A contribution to the study of hookworm disease in infants

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(1)Rev. Biol. Trop., 9 ( 2 ) : 1 7 1 - 1 85, 1961. A contribution to the study of Hookworm disease in infants by Carlos Sáenz Herrera':;'. Cecilia Lizano MadrigaF'X'. and. ( Rcceived fol' publication Scptembcr 1 6, 1961) A s pointed out in a previous publication ( 9 ) , presented at t h e Second Central American Congress of Pediatrics, ancylostomiasis i n i n fants shows great resistance to the usual forms of treatment. The fact should also be noted that. severe forms of hookworm infestation in infants exhibit peculiar characteristics. which make them different, to a certain extent, from the well known c1inica! pic­ tures of cases in th e pre-school age or older children and adults. Let us briefly reeaU the acute. and eady mani festation of anemia, the fre­. quent conservation of subcutaneous tissue, infiltration of the skin, anorexia, in. 'Some cases vomiting, and the typical aspect of the fe ces, normal in color or ranging from a pinkish tint to brick red, terracotta or wine red.. In the Department of Pcdiatrics of Hospital San Juan de Dios are admit­. ted yearly, to the infants' wards, about. 3000. patients aged from 0 to. 18. months.. LIZANO and DE ABATE ( 6 ) , in vestigating incidence of intes,tinal parasitcs in. dlildren hospitalized in the Departament of Pediatrics of Hospital San Juan de Dios, showed that. 2.7. per cent of children. O to. 18. for hookwonn in feces, which would mean some. months old give positive results. 80. cases of ancylostomiasis i n. infants for each yeaL The severe charaeter o f this disease and the relatively poor results of therapy used in infants prolong tbe period of hospitalization; to empha­ síze thÍs, we have included in om case studies the c1ínical histories of the children ( cases Nos. 1 and. 2). who. renuined one _ year or more in the hospital and '\overe. finally released with llGsatisfactory blood counts and positive results for hook­ . worm in the stool.. The usual therapeutic mcasures used in the treatment of infants ( tmnsfu.. sions, icon therapy, a \VeH balanced diet, and tetrachlorethylene in doses of 100. * <;,. Head, Department of Pediatrics, Hospital San Juan de Dios. Laboratories, Division of Pediatrics, Hospital San Juan de Dios, San José, Costa Ric¡¡. 171.

(2) REVISTA DE BIOLOGIA TROPICAL. 1 72. mg. per kilogram not followed by a laxative) were so unsatisfactory that we sought for other anthelmintics which could give better results. It also seemed indispensable to decrease the number of transfusions indicated in each case, which, as we sha11 show further on, was excessively high. This study comprises 14 cases of hookworm disease in infants, 2 of them corresponding to previous years. In aU cases with severe anemia there is intense paleness of the skin and mucous membranes. Edema is present in 3 5 % of the cases, in appreciable form; however, the fact that weight curve is always low during the first days in the hospital seems to indicate that superficial edema is frequent although it may be sub-clinica!. In most cases there is tachycardia; a functional murmur was found in only five cases. We should recaU here that in older children with a similar clinical picture there i s a higher incidence of cardiac murmurs. In many cases there were gross subcrepitant �ales but chest x-rays were always negalive. We may add that in two cases there were small tracheobronchial lymphadeniti�, and in two other cases, enlargement of the heart was detected. The abdomen was frequently enlarged, tense and painful. In most cases the liver was somewhat enlarged. The spleen was most often normal, but in orie case was found to be grcatly hypertrophied. The case was also positive for malaria (P. falcipart.t1n).. Vomiting was recorded in 5 cases ; but anorexia was· present in 1 0 cases. In 1 1 cases, feces with microscopicaUy perceptible blood were recorded. Most of these were liquid, but they soon became pasty, remaining fetid and requiring some time for the blood to disappear. Al! patients showed great mental depression upon admission to the hospital. The records are presented below for some of the most significant cases regarding laboratory examinations and results of the therapy employed. CASE N9 1 ( F.S.V. ). Remained in the hospital over a year, reCelV1l1g 26 transfusions, iron therapy and 16 doses of tetrachlorethylene. Feces were positive for hookworm before release. \Veight remained almost the same during the first 8 months in the. hospital. On departure from the hospital the patient had 8 g of hemoglobin per ' 1 00 cc and less than 3.'000.000 red ceUs, returning to the hospital some months later with a count of 1 .000. 000 red ceUs, 1. 5 g of hemoglobin and heavily positive stool for hookworm. CASE NQ 2 ( J.R.L.D. ). This child remained one year in the infants' ward, receiving 6 transfusions, 8 doses of tetrachlorethylene and ferrous Sl,llfate oraUy. Blood counts on leaving.

