Transcript 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
•Pruritus in anal region – at night
3 Days •No consult, no medications
•Persistence of symptoms –
1 Day awakened him at night
CONSULT
Review of Systems
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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
Developmental History
• At par with developmental age
• Emergence of primary teeth
• No incontinence, toilet trained, no head
banging, phobias, night terrors, sleep
disturbances
24 Hour Food Recall
breakfast
• 1 serving of biscuit
• 1 serving of bread
lunch
• 1 servings of rice
• 1 serving of vegetables
Snack
• none
Dinner
• 1 serving of chicken
• 2 serving of rice
Recommended Energy & Nutrient
Intake
CHO
1 servings of
chicken
CHON
FAT
Calories
28
45
73
3 servings of rice
180
36
27
243
1 serving of
biscuit
60
12
9
81
1 serving of
bread
60
12
9
281
1 serving of
vegetables
20
8
TOTAL
450 gms CHO
88 gms CHON
• RENI: 1410 kcal
28
90gms FAT
ACI: 49 %
706 kcal
Immunization
• Unrecalled
• Claimed to be complete
Past Medical History
• Parasitic infection
– 3 y/o
– Unrecalled medication
– Local health center
Family Profile and History
Member Age/Sex Educational
Attainment
Father
28/M
2nd yr College
Mother 25/F
High School
Sibling
6/F
Kindergarten
Occupation
Merchandiser
Housewife
Student
Health
Status
Healthy
Healthy
Healthy
• Primary caregiver – mother
• Lives with – both parents and sister
• (-) HTN, DM, asthma, cancer, thyroid problems,
blood dyscrasias, allergies
Socioeconomic and Environmental
History
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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
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
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
Physical Examination
• Neck: Supple neck, no palpable cervical lymph nodes,
thyroid gland not enlarged
• Chest: Symmetrical chest expansion, no retractions, clear
breath sounds
• Heart: Adynamic precordium, 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
Assessment
• t/c Enterobiasis, dental caries
Approach to a Patient with Anal
Pruritus
Salient Features
Subjective
• 4 year old male
• (+) nocturnal pruritus ani
• (+) history of previous
parasitic infection- treated
• (+) history of playing
outdoors and eating
without washing hands
Objective
• (+) hyperemic anal area
• (+) dental caries
• A symptom, sign, or laboratory finding
pathognomonic of a disease
Presenting Manifestation:
Pruritus Ani
Pruritus
Ani
Infectious
Noninfectious
Non-infectious
Diarrhea
Poor hygiene
Dietary
irritants
Abscess,
fissures,
fistulas
Allergic or
Contact
dermatitis
Hemorrhoids
Infectious
Perianal
Infectious
Dermatitis
Sexually
Transmitted
Infections
Erythrasma
Scabies
Candida
Enterobius
vermicularis
(pinworm)
Non Infectious
Diarrhea
Poor hygiene
Dietary
irritants
no passage
of loose
watery stools
Mother
cleans anal
area after
defecation
No intake of
coffee, cola,
beer,
tomatoes,
chocolate
Non Infectious
Abscess, fissure,
fistula
No fever, rectal pain,
perianal cellulitis,
pustules, anatomic
abnormalities
Allergic or
Contact
dermatitis
Hemorrhoids
No exposure to
irritants and
allergens
No rectal
bleeding
Uses mild soap
No visible dilated
veins in anal area
Infectious
Sexually
transmitted
Infection
Erythrasma
Candida
4 years old
No involvement of
toe webs
Not immunocompromised
Not sexually active
No history of
sexual abuse
No involvement of
other moist
intertriginous areas
such as axillae
No intake of
antibiotics and
corticosteroids
Laboratory work-up
• Scotch tape swab
Infectious
Perianal infectious
dermatitis
No rectal pain, no
blood streaked stools
Superficial,
erythematous, well
marginated rash
Presence of
pseudomembrane
Scabies
Enterobius
vermicularis
(pinworm)
Night itch
No burrows, non
scaly papules
Circle of Hebra not
involved
Night itch
History of playing
in the soil
(+) hyperemic
anal area
Management Done
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For scotch tape swab
Diet for age
Refer to dental services
Multivitamins 5ml once a day
Update immunizations
Anticipatory guidance
TCB w/ results
Follow up (after 6 days)
• Scotch tape swab – positive for enterobius
vermicularis ova
• Assessment – Enterobius Vermicularis
Parasitism
• Plans – Praziquantel pamoate 125mg/5ml,
give 7 ml once then after 2 weeks
DISCUSSION
Enterobius vermicularis
• 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)
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
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 pruritus ani
History
• often asymptomatic
(Worms may be
incidentally discovered
when they are seen in
the perineal region)
• If patients are
symptomatic, pruritus
ani and pruritus vulvae
are common presenting
symptoms.
