Two cases of eosinophilic gastroenteritis and malabsorption due to Enterobious vermicularis

UK guidelines for the investigation and management of eosinophilia in returning travellers and migrants

Eosinophilia is a common finding in returning travellers, migrants and other travelling groups. In this setting, it often indicates an underlying helminth infection. Infections associated with eosinophilia are frequently either asymptomatic or associated with non-specific symptoms but some can cause severe disease. Here the British Infection Association guidelines group has comprehensively reviewed and updated the UK recommendations for the investigation and management of eosinophilia in returning travellers, migrants and other relevant groups, first published in 2010.1 Literature reviews have been undertaken to update the evidence on the prevalence and causes of eosinophilia in these groups and on the treatment of relevant pathogens and clinical conditions. Diagnostic tests available to UK-based clinicians are summarised. Changes made to the guidelines include updates in the sections on the investigation and empirical treatment of asymptomatic eosinophilia and on the treatment of trichuriasis, lymphatic filariasis, onchocerciasis, hookworm, fascioliasis and taeniasis. Pathogens which are rarely encountered in UK practice have been removed from the guidelines and others added, including an expanded section on fungal infection. A section on off-license and rarely used drugs has been included.

Enterobiasis among Yemeni children: a cross-sectional study

Enterobiasis is a highly infectious parasitic disease spreading worldwide including Yemen. Therefore, this study aimed to investigate the prevalence and risk factors of enterobiasis among Yemeni children in Dhamar governorate. A total of 402 children (aged 1-12 years) participated in this cross-sectional survey carried out at Thamar University Al-Wahdah Teaching Hospital (TUWTH), between 2018 and 2019. Enterobius vermicularis infection was examined using the adhesive tape technique. Association between risk factors and enterobiasis were measured by prevalence ratio (PR). The overall prevalence of enterobiasis was found to be 29.4% (118/402). Risk factors that showed independent association with the infection were child's care responsibility (PR = 1.90; 95% CI = 1.37-2.63; P = 0.001); irregular washing hands before meals (PR = 2.01; 95% CI = 1.32-3.05; P = 0.003); habit of nail biting or cutting by teeth (PR = 1.61; 95% CI = 1.18-2.21; P = 0.002); habit of putting toys or pen in mouth (PR = 1.58; 95% CI = 1.19-2.10; P = 0.002); frequent anal itching (PR = 1.46; 95% CI = 1.10-1.93; P = 0.016); using anthelmintic during the last six months (PR = 1.68; 95% CI = 1.20-2.36; P = 0.011); and parents have no knowledge on preventive measures (PR = 1.62; 95% CI = 1.04-2.53; P = 0.036). Prevalence of enterobiasis among Yemeni children in Dhamar governorate is high with higher infection rate among those aged 1-6 years. Health education and mass treatment are highly recommended among this poor population.

Eosinophilic Gastrointestinal Disorders

Eosinophilic esophagitis (EoE) is an atopic disease that is characterized by an isolated infiltration of eosinophils into the epithelium of the esophagus and is triggered by specific allergens. Patients should undergo an upper endoscopy with biopsy after 6 to 8 weeks of treatment with a proton pump inhibitor in order to make the diagnosis of EoE. Eosinophilic gastroenteritis is a pathologic eosinophilic infiltration of any portion of the gastrointestinal tract, and eosinophilic proctocolitis is an eosinophilic infiltration in the colon alone.

New insights of Enterobius vermicularis infection among preschool children in an urban area in Malaysia

Enterobiasis is a common intestinal parasitic infection caused by the nematode, Enterobius vermicularis. To assess the prevalence and to identify the underlying risk factors associated with enterobiasis among preschool children aged 1 – 6 years in Malaysia, 136 children from four nurseries and four kindergartens residing in the urban area were examined for Enterobius vermicularis. The cellotape anal swab technique was used for the detection of pinworm eggs. The parents/guardians of the investigated children were asked to complete the questionnaire so as to ascertain the potential risk factors for enterobiasis. The overall egg positive rate for Enterobius vermicularis infection was 12.5 %. The prevalence of this infection showed an age-dependency relationship, with higher rates observed among older children, aged 5 – 6 years. Multivariate analysis confirmed that finger sucking and belonging to a large family were significant risk factors of enterobiasis in the population studied. Recent pre-medication with anthelminthics was also found to have a significant impact on decreasing the egg positive rate for pinworm. The establishment of such data will be beneficial for the public health authorities in the planning and implementation of specific prevention in order to better control the infection.

The post-treatment effects of enterobiasis on the occurrence of enuresis among children in Calabar, Nigeria

OBJECTIVE

To investigate the relationship between enterobiasis and enuresis before and after albendazole therapy among 632 children, aged, 5-14 years, in Calabar, Nigeria.

METHODS

The scotch tape (cellotape) technique was used for the detection of eggs of Enterobius vermicularis (E. vermicularis) while questionnaire-based interviews were used for screening for anal itching and/or enuresis among study participants. All subjects found positive for Enterobius infection as confirmed by the presence of eggs and those with persistent anal itching (both enuretic and non-enuretic) were treated with 400 mg of albendazole given as a single dose. The treated subjects were re-assessed post-treatment to ascertain whether they were cured and also to determine their enuretic status (for the enuretics).

RESULTS

The overall prevalences of Enterobius infection, anal itching, and enuresis prior to albendazole therapy were 6.8%, 42.9%, and 35.6% respectively. There was no statistically significant difference in the prevalence of these parameters by the socio-economic class of subjects (P = 0.462, P = 0.647, and P = 0.610, respectively). The pre-treatment prevalences of enuresis among Enterobius and anal itching-positive subjects were 53.5% and 49.8%, respectively versus 34.3% and 24.9%, respectively among their negative counterpart (P = 0.012 and P < 0.001, respectively). Four (20%) out of the 20 enuretic children found Enterobius egg-negative after albendazole therapy were equally cured while 8(40%) had reduction of their enuresis, thus giving a total resolution rate of 60%. Similarly, 64.2% resolution (25% cure and 32.8% reduction) of enuresis was observed amongst 120 anal itching-cured/enuretic children. Enuretic status of the Enterobius-/anal itching-uncured subjects, on the other hand, remained unchanged post-treatment.

CONCLUSIONS

This study is suggestive of the involvement of E. vermicularis in the aetiology of enuresis in Calabar. Children presenting with, especially, uncomplicated enuresis should be screened for enterobiasis.

Threadworm: an infrequent clinical finding in a genitourinary medicine clinic attendee presenting with ano-genital irritation

A 24-year-old lady presented to an evening genitourinary (GU) clinic with a short history of vulval and anal irritation. On perianal examination, several threadworms were visible. Symptoms resolved with oral mebendazole and strict personal and environmental hygiene. Threadworm is a common and easily treatable cause of pruritis ani, yet is underreported in GU literature. If the history is suggestive, consider performing the diagnostic cellophane test and/or prescribing empirical treatment.

Evaluation of the patient with suspected eosinophilic gastrointestinal disease

This article focuses on the evaluation and management of eosinophilic gastrointestinal diseases other than eosinophilic esophagitis. Those diseases include eosinophilic gastritis, gastroenteritis, enteritis, and colitis. The diagnosis of eosinophilic gastrointestinal disease is primarily dependent on the clinical history and histopathology of multiple biopsy specimens after ruling out other causes of intestinal eosinophilia. The diagnosis of eosinophilic gastrointestinal diseases other than eosinophilic esophagitis is complicated by the lack of uniformly accepted diagnostic criteria. Treatment involves evaluation for food sensitivity, elimination diets, and the use of anti-allergy and anti-inflammatory medications with varying degrees of success. Little is known about the natural history of eosinophilic gastrointestinal diseases, underscoring the need for long-term follow-up studies of patients with these disorders.

Eosinophilic gastroenteritis

Eosinophilic gastroenteritis is an infrequently diagnosed condition that is characterized by prominent eosinophilic infiltration of the stomach or small intestine, generally localized to one level of the intestinal wall; the variable organ locus and wall depth produce heterogeneous clinical presentations. A strong association with atopy is present in most cases, supported by circumstantial evidence and the demonstration of Th-2 proinflammatory cytokine profiles in animal studies. A high degree of suspicion is required to establish the diagnosis, which must be based on intense gastrointestinal eosinophilia. Management is directed toward removal of offending allergens and use of anti-inflammatory agents. Novel and emerging treatments on the horizon are biologic therapies and selective anti-eosinophil agents.

Association of atopy, asthma, allergic rhinoconjunctivitis, atopic dermatitis and intestinal helminth infections in Cuban children

OBJECTIVE

To examine the relationship of past and current intestinal helminth infections with asthma, allergic rhinoconjunctivitis, atopic dermatitis and atopy.

METHODS

Cross-sectional study of 1320 children aged 4-14 years from two Cuban municipalities. Helminth infections were determined by stool examination and parental questionnaire. Asthma, rhinoconjunctivitis and atopic dermatitis were diagnosed by International Study of Asthma and Allergies in Childhood questionnaire, asthma additionally by spirometry, atopy by skin prick testing.

RESULTS

Questionnaire-based frequencies were 21% for asthma, 14% for allergic rhinoconjunctivitis and 8% for atopic dermatitis. According to spirometry, 4% had asthma; 20% had a positive skin prick test. A history of infection for Enterobius vermicularis was associated with increased risk of atopic dermatitis (OR 1.88, P = 0.001) and allergic rhinoconjunctivitis (OR 1.34, P = 0.046), and hookworm with increased risk of allergic rhinoconjunctivitis (OR 2.77, P = 0.021). A positive stool examination for Ascaris lumbricoides infection was negatively associated with atopic dermatitis (OR 0.22, P = 0.007). Asthma and atopy were unrelated to helminth infections.

CONCLUSION

Current A. lumbricoides infection protects against atopic dermatitis in Cuban children, while past infection with E. vermicularis and hookworm are risk factors for allergic rhinoconjunctivitis and/or atopic dermatitis. Apparently, interactions differ depending on the type of helminth and atopic disease and on the time of helminth infestation.

Eosinophils in the gastrointestinal tract

Although we know that eosinophils reside in the normal gastrointestinal tract and increase during inflammatory states, their exact role in gut homeostasis and in the pathogenesis of inflammatory processes is not certain. An increasing number of clinical reports suggest that eosinophils participate in the pathogenesis of mucosal inflammation, and emerging literature is beginning to define these mechanisms. For example, homing of eosinophils to the gastrointestinal tract is better understood with respect to the roles of specific eosinophilic attractants, such as the eotaxins and interleukin-5. As mechanisms of eosinophil recruitment, activation, and functional responses are further elucidated, novel targets for treatment strategies in specific diseases will likely follow. We review recent developments in eosinophil immunobiology as they relate to gastrointestinal inflammation and provide an update on clinical aspects of eosinophilic esophagitis as they relate to eosoinophilic diseases of the gastrointestinal tract.