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Gastointestinal Parasitic Infections

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Gastointestinal Parasitic Infections Juan A. Embil, MD, FRCP(C) John M. Embil, BSc Gastointestinal Parasitic Infections SUMMARY RESUME This article surveys the most important Cet article passe en revue les principaux parasites gastro- gastrointestinal parasites that affect humans. intestinaux qui affectent les humains. L'auteur en examine brievement les modes d'infestation, la pathologie, The modes of acquisition, pathology, l1'pid6miologie, le diagnostic et le traitement. Les parasites epidemiology, diagnosis, and treatment are all gastro-intestinaux occupent une place de plus en plus briefly examined. Gastrointestinal parasites importante dans le diagnostic diffrentiel de la maladie have become increasingly important in the gastro-intestinale et ce, A cause d'un certain nombre de differential diagnosis of gastrointestinal circonstances. Celles-ci incluent: deplacements de plus en plus nombreux vers les pays en voie de developpement; disease, as a result of a number of augmentation, pour une raison ou pour une autre, du circumstances. These circumstances include: nombre d'individus dont l'immunite est compromise; plus increasing travel to developing countries; grande consommation de mets ethniques crus ou increased numbers, for one reason or another, partiellement cuits; surpopulation dans les garderies; of immunocompromised individuals; increased accroissement des immigrants en provenance de pays en consumption of raw or partially cooked ethnic voie de developpement; et une endemie d'individus dont delicacies; more crowding in day-care centres; les pratiques sont contraires A l'hygiene ou A la salubrite. increased immigration from developing countries; and an endemic pocket of individuals with certain unhygienic or unsanitary practices. (Can Fam Physician 1988; 34:619-626.) Key words: gastrointestinal parasites; nematode, cestode, trematode and protozoan infections. -------------- Dr. J.A. Embil is a professor of individual. For the attending physi- of gastrointestinal parasitic infections Microbiology, and Community Health cian, they may also present diagnostic has been increasing as a result of a and Epidemiology, and an associate conundrums. Infections that are symp- number of circumstances: increased professor of Pediatrics at Dalhousie tomatic usually mimic other diseases international travel3 to under- University and the Izaak Walton and thus can rarely be diagnosed on developed and developing countries; Killam Hospital for Children, clinical grounds alone. Unfortunately, growing numbers of immu- Halifax. Mr. J.M. Embil is a third- laboratory identification ofthe offend- nocompromised people whose condi- year medical student at Dalhousie ing parasite, which is usually accom- tion has come about either University. Requests for reprints to: plished by a technologists's subjective therapeutically, because of transplant Dr. J.A. Embil, Infection and assessment of the patient's stool sam- operations and other chemo- Immunology Research Laboratory, ple,' is the only way to determine the therapeutic interventions, or intrin- Izaak Walton Killam Hospital for most appropriate mode oftherapy. sically, as in the case of persons with Children, 5850 University Avenue, Parasitic infections can be acquired acquired immune deficiency syn- Halifax, N.S. B3J 3G9 in both tropical and temperate en- drome (AIDS);4 increased consumption vironments. The incidence depends on of raw or partially cooked ethnic deli- GASTROINTESTINAL PARA- climate, sanitation, and socio- cacies5-7 and organically grown pro- IJSITIC infections are often disturb- economic conditions.2 duce; more crowding in day-care cen- ing and uncomfortable for the afflicted During the past few years, awareness tres8 and nursing homes; increased CAN. FAM. PHYSICIAN Vol. 34: MARCH 1988 619 immigration from developing coun- soil before they become infective.9 in a single dose of 100 mg, repeated tries; and endemic pockets of indi- * Pathology and symptoms: Intes- after two weeks. This treatment is ap- viduals with certain unhygienic or un- tinal manifestations include obstruc- propriate for adults and children over sanitary practices.2 tion, vague abdominal discomfort, di- two years ofage.'2 Although the treatment of bacterial arrhea, and malabsorption of protein, infections is facilitated by an ever- fat, and vitamins.'0 The adult worms Trichuris trichiura (whipworm) growing armamentarium of chemo- may also migrate, penetrating to such * Disease: Trichuriasis. therapeutic agents, the treatment of unusual sites as the liver, gall bladder, * Mode ofacquisition: This parasite parasitic infections depends heavily on pancreas, peritoneal cavity, appendix, is acquired by a mechanism similar to just a few agents. We have made every and pharynx. Severe