr College Merchandiser HealthyMother 25/F High School Housewife HealthySibling 6/F Kindergarten Student Healthy

• Primary caregiver – mother• Lives with – both parents and sister• (-) HTN, DM, asthma, cancer, thyroid problems, blood

dyscrasias, allergies

Socioeconomic and Environmental History

• House - concrete, well lit, well ventilated• Pets - 53 pigeons• There are no factories nearby• Exposed to cigarette smoke - father• Drinking water - water station• Garbage collection – 1/week, not segregated

Physical Examination• General: Awake, alert, ambulatory, not in cardiorespiratory

distress, well nourished, well hydrated• Vital Signs: BP: 110/70 mmHg PR: 100 bpm RR: 26 cpm Temp:

36.5 C • Wt: 15.9kg ( 0 = normal) Ht: 103cm (above +3 = tall) BMI: 17

(below -1 = normal) Wt for ht: z score: 0 (normal)• Skin: Warm, moist, good turgor, no blanching, no petichae,

no rashes, no active dermatoses• Head: Normocephalic, black hair, fine texture, no nits/lice• Eyes: Pink palpebral conjunctiva, pupils 3-4 mm ERTL,

EOMs full and equal

Physical Examination

• Ears: No tragal tenderness, no aural discharge, (+) retained cerumen AU, nonhyperemic external auditory canal, tympanic membrane intact

• Nose: Nasal septum midline, no nasal discharge,

non hyperemic nasal mucosa, turbinates not congested, (+) nasal discharge

• Mouth: Moist buccal mucosa, no lesions, non hyperemic posterior pharyngeal wall, tonsils not enlarged, (+) dental carries

Physical Examination

• Neck: Supple neck, no palpable cervical lymph nodes, thyroid gland not enlarged

• Chest: Symmetrical chest expansion, no retractions, clear breath sounds

• Heart: Adynamic precordium, apex beat at the 5th LICS MCL, no murmurs

• Abdomen: Flabby abdomen, normoactive bowel sounds, soft, no masses, no tenderness

• Extremities: Pulses full & equal, capillary refill <2 sec, no cyanosis, no edema

• Recutm: (+) hyperemic anal region

Assessment

• t/c Enterobiasis, dental carries

Approach to a Patient with Anal Pruritus

• A symptom, sign, or laboratory finding pathognomonic of a disease

Presenting Manifestation: Pruritus Ani

Pruritus Ani

Infectious Non-infectious

Non-infectious

Diarrhea Poor hygiene Dietary irritants

Abscess, fissures, fistulas

Allergic or Contact

dermatitisHemorrhoids

Infectious

Perianal Dermatitis Erythrasma Scabies

Sexually Transmitted Infections

(Gonorrhea, herpes)Candida

Enterobius vermicularis (pinworm)

Non Infectious

Poor hygiene

Mother cleans anal area after defecation

Diarrhea

no passage of loose

watery stools

Dietary irritants

No intake of coffee, cola,

beer, tomatoes, chocolate

Non Infectious

Allergic or Contact

dermatitis

No exposure to irritants and

allergensUses mild soap

Abscess, fissure, fistula

No anatomic abnormalities

Hemorrhoids

No rectal bleeding

No visible dilated veins in anal area

Infectious

Erythrasma

No involvement of toe webs

No involvement of other moist

intertriginous areas such as axillae

Perianal Dermatitis

No flat, erythematous

patches in anal areaNo painful defecation

No bleeding

STI

4 years oldNot sexually

active

Infectious

Scabies

Night itchNo burrows, non

scaly papulesCircle of Hebra not

involved

Candida

Not immuno-compromised

Usually in femalesNo intake of

chemotherapeutic drugs

Enterobius vermicularis (pinworm)

Night itchHistory of playing

in the soil (+) hyperemic

anal area

Laboratory work-up

• Scotch tape swab

Management Done

• For scotch tape swab• Diet for age• Refer to dental services• Multivitamins 5ml once a day• Update immunizations • Anticipatory guidance• TCB w/ results

Follow up (after 6 days)

• Scotch tape swab – positive for enterobius vermicularis ova

• Assessment – Enterobius Vermicularis Parasitism

• Plans – Praziquantel pamoate 125mg/5ml, give 7 ml once then after 2 weeks

DISCUSSION

Enterobius vermicularis• small nematode• The female nematode averages 10 mm X 0.7 mm, whereas

males are smaller• All socioeconomic levels are affected• Infestation often occurs in family clusters• Infestation does not equate with poor home sanitary measures

(an important point when discussing therapy)

Frequency

• United States– 5-15% in the general population; – Humans are the only known host

• Sex– males = females

• Age– greatest in children aged 5-9 years, but all ages

can be affected

Mortality/Morbidity

• Secondary bacterial skin infection may develop from vigorous scratching

• Reinfestation is common• Infection can develop as long as female

pinworms continue to lay eggs on the skin• Restless sleeping may be due to pruritus ani

History

• often asymptomatic (Worms may be incidentally discovered when they are seen in the perineal region)

• If patients are symptomatic, pruritus ani and pruritus vulvae are common presenting symptoms.

