Case 8:The Flight of the Lonely Wanderer

““The Flight of the Lonely The Flight of the Lonely Wanderer”Wanderer”

Botchok is a 5-year old scavenger at Botchok is a 5-year old scavenger at the Smoky Mountain who was the Smoky Mountain who was brought to the Ospital ng Tondo brought to the Ospital ng Tondo because of persistent vomiting, because of persistent vomiting, abdominal pain and inability to pass abdominal pain and inability to pass stools for the past two days. He had stools for the past two days. He had a 1 year previous history of recurrent a 1 year previous history of recurrent abdominal pain and passing out abdominal pain and passing out worms.worms.

““The Flight of the Lonely The Flight of the Lonely Wanderer”Wanderer”

PE revealed a pot-bellied, PE revealed a pot-bellied, undernourished child in extreme undernourished child in extreme abdominal pain. Scout film of the abdominal pain. Scout film of the abdomen was requested.abdomen was requested.

““The Flight of the Lonely The Flight of the Lonely Wanderer” Guide QuestionsWanderer” Guide Questions

1.1. What is Botchok’s affliction?What is Botchok’s affliction?

2.2. What is a geohelminth?What is a geohelminth?

3.3. What are the soil-transmitted helminths?What are the soil-transmitted helminths?

4.4. How does Ascaris cause disease in man?How does Ascaris cause disease in man?

5.5. How does Ascaris present clinically?How does Ascaris present clinically?

6.6. What are the clinical findings of harboring What are the clinical findings of harboring the Geohelminths?the Geohelminths?

7.7. How should Botchok’s management be How should Botchok’s management be ideally instituted?ideally instituted?

Q1:Q1:What is Botchok’s What is Botchok’s

affliction?affliction?

Q1: “The Flight of the Lonely Q1: “The Flight of the Lonely Wanderer”Wanderer”

The triad of persistent vomiting, The triad of persistent vomiting, abdominal distension and obstipation abdominal distension and obstipation (inability to pass stools) speaks of (inability to pass stools) speaks of intestinal obstructionintestinal obstruction

With his past history of passing out With his past history of passing out worms visibly, his occupation, lack of worms visibly, his occupation, lack of personal hygiene and recurrent personal hygiene and recurrent abdominal pain one should think of a abdominal pain one should think of a geohelminth geohelminth

Q2:Q2:What is a geohelminth?What is a geohelminth?

Geohelminths Geohelminths (Soil-transmitted helminths)(Soil-transmitted helminths)

A geohelminth is a nematode parasite A geohelminth is a nematode parasite which is spread from man-to-man.which is spread from man-to-man.

The egg or larva of the worm is not The egg or larva of the worm is not infective when first passed in the stool, but infective when first passed in the stool, but has to undergo further development in the has to undergo further development in the soil. Thus transmission can only occur soil. Thus transmission can only occur when the ground is contaminated with when the ground is contaminated with fecesfeces

Q3:Q3:What are the soil-What are the soil-

transmittedtransmittedhelminths?helminths?

Soil-transmitted helminthsSoil-transmitted helminths

Ascaris lumbricoidesAscaris lumbricoides HookwormsHookworms Trichuris trichiuriaTrichuris trichiuria Strongyloides stercoralisStrongyloides stercoralis Toxocara canis (and cati)- rareToxocara canis (and cati)- rare

**Infection with Ascaris, hookworm and **Infection with Ascaris, hookworm and Trichuris – “The Unholy Trinity”Trichuris – “The Unholy Trinity”

Ascaris lumbricoidesAscaris lumbricoides

Adults are large, cream-colored Adults are large, cream-colored worms, the males 15-30 cms worms, the males 15-30 cms long, females 20-40 cms.They long, females 20-40 cms.They live in the small intestine and live in the small intestine and obtain nourishment from the obtain nourishment from the intestinal contentsintestinal contents

The fertilized female lays about The fertilized female lays about 200,000 eggs a day. Eggs 200,000 eggs a day. Eggs remain infective for weeks or remain infective for weeks or monthsmonths

From the time the egg is From the time the egg is swallowed to the time the worms swallowed to the time the worms mature is 60-75 daysmature is 60-75 days

Adult ascaris

Fertilized egg

Q4:Q4:How does AscarisHow does Ascaris

cause disease cause disease in man?in man?