(3) SAENZ & LlZANO: HOOK\\'lORM DISEASE lN lNFANTS. 1 73. were 8 g of hemoglobin and 2 . 800.000 red ceUs. Feces were consistently posi­ tive for hookworrtJ.. CASE N9 4 (M.P.B. ). Remained in the hospital 9 months. Received 5 transfusions. Four treatments with piperazine and 3 with tetrachlorethylene. Blood values remaining about equal, with high leucocytosi s and eosinophilia. After three treatments with hexylresorcinol, feces were negative for hookworm with increased hemoglobin and decreased leucocytes and eosinophiles. Weight gained rapidly after hexylresorcinol treatment. The lowest leucocyte and eosinophile counts were recorded during measles.. CASE· N9. 6. (M.M. C ). Remained 9 months in the hospital. Twelve transfusions, iron and vitamin B- 1 2 therapy given. Two doses of piperazine and 5 of tetrachlorethylene had no noticeable effects on the blood values or the fecal hookworm egg counts. Four heavy doses of hexylresorcinol resulted in negative stool egg counts and in a rapid favorable effect on red ceUs counts and hemoglobin content ; there was also a rapid gain in weight. Leucocytosis and eosinophilia decreased. Liver function tests on leaving the hospital were normal.. CASE N9 7 (CL.A.R. ). Eight months in the hospital. Received 8 transfusions. Four dases of tetrachlorethylene, ferrous sulfate and liver extract. Four hexylresorcinol treat­ ments had the same favorable effects as in foregoin� cases with regard to blood picture, weight curve, and eliminabon of ·hookworm after the treatments.. CASE N9 8 (W.G.P. ) Remained in the hospital 7 months. Received 4 tfansfusions, iron therapy and vitamin B- 1 2 ; this treatment resulted in improved blood values ando decreas­ ed egg counts without eliminating the parasites. A heavy trichocephalosis was cured with hexylresorcinol enemas. Gain in weight and negative stool exams for hookworm were the results of treatment with heavy doses oí hexyIresorcinol..

(4) 174. REVISTA DE mOLOGlA TROPICAL. CASE N'! 9 (G.z.CH . ) Five montbs i n the hospital. One transfusion and iron therapy;. 2 doses. of tetrachlorethylene, with no effect on hookworm egg counts. Three treatments with hexylresorcinol in heavy doses caused disappearance of eggs from feces.. Rapid improvement in blood values and weight followed.. CASE. N9 1 1 (Z.v.c.). Remained. 3 months in the hospital. Received three transfusions, and. iron therapy, three doses of tetrachlorethylene, with no significant effect on blood. values or fecal hookworm egg counts. Five hcxylrcsorcinol treatment s in hcavy closes resulted in sharp increase of red cells and hemoglobin, in decreased leu­. cocyte counts, and less marked decrease in eosinophile counts; negative stool exams and satisfactory gain in weight.. SOME REMARKS ON HEMATOLOGY AND PARASITOLOGY Parasitological and hC1l1atological tests. were made before,. during and. after treatments. The first parasitological datum recorded was the presence of hookworm in direct examination of feces with physiologic saline solution added.. Egg counts were made foHowing Stoll's method (cited in ANIDO & ANIDO,. 1).. Hematological examinations were carried out in blood obtained from a. finger, using for hemoglobin figures the Sahli-Adams hemoglobin01l1eter and. . 1l1aking the differential leucocyte count on Schilling's classification.. Blood vallles in infants with hookworm do not differ much from those. of older children. In both groups, almost all cases show 1l1icrocytic and hypochromic anemia.. Leucocytosis. in these children, over. is. a. present,. as. weH. as. eosinophilia.. The manifestation. long period of time, of low hemoglobin values and red. ceU counts, leucocytosis, and, to some extent, eosinophilia, was due to the lack. of an effective anthelminthic for the total elimination of hookworms.. As the graphs 5how, most of Ollr cases were children who remained with. anemia for several months in spite of numerOllS transfusions. (26. in case. N<! 1 ) ,. iron therapy, a weH balanced diet and anthelmintic treatment. There are case. histories of infants who, after a year of hospitalization, . were released slightly less anemic than they arrived, still with abundant hookworm eggs in their feces.. Our record s '$how that it was not until the hookworm were eliminated that. a remarkable change occurred toward normalization of hematic values. At the same rate that we approached the total elimination of hookworms we came closer also to normal valueS i,n hemoglobin, erythrocytes , leucocytes and differential.