History

• Restlessness during sleep is noted by the parents of many patients.

• Enuresis may be a symptom in children with pinworms.

Physical Exam• excoriation or erythema of the perineum, vulvae, or both• Visual sighting of a worm by a reliable source (eg, a parent) is

usually accepted as evidence of infestation and grounds for treatment.

• Worms can be found in stools or on the patient's perineum before bathing in the morning.

Physical Exam

• the gravid female worm may aberrantly migrate into the female genitalia and produce vaginitis

• Incidental recovery at surgery of small granulomatous lesions surrounding the worm, larvae, or eggs in the salphinx and peritoneum demonstrates the worm's ability to ascend the female genital tract

Management

Laboratory Work up• Glass slide microscopic analysis may be performed to

look for ova and female pinworms.– A specimen is best obtained by dabbing the stretched,

unwashed perianal folds in the early morning with cellophane tape and affixing on to a slide.

– A negative test for 5 consecutive mornings effectively rules out the diagnosis.

• Stool specimens are rarely diagnostic and are not indicated.

• In areas where pinworms are endemic, consider analyzing any removed appendiceal stump for infestation

Emergency Department Care

• Antihelmintic treatment benefit must be weighed with the risk of adverse effects and the possibility of reinfection, which is seldom harmful.

• Strict handwashing is required after contact with patient, patient clothing, and stretcher.

• All bedding and gowns should be cleaned.• Stretchers should be washed before further patient use.• The entire household should be treated simultaneously.• Treat itch, irritation, and excoriation symptomatically.

Medications• Anthelmintics• Parasite biochemical pathways are sufficiently different at from the human

host to allow selective interference by chemotherapeutic agents in relatively small doses.

Albendazole• MOA: decreases ATP production by the worm, causing energy depletion,

immobilization, and, finally, death.- Pediatric dose

<3 years: 200 mg/d PO as single dose; repeat in 3 wk if infestation persists>3 years: Administer as in adults

TreatmentMebendazole• Causes worm death by selectively and irreversibly blocking uptake of glucose and

other nutrients in susceptible adult intestine where helminths dwell.

- Pediatric dose<2 years: Not established>2 years: Administer as in adults

Pyrantel pamoate• Depolarizing neuromuscular blocking agent, inhibits cholinesterases, resulting in

spastic paralysis of the worm. Active against E vermicularis (pinworm) and Ascaris lumbricoides (roundworm). Effective against Ancylostoma duodenale (hookworm). Purging not necessary. May be taken with milk or fruit juices.

- Pediatric dose <2 years: Not established

>2 years: Administer as in adults

Treatment• If the infection has spread to the urinary and genital organs, a

combination therapy is required.– Mebendazole + Ivermectin (Stromectol) for the pinworms.– Topical tx for the eggs

Apart from the patient, everyone else in the house is treated with anti-worm drugs This is done to prevent the spread of infection.

– Soothing anti-itching ointments or creams are also available for relief from itching. Small children usually cannot bear the rectal pain due to the infection.

– In such cases, children should be given a sitz bath. In this type of bath, the pelvic region is immersed in lukewarm water.

• To prevent further infection and to ensure that the pinworm eggs do not spread further, proper hygiene has to be maintained. – All bedding, clothing, toys are machine-washed in hot water– This would kill all the eggs that might survive after treatment. – Toilet seats must be cleaned daily and fingernails have to be kept short and

clean. – The most basic and important healthy habit of all is to wash hands properly

before meals and after using the toilet.

Scrubbing of countertops, floors and other surfaces that the infected child touches is necessary in order to curtail further infections. Carpets should also be properly vacuumed.

– During treatment, it is advisable for the kids to wear closed sleeping garments. Snug inner-wear is also preferable. This would prevent hand contact and contamination.

Follow up• Follow-up is recommended if the pinworm symptoms persist longer than 2

weeks or if signs of bacterial superinfection occur.

Prognosis• Asymptomatic carriers are common.• The cure rate with treatment is 90-95%.• Re-infection is common, especially if not all contacts are treated

simultaneously.

Patient Education• Discharge instructions should include the following:

– Strict handwashing should be completed after using the toilet or changing a diaper of an affected baby and before and after eating for 2 weeks.

– All bedding and toys should be cleaned every 3-7 days for 3 weeks.– Underwear and pajamas should be washed daily for 2 weeks.

