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Case Conference

Case Conference. February 1, 2011 Geronimo RE, Go CM, Go CK, Go F, Go MR. JOP, 4 y/o, male. CC: ANAL PRURITUS. History of Present Illness. CONSULT. Review of Systems. General: No fever, no weight loss Skin: No rashes Respiratory: No dyspnea , no cough Cardiovascular: No chest pain

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Case Conference

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  1. Case Conference February 1, 2011 Geronimo RE, Go CM, Go CK, Go F, Go MR

  2. JOP, 4 y/o, male CC: ANAL PRURITUS

  3. History of Present Illness CONSULT

  4. 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

  5. Developmental History • At par with developmental age • Emergence of primary teeth • No incontinence, toilet trained, no head banging, phobias, night terrors, sleep disturbances

  6. 24 Hour Food Recall

  7. Recommended Energy & Nutrient Intake • RENI: 1410 kcal ACI: 49 %

  8. Immunization • Unrecalled • Claimed to be complete

  9. Past Medical History • Parasitic infection • 3 y/o • Unrecalled medication • Local health center

  10. Family Profile and History • Primary caregiver – mother • Lives with – both parents and sister • (-) HTN, DM, asthma, cancer, thyroid problems, blood dyscrasias, allergies

  11. 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

  12. 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

  13. 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

  14. Physical Examination • Neck: Supple neck, no palpable cervical lymph nodes, thyroid gland not enlarged • Chest: Symmetrical chest expansion, no retractions, clear breath sounds • Heart: Adynamicprecordium, 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

  15. Assessment • t/c Enterobiasis, dental carries

  16. Approach to a Patient with Anal Pruritus

  17. A symptom, sign, or laboratory finding pathognomonic of a disease

  18. Presenting Manifestation: PruritusAni

  19. Non-infectious

  20. Infectious

  21. Non Infectious

  22. Non Infectious

  23. Infectious

  24. Infectious

  25. Laboratory work-up • Scotch tape swab

  26. 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

  27. Follow up (after 6 days) • Scotch tape swab – positive for enterobiusvermicularis ova • Assessment – EnterobiusVermicularis Parasitism • Plans – Praziquantelpamoate 125mg/5ml, give 7 ml once then after 2 weeks

  28. DISCUSSION

  29. Enterobiusvermicularis • 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)

  30. 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

  31. 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 pruritusani

  32. History • often asymptomatic (Worms may be incidentally discovered when they are seen in the perineal region) • If patients are symptomatic, pruritusani and pruritus vulvae are common presenting symptoms.

  33. History • Restlessness during sleep is noted by the parents of many patients. • Enuresis may be a symptom in children with pinworms.

  34. 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.

  35. 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

  36. Management

  37. 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

  38. 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.

  39. 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

  40. Treatment Mebendazole • 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 Pyrantelpamoate • Depolarizing neuromuscular blocking agent, inhibits cholinesterases, resulting in spastic paralysis of the worm. Active against E vermicularis (pinworm) and Ascarislumbricoides (roundworm). Effective against Ancylostomaduodenale (hookworm). Purging not necessary. May be taken with milk or fruit juices. - Pediatric dose <2 years: Not established>2 years: Administer as in adults

  41. 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 eggsApart 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.

  42. 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.

  43. 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.

  44. 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.

  45. 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.

  46. 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.

  47. 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)

  48. 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

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