(5) SAENZ & LlZANO: HOOKWORM DISEASE IN INFANTS. NAME : FRANCISCO SEGNINI AGE. 1 75. ADMI$SION : AUGUST. VENEGAS. 25 - 1952. DISCHARGE : SEPTEMBER. : 4 MONTHS. 11 - 1953. N ° 190!S4 HOVUUIVI 11. 111. IV. �. ,. lit. I. IV. 11. 111. I. IV. ". 111. ,1. ,. Ofa:II8E:1I I. IV. •. I!. IV. 11. '. ". IV. r. 11. l.. IV ". ti. '1'. 'v. t. ,. 11. In. IV. ,. 11. 111. 11. '. IV. .. .. T.".CM . � _9'. -_____ ,-... ( u.e.." .. ) (00 I Eo.I...�IoiI.. 1. ___ 11•• IRN ." 040:.11'1_. NAME :. JOSE. AGE. 7. RAMON. '". IV. I 1. 'Io., ! " ... . <lnl \ ..,.,-, ,. ( H ''''.OI.'lo,. I. I�. T'O�.lu.loo , ... __ 11,_. IV. •.. .. ' "" ". 111. •. FlCUIE No. l. LOBO DURAN. MONTHS. ADMISSION : OCTOBER. 22. - 1953. DlSCHARGE: FEBRUARY. 19. - 1955. N - 24878. "'. IV. n. I. 111. IV. J AHIJ A RY. OtCOI ,[". N O"'lWBEII 11. I. n. IV. lit. I. 11. 111. IV. ,. 11. ,.. IV. I. 1I. 111. IV. I. 11. '. ". SEPTllUt ll IV. I. 11. 111. IV. .. �I. i : llook ...,,". ,:,-:a._...,........ H. ... I. �. 11. 111. IV. I. 11. 111. IV. I. •. PI. IV. I. 11. '1'. IV. OCTOI[ll I. N. 111. IV. I. ./. �i. · 1'. ,I. 11 0 ' 0 < 0 1 0 0 1. I _ �o l. .�I....I�y_. T.".. \ .,o ' k". --. K9b lH. --. Rb«. ....OIUi. .. ). 1 1". �_._. --. �.4 bl.. coD.I _ · _. .. ...,hUul. I.""«. l . ot�r" l. [o. I. Eo,I. mUlE Itt. 2. n. m. IV.

(6) DE. REVISTA. 1 76. BAOILLA. NAME : MARCIANO PADILLA AGE N". BlOLOGIA TROPICAL. ADMISSION'; DISCHARGE :. I YEAR. OECEMBER 23· 195,5 OCTOBER 1 6 - 1956. 29133 11. 111. IV. 1. 11. '!!. IV. ". ". 111. IV. I. ". ,.. 1. ,V. 11. 'N. IV. I. 11. '.. ", I v. ,. 11. "' ,v. l. ,'. .". V. 1. IV. 11 11. 11. I. IV. '''. 1. 11. m !\l. I. 1. j; " -� i� T,,,''''.'.. " ...1••1••, lu l. ��� ;ru ;-:. ��+H�++++H4++�'M�¡+++++HH+++4++.++��� .... '1. .. __ ---. NAME : , AGE. .. ... .. , ... IE"" o,."'". , . l '...·O'Ui. ) -'_____ LO"" I Lov...". R.'. 1�.4 .1•••••II'I. __ [. tlUIl u. �. - 19�6. 8. MIRIAM MORA CUlrllO. ADMISSION :. JANUARY. I YEAR. OISCHARGE:. OCTOBER I � - 19�6. :. , ; i, ' m ',v $[I'TEIII BEIt. AUGUST. -. .­. .-. ,'011 •. 1 HOOKWOMl. ¡.I-. -. �. .�. ¡... ;!r::-"-'"H++H. .... T. r,ichlw••. r-;,-.�:(ce). 1("" lIt,1 L r= •. � = .�� : :��+_ �+ �������H-H-H-H-�.. .... ,....,.... T.l'.d'. I�',.".. L" .nd :. ... .. __ H,b ( H•..,.t1.bln ) ______ I.Iw� t Ltwcoc,I," , __ A W ( 1t... oo. uMtI -·- r.o.. ( ["I .... �II .1. f". I FI GURE. i·. N° 4.