Prevention• Pinworm infections and reinfections can be diminished by the

following: • Make certain children wash their hands before meals and after using

the restroom. • Keep children's fingernails trimmed. • Discourage nail-biting and scratching the anal area. • Have children change into a clean pair of underwear each day. • Have children bathe in the morning to reduce egg contamination. • Open bedroom blinds and curtains during the day as eggs are

sensitive to sunlight. • After each treatment, change night clothes, underwear, and bedding

and wash them.

Anticipatory guidelines• Toddlers and Preschool Age (1–5 Years)• Regular visit in the dentist and brushing habits should be

discussed.• Elimination (bowel and bladder) training is an important topic at

this age. • Injury prevention should cover traffic safety, burn prevention, fall

prevention, drowning prevention, and dealing with strangers.• Poison prevention includes keeping medicines and household

products locked up and the poison control• Behavior guidance may focus on discipline and temper tantrums.

Development

PHYSICAL AND MOTOR• During the fourth year, a child typically:• Gains weight at the rate of about 6 grams per day• Grows to a height that is double the length at birth• Shows improved balance• Hops on one foot without losing balance• Throws a ball overhand with coordination• Can cut out a picture using scissors• May not be able to tie shoelaces• May still wet the bed (normal)

SENSORY AND COGNITIVE

• The typical 4-year-old:• Has a vocabulary of more than 1,000 words• Easily composes sentences of four or five words• Can use the past tense• Can count to four• Will ask the most questions of any age• May use words that aren't fully understood• May begin using vulgar terms, depending on their exposure• Learns and sings simple songs• Tries to be very independent• May show increased aggressive behavior• Talks about personal family matters to others• Commonly has imaginary playmates• Has an increased understanding of time• Is able to distinguish between two objects based on simple criteria such as size and weight• Lacks moral concepts of right and wrong• Is rebellious if expectations are excessive

PLAY• As the parent of a 4-year-old, you should:• Encourage and provide the necessary space for physical activity• Instruct the child on how to participate in, and follow the rules of

sporting activities• Encourage play and sharing with other children• Encourage creative play• Teach children to do small chores, such as setting the table• Read together• Monitor both the time and content of television viewing (preferably

less than 1.5 hours of TV, no more than 3 hours maximum)• Expose the child to different stimuli by visiting local areas of interest

Risk Factors of Enterobius vermicularis Infestation among Children Ages 2 to 6 Years Old in Baranggay 429 Sampaloc,

Manila

Daguman, Emmanuel J. IIErestain, Emmanuel O.

Gallardo, Estee Laurence Heart C.Gaw, Gem Minnie Mae M.

Joya, Ralph Vincent F.

JANUARY 2011

• The study aims to determine the effect of risk factors that can lead to Enterobius vermicularis infestation

• To be able to make recommendations that would be applicable to the population

Objective

• Population: ages 2 to 6 years old in Barangay 429, Sampaloc Manila

• Intervention: risk factors• Outcome: Enterobius vermicularis infestation

Methodology

• This study was concerned only in the investigation of risk factors of Enterobius vermicularis infestation among children in the age group 2-6 years of age in Baranggay 429 Sampaloc, Manila

• Does not include the reporting of the incidence of any other parasites seen during procedure

Methodology

Study design: Case control

The study focused on the risk factors◦ Sex◦ playing on the floor◦ biting nails◦ washing hands before eating◦ family size◦ sharing of beds◦ kind of drinking water◦ house lived in◦ own restrooms◦ other family members with infestation

Methodology

• The odds ratio for every factor was calculated

• The odds ratios computed were analyzed by Standard Deviation (95% confidence interval) for its statistical significance.

Methodology

Scotch tape swab

◦ gold standard for the diagnosis of Enterobius vermicularis◦ very easy and cheap to perform ◦ very sensitive and specific

Procedure

Procedure

A piece of scotch tape was attached to a glass slide in a way that its adhesive is exposed.

Procedure

The subject was asked to expose his perianal region and allowed to made contact with the adhesive on the slide

ProcedureAfter doing the procedure, the scotch tape was carefully turned so that its adhesive will now be attached to the slide and trap obtained specimen (if any) from the subject

The specimen was scanned under a light microscope, under a high power objective

Slides were examined the same day they were collected by a licensed medical technologist

Results and Discussion

• 90 patients, all of which are between 2 and 6 years old

• 30 (33%) were found to have Enterobius vermicularis infestation

• Living in shanties was found to be a statistically significant risk factor for having Enterobius vermicularis infestation.

• Other risk factors such as being male, frequent playing in the floor, big family size, and drinking tap water are associated with an increased risk of contracting Enterobius vermicularis infestation.

Conclusions

• Being female, nail biting, not washing hands before eating, sleeping beside others and not having their own restrooms does not increase the risk of having Enterobius vermicularis infestation.

Conclusions

Thank You!