INEDIBLES

MINI CASE 6

G A LV E Z - G R U YA L
CASE:
Eddie Ball Paras, the 3-year old youngest child of Bobby Paras and
Ellen Ball, complams of perianal itching for the Past two weeks.
Three months Prior to consult , Eddie was seen at the lawn while
playing house with their neighbors. Because he was enjoying
playing with his friends, it was only after a few hours when
Mommy Ellen brought him home and washed the dirt around his
mouth.
Two weeks prior to consult, Eddie was noted to be scratching his
anus especially at night which he claimed to be itchy. During sleep,
he was also noted to be restless and to involuntarily urinate in his
pajamas tn the middle of the night on some occasions.
On the night prior to consultation, Mommy Ellen noted small
moving worms in Eddie's perianal area for which she decided to
immediately consult the following day.
PE revealed tiny, white, threadlike worms with some excoriation
upon shining a flashlight in the perianal area. The scotch tape test
that you requested was positive for Enterobius vermicularis eggs.
Eddie now weighs 16 kg from his previous weight of 18 kg.
You prescribe an antihelminthic for Eddie and emphasized to him,
in words that he can understand, that anything that touches the
ground, including food and his dity hands, are inedible.
PERTINENT DATA

01 02 03 04 05
Eddie Ball Perianal During sleep: 1 Day PTC: 18 kg
Paras, 3 y/o M itching for 2 restless, at small moving
weeks times worms in
involuntarily perianal area
urinating in his seen
pajamas
PERTINENT DATA

Physical Exam:

• Tiny, white, thread-like worms w/

some excoriation
• Scotch tape test (+) Enterobius
vermicularis eggs
• Weight loss: 2 kg
CHIEF
COMPLAINT
Perianal itching for two
weeks duration
THERAPEUTIC GOALS FOR AN PATIENT WITH A
POSITIVE SCOTCH TAPE TEST?

• Cure the pinworm infection

– Kill and eradicate Enterobius vermicularis eggs/worms
• Relieve anal itching
• Prevent further complications
WOULD YOU REQUEST OTHER LABORATORY
TESTS FOR EDDIE?
• No, because the scotch tape test already confirmed the presence of the
pinworms.
• Scotch tabe test is the use of an adhesive cellulose tape on the anal in the
morning before defecation or bathing. This is done for at least three
consecutive days to confirm presence pinworms.
– The tape is examined under a microscope to confirm presence of pinworm eggs.
• The scotch tape test is said to be the most effective way in diagnosing
pinworm infections. It is quick, painless and cost-effective.
WHAT NON-DRUG MEASURES CAN YOU GIVE
MOMMY ELLEN FOR EDDIE'S CONDITION?

