Re: What to use to parasite cleanse my 5 years old

you might want to look into a rare but serious condition called munchausen's by proxy, and also, read the following article.
Delusions of Intestinal Parasitosis

South Med J 2001 May;94(5):545-7 (ISSN: 0038-4348)
Ford EB; Calfee DP; Pearson RD

Department of Internal Medicine, University of Virginia School of Medicine,
Charlottesville 22908, USA.

Abstract

Delusions of parasitosis, though uncommon, are an important cause of
distress for affected patients and frequently of frustration for their
physicians. They occur primarily in middle-aged or older women, who have the
delusional belief that they are infested with parasites. Although the vast
majority of cases involve dermatologic manifestations, some patients may
have delusions of intestinal infection, as illustrated by this case.

Introduction

Delusions of parasitosis have received substantial attention in European journals but have been described relatively infrequently in US literature since the 1890s, primarily in dermatology and psychiatry journals.[1] It is an uncommon though not rare syndrome.[2] Patients are primarily white women over the age of 50,[3] but cases have been reported across age groups and in men.[4] Patients with this disorder have the unshakable belief that they are infested with parasites.[5] The majority of cases in the literature involve delusions of parasites in the skin,[6] but other types of delusions of parasitic infestation may be encountered.

In the clinical paradigm, the symptoms are persistent and enduring, the patient has no obvious cognitive impairment, organic factors are absent, and there are no additional signs or symptoms of other psychotic or affective disorders.[7] In the classic disorder, patients have a monosymptomatic delusion that to them is very real. The morbidity and costs associated with such delusions are often substantial.

The following case report of a rare person with delusions of intestinal parasitic infection illustrates the manifestations of the syndrome and the difficulties encountered in treating patients who have it.

Case Report

A 40-year-old woman who was born in the Mediterranean littoral, but had lived in the United States for the previous 20 years, presented with a 5-year history of intestinal parasites and "fasciola infection." She had traveled to Greece and Turkey in 1994 but had otherwise remained in North America. Her family history was unremarkable; she denied recreational drug use. She had recently become engaged to be married. No other stressful factors were identified by history.

The patient reported that since 1995 she had done bowel "cleansing routines" that involved a vegetable-only dietary period. During these diets, she noticed "flukes" in the toilet after bowel movements. These flukes ranged from about 1 cm in diameter to the size of her thumb, and some of the flukes had "multiple back legs with eggs attached to them." She denied gastrointestinal symptoms and felt well during these periods. When she resumed her normal diet, the flukes would disappear.

She researched her condition and self-diagnosed "Fasciola" species as the problem. She unsuccessfully treated herself with Wormwood , ground cloves, and Black-Walnut s. She felt well until February 1999, when she had a case of gastritis associated with "burning" epigastric pain and low-grade fevers. She went to a local hospital with a stool specimen that she claimed had parasites. Examination for ova and parasites was negative. She was given a proton-pump inhibitor, and her pain resolved. She stopped the medication after several months.

Approximately 1 year later, the epigastric pain returned, and she began a diet of exclusively fruits and vegetables. She subsequently noticed flukes on a daily basis, both in her stool and during several episodes of emesis. She began to drink concentrated cherry juice after reading that such juice could kill flukes. The juice caused her considerable abdominal distress and was accompanied by the passage of "thousands" of flukes. She went to an emergency department, where results of examination and laboratory tests were normal, including stool test for ova and parasites and culture for bacterial pathogens. She was instructed to resume a normal diet and was given an antimotility agent.

She returned to the ambulatory clinic for follow-up. She reported feeling well except for occasional mild epigastric pain. Findings on physical examination were normal. She brought a stool specimen that she insisted was full of parasites. On careful inspection, the "flukes" that she identified were fecal material of varying shape and size that were easily pulled apart with forceps.

The physician offered to work with the patient and a doctor in her hometown and recommended psychiatric medication as a means of relieving her symptoms. She became angry, saying that the physician thought she was "crazy" and that what she really needed was medication for the parasites. She refused a referral and left the clinic.

Discussion

This case represents a rare form of delusions of intestinal parasitosis. A literature search of MEDLINE from 1966 to 2000 combining keywords "delusions" and "intestinal disease, parasitic" yielded only three references to delusions of intestinal parasitic infection.[8-10] The overwhelming number of cases of delusions of parasitosis in the literature involve the skin.[1-7] Although it is possible that this case represents a different disease entity, it is likely that the psychopathology is the same, given the many similarities between it and cases involving delusions of cutaneous parasitosis described in the literature.