History
• Restlessness during sleep is noted by the
parents of many patients.
• Enuresis may be a symptom in children with
pinworms.
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.
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
Management
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
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.
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
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
Pyrantel pamoate
• Depolarizing neuromuscular blocking agent, inhibits cholinesterases, resulting
in spastic paralysis of the worm. Active against E vermicularis (pinworm) and
Ascaris lumbricoides (roundworm). Effective against Ancylostoma duodenale
(hookworm). Purging not necessary. May be taken with milk or fruit juices.
- Pediatric dose
<2 years: Not established
>2 years: Administer as in adults
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 eggs
Apart 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.
• 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.
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.
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.
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.
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.
Development
PHYSICAL AND MOTOR
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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)
SENSORY AND COGNITIVE
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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
PLAY
• As the parent of a 4-year-old, you should:
• Encourage and provide the necessary space for physical activity
• Instruct the child on how to participate in, and follow the rules of
sporting activities
• Encourage play and sharing with other children
• Encourage creative play
• Teach children to do small chores, such as setting the table
• Read together
• Monitor both the time and content of television viewing (preferably
less than 1.5 hours of TV, no more than 3 hours maximum)
• Expose the child to different stimuli by visiting local areas of interest
Risk Factors of Enterobius vermicularis
Infestation among Children Ages 2 to 6
Years Old in Baranggay 429 Sampaloc,
Manila
Daguman, Emmanuel J. II
Erestain, Emmanuel O.
Gallardo, Estee Laurence Heart C.
Gaw, Gem Minnie Mae M.
Joya, Ralph Vincent F.
JANUARY 2011
Objective
• The study aims to determine the effect of risk
factors that can lead to Enterobius
vermicularis infestation
• To be able to make recommendations that
would be applicable to the population
• Population: ages 2 to 6 years old in Barangay
429, Sampaloc Manila
• Intervention: risk factors
• Outcome: Enterobius vermicularis infestation
Methodology
Methodology
• This study was concerned only in the investigation of risk
factors of Enterobius vermicularis infestation among children
in the age group 2-6 years of age in Baranggay 429 Sampaloc,
Manila
• Does not include the reporting of the incidence of any other
parasites seen during procedure
Methodology
 Study design: Case control
 The study focused on the risk factors
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Sex
playing on the floor
biting nails
washing hands before eating
family size
sharing of beds
kind of drinking water
house lived in
own restrooms
other family members with infestation
Methodology
• The odds ratio for every factor was calculated
• The odds ratios computed were analyzed by
Standard Deviation (95% confidence interval) for its
statistical significance.
Procedure
 Scotch tape swab
◦ gold standard for the diagnosis of Enterobius vermicularis
◦ very easy and cheap to perform
◦ very sensitive and specific
Procedure
A piece of scotch tape was
attached to a glass slide in a
way that its adhesive is
exposed.
Procedure
The subject was asked to
expose his perianal region and
allowed to made contact with
the adhesive on the slide
Procedure
After doing the procedure, the scotch tape
was carefully turned so that its adhesive
will now be attached to the slide and trap
obtained specimen (if any) from the
subject
 The specimen was scanned under a
light microscope, under a high power
objective
 Slides were examined the same day
they were collected by a licensed
medical technologist
Results and Discussion
• 90 patients, all of which are between 2 and 6
years old
• 30 (33%) were found to have Enterobius
vermicularis infestation
Conclusions
• Living in shanties was found to be a statistically significant risk
factor for having Enterobius vermicularis infestation.
• Other risk factors such as being male, frequent playing in the
floor, big family size, and drinking tap water are associated
with an increased risk of contracting Enterobius vermicularis
infestation.
Conclusions
• Being female, nail biting, not washing hands before eating,
sleeping beside others and not having their own restrooms
does not increase the risk of having Enterobius vermicularis
infestation.
Thank You!