Lascano, Joanne Alyssa H.

3J - Pediatrics 3B

PARASITOLOGY SGD

Clinical Vignette 1

Nena, a 5-year-old girl was brought to the OPD because of recurrent diarrhea of 2 days
duration. One day prior to consult she had 2 episodes of watery stool and was noted also to have
decrease appetite and decrease activity. Few hours prior to consult, stool was more watery and
there was low grade fever T= 38 C which was relieved by giving paracetamol. She has been
attending at a Day Care Center where 2 children had history of diarrhea a day prior to the onset
of Nena’s symptoms. Stool examination done revealed the presence of a tear drop shape
trophozoites.

Guide Questions
1. What is the most likely diagnosis?
Acute infectious diarrhea secondary to
Giardiasis
§ Recurrent diarrhea of 2 days duration
§ 2 episodes of watery
§ noted also to have decrease appetite
§ decrease activity
§ Low grade fever T= 38 C
§ attending at a Day Care Center where 2
children had history of diarrhea a day prior to the onset of Nena’s symptoms
§ Stool examination done revealed the presence of a tear drop shape trophozoites

2. Identify the etiologic agent.

Giardiasis, caused by Giardia intestinalis, is the most common intestinal protozoal
infection in children in the United States and in most of the world. The infection is classically
associated with drinking contaminated water, either in rural areas or in areas with faulty
purification systems. Even ostensibly clean urban water supplies and pristine mountain
streams can be contaminated intermittently, and infection has been acquired in swimming
pools. Fecal-oral contamination allows person-to-person spread. Day care centers are a
major source of infection. Food-borne outbreaks also occur. Giardiasis may occur at any
age, although infection is rare in neonates. High rates of transmission occur among men who
have sex with men. Domestic animals are rarely sources of human infection due to strain
differences between humans and pets.

3. Give the mode of transmission.

§ Source: stool of affected: Fecal-oral contamination allows person-to-person spread. Day
care centers are a major source of infection
§ HIGH-RISK: childcare centers, travelers, homosexual males, poor sanitation, institutions
for mentally delayed, immunodeficient, cystic fibrosis, achlorhydria
§ Ingestion of as few as 10-100 cysts. The infection is classically associated with drinking
contaminated water, either in rural areas or in areas with faulty purification systems. Even
ostensibly clean urban water supplies and pristine mountain streams can be
contaminated intermittently, and infection has been acquired in swimming pools.

4. What is the age prevalence and incubation period?

- Age prevalence: High during childhood; decline after adolescence;
Worldwide(2.5Mannually); Associated with drinking-water outbreaks (summer
- swimming),High during childhood
- Incubation period: 1-2 weeks (7-14 days)

5. Give your treatment.

§ Metronidazole x5 – 7days §Paromomycin (notrecomfor preggy) §Fluid & electrolyte

correction
§ Lactose free formula
§ Boiling water before consumption (100’C)
§ Metronidazole, Tinidazole, and Nitazoxanide are the traditional drugs of choice
for treatment of giardiasis.

o A recent meta-analysis concluded that single dose Tinidazole (50 mg/kg;

max 2 g) should be the preferred treatment based on both better efficacy and
convenience compared to other treatments.
o There are fewer data on the use of tinidazole in children under 3 years. When
given at 5 mg/kg (up to 250 mg) three times a day for 5-7 days,
metronidazole has 80%-95% efficacy.
o Nitazoxanide (100 mg [5 mL] every 12 hours for children 12-47 months
of age, 200 mg every 12 hours for 4- to 11-year-olds, and 500 mg every 12
hours for children 12 years or older) is available in liquid formulation and
requires only 3 days of treatment.
• For patients who do not respond to therapy or are reinfected, a second course with
the same drug or switching to another drug is equally effective.
• In cases of repeated treatment failure paromomycin or children under 3 years.

