Therapeutic Notes

NOTES ON SOME REMEDIES XXVIII.?DRUQS IN HELMINTHIC DISEASES, Part III

By R. N. CHAUDHURI, m.b., m.r.c.p., td.d. (Wales)

Professor of Tropical Medicine, School of Tropical Medicine, Calcutta

Treatment of helminthic diseases''

(1) Ascariasis

1. Santonin.?Preliminary fasting is not advisable since absorption of santonin is enhanced in an empty stomach. The patient takes an early light meal in the evening, and santonin 3 gr. mixed with an equal amount of calomel is given at bedtime, followed by a

saline purgative the next morning. Repeated treatment may be necessary but at intervals of not less than a week.

2. Hexylresorcinol.?It is prescribed in the form of caprokol

'

crystoidsIn the morning the patient takes 1 gm. of the drug, in five 0.2 gm. capsules, on an empty stomach, taking care not to chew them. Two hours later a saline purge is

* Diseases for which there is no effective drug have been omitted. Doses mentioned here are for adults qnly; for children see table in the previous article.

given to remove the worms, or it may be post- poned till next day. No food is given for 4 hours after administration of the drug. The treatment may be repeated in three days.

3. Oil of chenopodium and tetrachlor- ethylene.?This combination is recommended when ascariasis complicates hookworm infection. After a saline purgative on the previous day the patient takes in the morning a mixture of

tetrachlorethylene (2.7 cc.) and oil of cheno- podium (0.3 cc.) in capsules or on sugar in a spoon, or the mixture can be shaken up in magnesium sulphate solution and taken. The mixture can be given to children in a dosage of 3 minims per year of age. A saline purge is given 2 hours later. The patient should remain in bed and not take any food till the bowels have moved well. The treatment may be repeated after 7 days. See also remarks under <

hookworm infection.

(2) Oxyuriasis (threadworm infection) The adult worms inhabit the csecum and the

adjacent portions of the ileum and colon. The females migrate and deposit eggs in the peri-anal region, causing pruritus and probably nervous disturbances in young children. These eggs re-infect the host through fingers and expose other individuals to infection through contamin- ated bed clothing. Usually more than one

individual in a family is infected.

1. Gentian violet (medicinal).?Two 0.5 gr. 4-hour enteric-coated tablets are given thrice daily before meals for 8 days; this is repeated after a week's rest.

2. H exylresorcinol.?This is less satisfactory. The capsules are given in the morning as for ascariasis. The same night, after a preliminary wash with warm water, an enema is given with 250 to 400 cc. of a 1 in 1,000 solution of the drug and retained for 15 to 30 minutes. Two or three courses are usually sufficient.

3. Tetrachlorethylene.?Sometimes quite satisfactory. Used as for hookworms (vide infra).

4. There are many household remedies, e.g. high enema of salt water (2 tablespoonfuls of salt to a pint of water) or of afresh infusion of quassia, one or two pints being used after first cleansing the bowel with warm water. These are at first given daily, later bi-weekly or weekly. They are, however, not satisfactory.

General measures.?Cutaneous lesions around the anus caused by scratching are treated by applying ammoniated mercury ointment. To

complete the cure, personal hygiene is as

important as medical therapy : cutting finger nails short, cleaning the anal region with soap and water, and periodical disinfection of cloth- ing by boiling. To test cure, several peri-anal swabs should

be examined. 2!

April, i949] DRUGS IN HELMINTHIC DISEASES ; CHAUDHURI 155

(3) Trichuriasis (whipworm infection) Like threadworms, these worms live com-

monly in the caecum and are usually asympto- matic. Children tend to acquire a heavier infection which may manifest in the form of

diarrhoea, anaemia and nervous symptoms. Treatment is unsatisfactory. The common

anthelmintics (e.g. santonin, hexylresorcinol) are moderately effective in heavy infection but unsatisfactory in light infections. Craig and Faust in 1945 recommend (1) a saline purgative followed by a high enema of tepid salt solution and (2) next morning a dose of tetrachlorethylene (2.7 cc.) and oil of chenopodium (0.3 cc.). A second treatment may be given after a week,

(4) Ancylostomiasis (hookworm disease) The worms attach themselves to the mucosa

of the jejunum and suck the blood from the

capillaries of the villi, causing in course of time much loss of blood and microcytic hypochromic anaemia which is a characteristic of the disease.