PathogenesisPathogenesis

Symptoms due to pulmonary Symptoms due to pulmonary migrationmigration– Ascaris larvae are large and antigenic Ascaris larvae are large and antigenic

and cause damage during their entry and cause damage during their entry into the alveoliinto the alveoli

– Symptoms may be severe if many Symptoms may be severe if many larvae are migrating at the same timelarvae are migrating at the same time

– The clinical picture is of cough, fever, The clinical picture is of cough, fever, wheeze, dyspnea in severe cases, x-ray wheeze, dyspnea in severe cases, x-ray shadows and eosinophiliashadows and eosinophilia

PathogenesisPathogenesis

Effects of adult worms:Effects of adult worms:– Most infections are asymptomatic. The Most infections are asymptomatic. The

main effects are:main effects are:

1.1. MechanicalMechanical

2.2. ToxicToxic

3.3. MetabolicMetabolic

PathogenesisPathogenesis

Mechanical effects:Mechanical effects:

1.1. In the small bowel, impaction may cause In the small bowel, impaction may cause obstruction, volvulus or intussusceptionobstruction, volvulus or intussusception

2.2. In the appendix: appendicitisIn the appendix: appendicitis

3.3. In the biliary tree: obstructive jaundice In the biliary tree: obstructive jaundice and intrahepatic abscessesand intrahepatic abscesses

4.4. In the pancreatic duct: pancreatitisIn the pancreatic duct: pancreatitis

5.5. In the larynx: worms vomited up may In the larynx: worms vomited up may occasionally cause asphyxiaoccasionally cause asphyxia

PathogenesisPathogenesis

Toxic and metabolic effects:Toxic and metabolic effects:– These are vague and ill-understood but These are vague and ill-understood but

a heavy worm burden may significantly a heavy worm burden may significantly contribute to malnutritioncontribute to malnutrition

Q5:Q5:How does Ascariasis How does Ascariasis

present clinicallypresent clinically??

Presentation of AscariasisPresentation of Ascariasis

Mild bouts of recurrent colicMild bouts of recurrent colic The mother has seen a worm – passed in The mother has seen a worm – passed in

the stools, vomited up or even emerge from the stools, vomited up or even emerge from the ear via perforated ear drumsthe ear via perforated ear drums

The child may present with complicationsThe child may present with complications The infection is suspected in a poorly The infection is suspected in a poorly

nourished, pot-bellied child with edemanourished, pot-bellied child with edema

* Worms tend to be expelled during bouts of * Worms tend to be expelled during bouts of diarrhea of any cause. This does not mean diarrhea of any cause. This does not mean the worms caused the diarrheathe worms caused the diarrhea

Presentation of AscariasisPresentation of Ascariasis

Erraticism: a characteristic Ascaris is Erraticism: a characteristic Ascaris is notorious for. Depending on the GI notorious for. Depending on the GI milieu it wanders to many organs milieu it wanders to many organs within or outside of the within or outside of the gastrointestinal systemgastrointestinal system

DisclosureDisclosure

Botchok was done Botchok was done scout film of the scout film of the abdomen which abdomen which revealed a revealed a mechanical mechanical obstruction at the obstruction at the level of the small level of the small intestineintestine

A Barium meal was A Barium meal was therefore therefore requestedrequested

Botchok’s DisclosureBotchok’s Disclosure

The Barium meal The Barium meal revealed adult revealed adult ascaris seen as ascaris seen as radiolucent cord radiolucent cord like shadowlike shadow

Q6:Q6:What are the clinical What are the clinical

effectseffectsof the Geohelminths?of the Geohelminths?