6. Give the prognosis.

• Most infections evolve to either asymptomatic carrier state or eradication
• Extraintestinal infection carries about a 5% mortality.
• Acute diarrhea occurs 1-2 weeks after infection and is characterized by
abrupt onset of diarrhea with greasy, malodorous stools, malaise, flatulence,
bloating, and nausea. Fever and vomiting are unusual.
• The disease has a protracted course (> 1 week) and frequently leads to weight
loss.
• Patients who develop chronic diarrhea complain of profound malaise, lassitude,
headache, and diffuse abdominal pain in association with bouts of diarrhea-most
 typically foul-smelling, greasy stools-intercalated with periods of constipation or
normal bowel habits. This syndrome can persist for months until specific therapy
is administered or until it subsides spontaneously.
• Chronic diarrhea frequently leads to malabsorption, steatorrhea, micronutrient
deficiencies, and disaccharidase depletion.
• Lactose intolerance, which develops in 20%-40% of patients can persist for
several weeks after treatment, and needs to be differentiated from relapsing
giardiasis or reinfection.

7. What are the different measures to prevent?

• The prevention of giardiasis requires proper treatment of water supplies and

interruption of person-to-person transmission. Where water might be contaminated,
travelers, campers, and hikers should use methods to make water safe for drinking.
• Boiling is the most reliable method; the necessary time of boiling (1-3 minute at sea
level) will depend on the altitude.
• Chemical disinfection with iodine or chlorine and filtration are alternative methods of
water treatment.
• Interrupting fecal-oral transmission requires strict hand washing. However, outbreaks
of diarrhea in day care centers might be particularly difficult to eradicate. Reinforcing
hand washing and treating the disease in both symptomatic and asymptomatic
carriers may be necessary.

Clinical Vignette 2

G. C. 18 years old male from Region V or Bicol region is suffering from headache and
myalgias for about 2 weeks now. 8 days prior to consult, on and off low to moderately high grade
fever was also noted together with the headache and myalgia.
Physical examination revealed lymphangitis of extremities and lymphadenitis at the
inguinal and axillary areas. Temperature = 38 C CR= 100/min RR= 20/min BP=120/80 Height =
169 cm. Weight = 60 kg

Guide Questions
1. What is your working diagnosis?
Filariasis
§ from Bicol which is a high prevalent of Bancroftian Filariasis
§ headache and myalgias for about 2 weeks
§ 8 days prior to consult on and off low to moderately high grade fever together with
the headache and myalgia
§ Physical examination revealed lymphangitis of extremities and lymphadenitis at
the inguinal and axillary areas
§ Temperature = 38
 2. What diagnostic test will you request to prove your diagnosis?
- Adult in Tissue Biopsy
- Ultrasonography can be used to visualize adult worms. Lymphatic filariasis often
must be diagnosed clinically, because dependable serologic assays are not available
uniformly, and in patients with lymph- edema, microfilariae no longer may be present.
- Eosinophilia: Lymphatic Filariasis
- Circulating filarial antigen (CFA) detection = gold standard
o Immunochromatographic(ICT) / Filariasis or card test; Parasite Ag in serum
o ELISA : Parasite Ag in serum
§ Identification of adult worms in tissue biopsy specimen
§ Eosinophilia (25%) frequently occur in early phase
§ Lymphatic filariasis: diagnosed clinically
- Demonstration of microfilaria in the blood (Primary)
o Thick film: simplest technique
o Knott’s concentration technique
o Membrane filtration technique: most sensitive technique
- Serologic enzyme immunoassays are available, but interpretation of results is
affected by cross-reactions of filarial antibodies with antibodies against other
helminths. Assays for circulating parasite antigen of W bancrofti are available
commercially but are not licensed by the US Food and Drug Administration.

3. What is the source of infection?

Bancroftian filariasis from Bite of a mosquito (microfiliaria), blood of infected, and Blood
transfusion.
Other sources; Filariasis is caused by 3 filarial nematodes: W bancrofti, B malayi,
and B timori.