(7) SAENZ. :. NAME . CARLOS. AGE. N ° 1820. �r��t4:� I?Q 1 3j 1 : ::1 6 35 60 i � 30 )(1 11: 4 n !.a •7 i. 3 1° 1:'10. . -" 1 1. o. 0. L·O·� _. 1. U. 1. ,,. I. IV. ". I. u , ' IV. I. ti. 111 IV. ,. ''' ! li t. 11. , j. ¡ I. I. ,. -. ::1� ¡. : -1 - ¡-. .. .......... ,""' 1 _____ Loo"" ( Loo"",.,!. b,_ c. I _ [M. 1[. -. I. ¡ ' ¡ : J ). " ,. ..... ... ... __ 10'1 1 " ·__ II IC I III. ,. 11. -. J. , I. :l.J. H+. ". ,. IU ' I V. 6 - 19�6. " 1 "': IV. I 1 1'. ", . I V. I. 11 1. Il. I�. - !. �. �. lec ) H ,I 1I,,0.clllol C -. / k g ). -. j. /Í'. .. �. ' ,1. ' :. 11. l- r i ·. '� - - - 1'+' , " .. ]. F I G IJ R E ADMISSION : MARCH 9 - 1 956 DISCHARGE : OCTOBER 4'1956. ..;... 1. -. ''"1. : 1 3 MONTHS. �-. ... ,. .11 IV. ;- . ¡ ! - , - .. . . �- t i- - I !. N° 6106. ...... ¡. -. NAME : WALTER FCO. GUERRERO PRADO. 1. 177. ADMISSION : JANUARY 20 - 19�6. :. l ' '1 I. '0. AGE. I N FANTS. DISCHARGE : OCTOBER. -. '°1". :1 , �! I 1. IN. -. ,. '0. DISEASE. PI -fj= -- T-r -h+¡ I j- -- 1 ' ' I I¡' l . U' I ! ! tl �l'= t� � -bJ.--- ¡¡ /ru I i ¡ i /I �t ! -1 tl' - -¡ ¡t -¡-¡ - ; - I ll (0 j � rT , ! 1 ¡ I j \ I · , 'l i �I-�k-, M.', ' lt" r W-J . , FePn l t-J=-;H:: " ,,, i Y"¡ -j;t' ·.Y1 ¡\ ti" í" f-« 'j<J I i � yl ¡ . i -r-'f.f . , ., "','�. 10. t. HOOK\X'ORM. ARIAS ROJAS. ,: , , , .. < roo. '�"". �. '. LUIS. UZlll\' O ,. 7 MONTHS. .......... ... .... O\O.' R�. L 9. &. . . � !. �I. I 1, I ,. l·. �I � � I � .001700 w.¡. ••. !. 1.... ª. , �. ;.. �. •. '00 _1000 100. " 1". I -- H O b I H,moolOb i ft } - - - - -. I. -. Ltuc I L. --- Rbe I A.d bloa<l CI" ) _.__ Eo.. ... ,ocy'U ¡. [ [Otinophilu J. FIGURE. N° 6. ,i. I 1. N° 5.

