How Do You Treat Pinworms?

Patient Presentation
A 5-year-old male came to clinic with a history of constipation and anal itching. The anal itching had been occurring for over 1 month and was worse at night. He would wake his mother because of the itching and scratching. His mother said he had scratches on his bottom that then became so sore that the patient began to retain his bowel movements because of the irritation and soreness. This had been happening for about 2 weeks. “His cousin had pinworms a few months back, so I tried that pinworm medicine from the store, but it didn’t seem to help,” she noted. The past medical history was non-contributory. The pertinent physical exam showed a small but healthy appearing male with normal vital signs and growth parameter in the 10-25%. His perianal area had multiple excoriations. The diagnosis of presumed pinworm infection and secondary constipation was made. Because the cousin and several other extended family members frequently visited the home for extensive time periods, the patient and all the household and extended family members were treated with mebendazole. Hand hygiene and environmental control measures were discussed with the family. The clinical course 3 months later showed that although he was not reinfected, a female cousin had also developed pinworms. Everyone had been retreated and no one else had developed pinworms since.

Discussion
Pinworm infection is a parasitic infection caused by the roundworm, Enterobius vermicularis. A person is directly infected by fecal-oral transmission of eggs or indirectly such as through contaminated clothing or bedding. It is frequently seen in children and can easily pass to family members especially in crowded conditions. People can become easily reinfected. It is endemic worldwide. Incubation period is usually 1-2 months and eggs can survive outside humans for 2-3 weeks. Humans are the only known reservoir.

Adult worms migrate at night from the anus to the perianal skin and vulvar areas causing anal or vulvar itching. The itching can cause sleep problems and scratching can cause secondary bacterial infection. The worms can exist in alternative locations such as the vagina, Bartholin’s glands and the urethra. Other distant sites such as the appendix have also been cited in the literature.

Diagnosis is by direct visualization of the adult worms about 2-3 hours after sleep or by the “scotch-tape test” where upon wakening the patient has clear cellophane tape applied to the perianal skin. The tape is then reviewed under a microscope to identify the adult worms. See To Learn More below for images of pinworms. In many cases pinworms are treated presumptively because of the difficulty of obtaining specimens.

Learning Point
Treatment for pinworms is by antihelminthic agents such as mebendazole, albendazole, and pyrantel pamoate. Pyrantel pamoate is available over the counter in the US. Medications are given at diagnosis and 2 weeks later because all the eggs may not have been killed with the first dose. In high risk situations, all household or similar members should be treated concurrently. As reinfection is high, subsequent infections are treated the same way.

Hand-washing is imperative for infection control. Hygiene including daily bathing, frequent clothes changing and laundering along with avoidance of long fingernails or nail biting is helpful.

Items to be laundered should not be shaken to decrease the risk of transmitting eggs into the environment and should be placed directly into a washer. Items should be washed in hot water and dried in a hot dryer to kill any eggs. Underclothes and bedlinens should be changed first thing in the morning to decrease the risk of environmental transmission.

Questions for Further Discussion
1. What is the most common parasite in your location?
2. What is the most common helminth in your location?
3. What causes intense pruritis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Pinworms

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Maki AC, Combs B, McClure B, Slack P, Matheson P, Wiesenauer C. Enterobius vermicularis: a cause of acute appendicitis in children. Am Surg. 2012 Dec;78(12):E523-4.

Huh S, Cunha, BA. Pinworm Treatment and Management. Medscape.
Available from the Internet at http://emedicine.medscape.com/article/225652-treatment (rev. 10/26/2012, cited 11/12/13).

Centers for Disease Control. Pinworm (Enterobiasis, Oxyuriasis, Threadworm). Available from the Internet at http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/pinworm-enterobiasis-oxyuriasis-threadworm (rev. 8/1/2013, cited 11/12/13).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are the Complications of Measles?

    Patient Presentation
    A 3-year-old male came to clinic with a fever to 102°F, mouth sores and a rash. The mother said that the fever had started the day before and this morning he had the rash and mouth sores. He was not taking much fluid in the morning but had been urinating. He had been previously well and there was known Hand-Foot-Mouth disease in the community.

    The pertinent physical exam showed a wary male who was drooling. His temperature was 101.7° with other vital signs being normal. HEENT revealed ulcerations on the palate and tongue. His lungs were clear and abdomen was soft. He had a rash that was erythematous, blanching with papules on the trunk and extremities. On the palms and soles there were similar lesions, but some had a vesicular quality particularly on the proximal fingers. He had a few similar vesicular lesions on the buttocks. The diagnosis of Hand-Foot-Mouth disease was made and the family was counseled regarding the natural history, pain control and need for hydration.

