eMedicine Specialties > Pediatrics: General Medicine > Parasitology
Gnathostomiasis: Treatment & Medication
Updated: Jan 22, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The clinical presentation and course of gnathostomiasis dictate the appropriate measures.
Surgical Care
The only definitive treatment is surgical removal of the worm, which is possible only when it is accessible.
Consultations
Consultation with infectious diseases and other appropriate specialists, as dictated by the clinical circumstances, is reasonable.
Medication
Although surgical removal, when possible, is the treatment of choice in gnathostomiasis, albendazole appears to have an increasing role in complementing surgical intervention.3 Ivermectin in a single dose is better tolerated than albendazole but may be less effective.4 Mebendazole, which was formerly used, had variable results and significant toxicities and should no longer be used. Adjunctive corticosteroid therapy may have a role in the treatment of CNS disease.
Anthelmintics
These agents are the drugs of choice when surgical treatment is not possible or successful. Parasite biochemical pathways are different from the human host, thus toxicity is directed to the parasite, egg, or larvae. The mechanism of action varies within the drug class. Antiparasitic actions may include the following:
- Inhibition of microtubules that causes irreversible block of glucose uptake
- Tubulin polymerization inhibition
- Depolarizing neuromuscular blockade
- Cholinesterase inhibition
- Increased cell membrane permeability, resulting in intracellular calcium loss
- Vacuolization of the schistosome tegument
- Increased cell membrane permeability to chloride ions via chloride channels alteration
Albendazole (Albenza)
The first DOC for treating gnathostomiasis. A synthetic nitroimidazole that binds to tubulin, inhibits microtubule assembly, decreases glucose absorption, and inhibits fumarate reductase in the parasite. Poorly soluble in water, it is well absorbed when taken with a fatty meal. Concentration in the cerebrospinal fluid reaches 40% of that in the serum.
Adult
400 mg PO qd/bid for 21 d
Pediatric
Not established; 15 mg/kg/d PO divided bid/tid for 21 d may be appropriate; not to exceed 800 mg/d
Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity
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
Alopecia, reversible bone marrow suppression, or hepatocellular injury may occur after prolonged high-dose therapy
Thiabendazole (Mintezol)
A synthetic benzimidazole that should be used only when albendazole is not available because of its toxicities and questionable efficacy. Its mechanism of action is thought to be similar to that of albendazole.
Adult
50 mg/kg/d PO divided q12h for 5 d; not to exceed 3 g/d
Pediatric
Administer as in adults
May elevate serum levels of theophylline, increasing toxicity (monitor serum levels and reduce dose prn)
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
Clinical experience in children <30 lb is limited; nausea, vomiting, and vertigo occur in as many as 50% of patients; may cause rash, hypersensitivity, erythema multiforme, leukopenia, and hallucinations; caution in renal or hepatic impairment
Ivermectin (Mectizan, Stromectol)
Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing cell death. Half-life is 16 h; metabolized in liver.
Adult
150-200 mcg/kg/d PO as single dose
Pediatric
<5 years: Not established
>5 years: Administer as in adults
May interact with other ligand-gated chloride channels, such as those gated by GABA
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
Treat mothers who intend to breastfeed only when risk of delayed treatment outweighs possible risks to the newborn caused by ivermectin excretion in milk
Repeat courses of therapy may be required in immunocompromised patients
May cause nausea, vomiting, and mild CNS depression; may cause drowsiness
Corticosteroids
These agents may have an ancillary role in reducing inflammation associated with CNS gnathostomiasis.
Dexamethasone (Decadron, Dexone)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Adult
Loading dose: 10 mg IV
Maintenance dose: 4 mg IV q6h; not to exceed 16 mg/d
Pediatric
Loading dose: 1-2 mg/kg IV
Maintenance dose: 1-1.5 mg/kg/d divided q4-6h IV; not to exceed 16 mg/d
Effects decrease with coadministration of barbiturates phenytoin and rifampin; decreases effect of salicylates and vaccines; coadministration may increase albendazole levels by 50%
Documented hypersensitivity; active bacterial or fungal infection
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
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; 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 are possible complications of glucocorticoid use
More on Gnathostomiasis |
| Overview: Gnathostomiasis |
| Differential Diagnoses & Workup: Gnathostomiasis |
 Treatment & Medication: Gnathostomiasis |
| Follow-up: Gnathostomiasis |
| References |
| Further Reading |
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Keywords
gnathostomiasis, CNS infection, chokofishi, consular disease, encephalitis, eosinophilia, eosinophilic meningitis, eosinophilic myeloencephalitis, Gnathostoma binucleatum, G binucleatum, G doloresi, G hispidum, G nipponicum, G procyonis, G spinigerum, hematuria, hydropneumothorax, intraocular hemorrhage, iritis, meningitis, nodular (migratory) eosinophilic panniculitis, panniculitis, parasitic infection, photophobia, pleural effusions, pneumothorax, radiculomyelitis, radiculomyeloencephalitis, Shanghai rheumatism, Tau-cheed, tinnitus, urticaria, uveitis, Woodbury bug, Yangtze River edema