(8) N A M E : Z EN E I DA N A M E : GERARDO. ADMISSION : MAY. ZAMORA CHAVES. AGE. :. DISCHARGE : NOVEMBER 1 1 - 1956. N° 18224 N°. �. �;:I. W E E K. MAY I I. o¡. !-inm� ,tnn:I '. •.� �.. '. , 111. Il I v. . �ULY. JUNE t. Iv l I. A U GUST. I. 1 1 I I II I I V. I. I. 1 II I I U l l v. I. 1 1 1 1 1. ,-.. 1 111 ' IV. 10 1 1 0. I. O. 1-. �flf�. " �R-�I I I ¡:fR'1 1 Tti'Htt +�� ,. - ,-. .. "<i... O I O. W E I G HT I Q ms. ). ro. �. �. �. �. ro �. 1);. o. I. o. d· ·' HIA NmM". 'l l l l l l l l l lml l l l l l l l l l l l l l HODkworm. W. T. t rlchluro. u. Tr ons f s i on s. ( ce ). 141. 7. I 40 170. 12 1. 6. 1 3 � 160. 10 1. �. 1 3 0 150. 81. 4. 1 2 � 1 40. 61. 3. 1 20 1 30. 41. 2. 1. 1 3. 1 1. 1 11. I UI I IV. SE PTEMBER. 1 1 11 I III I IV. OCTOBER I 1" 11 I III I IV. 15. ...-. /.v-. ;yo-. 1 20. ::.; "' <: C;; >-l >. /Mv ' ·�. ,J"-. el. I/r' LL. "'. (3 t"' tl:l. O el. 1 0 1 10. O. O 1 O. I. W·E I G H T ( om• .. ). HOOlo:wor m. �I I�. o �. ;1 1�I I�. 1,+ , ¡.oo. F�5IOO 123OIO lOO I 700 J'OO. :;. �. n[:::�:d"1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Tron.fu.ion.. ( ce ). Helyl. o. R • •o r c i n o l ( mO$ / lo: I. Huyl. Aesorcinol ( mQs / kg ). L.eo·nd:. Tetrochlorethylene. ( mo. /. Telrochlorelh)'lene ( mg5 / k g l Legf:n d . , --- H g b ( HemogIObin ). AUGUST. ���;���:I�� I I I I I I I I I I I I I I I I. 01. �i g. �. J. 1 1 11 1 III I Iv l 1. WEEK. '�. -'-k ". J U LY. M O NTH. OCTOBER. j-j-j-j-H--t-t-t-t-t-t--+--+--+--+--t--t--t-t-t-H-1--t-1. r.t-;;--t-z-.-t.ol 1 1 1 1 1,:tftt++f4-I-h-l":'- e. 01. I. 1 11 I III I IV I I 1 11. 70. " 5-,30 50. 10. SEPTEMBER. -3 5 60 _6__ _. _ o' . -. ". I U. ",.f-+--+-++++-+-+-+-+-+---j-f-t-+-+-+++-l. H' R b e Leuc Eos gms. miUion thOU$. 1. .... ---J 00. 1 1 261 M ONTH. 0 .2 0. CALDERON. ADMISSION : JULY 28 - 1956. 9 MONTHS. DISCHARGE : OCTOBER 31 - 1956. 4 M O NTHS. AGE. VARGAS. 9 - 1956. --- HOb ( Hemoo. - - - - - - Leve (Leucoc)'tes). - - R b e { Red blood C8115 ) - ' - ' - E05. 10:0 ). FIGURE N o . 1. d. lo i. - - Rbe (Red bloo. ( Eosinophiles ). bn. I. cell.). -- - --- Leuc (Leucocyt.. ) _. _.. -. Eo. ( Eosinophiles. 1. FIGURE N o . 8. >-l ::.;. O ." ñ > t"'.

(9) SAENZ. &. ÜlANO: HOOKWORM D1SEASE IN U-lFANTS. count. There is an appreciab1e divergence i n the curves for hemog10bin and red cells on the one hand, and for 1eucocytes and e05inophi1es on the other, all of them tending to normal va1ues after the admin istration of heavy doses of hexy1re­ 'Sorcinol. Experience has taught us that the effects of parasitism can not be made to disappear without the elimination of parasites, in this case hookwonns. Nane of our findings supported the opinions oE authors 1ike GARRAHAN ( 5 ) who stated that with a good diet and iron therapy a10ne, the cli n i cal picture which was due to no other cause than the d i rect and indirect action oE the hookworm could be made to disappear. It is likely that even the complete elimination of the parasitc would not restore the i nEants to normal health immediately. Success depends on the j oint action of elimination of the parasites and administration oE iron and a weH balanced diet. Logi c points to this conclusion and the results support it.. We have not had occasion to observe cases oE hookworm d i'Sease com­. plicated by anemia tending to aplas i a as reported by some authors, including GARRAHAN. .. (5).. In. studies made by. (7),. MIRANDA. in which infants were. i ncluded, he showed that there is active regeneration of the erythrocytic series in the bone marrow of hookworm patients. He found no relation of the anemia to the number of nucleated elements or to the proportion oE inmature celis of the erythrocytic series in the bone marrow. In our cases we found i n itial hemoglobin values as 10w as and. 800.000. 1. g per cent. erythrocytes per mmB•. AEter administration oE hexylresorcino1, and even before comp lete e1imina­ tion of the hookworms, the increase in. hemoglobi n. and. red. ceH va1ues was. clearly noticeab1e. As complete e1imination of the parasites was achieved, values reached normal or near1y normal figures. Release of the children was indicated when they reached. 12. g per cent or more hemoglobin, and. 4.000.000. or more. crythrocytes per mmH • Leucocyte. values. were. aboye. the. maximum. accepted. as. normal,. as. is a1ways observed in hookworm cases seen in our Departament. No cases of leuwpenia were found, such as GARRJ\HAN ( 5 ). reported following an initial. leucocytosis. It was not until we were clo�c to complete elimination of the hook­ worms that leucocyte values tended to return to normal.. Eosinophilia was not always present when the children entered the hos­. pital ; the higher values were found some time aEter admission. In many cases cosinophiles in circulating blo.od increased after anthelmintic and icon therapy and transfusions had begun. The proportion oE eosinophiles decreased in almo�t parallel fashion to the leucocyte va1ues, that is, when the parasites wece nearly eliminated and hemog10bi n and erythrocyte va1ues were approaching n? rmal.. TREATMENT From the therapeutic viewpoint, the effectiveness of oral hexylresorcinol, given in doses higher than that previously recommended, was evident. As early.

