Case 8:

The Flight of the

Lonely Wanderer
 “The Flight of the Lonely
Wanderer”
 Botchok is a 5-year old scavenger at
the Smoky Mountain who was
brought to the Ospital ng Tondo
because of persistent vomiting,
abdominal pain and inability to pass
stools for the past two days. He had
a 1 year previous history of recurrent
abdominal pain and passing out
worms.
 “The Flight of the Lonely
Wanderer”
 PErevealed a pot-bellied,
undernourished child in extreme
abdominal pain. Scout film of the
abdomen was requested.
 “The Flight of the Lonely
Wanderer” Guide Questions
1. What is Botchok’s affliction?
2. What is a geohelminth?
3. What are the soil-transmitted helminths?
4. How does Ascaris cause disease in man?
5. How does Ascaris present clinically?
6. What are the clinical findings of harboring
the Geohelminths?
7. How should Botchok’s management be
ideally instituted?
 Q1:
What is Botchok’s
affliction?
 Q1: “The Flight of the Lonely
Wanderer”
 The triad of persistent vomiting,
abdominal distension and obstipation
(inability to pass stools) speaks of
intestinal obstruction
 With his past history of passing out
worms visibly, his occupation, lack of
personal hygiene and recurrent
abdominal pain one should think of a
geohelminth
 Q2:
What is a geohelminth?
 Geohelminths
(Soil-transmitted helminths)
 A geohelminth is a nematode parasite
which is spread from man-to-man.
 The egg or larva of the worm is not
infective when first passed in the stool,
but has to undergo further development in
the soil. Thus transmission can only occur
when the ground is contaminated with
feces
 Q3:
What are the soil-
transmitted
helminths?
 Soil-transmitted helminths
 Ascaris lumbricoides
 Hookworms
 Trichuris trichiuria
 Strongyloides stercoralis
 Toxocara canis (and cati)- rare

**Infection with Ascaris, hookworm

and Trichuris – “The Unholy Trinity”
 Ascaris lumbricoides
 Adults are large, cream-colored
worms, the males 15-30 cms
long, females 20-40 cms.They
live in the small intestine and
obtain nourishment from the
intestinal contents
Adult ascaris
 The fertilized female lays about
200,000 eggs a day. Eggs
remain infective for weeks or
months
 From the time the egg is
swallowed to the time the worms
mature is 60-75 days
Fertilized egg
 Q4:
How does Ascaris
cause disease
in man?
 Pathogenesis
 Symptoms due to pulmonary
migration
– Ascaris larvae are large and antigenic
and cause damage during their entry
into the alveoli
– Symptoms may be severe if many
larvae are migrating at the same time
– The clinical picture is of cough, fever,
wheeze, dyspnea in severe cases, x-ray
shadows and eosinophilia
 Pathogenesis
 Effects of adult worms:
– Most infections are asymptomatic. The
main effects are:
2. Mechanical
3. Toxic
4. Metabolic
 Pathogenesis
 Mechanical effects:
2. In the small bowel, impaction may cause
obstruction, volvulus or intussusception
3. In the appendix: appendicitis
4. In the biliary tree: obstructive jaundice
and intrahepatic abscesses
5. In the pancreatic duct: pancreatitis
6. In the larynx: worms vomited up may
occasionally cause asphyxia
 Pathogenesis
 Toxic and metabolic effects:
– These are vague and ill-understood but
a heavy worm burden may significantly
contribute to malnutrition
 Q5:
How does Ascariasis
present clinically?
 Presentation of Ascariasis
 Mild bouts of recurrent colic
 The mother has seen a worm – passed in
the stools, vomited up or even emerge
from the ear via perforated ear drums
 The child may present with complications
 The infection is suspected in a poorly
nourished, pot-bellied child with edema

* Worms tend to be expelled during bouts of

diarrhea of any cause. This does not mean
the worms caused the diarrhea
 Presentation of Ascariasis
 Erraticism:a characteristic Ascaris is
notorious for. Depending on the GI
milieu it wanders to many organs
within or outside of the
gastrointestinal system
Disclosure
 Botchok was done
scout film of the
abdomen which
revealed a
mechanical
obstruction at the
level of the small
intestine
 A Barium meal was
therefore
requested
Botchok’s Disclosure
 The Barium meal
revealed adult
ascaris seen as
radiolucent cord
like shadow
 Q6:
What are the clinical
effects
of the Geohelminths?
 Clinical findings of
Geohelminthiasis
 Clinical effects of Hookworm infection:
2. “Ground itch” – pruritus at site of larval
penetration
3. Migratory phase:pneumonitis with cough,
wheezing, transient x-ray shadows. Not
as severe as Ascaris
4. Acute intestinal phase: abdominal pain
and diarrhea with losses of iron and
proteins
5. Iron deficiency Anemia in chronic
infections
 Clinical findings of
Geohelminthiasis
 Clinical effects of
Trichuriasis:
2. Diarrhea with blood
but without fever
3. Rectal prolapse
4. Anemia in massive
trichuriasis
5. Wasting
6. Eosinophilia
 Clinical findings of
Geohelminthiasis
 Strongyloidiasis:
 Patients with light infections are
asymptomatic
 Heavy infections – severe diarrhea and
stetorrhea
 Massive infection resulting from
autoinfection – Hyperinfection syndrome
(infective larvae penetrate all body tissues
in life-threatening process)
 Marked peripheral eosinophilia
 Q7:
How should Botchok’s
management be
ideally instituted?
 Diagnosis and Treatment
 Diagnosis: directly by finding the
characteristic eggs in the feces
 Treatment:
– Piperazine salts are safe and very effective in
uncomplicated intestinal ascariasis
administered on 2 consecutive days. Piperazine
temporarily paralyses the worms after which
they are expelled by peristalsis
– Mebendazole or pyrantel pamoate may be
employed
– Education re sanitary disposal of feces and
hygienic practices together with periodic
deworming will be necessary if reduction in the
incidence of helminthic infection is to be
achieved
 Diagnosis and Treatment
– Intestinal, biliary or pancreatic obstruction in
the majority of cases respond to conservative
measures i.e. gastrointestinal decompression,
IV fluids, sedation and antispasmodics,
followed by vermifuge when acute symptoms
subside
– Laparotomy is indicated if response to
conservative treatment is unsatisfactory or if
obsruction is complete or complicated by the
formation of local abscesses or peritonitis
 Key Learning points
 The geohelminths are the major parasites
that can infect children in tropical
countries
 The geohelminths may manifest
pathogenic effects whether through the
larvae or the adult worm
 A fatal mechanical intestinal obstruction
can be one of the outcomes of Ascariasis
 Education, regular antihelminthic
treatment and proper hygienic practices
can prevent helminthiasis
 Case 8:
The Flight of the
Lonely Wanderer