Initial diagnosis and discussion
An Internet search, as well as consultation with several of the other medical staff, was conducted to determine the type of helminth. It looked like Ascaris lumbricoides species, according to comparative images, but it could also be a fairly long earthworm, which would be much more likely in the Northeastern United States.
Ascariasis is noted to be in tropical areas of Africa, Central America, South America, and in the Far East, with a prevalence as high as 90% (Butts and Henderson, 2003). A higher incidence of infectious disease has been documented in U.S. regions bordering Mexico, compared with nonborder areas (Cardenas et al, 2010). Shoff, Shoff, and Greenberg note an estimated four million cases in the United States, with transmission occurring in the Gulf States, southern New Mexico, and southern Arizona.
Further research reveals that the adult worm can survive in the lumen of the small intestine and can have a life span of up to 2 years before being passed in stool. Depending on whether there are male, female, or both, in the intestines, as many as 200,000 fertilized ova can be produced daily (Leder and Weller, 2011).
Diagram showing the life cycle of Ascaris lumbricoides, the largest roundworm parasitizing the human intestine.
Adapted from www.cdc.gov/parasites/ascariasis/biology.html
Although the specimen was brought to the ED by the boy’s mother, nobody witnessed an expulsion of the organism from the child, and the practitioner must consider other possibilities, such as the organism got into the child’s clothing while he was playing outdoors and then fell into the toilet when the child pulled his pants down to defecate. Perhaps the child deliberately put the worm into the toilet to frighten his mother. Or the mother is fabricating the entire story, which is entirely possible and should be in the differentials.
As an advanced practice provider, one must consider all of these potential explanations before jumping to treatment. The child could be treated with an antihelminth agent, which would help expel any remaining organisms from the gastrointestinal tract.
However, there are side effects associated with administering these medications, such as abdominal pain, cramping, diarrhea, abnormal liver function tests, neutropenia, seizures, rash, or anaphylaxis. Conversely, deferring treatment may lead to more devastating consequences. “The adult worm itself may reach the liver and cause liver abscess” (Bari et al, 2007).
Because this was not a witnessed expulsion, and this child did not appear acutely ill, the clinicians decided to seek infectious disease consultation. The concerns were affirmed by the infectious disease staff. The specimen was sent to the pathology lab for identification, and the child was sent home pending positive identification.
The mother was informed of the potential side effects of treating with antihelminth agents, and the decision to forego treatment at that time was explained to her. The family was advised to return if symptoms developed, including fever, abdominal pain, vomiting, and diarrhea, or if they witnessed expulsion of any parasites from any open body orifice.
This article originally appeared on Clinical Advisor