Two Cases of Dipylidiasis (Dog Tapeworm

Infection) in Children:
Update on an Old Problem

Harvey J. Hamrick, MD, W. Rodwell Drake, Jr, MD, H. Michael Jones,

MD, Anne Preston Askew, MD, and Norman F. Weatherly, PhD

From the Department of Pediatrics, University of North Carolina School of Medicine,

Chapel Hill; Family Medicine Clinic and Maria Parham Hospital, Henderson, North
Carolina; and Department of Parasitology and Laboratory Practice, School of Public
Health, University of North Carolina, Chapel Hill

ABSTRACT. Children in households with dogs and cats North Carolina are presented to introduce a new
may become infected with the dog tapeworm more fre- generation of practitioners to this unusual clinical
quently than suspected. Because ofage-appropriate hand-
entity.
to-mouth exploration, young infants and toddlers,
through contact with fleas on pets, floors, and furnish-
ings, are particularly susceptible. Knowledge of the life
CASE REPORTS
cycle of this animal parasite and the manner in which
children acquire and demonstrate infection can lead to
Case I
early diagnosis and effective treatment. Pediatrics
1983;72:114-117; tapeworm, Dipylidium caninum, para- Over a 2-week period, a 5-month-old male infant was
sites, pin worms. noted by his mother to have small, white objects in his
diapers. The objects resembled grains of rice and were
not associated with the passage of stools. The number of
white objects seen at any individual diaper change varied
A recent review’ points out that human infection from none to as many as 15 or 20. The identity of the
with the dog tapeworm (Dipylidium caninum) is objects was the mother’s only concern when she consulted
the primary physician. During examination, the physi-
often either unrecognized or misdiagnosed. Many
cian saw one of the objects emerge from the anus and
physicians are not familiar with the condition be-
move spontaneously on the perineum. A pathologist ten-
cause of its infrequent occurrence and the absence
tatively identified the object as a tapeworm proglottid
of symptoms in most patients. During the 5-year but was not sure of the specific species. A referral labo-
period from 1973 to 1977, the Centers for Disease ratory was given several dried specimens, but because the
Control (CDC) in Atlanta reported only 43 cases specimens were distorted, they were misdiagnosed as fly
(8.6 cases per year).2 Presumably, these nepresented larvae. Several days later, a moist specimen was identified
the majority of recognized cases in the United as a proglottid of D caninum. The family had two indoor
States during those years because the treatment cats, and flea infestation was a problem.
drug of choice was available only through the CDC. The decision was made to treat the infant with niclo-

Approximately 30 case reports have appeared in samide (Yomesan), but there was a ten-day delay in
obtaining the drug. During the delay and prior to treat-
the American medical literature since 1903, and
ment, the patient continued to pass proglottids and also
nearly all have involved infants and small children.
passed one scolex. He was then treated with niclosamide
Since the last published case in America was in
(500 mg orally for one dose) and no further tapeworm
1968, the following two cases of dipylidiasis from parts were passed. It was concluded that his infection
was due to a single tapeworm.

Received for publication June 11, 1982; accepted Aug 26, 1982. Case 2
Reprint requests to (H.J.H.) Department of Pediatrics, Clinical
Sciences Building 229H, University of North Carolina at Chapel The mother of a 22-month-old female infant (a twin)
Hill, Chapel Hill, NC 27514. noted highly motile, rice-like objects on the child’s pen-
PEDIATRICS (ISSN 0031 4005). Copyright © 1983 by the neum when her diaper was changed. The infant’s past
American Academy of Pediatrics. history was unremarkable, and there were no symptoms.

114 PEDIATRICS Vol. 72 No. 1 July 1983

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The child was initially treated for pinwonms, but the ment, an adult pinworm, and one species of fly
objects continued to appear. On two occasions, objects larvae are shown in Fig 1. When compared in this
were submitted in dry containers with stool specimens to manner, the specimens can easily be distinguished:
a hospital laboratory. On each occasion, the objects were
tapeworm segments are flat and barrel-shaped, pin-
not detected by laboratory personnel, and the stools were
worms are round with one tapered end, and fly
reported as negative for ova and parasites. Finally, several
larvae are round but not tapered. The same speci-
fresh objects were submitted in a specimen bottle con-
mens are shown in Fig 2, but the tapeworm segment
taming formalin and were identified as proglottids of D
is distorted due to desiccation. As depicted, distor-
caninum. The family cat was found to be infected with D
caninum, and flea infestation of house and garage was tion causes tapeworm segments to become rounded
noted. instead of staying flat and may cause confusion in
The child was treated with niclosamide (750 mg orally mistaking them for pinworms or various insect
for one dose) and has remained asymptomatic. No further larvae.
proglottids and no scolices were seen after treatment. Differences in the motility patterns of pinworms
and tapeworm segments can be useful in distin-
DISCUSSION guishing the two. Pinworms move in serpentine-

