ASCARIASIS PRESENTATION

ASCARIASIS

Daniel Mpandashulu a 7 year old boy is brought to the O.P.D with history of passing a worm at home.

a) State five signs and symptoms that Daniel will present with other than the one mentioned in the stem of the question 15%

b) Mention five tests that will be done in order to arrive at the diagnosis 10%

c) With the aid of a diagram describe the life cycle of ascarias lumbricoide 30%

d) Mention three (3) drugs that are used in the treatment of ascariasis , indicating the generic and brand name, mode

of action, dose, route, one specific side effect and nursing implications 27%

e) State six (6) points you are going to include in you I.E.C in order to reduce the incidence of Ascariasis in the community 18%

a) State five signs and symptoms that Daniel will present with other than the one mentioned in the stem of the question. 15%

 Mild ascariasis — with only a few parasites in the body may cause no symptoms. Symptoms occur with moderate or heavy infestations, sometimes progressing as the parasite migrates through the body. As the larvae migrate through the lungs it may cause the following symptoms::

 Persistent cough due to irritation of the airway as the worm larvae migrates

 Shortness of breath due to inflammation caused by the worm larvae in the lungs

 Wheezing due to the inflammatory process secondary to migration of the worm larvae through the lungs.

 The ascaris adult worm lives in the intestine and competes for food with the host. his may lead to the following symptoms:

 Vague abdominal pain due to presence of the worm in the intestines

 Nausea and vomiting due to abdominal upset secondary to worm infestation

 Diarrhea or bloody stools due to irritation of the intestinal mucosa by the worm. Severe abdominal pain heavy infestation

 Fatigue due to inadequate nutrients in the body secondary to heavy worm infestation

 Vomiting due to abdominal upset secondary to heavy worm infestation

 Weight loss due to body competing for nutrients with the worms

 A worm in vomit or stool due to heavy infestation

 A worm emerging from nose or mouth due to heavy infestation

b) Mention five tests that will be done in order to arrive at the diagnosis 10%

 History from the patient or care giver may reveal passing or vomiting a worm

 Clinical picture may show abdominal distention due to heavy infestation

 Stool for microcopy will show larvae

 FBC/CBC may show low Hb and eosinophilia

 Abdominal X ray may show worms in heavy infestation

 An ultrasound may show if any ascaris worms are in the pancreas or liver.

 A CT or MRI scan may show any if worms are in the liver or bile ducts.

b) With the aid of a diagram describe the life cycle of ascarias lumbricoide 30%

NOTE:

 Eggs are laid in the small intestine and are passed out as immature ova containing no segmented or differentiated embryo. In damp soil an embryo develops at 36-40degrees Celsius in 2-4 months; swallowed.

 When man passes eggs in stool the fertile eggs embryonate and become infective after 18 days to several weeks , depending on the environmental conditions (optimum: moist, warm, shaded soil). After infective eggs are swallowed, the larvae hatch into a second larvae of the rhabditoid form (Rhabditiform) which invade the intestinal mucosa, and are carried via the portal, then systemic circulation to the lungs.

 The larvae mature further in the lungs (10 to 14 days), penetrate the alveolar walls, ascend the bronchial tree to the throat, and are swallowed.

 Upon reaching the small intestine, they develop into adult worms. Between 2 and 3 months are required from ingestion of the infective eggs to oviposition by the adult worm

 The sign and symptoms may be noticed as the larvae migrate and due to heavy infestation

c) Mention three (3) drugs that are used in the treatment of ascariasis

indicating the generic and brand name, dose, route, one specific side effect and nursing

implications. 27%

 Agents of choice are pyrantel pamoatel (combantrin/Pin-X), mebendazole (Vermox), albendazole (Albenza) and Piperazine is an alternative.

 PYRANTEL PAMOETE: Mode of action: Results in spastic paralysis of the worm. The paralysed worms are dislodged and expelled by peristaltic activity.

 Route: Oral

 Dosage is 10-11 mg/kg body weight not to exceed 1 g as a single dose.

 Contraindication: It is contraindicated in persons who have shown hypersensitivity to the drug

 Adverse effects: Usually mild and transient and include:

 Nausea and vomiting,

 Anorexia, abdominal pain, diarrhoea

 Headache

 Dizziness

 Skin rash.

 Special Prescriber's Points

 Therapy should be discontinued at the first sign of hypersensitivity.

 As drowsiness may occur, patients should be warned not to drive or operate machinery.

 Piperazine: Mode of action: Its a flaccid paralyzing agent. This effect immobilizes the worm causing it to be passed out in feces.

 Route: Oral

 Dosage is 75 mg/kg (max 3.5 g) as a single oral dose.

 Contraindication: Absolute contraindication. Patients with a history of epilepsy or other neurological disorders, severe malnutrition or anaemia and persons who have shown hypersensitivity to the drug and . Relative contraindication include - impaired renal or hepatic function.

 Adverse effects: These are generally rare and dose-related. Mild nausea and abdominal pain may develop. Neurotoxicity with vertigo, ataxia, nystagmus and hyporeflexia are seen mostly in children and in patients with neurological or renal disease.Hypersensitivity reactions have been reported.

Nursing implications:

 If constipation is a problem, an effective purgative should be taken on the morning after the dose of piperazine to expel the worms before the effect of the drug wears off.

 Look out for signs of hypersensetivity reaction.

 Mebendazole (Vermox): Mode of action: It’s a broad spectrum anthelmenth that blocks uptake of glucose and other nutrients in susceptible adult worms resulting in death of the wor.

 Route: Oral

 Dose: 100 mg BD (12 hourly) for 3 days. Or 500mg stat

 Contraindication: Mebendazole is contraindicated in persons who have shown hypersensitivity to the drug

 Adverse effects: Uncommon with doses recommended for intestinal worms.

Occasionally - gastrointestinal discomfort; abdominal pain, nausea and diarrhoea are usually associated with severe infestations and upward migration of worms. Rarely - itching, pyrexia, dizziness, drowsiness and headache. High doses have been associated with bone marrow depression and hepatotoxicity; allergic reactions and alopecia may also occur.

 Special Prescriber's Points

 Leucocyte counts should be done at regular intervals if used in high doses.

 Caution should be exercised where hepatic metabolising capacity is impaired as high plasma mebendazole concentrations may develop with potential drug toxicity.

 Warn the client that upward migration of round worms may occur, with parasites being expelled through the nose and mouth of heavily infested persons.

 No fasting or purging is required.

 ALBENDAZOLE:

 Mode of action: A broad-spectrum antihelminthic agent that decreases ATP production in the worm, causing energy depletion, immobilization, and finally death

 Route: Oral

 Dosage is 400 mg given as single oral dose

 Contra indicated during pregnancy and children under 2 years.

 Adverse effectsinclude:

 GIT upset such as: Epigastric pain, Diarrhoea, Nausea and vomiting

 Headache

 Dizziness

 Pruritus ani and dry mouth have been reported in a small percentage of patients.

 Leucopenia has occurred with large doses and/or long periods of therapy

 Nursing implications

 Frequent white cell counts should be done when given in large doses or for long periods to rule out neutropenia.

 Advise patient to take a periods of rest after taking the drug to avoid accidents fro fall

 Tablets may be chewed, swallowed or crushed and mixed with food.

 No fasting or purging is necessary; however, since food increases systemic availability, it would seem preferable to administer it on an empty stomach.

 Take the medicine on an empty stomach when a high intraluminal concentration is desirable for treating intestinal worms

 THIABENDADOLE: The action of tiabendazole is uncertain but may involve interference with the source of energy of susceptible helminths resulting in death of the worm. This may cause migration of the worm into the esophagus before it dies, so it is usually combined with piperazine

 Route: Oral

 Dose: 25 mg/kg twice daily (maximum 3 g/day).

 Contraindication: Thiabendazole is contraindicated in persons who have shown hypersensitivity to the drug

 Adverse effects: Frequent - anorexia, nausea, vomiting and dizziness. Less frequent - pruritus, skin rashes, headache, drowsiness, tinnitus, disturbances of vision, effects on the liver, leucopenia, malodour of urine, hyperglycaemia, bradycardia, hypotension and collapse.

 Nursing implication

 Therapy should be discontinued at the first sign of hypersensitivity.

 As drowsiness may occur, patients should be warned not to drive or operate machinery.

 Not suitable for mixed infestation with Ascaris as it may cause these worms to migrate in this case it may be combined to piperazine.

 Tablets should be taken after meals and chewed before swallowing.

c) Outline six (6) points you are going to include in you I.E.C in order to reduce the incidence of Ascariasis in the community 18%

NOTE: one mark given for listing and for stating two