(10) 180. i�EVISTA DE BIOLOGIA TROPICAL. as 1934 BROWN ( 2 ) pointed out that while tetrachlorethylene i s more effectlve than hexylresorcinol, and is preferred for mass treatment, the latter is preferable in sorne individual cases, as in the treatment of children, weakened patients, and pregnant women. He also pointed out that except for possible local irritation, there is no contraindication for the oral administration of hexylresorcinol. In 1941 FAUST ( 4 ) also stated that tetrachlorethylene should be the pre­ ferred drug, but recommended the use of Caprokol ( hexylresorcinol) , conside­ ring its administration safer in anemic or undernourished children. He pointed out that no good anthelmintic could be used safely, without the necessary me­ dical control, with the possible exception of hexylresorcinol crystoids. We carne to have a similar opinion in our work in 1 9 5 5 ( 9 ) in which we stated our preference for the use of tetrachlorethylene without a laxative in infantile ancylostomiasis, according to the experience of CARR et al. ( 3 ) . However, in those cases, negative results for hookworm in feces were rarely obtained, i. e. only in 5 out of 2 2 cases treated with tetrachlorethylene in repeated doses oE 100 mg per kilogram of weight ( 9 ) . Besides, at that time we stressed the poor response obtained in heavily parasitized infants to the various anthelmintics pres­ Lribed. In the same publication we stressed that the use oE tetrachlorethylene orally, and even after the necessary intubation, did not give really satisfactory results. We decided therefore to increase progressively the doses of hexylresorci­ noI, usually recommended as 10 mg per k ilogram oE body ' weight. In previous experiences even this dosage had given fairly satisfactory results. Much larger doses such as 50 mg, and recentIy, even 100 mg per kilógram of body weight were given, focusing attention not so much on the physical characteristics of the patient, such as age, weight, or size, but rather on the closes required to attack the parasites effectively. We have thus come to give total doses of approximately 500 to 600 mg hexylresorcinol without having to restrict them according to age or weight. They were given in 0 . 1 0 g pills which the nurse causes to be swallowed by pIacing them at the back of the tongue of the child, giving at the same time a spoonful of water. In no case did we have any difficulty in hav­ ing the drug swaIlowed, although admittedIy the procedure does not have a 'Suf­ ficient margin of safety for home use. TabIes 1 and 2 are presented to alIow comparison oE results obtained with tetrachlorethylene and hexyIresorcinol. In the tabIes a remarkable dífference may be seen between the resuIts of treatment with tetrachlorethyIene and hexyIresorcinol in infants. With the former drug, given in doses of from 20 to 120 mg per kilogram weight, we obtained no favorable results, as the mean number of hookworm eggs per gram of feces changed from 3 .768 to 3.240 after treatment. It should be noted here that res­ ponse of preschooI children with hookworm to treatment with tetrachIorethylene in high doses and without a laxative, is quite satisfactory or at least much better than that oí infants, as shown by the mean figures oí 3.672 eggs per gram íeces before, and 1 . 2 1 8 after treatment, values shown in our study presented at the , previous Central American Pediatrics Congress. (9) ..