The patient fits the demographic profile of a middle-aged or older woman without any significant signs or symptoms of physical illness. She persisted in her delusional state despite repeatedly normal results of physical and stool examinations by various physicians in various parts of the country. Patients who have delusions of parasitosis, as well as other functional somatic syndromes, are only minimally relieved by negative findings on physical and laboratory evaluation and are less responsive to explanation, reassurance, and palliative treatment from physicians.[11] They often see multiple physicians in their search for someone who will agree with their interpretation of their condition.[12]

Similar to others with delusions of parasitic diseases, this patient went first to a local hospital, then to an emergency room, and finally to an internist with experience in parasitic diseases. This was not an attempt on her part to avoid reality; it was behavior that was reasonable for someone with a firm belief that her infestation was real. The majority of patients go first to their family physician, followed by parasitologists, entomologists, psychiatrists, public health personnel, or other medical specialists.[6] While psychiatric consultation is prudent, such a recommendation to these patients is usually not well received. They are often offended and may become angry and leave, as in our case.

The diagnosis of delusions of parasitosis is often suggested by the patient's report of seeing "parasites" that do not conform to known human pathogens. In this case, the patient's description of flukes with back legs containing egg sacks was obvious. However, a physical examination should be done to exclude organic problems, and fecal material should be examined to exclude the presence of parasites or artifacts that could be confused with them. It is not rare for parents to confuse vegetable matter in their children's stool with a parasite. On occasion, people have seen pill ghosts in their stool and thought that they were parasites. These situations are typically resolved quickly by examining the presumptive "parasite."

In a case of delusions of parasitosis, the physician should take a thorough history, including questions about family history (including mental illness), social history, drug use (especially psychoactive drugs), childhood abuse, sexual disorders, or past Depression or anxiety. It is important to perform a full mental status examination. The physician should also determine whether the patient has seen other doctors for the condition and whether they have researched the disease on their own and/or initiated treatment. An attempt should be made to identify whether a particular incident was associated with the onset of symptoms, since premorbid psychologic factors or current psychic or social issues can contribute to the onset of delusional symptoms.[10]

The etiology of delusions of parasitosis is unknown, though numerous theories have been proposed. Some of these theories, including persistent pruritus in an anxious or disturbed patient[3] and tactile hallucinations,[2] are applicable only to perceived skin infestations. More convincing are theories for a neurochemical etiology, based on reports of induction by psychoactive agents such as amphetamines and methylphenidate and the occurrence in Depression and schizophrenia; or a psychologic etiology, based on occurrence in association with social isolation and sensory impairment.[12] If one includes intestinal parasitic delusions in the same category as the cutaneous type, the latter theories seem more likely.

Generally, psychotherapy has been of limited efficacy in patients with delusions of parasitosis.[6,14] Pimozide (Orap) is considered by many physicians to be the treatment of choice.[12,15-17] It is reported to decrease symptoms in 80% to 90% of cases.[2,16] Pimozide is an antipsychotic of the diphenylbutylpiperidine class. It has a low incidence of anticholinergic effects, but a 10% to 15% risk of extrapyramidal symptoms and the possibility of inducing tardive dyskinesia with prolonged use. It has also been associated with prolonged QT interval and T wave changes.[2] Risperidone, an atypical antipsychotic with fewer side effects than pimozide, has also been reported to be effective.[18] There are no comparative studies upon which to recommend one or the other as the drug of choice. Electroconvulsive therapy and psychosurgery are minimally effective.[2]

The major challenge is to get patients with delusions of parasitosis to accept and comply with pimozide or risperidone therapy. They are often angered at the suggestion that there may be a psychiatric component to their condition and resist referral for psychiatric care. The physician must allow the patient to talk about the somatic complaints in order to begin to deal with the underlying psychic disturbance. A nonjudgmental, nonconfrontational attitude will help to preserve the physician-patient relationship. It is here that an alliance between the primary care physician and a psychiatrist is also extremely valuable. This relationship can exist purely on a consultative basis or can involve direct contact, if the patient is willing.

Gould and Gragg[19] outlined seven steps that we consider important in dealing with this frustrating disorder. (1) Be certain of the diagnosis, (2) listen carefully to the patient's history, (3) ask the patient how the condition has affected his or her life, (4) work to establish a common bond with the patient, (5) be alert to any area where the patient will allow help, (6) try to reduce the patient's sense of isolation, and (7) consider the use of medicine to reduce anxiety or psychotic thinking.

Summary

Delusions of parasitosis, while uncommon, are an important cause of distress for those affected. The majority of cases in the literature involve delusions of parasites of the skin, but as this unusual case illustrates, delusions may focus on intestinal parasites. Although these patients are not infested, their distress is typically substantial and often disabling. Treatment with pimozide or risperidone can relieve symptoms. The major challenge is to get patients to accept and comply with it. The importance of establishing a trusting, long-term physician-patient relationship and a close alliance between the primary care physician and a psychiatrist cannot be overemphasized.

References
http://www.medscape.com/SMA/SMJ/2001/v94.n05/smj9405.25.ford/ref-smj9405.25.f...

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