    The resident asked the attending physician afterward how these ulcerations were different from Koplik spots seen in measles. The attending said that these ulcerations were much more defined or ‘punched out” and larger. Koplik spots are usually smaller, seem to be more diffuse but still have the erythematous base. Both are white, she explained, but Koplik spots have a more bluish hue to them. She went on to say that she had seen Koplik spots be so numerous that basically they looked like a few huge plaques covering portions of the mouth. “I lived through a big measles outbreak during my residency. I saw just about every complication,” she said. She went on opining, “later in my residency, I even took care of a child from another country who had SSPE. It was so sad to see him deteriorate over even a few days. We arranged for a medical transport so he could die at home with his family. I think about these kids and family every time I have a family who doesn’t want to vaccinate their child. They haven’t seen what I have seen.”

    Discussion
    Measles was first described in the 9th century by an Arab physician. In 1757, Francis Home, a Scottish physician showed that measles was an infectious disease found in patient’s blood. The virus was isolated by Drs. John Enders and Thomas Peebles in Boston in 1954. In 1963, the first live virus vaccine for measles was licensed in the US.

    Measles is caused by a paramyxovirus that replicates in the oral pharynx and lungs and is spread by respiratory secretions. The incubation period is 8-12 days. Clinically measles causes erythematous macules and papules that first appears on the lateral and posterior neck, and that progresses to involve the face, trunk and extremities (spreading distally). The rash fades in the same direction. Cough, coryza, Koplik spots and fever also occur. Patients are contagious from 1-2 days before the rash until 4 days after the rash. Before widespread vaccination, most children had the disease by age 15.

    Subacute sclerosing panencephalitis (SSPE) is a rare, fatal neurogenerative disease that occurs several years after measles infection. Patient usually have personality changes and then deteriorate mentally and have muscle spasms. There can be typical electroencephalogram changes and elevated anti-measles antibody in the cerebrospinal fluid or serum. Typical brain biopsy histological findings are also seen. Decline varies but average survival is 2 years.

    Hand Foot and Mouth is a common viral exantham caused by coxsackievirus A16, other coxsackievirus, echovirus or enterovirus The rash appears as erythematous papules or intact vesicles on the palms, soles and also buttocks. Small ulcers on the palate, uvula, tonsils and tongue are also seen. The rash resolves in 1 week. Its incubation period is 3-6 days but patients can be contagious for weeks because of fecal shedding.

    A review of common viral exanthams can be found here.

    Learning Point
    Complications of measles occur in about 30% of cases and include:

    • Blindness – especially where Vitamin A deficiency is common
    • Dehydration
    • Diarrhea
    • Otitis media – 1 in 10
    • Pneumonia – 1 in 20 – leading cause of death
    • Encephalitis – 1 in 1000
      • Mental retardation
      • Seizures
      • Sensory neuronal deafness
      • Subacute sclerosing panencephalitis
    • Miscarriage and preterm birth

    Complications are more common in patients age 20 years.
    Approximately 160,000 people die each year around the world from measles and it is probably the most deadly vaccine preventable virus.
    Current data for the US shows ~160 cases of measles (Jan-August 2013), while in the world the number is ~57,000 (Jan-October 2013).
    The World Health Organization has monthly updates on the epidemiology of the virus available here.

    Questions for Further Discussion
    1. What is the vaccination rate in your own practice?
    2. What other risk factors increase the risk of acquiring measles?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Measles and Viral Infections.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Centers for Disease Control. Overview of Measles Disease. Available from the Internet at http://www.cdc.gov/measles/about/overview.html (rev. 9/12/13, cited 11/12/13).

    Centers for Disease Control. Complications of Measles. Available from the Internet at http://www.cdc.gov/measles/about/complications.html (rev. 8/30/13, cited 11/12/13).

    MMWR. Measles – United States, January 1-August 24, 2013. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a2.htm (rev. 9/13/13, cited 11/12/13).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    16. Learning of students and other health care professionals is facilitated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • When Can A Child Return to Learning?

    Patient Presentation
    A 9-year-old female came to clinic in the morning with a headache that began 4 days previously after a fall at school onto a concrete surface. The patient had been pushed down backwards and hit the posterior part of her head. Witnesses and the patient denied loss of consciousness but the patient said she was slow to get up. Ice was applied and the patient returned to her class, but a headache made her go to the school office and her parents were called to take her home. Over the next 24 hours she remained alert and appropriate but continued to have a constant headache including at night. Over the next 2 days, which were the weekend, her headache improved but would return after playing with her brothers or when watching TV. The family came to clinic because the headaches had continued over the weekend and she had scheduled dance lessons in the evening. She denied any nausea, emesis, dizziness, tinnitus, photo- or phonophobia, clumsiness or difficulty doing activities, or sleep problems. She denied problems with reading or taking longer to think. She had not had a headache yet today. The past medical history was positive for a febrile seizure as a 16 month old. There were no other head injuries or neurological problems. The family history was positive for an aunt with depression.

