Enterobius Vermicularis (Pinworm)


Article Author:
Prashanth Rawla


Article Editor:
Sandeep Sharma


Editors In Chief:
Wanda Wright
Cynthia Oster


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/4/2019 4:15:33 PM

Introduction

Enterobius vermicularis, also called pinworm, is one of the most common nematode infections in the world. Originally, E. vermicularis was named Oxyuris vermicularis. Humans are the only natural host for this infection. Transmission occurs in people who are living in crowded environments and usually occurs within families. The worms are tiny, thread-like, and whitish. The worm is named after the characteristic pin-like tail present on the posterior part of female worms.[1][2]

Etiology

Infection most commonly occurs in children, but any individual is susceptible to E. vermicularis infection. People from tropical climates and school-aged children are the most vulnerable. Infection is caused by ingestion of the pinworm eggs. Route of infection is most commonly through the fecal-oral route.[3]

Epidemiology

The male to female infection frequency is 2 to 1. However, a female predominance of infection is seen in those between the ages of 5 and 14 years. It most commonly affects children younger than 18 years of age. It is also commonly seen in adults who take care of children, institutionalized children. Center for Disease Control and Prevention data indicates that there about 40 million people estimated to have been infected in the United States. Transmission can occur via contact with contaminated clothes, bedding, personal care products, and furniture. Fecal-oral is the most common mode of transmission. Rarely, transmission can occur via inhalation mode when eggs are inhaled and then subsequently swallowed.

Pathophysiology

Enterobius vermicularis is an organism that primarily lives in ileum and cecum. Once E. vermicularis eggs are ingested, they take about 1 to 2 months to develop into adult worms which happens in the small intestine. These do not usually cause any symptoms when confined to the ileocecal area. The female adult worms and ova migrate to the anal area mostly at night time and deposit thousands of eggs in the perianal area. This migration causes a lot of itching and pruritus. Eggs hatch near the anal area causing itching, scratching and this causes perianal pruritus. This leads to contamination of the fingers and results in ingestion of the eggs (autoinfection) and restarting of the life cycle of the worm. Occasionally, the larvae migrate back into the rectum and to the small intestine and begin the life cycle (retro infection).

History and Physical

Infection is usually benign, and about a third of the patients are asymptomatic. The most common symptoms associated with pinworm infestation is perianal itching. Perianal erythema may be seen due to the itching and scratching. Sometimes a superficial bacterial infection can occur at the scratching sites resulting in erythema and warmth. Persistent itching can cause disturbances in sleep and may lead to insomnia. Female genitourinary infections have also been reported in the literature. Water diarrhea has been reported in some patients. Sometimes abdominal pain and other serious complications like appendicitis can occur due to worms blocking the lumen in the appendix or lead to inflammation around the appendix.[4] Sometimes tiny thread-like worms may be visible to the naked eye in the perianal area.

Evaluation

Enterobius can be diagnosed through a cellophane tape test or pinworm paddle test where an adhesive tape-like material is applied to the perianal area and then examined under a microscope. The examination might reveal characteristic ova which are 50 by 30 microns in size and have a flattened surface on one side or may reveal the worms. Female worms are around 8 to 13 mm long while male worms are 2 to 5 mm long. The examination is usually done early morning for higher diagnostic yield. If the examination is negative for five consecutive mornings, then the diagnosis is ruled out. Stool examination is not helpful in the diagnosis of E. vermicularis as they are only occasionally excreted in the stool usually. Sometimes analysis of the stool specimen is recommended to rule out other causes.

Treatment / Management

Treatment consists of the following antihelminthic medications:

Albendazole: Given on an empty stomach, a 400-mg, one-time dose followed by a repeat dose in 2 weeks

OR

Mebendazole: A 100-mg, one-time dose followed by a repeat dose in two weeks

OR

Pyrantel Pamoate: Available over the counter in the United States; Dose of 11 mg/kg up to a maximum 1 gm given 2 weeks apart

Other medications which have been used to treat enterobiasis are ivermectin and piperazine, although the latter has lower efficacy and higher toxicity.[5]

Enterobiasis can cause recurrent reinfection, so treating the entire household, whether symptomatic or not is recommended to prevent recurrence.

Treatment of Enterobius infection in pregnancy should be reserved for patients who have significant symptoms. In pregnant patients, pyrantel pamoate is preferred over other medications.