1. Tetrachlorethylene.?It is the drug of choice. After a saline purgative on the day before, 3 cc. of the drug is given in the morning, either shaken up in a saturated solution of sodium sulphate or in gelatine capsules or on

sugar in a spoon. In the latter cases a follow-up purgative is given after 2 hours. A light meal is allowed only after a copious bowel movement has been obtained. The eggs of the worms may be passed in the faeces for a week after effective treatment. If they persist beyond this period, the treatment should be repeated.

2. Hexylresorcinol.?It is less effective than

tetrachlorethylene, but being almost non-toxic is suitable for debilitated patients in whom other drugs are contra-indicated. It is used as for ascaris. Patients often continue to pass worms for 10 to 15 days after a single dose, so treat- ment should be repeated after a fortnight, if

necessary.

3. Carbon tetrachloride.?A highly efficient drug, but it has some important contra-indica- tions which have already been mentioned.

4. Oil of chenopodium and tetrachlor-

ethylene.?This is given in a mixed infection of ascaris and hookworms. In such cases some

prefer less potent drugs, using hexylresorcinol followed in a week by tetrachlorethylene.

5. For mass therapy, as in tea plantations, a simple mode of treatment is to give a mixture of tetrachlorethylene (2.7 cc.) and oil of

chenopodium (0.3 cc.) in a solution of Epsom salts.

General measures.?-It is most necessary to treat the anaemia by giving nutritious diet and iron medicinally. The latter is given as ferrous sulphate tablets or ferri et ammon citras in a mixture thrice daily for three weeks, and this is repeated after an interval. If macrocytic anaemia has developed, liver extract is indicated.

Anaemia, when severe, should invariably be treated first before putting the patient on

anthelmintic therapy.

(5) Strongyloidiasis These worms are said to be more common in

the Punjab and Rajputana. They have a com- plicated life-cycle during which they may cause symptoms simulating broncho-pneumonia in the course of their migration through the lungs. Or the female worms upon reaching the intestinal tract may provoke mucous diarrhoea (which frequently alternates with constipation) from the irritation caused by their entry into the mucosa of the small intestine and deposition of eggs which hatch in the tissues. During the early stage of active infection there may be a

high degree of eosinophilia (40 per cent or

more). Gentian violet is the best drug so far known.

Two 0.5 gr. l-|-hour enteric-coated tablets are

given thrice daily, one hour before meals, until 50 grains have been taken (i.e. 17 days). Two courses of treatment may be necessary. For

refractory cases transduodenal intubation of 25 cc. of a 1 per cent aqueous solution of

gentian violet may be effective. A 4-day treatment has been developed by

J. S. D'Antoni. Thus?

1st day?Two tablets (i gr.) t.d.s. before meals.

2nd day?Three tablets {I- gr.) t.d.s before meals.

3rd day?Four tablets (} gr.) t.d.s. before meals.

4th day?Five tablets (} gr.) t.d.s. before meals.

For pulmonary strongyloidiasis intravenous

injections of gentian violet are recommended. The drug is used in a sterile 0.5 per cent solu- tion, made up in distilled water and filtered. On alternate days 20 to 25 cc. of this solution are injected very slowly up to five doses. The

patient should be under close medical super- vision.

(6) Tceniasis (tapeworm infection) Infection occurs chiefly through eating beef or

pork. The large tapeworms {T. saginata and T. solium) live with their heads embedded in the wall of the small intestine and may give rise to no symptoms or cause mechanical obstruction by their mass or toxaemia due to metabolic wastes. The larvae of T. solium (pork tapeworm) some- times enter the blood stream, and becoming encysted in the tissues give rise to cysticercosis which may cause serious sequelae when located in vital organs. Of the dwarf tapeworms, H. nana carries infection directly from man to man, which when

_ heavy causes toxaemia with

nervous manifestations in small children. 1. Male fern.?Partial starvation for two

days is advisable before giving the treatment.