4. Give the mode of transmission.

In the case: possible Bite of a mosquito (microfiliaria),
Other mode of transmission: blood of infected, Blood transfusion

The parasite is transmitted by the bite of infected species of various genera of mosquitoes,
including Culex, Aedes, Anopheles, and Mansonia. W bancrofti, the most prevalent cause of
lymphatic filariasis, is found in Haiti, the Dominican Republic, Guyana, northeast Brazil, sub-
Saharan and North Africa, and Asia, extending from India through the Indonesian archipelago to
the western Pacific islands. Humans are the only definitive host for the parasite. B malayi is found
mostly in Southeast Asia and parts of India. B timori is restricted to certain islands at the eastern
end of the Indonesian archipelago. Live adult worms release microfilariae into the bloodstream,
and because adult worms live, on average, for 5 to 8 years and reinfection is common,
microfilariae infective for mosquitoes may remain in the patient’s blood for decades; individual
microfilaria have a lifespan up to 1.5 years. The adult worm is not transmissible from person to
person or by blood transfusion, but microfilariae may be transmitted by transfusion.

5. Give the incubation period.

 § 3-12 months: The incubation period is not well established; the period from
acquisition to the appearance of microfilariae in blood can be 3 to 12 months,
depending on the species of parasite.

6. What is the age incidence in Filariasis and their clinical manifestations?

Although the initial infection occurs commonly in young children living in areas with
endemic infection, chronic manifestations of infection, such as hydrocele and lymphedema,
occur infrequently in people younger than 20 years of age. Most filarial infections remain
asymptomatic but even then commonly cause subclinical lymphatic dilatation and dysfunction.
Lymphadenopathy, most frequently of the inguinal, crural, and axillary lymph nodes, is the
most common clinical sign of lymphatic filariasis in children and is associated with living adult
worms.

§ 10-20 years old

o Acute infection manifestations: Inflammation and dysfunction of lymphatics,
Lymphangitis, lymphadenitis, Fever, headache and myalgia
o Symptoms are due to acute inflammatory reaction triggered by death of adult
worms

§ Occur mostly in those >30 years old

o Chronic manifestations: Hydrocoele and elephantiasis, Direct result of
lymphatic fibrosis and obstruction to flow . Epididymitis, orchitis and chyluria
more in W. bancrofti

• 20-30 years old men

o Tropical Pulmonary Eosinophilia
§ Microfilariae found in the lungs and lymph nodes but not in the blood
stream
§ Paroxysmal cough, fever, weight loss, fatigue, occasional dyspnea
§ Rales or rhonchi on auscultation
§ Result in interstitial fibrosis and chronic respiratory insufficiency
§ Chest x-ray: increase in bronchovascular markings, discrete opacities
or diffuse miliary lesions 9
§ Diagnosis: History of exposure, Eosinophilia (>2,000/μL)
§ Signs and symptoms: increase in IgE (>1,000 IU/ mL) and increase in
antimicrofilarial antibodies in the absence of microfilaremia

7. Describe Elephantiasis.

Adult worms cause lymphatic dilatation and dysfunction, which results in abnormal lymph flow
and eventually may pre- dispose an infected person to lymphedema in the legs, scrotal area, and
arms. Recurrent secondary bacterial infections hasten progression of lymphedema to its
advanced stage, known as elephantiasis. Elephantiasis is a condition characterized by gross
enlargement of an area of the body, especially the limbs. Other areas commonly affected include
the external genitals. Elephantiasis is caused by obstruction of the lymphatic system, which
results in the accumulation of a fluid called lymph in the affected areas.

8. How will you manage or treat this case?

Specific:
- Diethylcarbamazine: drug of choice: he main goal of treatment of an infected person
is to kill the adult worm. Diethylcarbamazine citrate (DEC), which is both microfilaricidal
and active against the adult worm, is the drug of choice for lymphatic filariasis
o Bancroftian – to be given for 12 days
o Brugia malayi – to be given for 6 days
- Repeat doses to decrease the microfilaremia and kill lymphatic dwelling parasites (1-
6 monthly interval)
- Adverse effects: headache, general weakness, joint pains, anorexia, nausea and
vomiting
- Once lymphedema is established (the late phase of chronic disease), the disease
is not affected by chemotherapy.
- Ivermectin is effective against the microfilariae of W bancrofti but has no effect on
the adult parasite.
- In some studies, combination therapy with single-dose DEC-albendazole or
ivermectin-albendazole has been shown to be more effective than any one drug
alone in suppressing microfilaremia.
-