As most dogs and cats harbor D caninum, chil- like fashion by wiggling vigorously whereas tape-
dren in families with pets have a high potential for worm segments contract and expand lengthwise

exposure. The dog or cat flea is the usual intenme- like an “inch worm.” Also, the number of specimens
diate host for human infection. Flea larvae may reported in an individual case can be helpful. In
tapeworm infections, there is usually an abundance
feed on eggs released from detached tapeworm seg-
ments (proglottids) which are passed from the nec- of visible segments oven a period of days on weeks.
tum of the dog on cat. As the flea larvae mature, However, in pinworm, infection, it may be difficult
the ingested tapeworm eggs develop into infective
tapeworm larvae known as cysticercoids. A child
becomes infected by ingesting a flea. After inges-
tion, the tapeworm larvae attach to the mucosa of
the small intestine and develop into adult worms
after 3 or 4 weeks.4 Gravid segments from adult
tapeworms continually detach and migrate out of
the anus of the infected host. The segments, either
singly or in short chains, have independent motility
and can be observed to move briskly on a stool on
over a child’s perineum. Desiccation (which occurs
rapidly after passage) causes rupture of the seg-
ments and release of egg packets. As a single flea
may contain many tapeworm larvae, there is the
possibility of infection with more than one tape- Fig I. Comparison of moist Dipylidium caninum seg-
worm.5 ment (A) with adult pinworm (B) and one species of fly
larvae (C) (x2).
Although these infants were asymptomatic, hu-
man dipylidiasis has been associated with a variety
of complaints68; these include: irritability and nest-
lessness, anorexia, poor weight gain or weight loss,
difficulty in sleeping, anal prunitis, and vague ab-
dominal pain. There are no reports in this country
of serious intestinal on systemic complications. This
is in contrast to other helminthic infections such
as ascaniasis in which the parasite’s life cycle in-
volves extraintestinal tissue invasion and predict-
able complications.
The usual manner of presentation is for a parent
to discover segments in the diaper, on the stool, or
on the perineum of an infant or child. Telephone
descriptions of “small white worms that move” are
often assumed to be pinworms by the unsuspecting Fig 2. Comparison of dried Dipylidium caninum seg-
physician.57 As in case 1, segments have also been ment (A) with adult pinworm (B) and one species of fly
mistaken for fly larvae.9 A moist tapeworm seg- larvae (C) (x2).

ARTICLES 115
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 to find even one adult pinworm on the perineum
over a similar time span. If a gross specimen is felt
to be a pinworm, the presence of typical pinworm
eggs on the perineum can be confirmed by micro-
scopic examination of a clear tape preparation.
Occasionally, tapeworm eggs can be detected in this
manner also. In both situations, examination of a
stool for ova and parasites probably will be negative.
Pinwonm eggs are deposited on the perineum;
tapeworm eggs are passed out of the anus within
the segments.
Fresh tapeworm segments must be kept moist
(preferably by placing in a tube of isopropyl alcohol
or dilute formalin) prior to microscopic examina-
Fig 4. Pinworm eggs inside body of adult female (xlOO).
tions. It is recommended that the primary physician
send moist specimens to a panasitology laboratory
for identification. The laboratory (and the physi-
cian if interested) can use the following simple
technique to prepare and examine the specimens.
The three specimens above were each placed on a
glass slide with two drops of saline and flattened
by pressing firmly between a second glass slide. The
tapeworm proglottid was spread as flat as possible
on the first slide prior to being pressed between the
second slide. Part ofthe gravid tapeworm proglottid
with egg packets to the side is shown in Fig 3. Note
that each of the eggs within a packet is spherical
(approximate diameter, 40 sm). Also note that the
outer body wall of the proglottid is not segmented
and has no body spines. The hundreds of typical Fig 5. Body of typical fly larvae with characteristic
spines in rings and patches (arrows) (xlOO).
pinworm eggs that were visible when the female
pinworm was pressed and examined are shown in
Fig 4. The fly larvae with characteristic spines that container may reveal egg packets although the seg-
are grouped in rings and patches can be seen in Fig ments would no longer be visible.7 This may be the
5. Such spines are present on all species of fly reason that the laboratory was unable to find the
larvae. segments that were submitted with stool specimens
If placed in a dry container for a sufficient time, in dry containers in case 2.
the motile tapeworm segments can crawl up the Prior to the middle 1970s, dipylidiasis was treated
walls and disintegrate. If this occurs, microscopic with quinacnine (Atabnine). Today, niclosamide is
examination of scrapings from the walls of the recommended as a safe and more effective agent.2
It has few side effects and is not absorbed from the
intestinal tract. In the past few years, it has been
available only by special request to the Parasitic
Diseases Division of the CDC. However, niclosam-
ide has recently been approved for use in this coun-
try by the Federal Drug Administration and should
be available to American physicians by now. Be-
cause niclosamide is very effective in eradicating D
caninum, there is no longer a need to observe stools
for the passage of scolices and proglottids after
treatment.