156 THE INDIAN MEDICAL GAZETTE [April, 1946

The patient is given 1 ounce of saturated solution of sodium sulphate on the previous evening and next morning on an empty stomach 60 minims of the oleoresin of aspidium or liquid extract of male fern are administered in three equal doses in gelatine capsules (i.e. 20 minims in each, at 7, 7-30 and 8 a.m.). At 10 a.m. another saline

purge is given. He remains in bed and is

allowed no food until a copious bowel movement has been obtained.. All stools for 48 hours after

treatment are saved and searched for the heads

of the worms which are frequently discharged .after the main portion of the worm has been

evacuated. If not found, it is better to wait

for a month or two till the segments reappear before repeating the treatment.

Another method is to give the following emulsion by duodenal intubation : Oleoresin of aspidium 1 drachm, saturated solution of sodium sulphate 1 ounce, mucilage of acacia 1 dram and water 2 ounces. No post-treatment purgative is necessary.

2. Carbon tetrachloride or tetrachlor-

ethylene.?These are also effective. The former alone is the best if there is no contra-indication.

Associated anaemia is treated with iron or

liver therapy.

(7) Filariasis bancrofti Wuchereria bancrofti lives in the tissues, and

may produce obstruction in the lymph vessels and swelling of the affected part. The worms

eventually die and the resulting lymphangitis may end in elephantiasis. There may be no

signs for a long time. The microfilaria

(embryos) found in the peripheral blood do not cause any tissue reaction beyond periodical pyrexia. There is no specific. The antimony salts

reduce the number of microfilariae for varying periods, but the adult worms remain unaffected. Fouadin is given intramuscularly up to a total of 45 cc., the amounts on first three days being 1.5, 3.5 and 5 cc. and then 5 cc. on alternate days. Anthiomaline seems to give better results by reducing the microfilariae for a longer period, it may be several months. Two to 4 cc. of the solution are injected into muscle or vein on alternate days up to 10 doses. The treatment of elephantiasis is mainly surgical; scrotal cases give the most satisfactory results. Treatment of filariasis due to Wuchereria malayi is on the same lines.

A more promising drug is the new compound, hetrazan. It has possibly no direct lethal action on the microfilariae but it seems to modify them in some ways so that they are destroyed by the phagocytes of the reticuloendothelial system. With 100 to 300 milligrammes daily by mouth in divided doses over a period of 3 to 7 days, the parasite quickly disappears from the blood stream, but reappears in a few days after the drug is discontinued. When it is given for 3 to"

4 weeks, the parasite has in some patients remained absent for about a year. Reports suggest that hetrazan has only moderate effect on the adult worms, but prolonged intensive treatment may destroy them. Trials are not

complete. It seems to be less effective on other filarial infections of man. Toxic symptoms so

far observed are headache, lassitude and vague malaise. These symptoms come on within a few hours of the treatment being started, but usually disappear within 48 hours, even when adminis- tration is continued,

(8) Schistosomiasis This has been dealt with in a previous article

{I.M.G., 82, 541). General instructions on the use of intestinal

anthelmintics 1. Most of these drugs are protoplasmic

poisons and call for careful judgment before they are used in lung, liver and kidney disease, intestinal ulceration, fevers and marked debility.

2. Alcohol and fats favour their absorption in most cases, thus increasing their toxicity, so

they should be withheld a day or two before and after treatment.

3. On the day previous to treatment the bowel is emptied of its contents as far as

possible by a light diet and a purgative which may be a saturated solution of sodium or

magnesium sulphate. Castor oil should not be used,

4. Next morning the anthelmintic is given on an empty stomach. Tea or coffee is allowed, but the usual breakfast is omitted.

5. A second purgative should follow two hours after the last dose of the anthelmintic to expel the dead or moribund worms as well as

to remove the unabsorbed portion of the drug out of the intestine. Many clinicians find it con- venient and effective to mix the purgative with the drug when prescribing carbon tetrachloride or tetrachlorethylene.

6. No food is allowed except water until a

good post-treatment bowel movement has been obtained. First give fruit juices with ample sugar and later a light meal.

7. Except in the case of non-toxic drugs like hexylresorcinol the patient should be resting in bed during treatment.

8. Toxic symptoms are_ mainly of three types ?gastro-intestinal irritation, inflammation of kidneys and nervous manifestations including dis- turbances of vision. There is no specific anti- dote and the usual treatment consists of purgative, enema, and stimulants to avert collapse, chloroform for convulsions, etc.

9. In most cases the treatment may be repeated after a week, but it should be noted that the ova or the dead worms may continue to be passed in the feces for some days after the treatment.