Pinworm (Enterobiasis)
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Pinworm infection, also called enterobiasis, is caused by Enterobius vermicularis. E vermicularis is a white slender nematode with a pointed tail. In humans, they reside in the cecum, appendix, and ascending colon. Female pinworms are 8-13 mm long, and males are 2-5 mm long.
Pinworm infection is primarily a pediatric condition, and parents are typically infected via transmission through their children. Pinworm is prevalent throughout the temperate regions of the world and is the most common helminthic infection in the United States. [1]
Transmission can occur via direct contact with contaminated furniture, bedclothes, bedding, towels, toilets, doorknobs, or other objects. The parasite can also be transmitted during sexual contact.
Pinworm infection is generally asymptomatic; asymptomatic carriers are common.
The cure rate with treatment is 90-95%. Re-infection is common, especially if all contacts are not treated simultaneously.
See the images of pinworms, below.
The primary symptoms of pinworm infection include pruritus or a prickling sensation in the perianal area, which is produced when a gravid female pinworm migrates to the anal area and inserts her tail pin into the mucosa for ovideposition, usually at nighttime. E vermicularis lives in the small intestines, primarily the ileocecal region.
The movement of the female and the ova cause intense local itching. Ova may survive for up to 3 weeks before hatching. The hatched larvae can then migrate back into the anus and lower intestine, causing retroinfection. Embryonated eggs may be released into the air or onto fomites (eg, bedding, clothing, toys, paper money) or onto hands and then placed directly into the mouth and swallowed (autoinfection), after which they settle in the small intestines.
Pinworms that inhabit the cecum and adjacent areas typically cause no symptoms. Diarrhea due to inflammation of the bowel wall can occur during acute infection. Although pinworms have been found in the region of the appendix during histologic studies of acute appendicitis, the relationship is most likely incidental. [2]
Risk factors for pinworms include living with a person who is egg-positive, eating before washing hands, and poor personal or group hygiene.
E vermicularis is the most common helminthic infestation in the United States. General prevalence in children is reported to be 0.2-20%. Pinworm infection is most common in persons who live in crowded living conditions and in individuals who are institutionalized. Prevalence in institutionalized persons is reported to be 50-100%. A similar prevalence of pinworm infestation has been reported in European countries. [3]
The general prevalence of pinworm infection in some regions may be as high as 12%. Pinworm infection is most common in cosmopolitan areas in cool and temperate regions. Egg carrier rates vary by country, from 0.1-98.4%.
Of all age groups, school-aged children are most at risk for pinworm infections. In adults, pinworm infection is most common in parents aged 30-39 years, typically because of transmission from their children aged 5-9 years.
Overall, males are affected twice as often as females, except in people aged 5-14 years, when infection is predominantly in females.
Pinworm infection does not cause severe morbidity unless ectopic infection occurs. This rare complication occurs in individuals with conditions that compromise the integrity of the bowel wall (eg, inflammatory bowel disease). Parasites migrate through the bowel wall and are found in extracolonic sites.
Ectopic enterobiases have been described in various locations, including the vagina, salpinx, inguinal area, genital area, pelvic peritoneum, omentum, liver, salivary glands, male genital tract, and even the lungs. They have also been associated with acute appendicitis, eosinophilic colitis, and eosinophilic gastroenteritis. [4]
Pinworm infestation is very rarely fatal; death and morbidity are from secondary infection. A 28-68% increased risk for appendicitis is associated with pinworm infestation. [2]
Eradicating pinworm in groups of institutionalized persons is difficult. Continuous follow-up examination is necessary.
Therapy is much more effective if the child’s family and classmates are treated at the same time.
Some case reports have suggested that severe pinworm infection may be associated with an increased risk of appendicitis. [1]
Scratching the itchy area may cause eczema or a bacterial infection around the rectum. In girls, pinworm infection can spread to the vagina and may cause a vaginal discharge.
E vermicularis can mimic other disease processes and, although rare, can lead to serious infectious complications such as tubo-ovarian abscesses. [5]
The following complications have also been noted: appendicitis, endometritis, salpingitis, urethritis, urinary tract infection, and vulvovaginitis.
Focus on handwashing, especially before eating. Strict handwashing should be completed after using the toilet or changing a diaper of an affected baby.
Washing sheets, clothes, and towels in a washing machine using regular laundry soap can eliminate pinworm eggs. All bedding and toys should be cleaned every 3-7 days for 3 weeks. Underwear and pajamas should be washed daily for 2 weeks.