REFERENCES

1. Turner JA: Other cestode infections, in Hubbert WT,

McCulloch WF, Schnurrenberger PD (eds): Diseases Trans-
Fig 3. Dipylidium caninum segment with egg packets mitted from Animals to Man, ed 6. Springfield, Charles C
(arrows) (xlOO). Thomas, 1975, pp 708-711

116 DIPYLIDIASIS IN CHILDREN

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2. Jones WE: Niclosamide as a treatment for Hymeriolepis children in the United States. Am J Trop Med Hyg
diminuta and Dipylidium caninum infection in man. Am J 1962;11:365
Trop Med Hyg 1979;28:300 7. Moore DV, Connell FH: Additional records of Dipylidium
3. Anderson OW: Dipylidium caninum infestation. Am J Dis caninum infections in children in the United States with
Child 1968;116:328 observations on treatment. Am J Trop Med Hyg 1960;9:604
4. Markell EK, Vogue M: Medical Parasitology, ed 5. Philadel- 8. Hutchison WF, Ricks HC, Woolridge DS: A new record of
phia, WB Saunders, 1981, pp 200-201 human infection with Dipylidium caninum in the United
5. Stuart HC, Augustine DL: Dipylidium caninum infection in States. Am J Trop Med Hyg 1959;8:603
an infant six months of age. Am J Dis Child 1928;36:523 9. Turner JA: Human dipylidiasis (dog tapeworm infection) in
6. Hunter GW, Slotnick IJ: Further records of dipylidiasis in the United States. J Pediatr 1962;61:763

THE DEATH PENALTY FOR TODDLERS

Most people accept, almost without question, that cars and trucks are essen-
tial for transport and services; that roads must facilitate the rapid flow of motor
vehicles; that death, crippling and a great deal of less severe injuries naturally
result from the interaction of motor vehicles with people, but this is the price
that must be paid for a modern transport system.
We have been conditioned to accept the first two assumptions and to ignore
the third-not to see it at all-though it has become a fact everywhere in the
world. When a two-year-old toddies into the street and is instantly killed by a
passing can, we accept
the idea that the toddler should not have been in the
road. The accepted penalty for the two-year-old being in the wrong place is
death. Roads are built for cans. The driver has the night to drive, at reasonable
speeds, along residential streets. Nobody questions the driver’s purpose in
getting about swiftly and comfortably; speed and ease of transport are under-
stood to be essential in a modern society. Time spent getting from here to there
is time which costs money. Our traffic systems must facilitate the swift,
uninterrupted flow of traffic. It is not economic to be slow. It is backward....
What can
we do about this? We can start by setting the stage for the
development of systems which will be uniquely appropriate for the societies and
cultures which developing nations want to preserve, and toward which they
want to move in the next few decades. We can state, clearly and forcibly, that
mechanical and civil engineering practices which have been developed elsewhere
are not to be superimposed on the developing nations, because we know that
there can be something better. Life is too important to be sacrificed on the alter
of speed.
Submitted by Student

From Sondel DP: Keep death off the road! World Health, May 1982, pp 9-10.

ARTICLES
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Two Cases of Dipylidiasis (Dog Tapeworm Infection) in Children: Update on an Old
Problem
Harvey J. Hamrick, W. Rodwell Drake, Jr, H. Michael Jones, Anne Preston Askew and
Norman F. Weatherly
Pediatrics 1983;72;114

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 Two Cases of Dipylidiasis (Dog Tapeworm Infection) in Children: Update on an Old
Problem
Harvey J. Hamrick, W. Rodwell Drake, Jr, H. Michael Jones, Anne Preston Askew and
Norman F. Weatherly
Pediatrics 1983;72;114

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/72/1/114

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since 1948. Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1983 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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