Differential Diagnosis

  • Pruritus ani
  • Pruritus vulvae
  • Atopic dermatitis
  • Perirectal abscess
  • Cellulitis

Toxicity and Side Effect Management

Pyrantel pamoate can cause adverse effects like nausea, vomiting, anorexia, abdominal cramps, diarrhea. It should be avoided in children younger than 2 years of age. Mebendazole and albendazole should be avoided in the first trimester of pregnancy and children younger than 1 year of age. Pregnant patients should consult their doctors before initiating any therapy.

Prognosis

Prognosis following a pinworm infection is excellent. Patients are recommended to follow up with their physicians after completion of the treatment to make sure they do not have any reinfection. Is symptoms recur then testing and treatment as above should be re-initiated.

Complications

Occasionally a superficial bacterial infection can occur at the scratching sites due to intense perianal pruritus. Other complications reported are female genitourinary infections like vulvovaginitis, urinary tract infection in young girls. Appendicitis has also been reported as a consequence of longstanding pinworm infestation.

Deterrence and Patient Education

Patients should be educated on the need to maintain hygiene and wash their hands regularly to prevent the spread of infection and reinfection. Family members should recognize the signs and symptoms of pinworm infection early and should make sure that they get appropriate medications to treat it.

Pearls and Other Issues

Preventive strategies recommended are:

  1. Washing hands regularly, particularly before eating, after changing diapers
  2. Taking a bath early in the morning to prevent egg contamination should be encouraged in at-risk patients.
  3. Trimming of fingernails should be encouraged.
  4. Children should be advised to avoid sucking their fingers and touching their perianal area.

Enhancing Healthcare Team Outcomes

Enterobius vermicularis infection is usually treated by the primary care nurse practitioner, physician assistant, or family physician. If having any difficulty in treating then the patient may be referred to specialists like an infectious disease or parasitologists. Pharmacists have a role in explaining to the patients the side effects of these medications used to treat pinworms as one of the drugs. Pyrantel pamoate is available over the counter in the United States. School nurses should also be aware of the manifestations of pinworm infection to prevent their spread in the schools and daycares.[6] A coordinated team approach to care and followup will provide the best results. [Level V]


  • Image 5570 Not availableImage 5570 Not available
    Contributed by Centers for Disease Control and Prevention (Public Domain)
Attributed To: Contributed by Centers for Disease Control and Prevention (Public Domain)

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Enterobius Vermicularis (Pinworm) - Questions

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Which of the following is the drug of choice for the treatment of pinworms?



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A 4-year-old boy presented with perianal itching that worsens at night. What is the most likely diagnosis?



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Which of the following medications is the drug of choice for Enterobius (pinworms) infection?



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Which of the following is appropriate therapy for pinworms?



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The adult pinworm may dwell in what part of the gastrointestinal tract? Select all that apply.



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A 17-year-old female presents with a complaint of vague perianal itching, which mostly occurs at night. She also complaints of feeling nauseous for the last few days. The patient admits that she is sexually active and is worried that she may have a sexually transmitted disease. On physical examination, the patient has excoriations in her perianal area. A tape test is done and confirms the diagnosis of Enterobius vermicularis infection. What is the best next step in the management of this patient?



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Enterobius Vermicularis (Pinworm) - References

References

Cook GC, Enterobius vermicularis infection. Gut. 1994 Sep     [PubMed]
Dahlstrom JE,Macarthur EB, Enterobius vermicularis: a possible cause of symptoms resembling appendicitis. The Australian and New Zealand journal of surgery. 1994 Oct     [PubMed]
Wang S,Yao Z,Hou Y,Wang D,Zhang H,Ma J,Zhang L,Liu S, Prevalence of Enterobius vermicularis among preschool children in 2003 and 2013 in Xinxiang city, Henan province, Central China. Parasite (Paris, France). 2016     [PubMed]
Yang CA,Liang C,Lin CL,Hsiao CT,Peng CT,Lin HC,Chang JG, Impact of Enterobius vermicularis infection and mebendazole treatment on intestinal microbiota and host immune response. PLoS neglected tropical diseases. 2017 Sep     [PubMed]
Ashford RW,Hart CA,Williams RG, Enterobius vermicularis infection in a children's ward. The Journal of hospital infection. 1988 Oct     [PubMed]
Markell EK, Intestinal nematode infections. Pediatric clinics of North America. 1985 Aug     [PubMed]

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