    The pertinent physical exam showed a well-appearing female with normal vital signs and growth parameters were in the 10-25%. Her neurological examination was normal as was the rest of her examination. The diagnosis of head trauma with minor concussion that was improving was made. Since the headaches still had occurred the evening before and the child hadn’t been up in the morning for long, the physician said it was difficult to tell how the child might do at school that day. However, he recommended to keep her out of school for the rest of the day and to not go to dance in the evening. Then he said that she could return to school, but the parents and school would need to be aware that her symptoms could return. He recommended they talk with the school today to make sure that the school could have her do quieter activities for shorter times and that if her symptoms returned that she could go to the office. He told the parents that light, noise and the concentration of doing school work could make the symptoms return. He went over symptoms for the parents to monitor and instructions about when to call the office. The physician did not hear back from the family and they returned to clinic about 10 days later for an unrelated problem. They said that she had one more headache on the day of presentation but none since. She had returned to school and dance without any problems. About the same time, the pediatrician learned that the American Academy of Pediatrics had released new guidelines on returning to learning after a concussion and then he reviewed them because of this patient.

    Discussion
    Head injury whether because of athletics or other trauma is a common problem in pediatrics. Fortunately most are benign because they are low impact that may not even result in edema or bruising. However, others cause concussion or traumatic brain injuries. There are an estimated 1.7 million traumatic brain injuries in the US yearly. Concussion can be very difficult to diagnose because there may not be external signs and the symptoms are highly subjective. For example, difficulties with concentration and thought processing speed are concepts that can be difficult for patients to understand, can be variable, and highly individualized. It can be even more difficult with younger children who really may not understand what a provider or parent is trying to ask them. There are symptoms scales available that can help with initial diagnosis and monitoring that were developed for concussion after athletic injury. These are the SCAT 3 for patients 13 years and older and the Child SCAT 3 for patients 5-12 years. The American Academy of Pediatrics Clinical Report also has symptom checklists available.

    The school setting itself can provide challenges to student after a concussion. Schools are often noisy, visually stimulating, and require differentiated attention and behavioral standards which may be difficult for a concussed student to manage without adjustments being made. Fortunately most students with concussions recover within 1-3 weeks and adjustments in the classroom and other school settings can often be easily made by the regular education teachers and adminstrators. Examples would be frequent breaks, change of classroom seating, having lunch/recess in a quiet area, allowing extra time for assignment/assessment completion, giving prepared notes, etc.. For students with more prolonged symptoms, they would need more intensive evaluation and/or monitoring by concussion specialists, and in the school may or may not need a more formalized plan of adjustments or longer term accommodations or modifications in the school setting. For these students it is important to realize that these adjustments, accommodations and modifications need to carry over into the broad range of extra curricular activities also such as music, speech and debate, chess or language clubs, robotics or theatre.

    Educational terminology that health care providers should be familiar with include:

    • Adjustments are usually short term changes to the physical or educational environment and instruction. These do not require a formalized educational plan and are the normal changes that teachers and administrators make allowing for each individual student’s circumstances.
    • Accommodations allow a student to complete the same tasks as their typical peers but with some variation in time, format, setting and/or presentation. The purpose is to provide the student with equal access to learning and an equal opportunity to show what he knows and what he can do. It does not change the instruction level, content or performance criteria.
    • Modifications are alterations in instructional level, content or performance criteria (one or more of those elements) for a given assignment. These are change in what students are expected to learn, based on their individual abilities

    Formalized educational plans fall under two major different types:

    • IEP – individualized education plan which is often called special education. This comes from US Federal law under the Individuals with Disabilities Education Act or IDEA.
    • 504 plan – this is a formalized plan for students who may not meet the specific eligibility for an IEP, but still need/require accommodations and modifications. This comes from a US Federal Law under the Americans with Disabilities Act and the Rehabilitation Act.
      Students with many chronic medical conditions have 504 plans such as patients with diabetes who need to check glucose levels at school.

    For more information about formalized educational plans, click here.

    Learning Point
    The American Academy of Pediatrics also recommends a team approach to management of students with concussion including health care professionals, educators and the patient/family in helping the patient to return to learning and extracurricular activities. It also recommends that students who are able to tolerate 30-45 minutes of cognitive activity and stimulation can go to school with appropriate adjustments. Students who cannot tolerate this amount of cognitive activity or stimulation should remain home. The patient should be performing at baseline academically before extracurricular activities are allowed.

    Many health care providers will recommend cognitive rest and then as symptoms and concentration improves light mental activities such as light reading, watching television, social interactions etc. can be started and increased in intensity and time as the patient tolerates. However, “…to date, there is no research documenting the benefits or harm of these methods in either the prolongation of symptoms or the ultimate outcome for the student following a concussion.”

    Questions for Further Discussion
    1. What are indications for head imaging in head trauma?
    2. Who are the contacts in your local school system who could help to manage educational adjustments for students with concussions?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Concussion, Developmental Disabilities, and School Health.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Consensus statement, SCAT3. Br J Sports Med 2013;47:5 259.

    Consensus statement, Child SCAT3, Br J Sports Med 2013;47:5 263.

    Halstead ME, Devore CD, Carl R, Lee M, Logan K, Council on Sports Medicine and Fitness and Council on School Health. Returning to Learning Following a Concussion. American Academy of Pediatrics.
    Available from the Internet at http://pediatrics.aappublications.org/content/early/2013/10/23/peds.2013-2867.abstract (rev. 10/27/13, cited 11/5/13).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital