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Is it worms or a behaviour disorder?

Chronic pinworm infection can lead to disruptions in mood, behavior and sleep, particularly in children. Recognize some key manifestations of this often overlooked, insidious co-infection.

A common presentation, often undiscovered and ill-perceived, may relate to parasitic or worm infections and the complications known to arise from it. Although often asymptomatic,2 this article aims to shed light on some key symptoms of chronic pinworm infection.

The most common worm infection in Australia is threadworm (aka pinworm, Enterobius vermicularis), with other worms such as roundworms, hookworms and tapeworms being far less common.2 It is estimated that 4-28% of children are infected globally with pinworms4 and occur most frequently in school children aged 5-10 years of age.5

What are worms?

Pinworms, or E. vermicularis are tiny, white worms that live in the colon and rectum. Despite best efforts, worms are passed along quite readily within confined environments, often within the home, daycare and school environment5 due to close personal contact. Transmission occurs via the faecal-oral route, by the transfer of eggs either directly or indirectly by hand contact or through contaminated clothing, bedding, food or other articles1 (see Figure 1). Eggs can survive up to 2 weeks on clothing, bedding and other objects,5 making persistent re-infection a common occurrence and treatment difficult.

Enterobius symptoms are generally mild and occur nocturnally, as this is when the female exits the rectum to lay her eggs in perianal and perineal tissue and surrounding areas1. Symptoms include: itchy anus, teeth grinding, bed wetting, insomnia, restless or disturbed sleep3, anorexia, irritability, and abdominal pain, which can mimic appendicitis1.

E. vermicularis larvae hatch in the small intestine before wiggling their way to the rectum,1 however they are often discovered in surrounding areas on routine examinations. Some examples include: commonly within the appendix on appendectomy; rare instances of eosinophilic colitis associated with E. vermicularis larvae1; cases of pelvic inflammatory disease and infection of the female genital tract has been well reported in the literature.6

Females are more vulnerable due to the anatomical proximity between rectum and vagina, increasing opportunity for cross-/co-infection within the genitourinary tract. 3, 5, 7 As such, persistent cases of urinary tract infections, urinary irritation, vaginal thrush, enuresis or other conditions related to the genito-urinary area should consider E. vermicularis as a potential causative factor.

Figure 1: Lifecycle of the pinworm

 

 

Disturbed microbiota & altered gut-brain axis

Disturbances to the gut-brain communication can occur due to chronic infection. Altered intercommunication of the gut-brain axis has been linked to behavioural disorders, mood disturbances, depression and anxiety, and issues with learning and memory.7, 9

Disturbances to the gut microbiome and altered microbiota have been observed in patients with E. vermicularis infection.10 A study on primary school children in China affected by E. vermicularis uncovered that those with a heavy burden of infection were found to have lower secretory IgA (SIgA).10

Due to SIgA’s crucial role in the communication between the mucosal surface environment, in sensing and correctly identifying ‘friend or foe’, lowered SIgA levels are associated with higher inflammatory responses and reduced regulation of immune function.11

Nervous system health & children

As previously stated, pinworms are nocturnal which contributes to symptoms such as sleeplessness, restlessness, itching, irritation and ultimately poor sleep quality. Insufficient and unrestful sleep is well-known for its negative effects on children’s moods and behavior,12 significantly attributing to problems with memory, cognition, learning and overall school academic performance.13

Not only can inadequate sleep predispose children to mental health problems including anxiety and depression,12 research has found children to be more likely to exhibit symptoms of hostile-aggressive, hyperactive-distractable behavior and attention deficit hyperactivity disorder (ADHD),14 with the addition of an increased likelihood of becoming overweight.15

Sleep recommendations for school-aged children is between 9-11 hours, with any less than 7 hours contributing to the aforementioned poor mental health, behaviour and performance outcomes.16

The early bird catches the pinworm – identifying E. vermicularis

The gold standard for diagnosis is the ‘sticky-tape test’ which involves placing sticky-tape over the peri-anal area on rising for three consecutive days, then investigating for the presence of eggs or actual worms.17 This screening is considered far more accurate than stool samples as eggs can only be detected in about 5% of fecal samples,18 perhaps accounting for the under-detection and underestimation of infestation prevalence.

Herbal worming intervention

Based on traditional ethnobotanical use, there are several herbs that have been time-honoured, effective strategies in dealing with parasitic infections in both children and adults.  These are available at True Medicine in conjunction with a professional consultation.

Digging for worms

Given the poor diagnostic methods and multitude of possible manifestations of this infection, particularly with regards to behavior, learning and mood, this seemingly common infection may have many influences on a child’s health and well-being . This highlights the importance of investigating a little deeper to uncover if worms may be playing a part in children’s clinical presentations.

If you would like assistance with treating pinworms or other health issues, phone True Medicine on 07 5530 1863.

 

References

  1. Centre for Disease Control and Prevention. Parasites – Pinworm – Biology [Available from: https://www.cdc.gov/parasites/pinworm/gen_info/faqs.html
  2. South Australian Health. Health Topics – Infectious diseases – worms 2012 [Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+topics/health+conditions+prevention+and+treatment/infectious+diseases/worms/worms+-+including+symptoms+treatment+and+prevention.
  3. Salim N, Schindler T, Abdul U, Rothen J, Genton B, Lweno O, et al. Enterobiasis and strongyloidiasis and associated co-infections and morbidity markers in infants, preschool-and school-aged children from rural coastal Tanzania: a cross-sectional study. BMC infectious diseases. 2014;14(1):644.
  4. Li H-M, Zhou C-H, Li Z-S, Deng Z-H, Ruan C-W, Zhang Q-M, et al. Risk factors for Enterobius vermicularis infection in children in Gaozhou, Guangdong, China. Infectious diseases of poverty. 2015;4(1):28.
  5. Farrer F. Worms-a review. SA Pharmaceutical Journal. 2010;77(10):38-48.
  6. Fan C-K, Chuang T-W, Huang Y-C, Yin A-W, Chou C-M, Hsu Y-T, et al. Enterobius vermicularis infection: prevalence and risk factors among preschool children in kindergarten in the capital area, Republic of the Marshall Islands. BMC infectious diseases. 2019;19(1):536.
  7. Guernier V, Brennan B, Yakob L, Milinovich G, Clements AC, Magalhaes RJS. Gut microbiota disturbance during helminth infection: can it affect cognition and behaviour of children? BMC infectious diseases. 2017;17(1):58.
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  10. Yang C-A, Liang C, Lin C-L, Hsiao C-T, Peng C-T, Lin H-C, et al. Impact of Enterobius vermicularis infection and mebendazole treatment on intestinal microbiota and host immune response. PLoS neglected tropical diseases. 2017;11(9):e0005963.
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  15. Danielsen YS, Pallesen S, Stormark KM, Nordhus IH, Bjorvatn B. The relationship between school day sleep duration and body mass index in Norwegian children (aged 10–12). International Journal of Pediatric Obesity. 2010;5(3):214-20.
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  18. Corry et al. Commmon Intestinal Parasites. American Family Physician,. 2004.
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  21. Valentynivna TK. Scientific justification of anthelmintic medicines based on medicinal plant material. International Journal of Green Pharmacy (IJGP). 2017;11(03).
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