Opisthorchiasis in children: causes, symptoms, diagnosis, treatment

Opisthorchiasis is a chronic helminthiasis with a primary lesion of the biliary system and the pancreas. In indigenous children of highly endemic foci, invasion usually occurs subclinically and is realized in mature or old age. In the area of endemia, visitors from non-endemic opisthorchiasis areas develop an acute stage of the disease of varying severity, followed by a transition to a chronic one.

ICD-10 code

В66.0 Opisthorchias.

[1],

Epidemiology of the OpiTorhosa

Opisthorchiasis is a natural focal invasion widespread among fish-eating animals, but in endemic foci man is the main source of infection. Infection occurs when eating raw, frozen, salted, dried fish of the carp family - ide, dace, chebak, roach, bream, carp, etc. The infestation of children with opisthorchosis in the north of Western Siberia already reaches the age of 80-100% by the age of 8. In the Kama basin, in indigenous children, opisthorchiasis is detected from 1–3 years of age, by age 14–15, the incidence reaches 30–40%. The affection of the local Russian population is somewhat lower.

Pathogenesis of opisthorchiasis

When digesting invasive fish in the stomach and duodenum, metacercariae are released from the membrane and along the common bile duct within 3-5 hours they move into the intrahepatic bile ducts. In individuals with a combined output of the common gall and wirsung ducts, metacercaria invasive the pancreas. The metabolites secreted by the parasite during migration and maturation have a direct toxic effect on the epithelium of the ducts, activate the release of endogenous inflammatory factors by lymphoid and macrophage elements, epithelial cells, and have a sensitizing effect. Clinical manifestations of invasion depend on the massiveness of infection, the age of the child and the level of immunity. The proliferative-exudative process in the mucous membranes of the gastrointestinal tract, the respiratory tract, the urinary system, and the production of antibodies determine the common allergic reaction. Cell proliferation in the walls of the microvessels, the stroma of the internal organs leads to the development of degenerative processes in the liver and myocardium. An imbalance in the production of peptide hormones — gastrin, pancreozymin, cholecystokinin — plays a significant role in the disruption of the activity of the digestive organs. In children of indigenous peoples of the North - Khanty, Mansi, Komi, Permian, the early stage of the disease proceeds subclinically, which is associated with transplacental immunization of parasite antigens, intake of protective antibodies with mother's milk.

The pathogenesis of the chronic stage of opisthorchiasis in the foci of invasion is largely determined by repeated multiple infections with persistent cell proliferation in the walls of the ducts, the stroma of the organs with the development of cholangitis, periholangitis, canaliculitis with elements of fibrosis, a violation of the glandular apparatus of the upper GI tract. Dysregulation of peptide hormone production leads to dyskinetic and dystonic disorders of the biliary system, stomach, duodenum with pain syndrome, cholestasis, and impaired stool. Allergic phenomena in the chronic stage of the disease are expressed slightly. Phenomena of immunosuppression prevail, which contributes to the complicated course of bacterial, viral infections, and the development of bacterial carriage.

[2],

Symptoms of opisthorchiasis

In children living in high-endemic foci of invasion, opisthorchiasis usually has a primary chronic course. Clinical symptoms develop on average and even in old age, provoked by concomitant diseases, intoxications. In the foci of medium endemicity, the acute stage of the disease is recorded in children 1–3 years old in the form of subfebrile, pain in the right hypochondrium, epigastria, sometimes exudative or polymorphic lesions on the skin, catarrh of the upper respiratory tract, and disorders of the chair. Lymphadenopathy, liver enlargement, blood eosinophilia up to 12-15%, hypoalbuminemia are determined.

Primary manifestations are followed by an increase in ESR to 20–25 mm / h, an increase in the level of alpha2-globulins, a tendency to anemia, and a lag in development. At the age of 4-7 years, allergic symptoms are more pronounced, eosinophilia reaches 20-25% on the background of leukocytosis up to 10-12x10 ⁹ / l. Middle-aged and older children 2-3 weeks after massive invasion develop fever, skin rash, pulmonary syndrome in the form of "volatile" infiltrates or pneumonia, pronounced dystrophic changes of the myocardium, with a particularly severe course - allergic hepatitis with jaundice, hepatosplenomegaly. Eosinophilia reaches 30-40%, ESR - 25-40 mm / h, alpha ₂ and serum gamma globulins are increasing, transaminase activity increases, to a greater extent alkaline phosphatase, the concentration of serum bilirubin increases to 25-35 µmol / l due to conjugated fraction. Acute symptoms can develop gradually, reaching a maximum within 1-2 weeks.