(11) �AENZ. &. LlZANO: i-IOOKWORM. 1si. DISEASE IN INFANTS. TABLE 1 EGG COVNT BEFORE AND AFTER TREATMENT WITH TETRACHLORETYLENE ( ORALLY). CASE. NAME. N·. 2. 3. ].R.L.D.. G.Ch.M. ". 4. S. 6. 7. 8. 9. 10. .. M.P.B.. ].M.G .. M.M.C. CL.A.R.. W.G.P.. G.2.Ch.. A.S.V.. AVERAGE. COVNT BEFORE TREATMENT Eggs/g feces. TREATMENT Doses rng. I. N". 2. I. COVNI' AFTER TREATMENT · Eggs/g feces. Doses mg/Kg _.. .. 20. S .800. 25. 1 0.800. 2. 30. 2 .800. 3. 120. 1 .900. 1 .000. 100. 600. 600. 1 .000. 100. 1 00. 2 .500. 800. 100. 3 .000. 3.000. 850. lOO. 1 1 . 1 00. 1 1 . 100. 8S0. 1 00. 4.000. 1 .300. 850. 120. 2 .800. 4.200. 1 .000. 120. 2 . 300. 2 .300. 1 .000. 100. 700. 7.900. 6S0. 1 00. 3.000. 3 .000. 6S0. 1 00. 2.500. 6.100. 500. 100. 3.500. 3.S00. S OO. 100. 1 .600. 2 . S00. 300. 40. 2.900. 2.900. 7QO. 100. 400. 400. 700. 100. 300. SOO. 4S0. 1 00. 1 .400. 1 .400. 4S0. 100. 8.600. . 120. 1 .200. 3 .400. 100. 5 .800. 1 50. 1 0.800. 150. 2 .800. 1 .000. 900. 6.000 .. 3 .768. 1 .000. 1. 2. 3.240.

(12) h\i¡STA DE i3loi.oi:;¡A Tiwp¡cAi.. 1$2. TABLE. 2. EGG COUNT BEFORE AND AFTER TREATMENT WITH HEXYLRESORCINOL CRYSTOID'S ( ORAUY). N9 CASE. 4. NAME. M.P.Il,. ].M.G.. 5. COUNT BEFORE TRT;ATMENT Eggs/g feces. TREATMENT D ose s mg. Doses. mg /Kg. COUNT AFTER TREATMENT Eggs/g feces. 4.000. 400. 40. 1 .800. 1.800. 400. 40. 1 . 100. 1 . 100. 600. 60. O. 750. 500. 40. 200. 200. 500. 40. O. 6. M.M. C.. 250. 500. 50. O. 7. C l. . A.R.. 150. 400. 60. O. 8. \'{f.G.P.. 100. 600. 60. O. 9. G.Z.Ch.. 100. 400. 60. O. 10. A.S.V.. 1.200. 500. 60. 1 00. 100. 500. 60. 50. 50. 500. 60. O. 3 . 100. 400. 50. 2.400. 2 .400. 500. 60. 700. 700. 500. 60. O. 11. Z.V.C. 12. e.V.e.. 4.700. 500. 1 00. 200. 13. GZO.. 5 .800. 400. 60. 400. AVERAGE. 1.5 5 8. 432.

(13) 183 In the tables it can be seen that sorne oE our cases treated with hexylre­ sorcinol had received p reviously one or more and up to five doses oE tetra­ chlorethylene without the desired results ( Case N9 6 ) . The data of tabla 2 show that, at least in infants, hexylresorcinol is the drug oE choice for treatment oE severc forms of hookworm disease; the minimum effeetive dose must still be investigated, although it appears to be between 500 and 600 mg, whatever the age or the weight of the infant. These amounts gave us the best results to date in om search for a solu­ tion to the problem of inEants' hookworm disease. AH children treated with slleh closes showed no hookworm eggs in their feces. Even though hexylresorcinol, aecording to many authors, including FAUST (4) , is one oE the few drugs which may be used without medical super­ vis ion, we preferred to begin om experiments with low doses, 'Such as 1 50, 200 and 300 mg. Most cases showed a decrease in the number of eggs in fecal matter, although not completely satisfactory Thus, . hexylresorcinol in doses below 400 mg, whatever the weight and age of the infant has no advantage over tetrachlorethylene. We obtained no negative eounts after several doses of 1 00 to 300 mg. It was . doses of 400 to 600 mg, which, given singly or repeatedly, aehieved the complete elimination oE the parasite in question. We have therefore included in table 2 the most significant cases, that is, those treated with doses which were successful in eliminating the · hookworms. AH children under study showed good toleral'lce for the anthelmintic drug; in only one case there was vomiting several hours after the patient had been given the dose, and there were no other side effects. The cases which were given transfusions whenever indispensable, ferrous sulfate elixir U.S.P., in doses of approximately 1 00 mg per kilogram of body weight (which we consider advantageous because of its high citrie content favoring assimilation of iron ) ( 8 ) and during the last weeks, hexylresorcinol, as described aboye, reacted quickly and favorably. The general condition improved rapidly, as may be noted from an increase in weight of 200 or more grams weekly. These first results reported lead us to expect a remarkable shortening of the period of hospitalization of infant hOokwofm cases and of tIle possibility oE rendering their feces negative for ' hookworm by means of heavy doses oE hexyl­ resorcinol and of hemotherapy and iron therapy, combined with a good diet and attention to the patients morale. SUMMARY AND CONCLUSIONS. Fourteen cases of serious hookworm disease in infants (O to lB months old ) are studied, in an effort to analyse the unsatisfactory restilts obtained with the therapy we had been using. The clinical aspects and laboratory analysis results are discussed. The results given by tethrachlorethylene and hexylresorcinol.