Non-specific: Complex decongestive physiotherapy may be effective for treating

lymphedema. Chyluria originating in the bladder responds to fulguration; chyluria originating
in the kidney usually cannot be corrected. Prompt identification and treatment of bacterial
superinfections, particularly streptococcal and staphylococcal infections, and careful
treatment of intertriginous and ungual fungal infections are important aspects of therapy for
lymphedema.
- Antihistamines or corticosteroids for allergic reactions
- Surgical excision subcutaneous nodules
- Surgical procedures for large hydroceles
- Elephantiasis –physiotherapy; plastic surgical repair of genitalia
- Careful treatment of bacterial infection

Supportive Management: for lymphedema and elephantiasis:

- Twice-daily washing of the affected parts with soap and water
- Raising the affected limb at night
- Regularly exercising the affected limb to promote lymph flow 9 Keeping nails clean
- Wearing shoes
- Antiseptic or antibiotic cream to treat small wound/abrasions

9. Cite the different ways to prevent or avoid the disease.

 CONTROL MEASURES: Control measures have been instituted on the basis of annual
community-wide combinations of DEC and albendazole (worldwide except Africa) or
albendazole and ivermectin (in Africa) to decrease or possibly eliminate transmission. No
vaccine is available for filariasis.

Clinical Vignette 3

2 year-old Susie was brought in your clinic because of rectal prolapse of 1 day duration.
She was having peri-umbilical pain/right lower quadrant for 3 days now which was temporarily
relieved by taking paracetamol every 6 hours. 1 day prior to consult there were 2 episodes of
loose stools Bristol type 6. There was no fever, no vomiting but with decreased in activity.

Pertinent physical examination findings:

Weight = 13kg Height= 85 cm. CR= 80 /min RR= 25 / min Temperature = 37oC

Guide Questions
1. What is the most likely diagnosis in this case?
Trichuriasis or Whipworm infection
o rectal prolapse
o peri-umbilical pain/right lower quadrant for 3 days
o 1 day prior to consult there were 2 episodes of loose stools Bristol type 6
o no fever, no vomiting but with decreased in activity

2. What diagnostic test will you request to confirm your diagnosis?

§ Eggs may be found on direct examination of stool or, preferably, by using

concentration techniques.
§ Identification of the barrel-shaped egg in the stool

3. Identify the etiologic agent, its habitat and the principal host.
Etiology: Trichuris trichiuria (whipworm)
Habitat: small intestine
Host: Human

4. How will you treat Susie?

Mebendazole, albendazole, or ivermectin administered for 3 days provide moderate rates
of cure, with mebendazole being the treatment of choice. In mass treatment efforts involving
entire communities, a single dose of either mebendazole (500 mg) or albendazole (400 mg)
will reduce worm burdens . In 1-year-old children, the World Health Organization recommends
reducing the albendazole dose to half of that given to older children and adults for single-dose
and 3-day treatment. Albendazole and ivermectin are not approved by the US Food and Drug
Administration for treatment of trichuriasis. Reexamination of stool specimens 2 weeks after
 therapy to determine whether the worms have been eliminated is helpful for assessing
therapy.

- Albendazole 400 mg PO x 3 days – drug of choice

- Mebendazole 100 mg PO BID x 3 days
- Ivermectin 200 μg/kg PO for 3 days
- Oxantel pamoate 20 mg/kg + 400 mg Albendazole on consecutive
§ days – highest cure rate

5. How can you prevent it?

CONTROL MEASURES: Proper disposal of fecal material is indicated. Mass treatment of

infected school-aged populations can reduce whipworm transmission in communities with
endemic infection.

References:

§ Nelson’s Textbook of Pediatrics

§ Current Pediatric Medical Diagnosis and Treatment 2021
§ Pediatrics Redbook