Clinical findings ofClinical findings ofGeohelminthiasisGeohelminthiasis

Clinical effects of Hookworm infection:Clinical effects of Hookworm infection:1.1. ““Ground itch” – pruritus at site of larval Ground itch” – pruritus at site of larval

penetrationpenetration2.2. Migratory phase:pneumonitis with cough, Migratory phase:pneumonitis with cough,

wheezing, transient x-ray shadows. Not wheezing, transient x-ray shadows. Not as severe as Ascarisas severe as Ascaris

3.3. Acute intestinal phase: abdominal pain Acute intestinal phase: abdominal pain and diarrhea with losses of iron and and diarrhea with losses of iron and proteinsproteins

4.4. Iron deficiency Anemia in chronic Iron deficiency Anemia in chronic infectionsinfections

Clinical findings ofClinical findings ofGeohelminthiasisGeohelminthiasis

Clinical effects of Clinical effects of Trichuriasis:Trichuriasis:

1.1. Diarrhea with blood Diarrhea with blood but without feverbut without fever

2.2. Rectal prolapse Rectal prolapse 3.3. Anemia in massive Anemia in massive

trichuriasistrichuriasis4.4. WastingWasting5.5. EosinophiliaEosinophilia

Clinical findings ofClinical findings ofGeohelminthiasisGeohelminthiasis

Strongyloidiasis:Strongyloidiasis:1.1. Patients with light infections are Patients with light infections are

asymptomaticasymptomatic2.2. Heavy infections – severe diarrhea and Heavy infections – severe diarrhea and

stetorrheastetorrhea3.3. Massive infection resulting from Massive infection resulting from

autoinfection – autoinfection – Hyperinfection syndromeHyperinfection syndrome (infective larvae penetrate all body tissues (infective larvae penetrate all body tissues in life-threatening process)in life-threatening process)

4.4. Marked peripheral eosinophiliaMarked peripheral eosinophilia

Q7:Q7:How should Botchok’s How should Botchok’s

management be management be ideally instituted?ideally instituted?

Diagnosis and TreatmentDiagnosis and Treatment Diagnosis: directly by finding the Diagnosis: directly by finding the

characteristic eggs in the fecescharacteristic eggs in the feces Treatment:Treatment:

– Piperazine salts are safe and very effective in Piperazine salts are safe and very effective in uncomplicated intestinal ascariasis administered uncomplicated intestinal ascariasis administered on 2 consecutive days. Piperazine temporarily on 2 consecutive days. Piperazine temporarily paralyses the worms after which they are paralyses the worms after which they are expelled by peristalsisexpelled by peristalsis

– Mebendazole or pyrantel pamoate may be Mebendazole or pyrantel pamoate may be employedemployed

– Education re sanitary disposal of feces and Education re sanitary disposal of feces and hygienic practices together with periodic hygienic practices together with periodic deworming will be necessary if reduction in the deworming will be necessary if reduction in the incidence of helminthic infection is to be achievedincidence of helminthic infection is to be achieved

Diagnosis and TreatmentDiagnosis and Treatment

– Intestinal, biliary or pancreatic obstruction in Intestinal, biliary or pancreatic obstruction in the majority of cases respond to conservative the majority of cases respond to conservative measures i.e. gastrointestinal decompression, measures i.e. gastrointestinal decompression, IV fluids, sedation and antispasmodics, IV fluids, sedation and antispasmodics, followed by vermifuge when acute symptoms followed by vermifuge when acute symptoms subsidesubside

– Laparotomy is indicated if response to Laparotomy is indicated if response to conservative treatment is unsatisfactory or if conservative treatment is unsatisfactory or if obsruction is complete or complicated by the obsruction is complete or complicated by the formation of local abscesses or peritonitis formation of local abscesses or peritonitis

Key Learning pointsKey Learning points

The geohelminths are the major parasites The geohelminths are the major parasites that can infect children in tropical that can infect children in tropical countriescountries

The geohelminths may manifest The geohelminths may manifest pathogenic effects whether through the pathogenic effects whether through the larvae or the adult wormlarvae or the adult worm

A fatal mechanical intestinal obstruction A fatal mechanical intestinal obstruction can be one of the outcomes of Ascariasiscan be one of the outcomes of Ascariasis

Education, regular antihelminthic Education, regular antihelminthic treatment and proper hygienic practices treatment and proper hygienic practices can prevent helminthiasis can prevent helminthiasis

Case 8:The Flight of the Lonely Wanderer