(14) REVISTA bE BIOlOGIA 'TROPICAt. 1 84. crystoids as anthelmintic are compared. Heavy doses of hexylresorcinol given orally have proved to be superior to other drugs as anthelmintics in infants. The good tolerance and apparent non toxicity of the substance are stressed. Good results are reported with a treatment including hexylresorcinol, transfusions, iron therapy, a well balanced diet and psychotherapy, regarding the general condition of the child and its blood values. With this treatment we obtained an important shortening of the period of hospitalization in serious forms of hookworm disease in infants. For the first time we can report a fully satisfactory condition on releas e of children hospitalized with this disease. RESUMEN. Se estudian catorce casos de anquilostomiasis seria en niños de O a 1 8 meses, con e l fin d e analizar los resultados poco satisfactorios obtenidos con los métodos terapéuticos empleados hasta ese momento. Se comparan los resultados obtenidos con tetracloretileno y hexilresorcinol. Dosis altas de hexilresorcinol por vía oral dan mejores resultados que otras drogas como antihelmínticos para infantes. Se hace hincapié en la buena tolerancia y ausencia de toxicidad de la droga. Se obtuvieron buenos resultados en cuanto al estado general del niño y a los valores hematológicos, con un tratamiento que incluía hexilresorcinol, transfusiones sanguíneas, ferroterapia, una dieta bien balanceada y psicoterapia. Con este tratamiento se puede obtener un acortamiento importante del período de hospitalización' en formas serias de anquilostomiasis en infantes. Por primera vez podemos informar de condición completamente satisfactoria de niños con tal enfermedad, al salir del ho·spital.. REFERENCES. 1 . ANIDO, V., & G. ANIDO. 1 943. Labofator;o e/fllico; técnica e interpretaclo/les. Tomo Cultural S. A., Habana, Cuba. 2.. 11,. + 990 pp. Ed.. BRo,!<,N H . W. 1 934. Intestinal parasltlc worms in the United States ;' their diagnosis and treatment. f. Am. Med. Ass., 1 03( 9 ) : 65 1-660: ,. 3. CARR, H. P., M. E. PiCHARDO SARDÁ & NADlNE AUDE NÚÑEZ. 1954. Anthelmintic treatment of uncinatiasis. Amer. J. Tmp. 495-503. 4.. XII. FAUST, E. C. 1 94 1 . The chemotherapy of · intestinal parasites. 1 331 - 1 335.. ¡.. Med. & Hyg., 3 (5 ) :. Am: Med.. 5. GARRAHAN, J. P. 1 956. Medicina Infantil: Pediatría y Puericultura. 8' ed. xviii "El Ateneo" Ed. Buenos Aires, Argentina.. Ass.,. + 1 247. 1 17 ( 1 6 ) :. pp. Librería.

(15) ,. ,. SAENZ & LlZANO: HOOKWORM DISEASE IN INFANTS. 1�5. 6. LIZANO, CECILIA & ]. DE ABATE, 1953, Incidencia del parasitismo intestinal e n los mnos de la Sección de Pediatría del Hospital San Juan de Dios, Rev, Biol, Trop" 1 ( 2 ) : 2 2 3-233. 7 , MIRANDA, M, 1956. Contribución al estudio de la médula ósea en niños con anquilostomiasis tricocefalosis, Re1), Biol. Trop., 4 ( 1 ) : 69-78. R.. y. PEÑA CH., A" R. PIEDRA, C. SÁENZ & E. CORDERO. 1 945 . Influencia de la acidez gástrica en el metabolismo del hierro de las anemias secundarias de la malaria y anquilostomiasis del niño. Rev. Med. Costa Rica, 6 ( 1 32 ) : 383-387,. 9, SÁENZ HERRERA, c., M. E . CALVO B., E . CORDERO, CECILIA LIZANO, ]. ARGUEDAS & Mi. E. CHAVARRÍA. 1955. Clínica y terapéutica de la anquilostomiasis y de la tricocefalosis infantil. Rev. Biol. Trop., 3 ( 2 ) : 1 3 5- 1 60,.

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