The chronic stage of opisthorchiasis in children in an endemic focus is manifested mainly by pronounced cholepathy, less commonly gastroenteropathic syndrome, and approximately 1/3 of children are characterized by asthenic syndrome. In young children, a slowdown in physical development, a decrease in nutrition, unstable stool, anorexia, a moderate increase in the liver, rarely its pain on palpation, eosinophilia up to 5-12%, a tendency to anemia are detected. In connection with repeated infections, the clinical symptoms reach a maximum by the age of 10-12. Complaints of heaviness, pain in the right hypochondrium, nausea, unstable stool, lack of appetite, which is determined by the transition of hypertensive dyskinesia of the gallbladder to hypotonic, prevail. Often persists eosinophilia up to 5-12%, reveal a tendency to anemization, hypoalbuminemia. By the age of 14-15, the clinical manifestations of invasion are often compensated, the laboratory indices are normalized, the dyskinetic disorders of the biliary system are rarely manifested, which seems to be associated with the development of immunity to parasite antigens.

[3], [4], [5], [6]

Classification of opisthorchiasis

Children with acute opisthorchiasis distinguish asymptomatic, erased and clinical forms of the disease with cholangitis, hepatocholangitis, typhoid-like and broncho-pulmonary diseases, and among chronic opisthorchiasis - latent and clinically pronounced forms with manifestations of cholepathy (angiocholitis, angiocolitis, aspirant, asylum, aspirant, aspirant, asylum aspirant, asylum aspirant, aspirant, aspirant, aspirant, asymptomatic asbestos The development of cirrhosis in children with opisthorchosis is rightly associated with a viral infection.

[7], [8], [9], [10]

Diagnosis of opisthorchiasis

Acute opisthorchiasis is diagnosed on the basis of the epidemiological history (consumption of raw fish of the carp family), a characteristic optics pattern (the appearance of acute febrile illness or a high subfebrile condition with skin rashes, myalgia, arthralgia, catarrhal symptoms, pneumonia, jaundice, hepatosplenomegaly with an atsyx patient, and a patient with an intoxicant who has ache;); reactions (RNGA, ELISA) with opisthorchosis diagnosticum. Opistorchis eggs in feces and bile are detected no earlier than 1.5 months after infection.

In the chronic stage, the diagnosis of opisthorchiasis is also given on the epidemiological history, the clinical picture of cholepathy or gastroenteropathy with exacerbations and remissions and asthenia, in children with blood eosinophilia up to 5-12%. The diagnosis is confirmed by detection in the feces and duodenal contents (with a low intensity of invasion only in the latter) of parasite eggs. Ultrasonography reveals biliary tract dyskinesia of a predominantly hypertonic type in young children and hypotonic type in older children.

[11], [12], [13], [14]

Treatment of opisthorchiasis

Treatment of opisthorchiasis in the acute stage with high fever, organ lesions begin with detoxification therapy, prescription of antihistaminic drugs, calcium salts, give a heavy flow to the inside or give parenterally glucocorticoid drugs in moderate doses for 5-7 days with rapid withdrawal of drugs, cardiovascular drugs. After the cessation of fever, the onset of positive ECG dynamics (better with its normalization), the disappearance of focal changes in the lungs for 1 day, treatment with praziquantel (azinox, biltricid) in a dose of 60-75 mg / kg in 3 doses with intervals of at least 4 h. The drug is given after a meal. Diet number 5 is preferable, restriction of coarse fiber and fats is necessary. Laxative is not prescribed. The treatment is carried out on the background of antihistamine drugs, the introduction of calcium salts, ascorbic acid.

Monitoring the effectiveness of treatment carried out after 3 and 6 months 3-fold examination of feces according to the method of Cato and duodenal contents. If parasite eggs are detected after 6 months, a second course of azinox treatment can be carried out. Clinical observation of children and, if necessary, pathogenetic therapy is carried out for 3 years after the last course of treatment.

Prevention of opisthorchiasis

The main method of prevention of opisthorchiasis in children remains the use of carp fish only in thermally processed form. In the foci of invasion, hygienic education of parents, especially older family members, is necessary (inadmissibility of feeding young children with raw fish and using it as a nipple). General preventive measures include preventing sewage from entering river basins, destroying mollusks, intermediate hosts of opisthorchiasis, and controlling the invasion of fish in production and in the distribution network.

[15],

[16],