Whipped!

A five-year-old male child was brought to the Emergency Room because of a prolapsed rectum. Numerous worms, up to two inches in length, were seen firmly attached to the mucosa of the rectum. The mother stated that the child had been fussy, complained of a "tummy" ache and had severe diarrhea for several days. The child appeared undernourished but the mother indicated no other chronic medical problems.

Question 1 - Single Best Answer

In considering the probable cause of the rectal prolapse,   

A) the worms in the rectum were incidental to the prolapse
B) the prolapse probably reflected an underlying congenital defect in the GI tract
C) the worms attached to the rectal mucosa were probably hookworms and the inflammatory reactions they produce could cause the prolapse
D) the worms could be pinworms, a common infection of children, and local hypersensitivity reactions could have initiated the prolapse
E) the worms were whipworms, a reported cause of rectal prolapse

Question 2 - Single Best Answer

Worms removed from the mucosa were compared with preserved specimens of intestinal helminths as shown and identified as?   

A) whipworms (Trichuris trichiura)
B) hookworms (Necator americanus)
C) ascarids (Ascaris lumbricoides)
D) pinworms (Enterobius vermicularis)
E) dwarf tapeworms (hymenolepis nana)

The child's family lived in migrant worker camps at the poverty level, usually without indoor sanitary facilities. They had no easy access to health care and the child had not received any medical attention within the past two years.

Question 3 - Single Best Answer

The heavy infection of whipworms in this child was probably dependent on?   

A) sanitary conditions facilitating direct fecal-oral contact
B) frequent ingestion of helminth eggs from the soil
C) the fact that the child had not received his whipworm vaccination which is recommended for all migrant worker children
D) multiplication of whipworms within the gut associated with malnutrition and immunosuppression
E) A and C

Question 4 - Single Best Answer

Whipworms are soil transmitted (geohelminths) and infections are common in moist, warm climates where sanitary conditions and practices facilitate fecal contamination of soil and subsequent ingestion of eggs from the contaminated soil. The most common manifestation of this infection is?   

A) No obvious disease
B) inflammatory diarrhea or dysentery
C) anemia
D) rectal prolapse
E) abdominal pain and nausea

Although not common, it was concluded that the child's prolapse was caused by the heavy infection of worms. Treatment of the infection and correction of the prolapse were initiated.

Question 5 - Single Best Answer

Prolapse can require surgery but in this case elimination of the worms and manual replacement of the bowel took care of the problem. What treatment would be used to eliminate the whipworms?   

A) amikacin
B) antiserum
C) ivermectin
D) mebendazole
E) sulfadiazine

Question 6 - Single Best Answer

What is the mechanism by which the worms cause the prolapse?   

A) they eat away the ligaments that hold the bowel in place
B) they produce an autoimmune reaction that directly causes the prolapse
C) they cause diarrhea and tenesmus that cause the prolapse
D) the produce a toxin that causes tetanic spasms and prolapse

Question 7 - Single Best Answer

In the absence of overt disease, how could this child's, and that of other children living in similar conditions, whipworm infection have been diagnosed?   

A) serology
B) fecal exam
C) skin test
D) culture
E) none of the above

Question 8 - Single Best Answer

The sanitary practices and conditions that result in whip worm infections promote transmission of many intestinal pathogens including other intestinal worms. In this case microscopic examination of a fecal specimen revealed two apparently different helminth eggs, as pictured. This indicates?   

A) infection with both whipworm and hookworm
B) did not demonstrate a diagnostic stage of whipworms
C) demonstrated the two kinds of whipworm eggs, male and female
D) revealed eggs not typical of any common intestinal helminths
E) indicated two different helminth infections with identical transmission cycles

Question 9 - Single Best Answer

Hookworms (Necator americanus), as whipworms, are soil transmitted helminths. The adult hookworms "bite" into the small bowel mucosa and remain attached there. Light infections cause little damage. With chronic, heavy infections, particularly in growing children, what disease manifestations may be present?   

A) abdominal pain and diarrhea
B) cardiovascular disease
C) anemia and failure to thrive
D) dermal and pulmonary disease
E) all of the above