eMedicine Specialties > Emergency Medicine > Infectious Diseases
Tapeworm Infestation: Treatment & Medication
Updated: Apr 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
Unless the parasite is detected (eg, presence of eggs, worm segments, cysts), definitive therapy in the ED is unlikely. Stabilization of any patient in the presence of a systemic disease or organ failure is essential.
- Intestinal T solium infections
- In cysticercosis, if the patient is asymptomatic with calcified soft tissue or neural lesions, no treatment is required.
- For symptomatic patients with neurocysticercosis, the neurologic manifestations may indicate a need for antiepileptics or antibiotics. These medications may resolve some of the symptoms or discomfort. However, once the definitive diagnosis has been confirmed, the treatment is praziquantel or albendazole. These agents can provoke an inflammatory response in the central nervous system. Thus, if either drug is given, the patient must be started on high-dose glucocorticoids.
- Effectiveness of therapy can be monitored via radiographic imaging. The size of the active lesions should decrease within 3-6 months.
- Ocular, ventricular, and spinal lesions are subject to irreversible drug-induced inflammation, which may require surgical treatments.
- T saginata, Diphyllobothrium, and D caninum (similar to intestinal T solium infections) infections can be treated with niclosamide or praziquantel (see Medication). Niclosamide is the drug of choice in these infections, with cure rates of 95%. Administer parenteral vitamin B-12 if evidence of vitamin B-12 deficiency occurs with Diphyllobothrium infections.
- The drug of choice against Hymenolepis is praziquantel because it is effective against both the adult and the cysticercoids in the intestinal villi. A 95% cure rate has been reported. Alternatively, consider niclosamide, which has a cure rate of 75%. Niclosamide must be given over 1 week because it is ineffective against the cysticercoids stage.
- Since determining whether all cestode tissue has been removed surgically is impossible, the World Health Organization (WHO) recommends that patients receive postoperative chemotherapy with benzimidazole derivatives (ie, mebendazole and albendazole) for 2 years after surgery.
- Cysts with homogenously calcified cyst walls are not likely to require therapy since spontaneous inactivation of larvae tissue has probably occurred.
- Medical therapy consists of albendazole for 28 days, repeated 1-8 times, and separated by 2-3 weeks of drug-free intervals.
- According to the WHO, chemotherapy for these infections should be reserved for patients with inoperative disease or after incomplete surgery. Chemotherapy is also indicated to prevent secondary echinococcosis after spontaneous or traumatic (perioperative) rupture of cysts.
- Echinococcosis is treated with albendazole and surgery or albendazole and PAIR (ie, puncture, aspiration, injection of scolicidal agent, and reaspiration).
- Sparganosis and coenurosis treatment involves surgical excision for localized infections.
Consultations
- An infectious diseases specialist can secure the tracking and reporting of important epidemiologic and epidemic patterns.
- Gastroenterologist and/or primary care physician
- Most patients' symptoms hasten the physician to notify the gastroenterologist for evaluation of their source of symptoms.
- After treatment, the passage of segments and eggs may continue for several days. Treatment is reevaluated for success by examining the stool at intervals allowing regrowth of worms: 3 months for Taenia species and 1 month for Hymenolepis, Diphyllobothrium, and other species. The difficulty arises with H nana, which can result in reinfection through internal autoinfection, causing patients to appear as though treatment has failed. Fortunately, the medications will reduce the worm burden, and the infections in children are usually spontaneously resolved in adolescence.
- In the presence of apparent cysts in the brain, meninges, or spinal cord, consultation with a neurologist may be indicated. Aspiration may be needed for diagnostic purposes and for relief of compression that may cause severe or discomforting symptoms.
- Surgery
- Some cestode infections require surgery not only for diagnostic purposes but also for therapy.
- Patients with hydrocephalus due to cysticercosis require placement of a ventricular shunt. This is needed prior to any recommended drug therapies because drug therapies typically result in further increases in intracranial pressures. In patients with neurocysticercosis, the rate of shunt dysfunctions requiring frequent revisions is high. These patients high mortality rate (50% in 2 y) is directly related to the number of surgeries involving their shunt.
- Symptomatic echinococcosis infections require surgical treatment with perioperative medical interventions. The surgical resections that are usually performed have an operative mortality rate that has dropped from about 7-23% before 1980 to 0-5% in more recent years. The recurrence rate is between 3% and 10% after open surgery for patients with hepatic hydatid cyst. Special laparoscopic surgery technique for liver hydatid cysts has been described, with a result of 0% recurrence rate.2
- The puncture of cysts percutaneously, aspiration of fluid, introduction of protoscolicidal agent, and reaspiration method, also known as the PAIR method, has been described as an alternative treatment for hepatic cysts. Currently, however, the efficacy and safety of the PAIR method has not been confirmed. Therefore, the PAIR method cannot be regarded as an established alternative to surgery.
