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Transmission, Resistance & Reinfection - D. Fragilis
Below I outline my personal theories, based on reading the scientific literature, and from personal experience.
Date: 7/27/2013 9:08:05 PM ( 11 y ) ... viewed 12671 times TRANSMISSION
It is believed that D. fragilis is transmitted via the fecal-oral route, but some schools of thought also posit the human pinworm (Enterobius vermicularis) as a vector. Pinworms are also known as seatworms or threadworms.
Ockert [1, 2] not only successfully infected himself with D. fragilis by ingesting eggs of E. vermicularis, taken from a young boy who was coinfected with D. fragilis, but also successfully infected two other human subjects. More recently, DNA of D. fragilis has been detected within surface-sterilized eggs of Enterobius vermicularis. [3].
RESISTANCE
Treatment for D. fragilis
Insensitive diagnostics, indistinct symptoms and absence of effective therapies have contributed to misdiagnosis and development of resistant forms of D. fragilis due to 'under-treatment'. The high failure rates of eradication using single drugs such as Metronidazole (Flagyl), in treating D. fragilis parasite infections, have led to development of novel combination therapies for treatment.
REINFECTION
The pinworm has a worldwide distribution, and is the most common parasitic worm infection in the United States and Western Europe.
I believe that a pinworm infection can exist alongside a D. fragilis infection. Pinworm like to ‘hang out’ in the ileum, caecum (i.e., beginning of the large intestine), appendix and ascending colon, [4, 5, 6] where they attach themselves to the mucosa and ingest colonic contents.
Treatment for pinworm:
I personally believe you need to be careful choosing the medications with which you treat pinworm infection. D. fragilis have been detected in the lumen (guts) of pinworms [7]. Whether the pinworm consumes the D. fragilis in its travels, or there is a symbiotic relationship between the two – given that D. fragilis may use the pinworm egg as a host, I do not know.
What I do know is that the Benzimidazole compounds Albendazole (brand names e.g., Albenza, Eskazole, Zentel and Andazol) and mebendazole (brand names e.g., Ovex, Vermox, Antiox and Pripsen) work by inhibiting the microtubule function in the pinworm adults, causing glycogen depletion, thereby effectively starving the parasite. [4]
My concern is around the use of Pyrantel pamoate (also called Pyrantel embonate, brand names e.g., Reese's Pinworm Medicine, Pin-X, Combantrin, Anthel, Helmintox, and Helmex) which kills adult pinworms through neuromuscular blockade – essentially it is a spasmodic. It causes the worm to spasm violently and detach from the intestinal wall. [4]
THEORY 1:
If D. fragilis live in the intestinal lumen of pinworms [7], and you have treated the infection with Pyrantel pamoate (see above) then D. fragilis will likely be expelled into the host (you) – there to start multiplying in your intestines and causing further malaise.
THEORY 2:
You have a pinworm infection and the pinworms travel in your large colon and consume D. fragilis as part of their colon-contents diet (assuming you have both infections). If you then remove the pinworm infection the D. fragilis infection may become worse, as there is nothing consuming them.
THEORY 3:
If the pinworms like to hang out in the appendix [4, 5, 6], and you treat a D. fragilis infection with antibiotics, this will not kill the pinworms. The pinworms will still harbour D. fragilis in their intestines. The D fragilis trophozoites and can then freely spread from their worm hosts, and repopulate the large bowel (having been protected from the antibiotics within their pinworm hosts). See function of appendix [8].
THEORY 4:
You can get infected with D. fragilis from pinworm eggs. [1,2,3]
THEORY 5:
You can get appendicitis from treating a pinworm infection. Essentially, the pinworms living in your appendix die in there, start to decompose, cause an infection, which can become acute appendicitis. I have some experience of this, but also see [4, 5, 6, 9].
PERSONAL STORY:
I had been feeling very ill in January and February of this year (2013), then found a pinworm swimming in my stool on the 8th of February.
