Case 8: The Flight of the Lonely Wanderer

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

“The Flight of the Lonely Wanderer”  PE revealed a pot-bellied, undernourished child in extreme abdominal pain. Scout film of the abdomen was requested.

“The Flight of the Lonely Wanderer” Guide Questions 1. What is Botchok’s affliction? 2. What is a geohelminth? 3. What are the soil-transmitted helminths? 4. How does Ascaris cause disease in man? 5. How does Ascaris present clinically? 6. What are the clinical findings of harboring the Geohelminths? 7. How should Botchok’s management be ideally instituted?

Q1: What is Botchok’s affliction?

Q1: “The Flight of the Lonely Wanderer”  The triad of persistent vomiting, abdominal distension and obstipation (inability to pass stools) speaks of intestinal obstruction  With his past history of passing out worms visibly, his occupation, lack of personal hygiene and recurrent abdominal pain one should think of a geohelminth

Q2: What is a geohelminth?

Geohelminths (Soil-transmitted helminths)  A geohelminth is a nematode parasite which is spread from man-to-man.  The egg or larva of the worm is not infective when first passed in the stool, but has to undergo further development in the soil. Thus transmission can only occur when the ground is contaminated with feces

Q3: What are the soil- transmitted helminths?

Soil-transmitted helminths  Ascaris lumbricoides  Hookworms  Trichuris trichiuria  Strongyloides stercoralis  Toxocara canis (and cati)- rare **Infection with Ascaris, hookworm and Trichuris – “The Unholy Trinity”

Ascaris lumbricoides  Adults are large, cream-colored worms, the males cms long, females cms.They live in the small intestine and obtain nourishment from the intestinal contents  The fertilized female lays about 200,000 eggs a day. Eggs remain infective for weeks or months  From the time the egg is swallowed to the time the worms mature is days Adult ascaris Fertilized egg

Q4: How does Ascaris cause disease in man?

Pathogenesis  Symptoms due to pulmonary migration –Ascaris larvae are large and antigenic and cause damage during their entry into the alveoli –Symptoms may be severe if many larvae are migrating at the same time –The clinical picture is of cough, fever, wheeze, dyspnea in severe cases, x-ray shadows and eosinophilia

Pathogenesis  Effects of adult worms: –Most infections are asymptomatic. The main effects are: 1.Mechanical 2.Toxic 3.Metabolic

Pathogenesis  Mechanical effects: 1. In the small bowel, impaction may cause obstruction, volvulus or intussusception 2. In the appendix: appendicitis 3. In the biliary tree: obstructive jaundice and intrahepatic abscesses 4. In the pancreatic duct: pancreatitis 5. In the larynx: worms vomited up may occasionally cause asphyxia

Pathogenesis  Toxic and metabolic effects: –These are vague and ill-understood but a heavy worm burden may significantly contribute to malnutrition

Q5: How does Ascariasis present clinically ?

Presentation of Ascariasis  Mild bouts of recurrent colic  The mother has seen a worm – passed in the stools, vomited up or even emerge from the ear via perforated ear drums  The child may present with complications  The infection is suspected in a poorly nourished, pot-bellied child with edema * Worms tend to be expelled during bouts of diarrhea of any cause. This does not mean the worms caused the diarrhea

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

Disclosure  Botchok was done scout film of the abdomen which revealed a mechanical obstruction at the level of the small intestine  A Barium meal was therefore requested

Botchok’s Disclosure  The Barium meal revealed adult ascaris seen as radiolucent cord like shadow

Q6: What are the clinical effects of the Geohelminths?

Clinical findings of Geohelminthiasis  Clinical effects of Hookworm infection: 1. “Ground itch” – pruritus at site of larval penetration 2. Migratory phase:pneumonitis with cough, wheezing, transient x-ray shadows. Not as severe as Ascaris 3. Acute intestinal phase: abdominal pain and diarrhea with losses of iron and proteins 4. Iron deficiency Anemia in chronic infections

Clinical findings of Geohelminthiasis  Clinical effects of Trichuriasis: 1. Diarrhea with blood but without fever 2. Rectal prolapse 3. Anemia in massive trichuriasis 4. Wasting 5. Eosinophilia

Clinical findings of Geohelminthiasis  Strongyloidiasis: 1. Patients with light infections are asymptomatic 2. Heavy infections – severe diarrhea and stetorrhea 3. Massive infection resulting from autoinfection – Hyperinfection syndrome (infective larvae penetrate all body tissues in life-threatening process) 4. Marked peripheral eosinophilia

Q7: How should Botchok’s management be ideally instituted?

Diagnosis and Treatment  Diagnosis: directly by finding the characteristic eggs in the feces  Treatment: –Piperazine salts are safe and very effective in uncomplicated intestinal ascariasis administered on 2 consecutive days. Piperazine temporarily paralyses the worms after which they are expelled by peristalsis –Mebendazole or pyrantel pamoate may be employed –Education re sanitary disposal of feces and hygienic practices together with periodic deworming will be necessary if reduction in the incidence of helminthic infection is to be achieved

Diagnosis and Treatment –Intestinal, biliary or pancreatic obstruction in the majority of cases respond to conservative measures i.e. gastrointestinal decompression, IV fluids, sedation and antispasmodics, followed by vermifuge when acute symptoms subside –Laparotomy is indicated if response to conservative treatment is unsatisfactory or if obsruction is complete or complicated by the formation of local abscesses or peritonitis

Key Learning points  The geohelminths are the major parasites that can infect children in tropical countries  The geohelminths may manifest pathogenic effects whether through the larvae or the adult worm  A fatal mechanical intestinal obstruction can be one of the outcomes of Ascariasis  Education, regular antihelminthic treatment and proper hygienic practices can prevent helminthiasis

Case 8: The Flight of the Lonely Wanderer