- The only treatment for sparganosis and coenurosis is surgical excision of the localized infections.
Medication
Anthelmintic drugs act locally to rid the GI tract of worms or systemically to rid the body of the helminth forms that invade organs and tissues. Much of the success of development of these medications is dedicated to the efforts of veterinarians because many cestodes have animal hosts.
Anthelmintics
Parasite biochemical pathways are sufficiently different from the human host, which allows for selective interference by chemotherapeutic agents in relatively small doses.
Albendazole (Albenza)
Decreases ATP production in worm, causing energy depletion, immobilization, and finally death. To avoid inflammatory response in CNS, patient also must be started on anticonvulsants and high-dose glucocorticoids. DOC for some of the potentially fatal cestode infections, namely cysticercosis (for T solium) and hydatid cyst disease (from Echinococcus).
Patients with cysticercotic encephalitis develop intracranial hypertension with antihelmintic use and, thus, require a ventricular shunt prior to drug therapy.
Adult
<60 kg: 3 cycles of 15 mg/kg/d PO divided bid for 28 d with 14-d drug-free intervals in between
Hydatid cyst infestation:
<60 kg: 15 mg/kg/d PO divided bid for 8-30 d
>60 kg: 400 mg PO bid for 3 cycles as above; not to exceed 800 mg/d
Symptomatic neurocysticercosis infections:
>60 kg: 400 mg PO bid for 8-30 d; not to exceed 800 mg/d
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Jaundice or cholestasis may occur; discontinue use if LFTs increase significantly (resume when levels decrease to pretest values)
Paromomycin (Humatin)
Alternative therapy for patients infected with Diphyllobothrium species, Hymenolepis species, T solium, and T saginata. Since action is mainly in adult worms, does not reach ova. Patients with T solium infections remain at risk of cysticercosis.
Adult
D latum, T saginata, T solium, D caninum infections: 1 g PO q15min for 4 doses
H nana infections: 45 mg/kg/d PO for 5-7 d
Pediatric
D latum, T saginata, T solium, D caninum infections: 11 mg/kg PO q15min for 4 doses
H nana infections: Administer as in adults
Nephrotoxic potential may increase with concurrent administration of other aminoglycosides, penicillins, cephalosporins, amphotericin B, and loop diuretics
Documented hypersensitivity; intestinal obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Because of narrow therapeutic index and toxic hazards associated with extended administration, do not use for long-term therapy; caution in renal failure, hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Praziquantel (Biltricide)
Acylated isoquinoline that increases cell membrane permeability in susceptible worms, resulting in a loss of intracellular calcium, massive contractions, and paralysis of their musculature. In addition, produces vacuolization and disintegration of the schistosome tegument. This is followed by attachment of phagocytes to the parasite and death. Tablets should be swallowed whole with some liquid during meals. Keeping tablet in the mouth may reveal a bitter taste that can produce nausea or vomiting.
Effective against cestodes (except Echinococcus species) and trematodes, but not nematodes. DOC in the treatment of hymenolepiasis.
In cysticercosis, this medication has the potential to provoke an inflammatory response in the CNS. Thus, the patient must also be started on high-dose glucocorticoids.
Patients with cysticercotic encephalitis develop intracranial hypertension with antihelmintic use and, thus, require a ventricular shunt prior to drug therapy.
Adult
Hymenolepis: 25 mg/kg PO once
Intestinal T solium, T saginata, D caninum, Diphyllobothrium species: 10-20 mg/kg PO once
Cysticercosis infections: 50 mg/kg/d PO divided tid for 14 d
Pediatric
<4 years: Not established
>4 years: Administer as in adults
Serum praziquantel concentrations may be reduced by hydantoin, possibly leading to treatment failures; may lower serum levels of phenytoin and carbamazepine; serum levels of praziquantel decrease with concomitant steroids (unknown clinical significance)
Documented hypersensitivity; ocular cysticercosis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May use during pregnancy if benefits outweigh risks; neurocysticercosis a possibility when convulsions observed for first time in patients from developing countries; if seizures are well controlled on antiepileptics alone, antihelmintic therapy can be withheld until postpartum; consider praziquantel in patients in whom antiepileptic drugs fail to adequately control seizures
When destruction of parasite within eyes, may cause irreparable lesions (do not treat ocular cysticercosis with praziquantel); may produce drowsiness; caution while driving or performing other tasks that require alertness on day of and following treatment; minimal increases in liver enzyme levels documented in some patients; when schistosomiasis or flulike infection is associated with cerebral cysticercosis, hospitalize patient for duration of treatment
Niclosamide (Niclocide)
A chlorinated salicylanilide. DOC; inhibits mitochondrial oxidative phosphorylation and glucose uptake in parasite. Cure rate of about 90% for Taenia species and a little less than 90% for Diphyllobothrium species.