Centers for Disease Control and Prevention. Parasites – Enterobiasis (also known as Pinworm Infection). Parasitic Diseases Information. Available at http://www.cdc.gov/parasites/pinworm/index.html. Accessed: July 7, 2012.
Ramezani MA, Dehghani MR. Relationship between Enterobius vermicularis and the incidence of acute appendicitis. Southeast Asian J Trop Med Public Health. January 2007. 38:20-3. [Medline].
Bøås H, Tapia G, Sødahl JA, Rasmussen T, Rønningen KS. Enterobius vermicularis and Risk Factors in Healthy Norwegian Children. Pediatr Infect Dis J. 2012 Sep. 31(9):927-30. [Medline].
Tsibouris P, Galeas T, Moussia M, et al. Two cases of eosinophilic gastroenteritis and malabsorption due to Enterobious vermicularis. Dig Dis Sci. December 2005. 60:2389-92. [Medline]. [Full Text].
Craggs B, De Waele E, De Vogelaere K, Wybo I, Laubach M, Hoorens A, et al. Enterobius vermicularis infection with tuboovarian abscess and peritonitis occurring during pregnancy. Surg Infect (Larchmt). 2009 Dec. 10(6):545-7. [Medline].
Erian M, McLaren G. Unexpected causes of gynecological pelvic pain. JSLS. 2004 Oct-Dec. 8(4):380-3. [Medline]. [Full Text].
Aydin O. Incidental parasitic infestations in surgically removed appendices: a retrospective analysis. Diagn Pathol. 2007 May 24. 2:16. [Medline]. [Full Text].
Samkari A, Kiska DL, Riddell SW, Wilson K, Weiner LB, Domachowske JB. Dipylidium caninum mimicking recurrent enterobius vermicularis (pinworm) infection. Clin Pediatr (Phila). 2008 May. 47(4):397-9. [Medline].
Cho SY, Kang SY. Significance of scotch-tape anal swab technique in diagnosis of Enterobius vermicularis infection. Kisaengchunghak Chapchi. December 1975. 13:102-14. [Medline]. [Full Text].
Cho SY, Kang SY, Kim SI, et al. Effect of anthelmintics on the early stage of Enterobius vermicularis. Kisaengchunghak Chapchi. June 1985. 23:7-17. [Medline]. [Full Text].
Hong ST, Cho SY, Seo BS et al. Chemotherapeutic control of Enterobius vermicularis infection in orphanages. Kisaengchunghak Chapchi. June 1980. 18:37-44. [Medline]. [Full Text].
Patsantara GG, Piperaki ET, Tzoumaka-Bakoula C, Kanariou MG. Immune responses in children infected with the pinworm Enterobius vermicularis in central Greece. J Helminthol. 2015 May 20. 1-5. [Medline].
CDC. Parasites – Enterobiasis (also known as Pinworm Infection). Available at https://www.cdc.gov/parasites/pinworm/treatment.html. August 30, 2016; Accessed: August 14, 2017.
Sun Huh, MD, PhD Chairman, Professor, Department of Parasitology, College of Medicine, Hallym University, Korea
Disclosure: Nothing to disclose.
Soo-Ung Lee, PhD Manager, Research and Development, Chuncheon Bioindustry Foundation, Korea
Disclosure: Nothing to disclose.
Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.
Joseph J Bocka, MD Director of Shelby Emergency Department, Attending Emergency Physician at Mansfield Hospital, Med Central Health System (Mansfield and Shelby, Ohio); Emergency Medical Service Medical Director for several services
Joseph J Bocka, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, and Phi Beta Kappa
Disclosure: Nothing to disclose.
Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose
Mary D Nettleman, MD, MS, MACP Professor and Chair, Department of Medicine, Michigan State University College of Human Medicine
Mary D Nettleman, MD, MS, MACP is a member of the following medical societies: American College of Physicians, Association of Professors of Medicine, Central Society for Clinical Research, Infectious Diseases Society of America, and Society of General Internal Medicine
Disclosure: Nothing to disclose.
David A Peak, MD Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary
David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Jeter (Jay) Pritchard Taylor III, MD Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist
Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Gordon L Woods, MD Consulting Staff, Department of Internal Medicine, University Medical Center
Gordon L Woods, MD is a member of the following medical societies: Society of General Internal Medicine
Disclosure: Nothing to disclose.
Pinworm (Enterobiasis)
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