History

Fact Explanation
Abdominal pain Hymenolepiasis is caused by cestods called Hymenolepis nana (dwarf tapeworm) and Hymenolepis diminuta (rat tapeworm). H deminuta rarely cause human infestation while H. nana causes most of Hymenolepiasis cases. It is commonly found in warm countries in Africa, South America, Asia and Europe. Humans become infected with H. nana by ingesting the infective eggs, most commonly by through fecal-oral exposure. Auto infection is also not uncommon. Infective eggs passed out in stools. Humans get H.diminuta through swallowing of infected fleas or grain beetles in dried grains or fruits. They are accidentally swallowed by men. Adult worms get attached to mucosa of small intestine. The symptoms depends on the parasite load. Most of them are asymptomatic. An insidious onset epigastric pain occurs due to the trauma by adult worms in the in upper two thirds of ileum. This results in an allergic/ inflammatory reaction. The pain is accompanied by anorexia, increased appetite, nausea and vomiting. [1,2,3,4,5]
Diarrhea The diarrhea is watery type and often mild. [1,2,3,4]
Hives Generalized toxic and allergic reactions causes red, itchy, raised areas of skin that appear in varying shapes and sizes. [4,5,6]
Non specific symptoms Itching around the anus, extremity pain, headache, dizziness, behavioral disturbances, and seizures are rare and non specific symptoms of the disease. [1,2,3]
References
  1. ROHELA M, NGUI R, LIM YA, KALAICHELVAN B, WAN HAFIZ WI, MOHD REDZUAN AN. A case report of Hymenolepis diminuta infection in a Malaysian child. Trop Biomed [online] 2012 Jun, 29(2):224-30 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22735844
  2. RIM HJ, PARK CY, LEE JS, JOO KH, LYU KS. Therapeutic Effects Of Praziquantel (Embay 8440) Against Hymenolepis Nana Infection. Kisaengchunghak Chapchi [online] 1978 Dec, 16(2):82-87 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12902768
  3. MAGGI P, BRANDONISIO O, CARITO V, BELLACOSA C, EPIFANI G, PASTORE G. Hymenolepis nana parasites in adopted children. Clin Infect Dis [online] 2005 Aug 15, 41(4):571-2 [viewed 28 July 2014] Available from: doi:10.1086/432125
  4. ALVAREZ-FERNáNDEZ BE, RODRíGUEZ-BATAZ E, DíAZ-CHIGUER DL, MáRQUEZ-NAVARRO A, SáNCHEZ-MANZANO RM, NOGUEDA-TORRES B. Mixed Hymenolepis species infection in two family members: a case report from an urban area of Chilpancingo, Guerrero, México. Trop Gastroenterol [online] 2012 Jan-Mar, 33(1):83-4 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22803308
  5. WIWANITKIT V. Overview of hymenolepis diminuta infection among Thai patients. MedGenMed [online] 2004 Apr 22, 6(2):7 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15266234
  6. KIM BJ, SONG KS, KONG HH, CHA HJ, OCK M. Heavy Hymenolepis nana infection possibly through organic foods: report of a case. Korean J Parasitol [online] 2014 Feb, 52(1):85-7 [viewed 28 July 2014] Available from: doi:10.3347/kjp.2014.52.1.85

Examination

Fact Explanation
Urticaria Red, itchy raised areas (hives) occur all over the body due to allergy. [1,2,3]
Abdominal tenderness Abdominal tenderness is rare and more common in the epigastric and peri-umbilical region. [1,2,3]
References
  1. ROHELA M, NGUI R, LIM YA, KALAICHELVAN B, WAN HAFIZ WI, MOHD REDZUAN AN. A case report of Hymenolepis diminuta infection in a Malaysian child. Trop Biomed [online] 2012 Jun, 29(2):224-30 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22735844
  2. KIM BJ, SONG KS, KONG HH, CHA HJ, OCK M. Heavy Hymenolepis nana infection possibly through organic foods: report of a case. Korean J Parasitol [online] 2014 Feb, 52(1):85-7 [viewed 28 July 2014] Available from: doi:10.3347/kjp.2014.52.1.85
  3. ALVAREZ-FERNáNDEZ BE, RODRíGUEZ-BATAZ E, DíAZ-CHIGUER DL, MáRQUEZ-NAVARRO A, SáNCHEZ-MANZANO RM, NOGUEDA-TORRES B. Mixed Hymenolepis species infection in two family members: a case report from an urban area of Chilpancingo, Guerrero, México. Trop Gastroenterol [online] 2012 Jan-Mar, 33(1):83-4 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22803308

Differential Diagnoses

Fact Explanation
Amebiasis Amoebiasis, or Amebiasis, refers to infection caused by the amoeba Entamoeba histolytica. Most infected people are asymptomatic. Severe amoebiasis infections (known as invasive or fulminant amoebiasis) occur in two major forms. Invasion of the intestinal lining causes amoebic dysentery or amoebic colitis. Symptoms can range from mild diarrhea to severe dysentery with blood and mucus. [1]
Ascariasis Ascariasis is caused by Ascaris lumbricoides (large roundworm of humans) It is extremely common infection worldwide and associated with poor sanitation (lack of latrines) in slum areas and estate line rooms. Ascariasis affects more in children than in adults. Mild infection of adult worms does not show symptoms or signs. Increasing worm loads result in worsening of chronic malnutrition especially in children with a poor diet, poor weight gain and stunting. Symptoms may include shortness of breath and fever in the beginning of the disease. These may be followed by symptoms of abdominal swelling, abdominal pain and diarrhea. [2]
Fascioliasis Fasciola hepatica or the sheep liver fluke is a common parasite of sheep and cattle kept on damp pastures in many parts of the world, but is only occasionally found in men. Most cases have been reported from from sheep rearing countries such as South America, Europe and North America. The major symptoms includes fever, abdominal pain, gastrointestinal disturbances such as loss of appetite, flatulence, nausea, diarrhea and urticaria. [3]
Gastroenteritis Viral gastroenteritis is the most common cause of watery diarrhea.It is associated with abdominal pain,nausea and vomiting. Bacterial gastroenteritis usually results in watery diarrhea and sometimes blood and mucous diarrhea.Dehydration is common . Bacterial disease responds to antibacterial agents. [4]
Giardiasis Giardiasis is caused by Giardia intestinalis, a flagellate protozoan which decreases expression of brush-border enzymes namely disaccharidases and lipase. It causes impairment of carbohydrate and lipid digestion resulting osmotic diarrhea.Travelers to countries where giardiasis is common, People in child care settings, those who are in close contacts with patients, people who swallow contaminated or untreated water,men who have sex with men have a greater risk of becoming infected. Diarrhea is the most common symptom in acute giardiasis. It is more specifically, a steatorrhoea which contains pale, bulky, frothy, foul smelling stools which are floating in the lavatory pan due to fat content. [5]
References
  1. ARCHAMPONG EQ, CLARK CG. Surgical problems in amoebiasis. Ann R Coll Surg Engl [online] 1973 Jan, 52(1):36-48 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/4568445
  2. WANG J, PAN YL, XIE Y, WU KC, GUO XG. Biliary ascariasis in a bile duct stones-removed female patient. World J Gastroenterol [online] 2013 Sep 28, 19(36):6122-4 [viewed 27 July 2014] Available from: doi:10.3748/wjg.v19.i36.6122
  3. ARADAğ-ÖNCEL E, OZSüREKçI Y, OZKAYA-PARLAKAY A, CELIK M, CENGIZ AB, HALILOğLU M, CEYHAN M, KARA A. Fasciola hepatica infection: clinical and radiological findings in pediatric patients. Turk J Pediatr [online] 2012 Jul-Aug, 54(4):362-7 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23692716
  4. GODANA W, MENGISTIE B. Determinants of acute diarrhoea among children under five years of age in Derashe District, Southern Ethiopia. Rural Remote Health [online] 2013, 13(3):2329 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24016301
  5. VESY , PETERSON . Review article: the management of Giardiasis. Aliment Pharmacol Ther [online] 1999 July, 13(7):843-850 [viewed 27 July 2014] Available from: doi:10.1046/j.1365-2036.1999.00537.x

Investigations - for Diagnosis

Fact Explanation
Full blood count Parasitic infestation is characterized by high degree of eosinophilia. Leukocytosis and anemia (rarely) may also occur. [1,2]
Stool examination The diagnosis depends on the demonstration of eggs in stool specimens. Concentration techniques and repeated examinations will increase the likelihood of detecting light infections. Eggs of Hynemolepis nana are oval or sub-spherical and smaller than those of H. diminuta. Their size is 40 - 60 µm x 30 - 50 µm. On the inner membrane, there are two poles, from which 4-8 polar filaments spread out between the two membranes. The oncosphere inside the egg has six hooks [1,2,3]
References
  1. WIWANITKIT V. Overview of hymenolepis diminuta infection among Thai patients. MedGenMed [online] 2004 Apr 22, 6(2):7 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15266234
  2. RIM HJ, PARK CY, LEE JS, JOO KH, LYU KS. Therapeutic Effects Of Praziquantel (Embay 8440) Against Hymenolepis Nana Infection. Kisaengchunghak Chapchi [online] 1978 Dec, 16(2):82-87 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12902768
  3. MAGGI P, BRANDONISIO O, CARITO V, BELLACOSA C, EPIFANI G, PASTORE G. Hymenolepis nana parasites in adopted children. Clin Infect Dis [online] 2005 Aug 15, 41(4):571-2 [viewed 28 July 2014] Available from: doi:10.1086/432125

Management - General Measures

Fact Explanation
Prevention Prevention is difficult due to the direct transmission and single host requirement. Improvement of the hygienic habits of children, environmental sanitation and treating the infected persons may be effective. [1,2,3]
References
  1. ROHELA M, NGUI R, LIM YA, KALAICHELVAN B, WAN HAFIZ WI, MOHD REDZUAN AN. A case report of Hymenolepis diminuta infection in a Malaysian child. Trop Biomed [online] 2012 Jun, 29(2):224-30 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22735844
  2. KIM BJ, SONG KS, KONG HH, CHA HJ, OCK M. Heavy Hymenolepis nana infection possibly through organic foods: report of a case. Korean J Parasitol [online] 2014 Feb, 52(1):85-7 [viewed 28 July 2014] Available from: doi:10.3347/kjp.2014.52.1.85
  3. ALVAREZ-FERNáNDEZ BE, RODRíGUEZ-BATAZ E, DíAZ-CHIGUER DL, MáRQUEZ-NAVARRO A, SáNCHEZ-MANZANO RM, NOGUEDA-TORRES B. Mixed Hymenolepis species infection in two family members: a case report from an urban area of Chilpancingo, Guerrero, México. Trop Gastroenterol [online] 2012 Jan-Mar, 33(1):83-4 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22803308

Management - Specific Treatments

Fact Explanation
Praziquantel Praziquantel as a single dose (25 mg/kg) is the current treatment of choice for hymenolepiasis and has an efficacy of 96%. Frequently occurring side effects are dizziness, headache, and malaise. Approximately 90% of all patients have abdominal pain or cramps with or without nausea and vomiting. [1,2,3,4,5]
Niclosamide The mitochondrial oxidative phosphorylation and glucose uptake in the parasite is inhibited. & day treatment is recommended. 2g during the first day and 1g/day in next 6 days is the recommended regimen. Children up to 2 years are given one fourth of the adult dose Children from 2-6 years of age are given half of the adult dose. [2,3,4,5]
Nitazoxanide It is an alternative for Praziquantel and Niclosamide and not as effective as them. [1,2,4,5]
References
  1. ROHELA M, NGUI R, LIM YA, KALAICHELVAN B, WAN HAFIZ WI, MOHD REDZUAN AN. A case report of Hymenolepis diminuta infection in a Malaysian child. Trop Biomed [online] 2012 Jun, 29(2):224-30 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22735844
  2. ALVAREZ-FERNáNDEZ BE, RODRíGUEZ-BATAZ E, DíAZ-CHIGUER DL, MáRQUEZ-NAVARRO A, SáNCHEZ-MANZANO RM, NOGUEDA-TORRES B. Mixed Hymenolepis species infection in two family members: a case report from an urban area of Chilpancingo, Guerrero, México. Trop Gastroenterol [online] 2012 Jan-Mar, 33(1):83-4 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22803308
  3. RIM HJ, PARK CY, LEE JS, JOO KH, LYU KS. Therapeutic Effects Of Praziquantel (Embay 8440) Against Hymenolepis Nana Infection. Kisaengchunghak Chapchi [online] 1978 Dec, 16(2):82-87 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12902768
  4. WIWANITKIT V. Overview of hymenolepis diminuta infection among Thai patients. MedGenMed [online] 2004 Apr 22, 6(2):7 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15266234
  5. MAGGI P, BRANDONISIO O, CARITO V, BELLACOSA C, EPIFANI G, PASTORE G. Hymenolepis nana parasites in adopted children. Clin Infect Dis [online] 2005 Aug 15, 41(4):571-2 [viewed 28 July 2014] Available from: doi:10.1086/432125