Adult
D latum, T saginata, T solium, D caninum infections: 2 g PO once
Pediatric
D latum, T saginata, T solium, D caninum infections:
<11 kg: Not established
11-34 kg: 1 g PO once
>34 kg: 1.5 g PO once
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Associated with GI distress, anorexia, drowsiness, dizziness, headache, and rash; not FDA approved for this indication, although generally accepted as antimicrobial of choice for treating D latum infection
Mebendazole (Vermox)
Causes worm death by selectively and irreversibly blocking uptake of glucose and other nutrients in susceptible adult intestine where helminths dwell.
Adult
100 mg PO bid for 3 d; second course if patient not cured in 3-4 wk
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Carbamazepine and phenytoin may decrease effects; cimetidine may increase levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in hepatic impairment
Anticonvulsants
These agents are used to manage symptoms in patients being treated for neurocysticercosis.
Diazepam (Valium)
Depresses all levels of CNS, including limbic and reticular formation, possibly by increasing activity of GABA, which is a major inhibitory neurotransmitter.
Individualize dosage and increase it cautiously to avoid adverse effects.
Adult
5-10 mg IV q10-20min; not to exceed 30 mg in an 8-h period; repeat in 2-4 h prn
Pediatric
0.05-0.3 mg/kg/dose IV over 2-3 min q15-30min; not to exceed 10 mg; repeat in 2-4 h prn
Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohols, and MAOIs
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Glucocorticoids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, they modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Sterapred, Orasone)
Useful in treatment of inflammatory and allergic reactions. By reversing increased capillary permeability and suppressing PMN activity, may decrease inflammation.
If a safer alternative therapy is available, do not administer glucocorticoids.
Adult
Not to exceed 80 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve
Pediatric
4-5 mg/m2/d PO; alternatively, 1-2 mg/kg PO qd; taper over 2 wk as symptoms resolve
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, tubercular skin, or connective tissue diseases; peptic ulcer disease; hepatic dysfunction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Methylprednisolone (Solu-Medrol, Depo-Medrol, Medrol)
Decreases inflammation by suppressing migration of PMNs and reversing increased capillary permeability.
Adult
Loading dose: 125-250 mg IV
Maintenance dose: 0.5-1 mg/kg/dose IV q6h; not to exceed 5 d
Pediatric
Loading dose: 2 mg/kg IV
Maintenance dose: Administer as in adults
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Vitamins
These agents are essential for normal DNA synthesis. Indicated for use in patients with megaloblastic anemia due to deficiency in vitamin B-12.
Cyanocobalamin (Cobex, Berubigen, Crystamine)
Deoxyadenosylcobalamin and hydroxocobalamin are active forms of vitamin B-12 in humans. Vitamin B-12 synthesized by microbes but not humans or plants.
Adult
25-250 mcg PO qd
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; hereditary optic nerve atrophy
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Severe hypokalemia may result in vitamin B-12 megaloblastic anemia (may be fatal) due to increased cellular potassium requirements when anemia corrects
More on Tapeworm Infestation |
| Overview: Tapeworm Infestation |
| Differential Diagnoses & Workup: Tapeworm Infestation |
 Treatment & Medication: Tapeworm Infestation |
| Follow-up: Tapeworm Infestation |
| Multimedia: Tapeworm Infestation |
| References |
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References
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Further Reading
Keywords
tapeworm, tapeworm infestation, cestodes, Cestoda, Diphyllobothrium latum, broad fish tapeworm, Echinococcus granulosus, hydatid tapeworm, Hymenolepis nana, dwarf tapeworm, Taenia saginata, T saginata, beef tapeworm, hookless tapeworm, unarmed tapeworm, Taenia solium, T solium, armed tapeworm, pork tapeworm, solitary tapeworm, Thysanosoma actinoides fringed tapeworm of sheep, parasitic worms, Cestoidea, Dipylidium caninum, D caninum, Diphyllobothrium species, Hymenolepis species, Echinococcus multilocularis, hepatic echinococcosis, cysticercosis, echinococcosis, sparganosis, coenurosis, Taenia multiceps, T multiceps, Spirometra