damage to the pa- that described for Ascaris effort to include, in the material that tient is the usual result of this lumbricoides.'3 follows, the most up-to-date treatment migration.9 * Pathology and symptoms: Patients regimens and dosages; however, as * Epidemiology: While this parasite with light parasite loads generally have medicine is a dynamic field in which is cosmopolitan, it is most frequently asymptomatic infections; patients with changes are constantly evolving, every associated with poor sanitation and the very heavy chronic infections, physician, before administering any use of human feces for fertilizing however, present with anemia, abdom- therapeutic agent, should consult the crops." inal pain, and diarrhea; rectal prolapse directions on the drugpackage to verify * Diagnosis: Diagnosis is established may develop in children. dosages, dose intervals, contraindica- by finding the characteristic ova in a . Epidemiology: The incidence of tions, and recommendations for use. stool specimen. this infection is relatively low in tem- The four major classes of gastroin- * Treatment: Treatment consists of perate zones; in tropical areas preva- testinal parasites-nematodes, ces- mebendazole, 100 mg bid x 3 d; or lence is very high.9 todes, trematodes and protozoans- pyrantel pamoate at a single dose of 11 * Diagnosis: Diagnosis is established contain organisms that are unique in mg/kg to a maximum of 1.0 g; or byfinding in the stool the characteristic the structure, the morphology, and the piperazine citrate, 75 mg/kg (max. 3.5 barrel-shaped eggs with bipolar plugs. gastrointestinal and systemic man- g)/d x 2 d. These therapies are recom- * Treatment: Mebendazole, 100 mg ifestations they produce. mended for adults and children over bid x 3 dis useful fortreatingadults and two years ofage.'2 children over two years ofage. The Nematodes Enterobius vermicularis (pinworm) Ancylostoma duodenale and Necator Nematodes are non-segmented * Disease: Enterobiasis. americanus (Old and New World round worms which are, for the most * Mode ofacquisition: This parasite hookworms) part, free-living inhabitants ofsoil and is acquired by ingestion of embryo- * Disease: Ancylostomiasis. fresh water. The parasitic species of nated eggs or by inhalation ofdust con- * Mode ofacquisition: Hosts acquire nematodes, however, have generally taminated with eggs. The female para- this parasite by walking barefoot over developed a complex dependence on a site travels at night to the host's anus contaminated soil, where the infective particular host or group ofhosts with- and perianal areas to lay her eggs, caus- filariform larvae penetrate the intact out which they would be unable to sur- ing pruritus. The eggs thus introduced skin. Once through the skin, the larvae vive.9 The most commonly encoun- hatch in the duodenum and mature in migrate through the circulation system tered intestinal nematodes infecting the large intestine.'3 Hosts who scratch and, after arriving at the lungs, burst humans are discussed below. the pruritic area and then, un- through the alveoli and ascend the thinkingly, put their hands into their pharynx, where they are coughed out mouth may reintroduce the eggs. or swallowed. When those swallowed Ascaris lumbricoides (roundworm) * Pathology and symptoms: Pin- reach the small intestine, they attach to * Disease: Ascariasis. worm infections are frequently the mucosa and mature into adults. * Mode of acquisition: These para- asymptomatic, but ifthe worm load is Eggs are passed in the feces and mature sites are acquired through ingestion of extreme, obstruction or perforation of in the soil.9 feces-contaminated food or water con- the intestine may occur. It has been * Pathology and symptoms: Patients taining embryonated eggs carrying the suggested that enterobiasis may cause experience gastrointestinal blood loss fully developed second-stage larvae. cystitis in young females.'4 because the parasites feed on the villus Larvae emerge in the host's duo- * Epidemiology: E. vermicularis has tissues. However, iron-deficiency ane- denum, enter the portal system into the the widest geographic distribution of mia and hypoalbuminemia are seen liver, travel through the venous system any helminth, crossing all social and only in patients with heavy parasite into the lungs (producing a transient economic barriers.'5 loads.'0 pneumonia-like syndrome), penetrate * Diagnosis: Enterobiasis is readily o Epidemiology: Necator americanus through the alveoli, and ascend the diagnosed by a finding of female is common not only in America but bronchial tree to the pharynx, where worms or characteric eggs (flat on one also in West Africa, Ceylon, the Pacific they may be coughed out or swallowed. side and rounded on the other) on anal Islands, and Malaya. Ninety percent of Those that are swallowed
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