Comprehensive treatment with Mebendazole of all family members followed, with further treatment two weeks later. I completely cleaned all bedding and house every second day to try to remove the eggs. However I must have ingested eggs in the process of trying to rid us of pinworm (I only found out later that pinworm eggs are viable up to three weeks, and can be inhaled). [5].
On the 24th February I was admitted to hospital to have an operation to remove my appendix, having experienced acute appendicitis. (Very painful). I believe that the pinworms in my appendix died after being treated with Mebendazole, and caused the infection in my appendix.
On July 22nd, I found another pinworm swimming in my stool. So we treated the whole family again. This time, I will treat everyone once every two weeks for a year, and wash all the bedding etc. to try to truly eradicate them. I went into research overdrive (a tendency of mine….) I hope it helps someone… This whole thing is a royal pain in the ass.
REFERENCES
[1] Ockert, G. 1972. “Zur epidemiologie von Dientamoeba fragilis” Jepps et Dobell 1918. 2. “Mitteilung: Versuch der Uebertragung der Art mit Enterobius-Eiern”. J. Hyg. Epidemiol. Microbiol. Immunol.16:222-225.
[2] Ockert, G. 1975. “Zur epidemiologie von Dientamoeba fragilis.” “Weitere zur Uebertragung der Art mit Enterobius-Eiern.” J. Hyg. Epidemiol. Microbiol. Immunol. 19:17-21.
[3] Exp Parasitol. 2013 Jan;133(1):57-61. doi: 10.1016/j.exppara.2012.10.009. Epub 2012 Oct 29. “DNA of Dientamoeba fragilis detected within surface-sterilized eggs of Enterobius vermicularis.”
Röser D, Nejsum P, Carlsgart AJ, Nielsen HV, Stensvold CR.
http://www.ncbi.nlm.nih.gov/pubmed/23116599
and Parasitology. 2011 Apr;138(5):557-72. doi: 10.1017/S0031182010001733. Epub 2011 Feb 24.
“The ambiguous life of Dientamoeba fragilis: the need to investigate current hypotheses on transmission.”
Barratt JL, Harkness J, Marriott D, Ellis JT, Stark D. http://www.ncbi.nlm.nih.gov/pubmed/21349214
[4] Gut. 1994 September; 35(9): 1159–1162. PMCID: PMC1375686 “Enterobius vermicularis infection”. G C Cook http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1375686/
[5] Caldwell JP (February 1982). "Pinworms (Enterobius Vermicularis)". Canadian Family Physician 28: 306–9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2306321/
[6] CLINICAL MICROBIOLOGY REVIEWS, July 2004, p. 553–570 Vol. 17, No. 3 “Emerging from Obscurity: Biological, Clinical, and Diagnostic Aspects of Dientamoeba fragilis” Eugene H. Johnson,* Jeffrey J. Windsor and C. Graham Clark http://cmr.asm.org/content/17/3/553.full.pdf
[7] IRRITABLE BOWEL SYNDROME AND DIENTAMOEBA FRAGILIS
Borody TJ, Robertson C, Wettstein A, Warren E, Leis S and Surace R.
(WINTER 2002 EDITION OF IBIS NEWS AND VIEWS pages 4 & 5) http://www.badbugs.org/dfragilis/dr_borody_IBIS_paper.htm
[8] Your Appendix Could Save Your Life - Rob Dunn January 2, 2012 http://blogs.scientificamerican.com/guest-blog/2012/01/02/your-appendix-could...
and Gut Ecology and Human Appendix | Ecology Global Network
http://www.ecology.com/2011/09/10/gut-ecology-human-appendix/
[9] Diagn Pathol. 2007; 2: 16. "Incidental parasitic infestations in surgically removed appendices: a retrospective analysis" http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1887519/ Özgür Aydin; "Pinworm infestation of the appendix" - P. B. Boulos†, A. G. A. Cowie, 2005 http://onlinelibrary.wiley.com/doi/10.1002/bjs.1800601215/abstract.
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