Robert P. Blereau, MD

This picture is of a 4-year-old girl’s perianal area showing numerous typical white thread pinworms.

The child’s mother stated the girl had been “pulling at her bottom” for 2 to 3 weeks. The mother thought she had been imitating her younger brother.

The clinical diagnosis was readily made by simple inspection of the perianal area. The patient and her household were treated with a single mebandazole (Vermox) chewable tablet, and a second in 2 weeks.

Pinworm infection is caused by the nematode 

and is the most common helminth infection in the United States. This worm is white, thready, and about 1 cm in length.

The pregnant female worm deposits up to 15,000 eggs perianally at night. Infection occurs by fecal-oral ingestion of the eggs, which mature in the gut. This worm inhabits the cecum, appendix, and adjacent ileum and colon.

The typical symptom of pinworm infestation is nocturnal perianal pruritis with resulting restless sleep. Symptoms parallel the severity of the infection.

Diagnosis is made by a history of perianal pruritis, most commonly in children although people of any age may be affected. If necessary, the diagnosis can be confirmed by microscopic examination of an adhesive glass slide or similar testing tool applied to the perianal area at night or early in the morning if no typical worms are present on visual perianal inspection.

Very infrequently, pinworms may be associated with appendicitis, chronic salpingitis, pelvic inflammatory disease, peritonitis, hepatitis, and ulceration of the small and large intestines.

Treatment is most commonly with oral mebendazole, 100 mg for all ages with a repeat dose in 2 weeks. Alternative treatments are:
o Albendazole, 400 mg by mouth for all ages, also repeated in 2 weeks,
or
o Pyrantel pamoate, 11 mg/kg by mouth, maximum 1 g in children age 2 years and older as a single dose.

Repeated treatments every 3 to 4 months may be necessary with repeated exposure, especially in institutionalized children.

The most effective prevention is good hand hygiene. Morning bathing and frequent washing of all bed-associated clothing and sheets may decrease autoinfection.

A couple of reminders for the clinician:
1. Visually inspect the symptomatic area. It’s amazing what one might find.
2. A microscopic sticky slide exam is unnecessary when you see the typical worms.

 1. Kliegman RM, Stanton BF, St Geme III JW, et al. Nelson Texbook of Pediatrics. 19th ed. Elesevier Saunders. 2011: 1222.

Articles

The mother of a 4-year old girl complained that the child had been "pulling at her bottom" for several weeks, presumably imitating her younger brother. Visual inspection of the area revealed the real problem.

Perianal Pinworms (Enterobiasis)

Rarely encountered these days, scarlet fever is believed to be caused by sensitization to an erythrogenic toxin produced by strains of group A beta-hemolytic streptococci. Thus, previous exposure to the toxin is necessary for development of the rash seen here-fine, sandpaper-like and papular on an erythematous background (

). It usually begins on the trunk and spreads over the entire body within hours or days. Scarlet fever is unusual in infancy, possible because of maternal transfer of antibodies.

This 5-year-old girl's pharynx was injected, and a group A beta-hemolytic streptococcal antigen test had a positive result. The child was given penicillin V orally, 250 mg twice daily, and the rash cleared completely within several days. Parents should be warned that the child's skin may desquamate as the last stage of healing-usually after 1 to 2 weeks.

Rarely encountered these days, scarlet fever is believed to be caused by sensitization to an erythrogenic toxin produced by strains of group A beta-hemolytic streptococci.

Scarlet Fever Rash

A right parietal cephalhematoma was first noted on this 2-week-old girl 2 days after her birth. Caused by bleeding under the outer periosteum of a newborn's skull bone, usually the parietal bone, swelling  becomes evident by day 2 or 3 after delivery. The swelling is confined to the involved bone and does not extend beyond the suture lines or the midline of the skull.

A cephalhematoma is believed to occur from the compression or shearing forces exerted on the head as it descends through the birth canal. Underlying skull fractures are present in up to 25% of neonates with this condition. All resolve completely and spontaneously without sequelae, usually by 6 to 8 weeks of age.

Treatment with needle aspiration is contraindicated because of the possibility of introducing an infection. The major differential diagnosis is caput succedaneum (edema of the presenting part of the scalp), which, unlike a cephalhematoma, is present at birth and may extend beyond the suture lines or midline of the skull.

A right parietal cephalhematoma was first noted on this 2-week-old girl 2 days after her birth.

Cephalhematoma

A 2-day history of fever and sore throat and an erupting rash prompted the mother of a 5-year-old boy to bring her son into the office for evaluation. This case demonstrates typical aspects of a disease now seen far less often than in the past-scarlet fever.

The physical examination revealed intensely injected, enlarged tonsils with purulent exudate in the crypts (

). The soft palate also was intensely erythematous. On each side of the tongue blade, a “white strawberry” tongue is evident as the reddened edematous papillae project through the tongue's white coating. Anterior cervical glands were enlarged and tender.

A day before presentation, a fine, sandpaper-like rash erupted in the genital area (

). The rash spread to the patient's anterior trunk, back, and upper thighs.

A test for rapid identification of group A β-hemolytic streptococci was positive, confirming the diagnosis of scarlet fever. A 10-day course of amoxicillin, 250 mg three times a day, was prescribed.

Two days later, while his condition was improving and the exanthem was fading, the skin of the youngster's genitalia began to desquamate; this is a characteristic feature of scarlet fever. The hyperpigmentation of the skin and the Pastia lines in the inguinal areas also are seen commonly in this disease. This boy completed the antibiotic therapy, and his recovery was uneventful.

A 2-day history of fever and sore throat and an erupting rash prompted the mother of a 5-year-old boy to bring her son into the office for evaluation.

Scarlet Fever

This picture shows an unusual linear white object positioned vertically at the center of the posterior pharynx of a 5-year-old girl’s throat. The child had eaten spaghetti the night before and somehow managed to get a piece of it stuck as shown. She was entirely uncooperative during attempts to remove the strand.

The mother was told to give her something bulky to swallow, such as bread or meat, in the hopes that the spaghetti would be swallowed along with it. This approach worked: the following morning, the mother called to report that the spaghetti was gone.

This picture shows an unusual linear white object positioned vertically at the center of the posterior pharynx of a 5-year-old girl’s throat.

Lodged Spaghetti Strand

Erythematous pustules and papules with some coalescence developed on the anterior trunk and to a lesser degree on the face and extremities of a newborn boy the day after birth. The baby was born at full term after an uncomplicated pregnancy and delivery.

These lesions are characteristic of erythema toxicum. This benign,   asymptomatic macular rash of unknown etiology may present with or   without pustules and papules within the first few days of life in full-term infants,   or within the first 2 weeks of life in premature infants. The incidence   varies and may increase with gestational age. Lesions may occur anywhere   on the body, except the palms and soles. The rash may wax and wane but is   self-limited; it typically resolves within 2 weeks-as it did in this infant.

Diagnosis is generally based on the appearance of the rash. The differential   diagnosis includes congenital infections, pyoderma, candidiasis, herpes   simplex, transient neonatal pustular melanosis, milia, and miliaria. Of these,   it is most important to rule out herpes simplex. Any neonatal lesion of a   vesicular nature warrants closer observation.

Parental reassurance is the only treatment necessary.