• Treatment of the entire

household since pinworm
infection is easily transmitted
from one individual to
another.
• Strict hand washing routines
especially before and after
eating, and after defecation.
AVAILABLE LOCAL DRUGS WHICH
YOU CAN GIVE FOR DEFINITIVE
TREATMENT.
• Mebendazole
– Targets adult worms by blocking
glucose uptake, thus causing death.
• Albendazole
– Targets adult worms, decreasing
their ATP production and causing
energy depletion, immobilization, and
ultimately death.
• Pyrantel Pamoate
– Serves as a depolarizing
neuromuscular blocking agent,
inhibiting cholinesterases and
resulting in spastic paralysis of the
adult worms.
FROM AMONG THE
AVAILABLE DRUGS IN THE
M A R K E T, C H O O S E T H E B E S T
DRUG TO GIVE FOR EDDIE.
G I V E A S H O R T E X P L A N AT I O N
OF YOUR CHOICE BASED ON
THE ESSC
 Drugs Efficacy
Mebendazole MOA:
Blocks glucose uptake; inhibits the
formation of helminth microtubules
in susceptible adult intestine-dwelling
helminths
BA: 2-10%
PPC: 2-4 hrs.
Distribution: To serum, cyst fluid, liver,
omental fat, and pelvic, pulmonary,
and hepatic cysts; highest
concentrations found in liver;
relatively high concentrations found
in muscle-encysted Trichinella spiralis
larvae; crosses placenta
Vd: 1-2 L/kg
Metabolism: Extensively hepatic
Half-life: 3-6 hrs
Excretion: Feces (primarily); urine
(~2%)
Safety Suitability Cost
ADR: Transient diarrhea, abdominal ADF: Tablet, chewable Tablet: P 1.25/ tablet
pain, nausea, vomiting, headache, DDI: Decreased plasma (100 mg)
tinnitus, numbness, fever, alopecia, concentrations w/
rash, pruritus, urticaria, angioedema, carbamazepine and
flushing, hiccups, cough, weakness, phenytoin. Increased
drowsiness, chills, hypotension, plasma concentrations w/
seizures, transient abnormalities in cimetidine.
LFT (e.g. increased serum CI: Hypersensitivity
concentrations of FI: Fatty food increases
aminotransferases, absorption.
glutamyltransferase alkaline
phosphatase, and/or bilirubin),
hepatitis, increased BUN, decreased
Hb concentration and/or
hematocrit, leucopenia, eosinophilia,
hematuria, cylindruria, migration of
roundworms through the mouth
and nose.
Potentially Fatal: Myelosuppression,
manifested as neutropenia
(including agranulocytosis) and/or
thrombocytopenia.
 Drugs Efficacy
Albendazole MOA: Causes selective degeneration
of cytoplasmic microtubules in
intestinal and tegmental cells of
intestinal helminths and larvae;
glycogen is depleted, glucose uptake
and cholinesterase secretion are
impaired and desecratory substances
accumulate intracellularly. ATP
production decreases, causing energy
depletion, immobilization and worm
death.
Absorption: Poorly absorbed from
the GI tract. Absorption may be
enhanced by a fatty meal.
PPC: 2-5 hr.
Distribution: Widely distributed
throughout the body including the
bile and CSF.
Metabolism: Undergoes extensive
hepatic first-pass metabolism;
converted to albendazole sulfoxide.
Excretion: Mainly via the bile, and
small amounts in urine.
Half-life: ~8.5 hr.
Safety Suitability Cost
ADR: Headache, increased ADF: Tablet, chewable Chewable: P
intracranial pressure, dizziness, fever, DDI: Increased serum 1.00/tablet (400 mg)
vertigo, meningeal signs, alopecia, concentrations w/
abdominal pain, nausea and dexamethasone,
vomiting, hypersensitivity reactions praziquantel and
including rash and urticaria, cimetidine. Decreased
elevations of hepatic enzymes, serum concentrations w/
hepatitis, acute liver failure, aminoquinoline
erythema multiforme, Stevens- (antimalarials),
Johnson syndrome, acute renal carbamazepine,
failure. phenobarbital, and
Potentially Fatal: Bone marrow phenytoin.
suppression leading to FI: Increased serum levels
pancytopenia, aplastic anemia, w/ a fatty meal. Grapefruit
agranulocytosis and leucopenia. juice may increase serum
concentrations of
albendazole.
 Drugs Efficacy Safety Suitability Cost
Pyrantel MOA: Acts by paralyzing the worms ADR: Anorexia, nausea, vomiting, ADF: Oral suspension, Oral suspension: P
pamoate which get detached and are excreted abdominal cramps, drowsiness, capsule, chewable tablet 80-153.50/ 10 mL
by intestinal peristalsis. Depolarizing insomnia, diarrhea, tenesmus, SGOT DDI: Dyphylline, bottle (125
neuromuscular blocker, inhibits elevations, headache, dizziness, rash. theophylline Potentially mg/5mL)
cholinesterases, causing spastic Fatal: Mutually antagonistic Tablet: P 28.525/
paralysis of the helminths with piperazine tablet (125 mg)
Absorption: Minimally absorbed from
the GI tract (oral).
Metabolism: Partially hepatic
PPC: 1-3 hr.
Excretion:Via urine (7% as unchanged
drug and metabolites), via faeces
(>50% as unchanged).
• In our research, we have found that sometimes a two drug
combination is used. For example, albendazole and
mebendazole are the recommended drugs to be taken by
family members of the patient in case they were also infected.
• Based on the ESSC, the drug of choice would be Pyrantel
pamoate.
Eddie Ball Paras, 3y/o, M
Quezon City

Rx
Pyrantel pamoate Tablet 125mg
Dispense No. 1
Label: Take 1 one tablet every 3 months.

Marco Asensio, MD
Dua Lipa City
Lic No. 576
PTR No. 326