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Chronic Threadworm Infections with Rachel Arthur

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Chronic Threadworm Infections with Rachel Arthur

Worms never conjure up a pleasant picture in our minds and threadworm might be more sinister than we've been led to believe.

Despite much talk of the potential therapeutic activity of helminths for things like autoimmune diseases and allergies, Enterobius vermicularis (threadworm) just doesn't seem to have a nice side at all.

In today's podcast we are joined by Rachel Arthur aka The Worm Whisperer.  She will be busting a few myths & misconceptions about threadworms, sharing what she's learned about breaking the cycle and resolving chronic worm infections in children and adults.

Rachel's passion for worms is borne from witnessing a growing a trend of chronic worm infections in kids and adults, particularly women, which aren't responding to standard medical treatments. What she is finding is that worms are migrating into other tissues, in particular, the genitourinary system and therefore, intestinal-based therapeutic interventions just aren't cutting it. True to Rachel's unique style, she's deep dived into the available research on this topic and today she shares what she's uncovered. 

Covered in this episode

[00:47] Welcoming back Rachel Arthur
[01:30] Today's topic: Worms
[04:18] Myths and misconceptions
[05:31] Vector, retroinfection and autoinfection
[10:23] Treatment selection: Drugs vs. CM
[12:05] Recognising signs and symptoms
[14:14] Vaginal threadworm: more common than you'd think
[16:16] Extra-intestinal infestations
[18:44] How do we treat vaginal and extra-intestinal worms?
[27:11] There are good and bad worms
[34:34] Chondroitin therapy: for more than just joints
[38:53] Where can people learn more about worms?

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today, again, is Rachel Arthur. 

Rachel Arthur has had many wonderful teachers and mentors over the last 20 years, including Dr Tini Gruner. Each of Rachel's past and present mentors have fed her passion for critical thinking and independent education in naturopathy, making it a major focus in Rachel's ongoing career. 

She contributed a decade of teaching naturopathy across SSNT, Endeavour, Monash University, Victoria University and, lastly, Southern Cross University. And I warmly welcome you, Rachel, back to FX Medicine, how are you? 
Rachel: I'm good, thanks, Andrew.  
Andrew: Now, today, we're talking about lovely little greeblies. We're talking about worms.  
Rachel: We are. 

 Andrew: But particular types...  

Rachel: A conversation nobody wants to have.  
Andrew: Yeah. But particular types of worms. Like I don't know how you nut this down, but let's talk first worms.  
Rachel: Okay. So the reason I'm going to be talking to you about it at all is, as is often the case, this was my clinical encounter, so to speak. I had several clinical encounters with horrible worm infestations in children. And I thought, "What do I know? What don't I know?" And there was a lot more that I didn't know. I really couldn't understand why I was seeing a raft of patients who effectively had treatment-resistant threadworm.  
So everybody said, "Go and get some OTC worming product." And they'd done that and done that and done that. And the little blighters were still there and the problems were getting worse and worse in these kids. 

So that was a long time ago now and it triggered my interests about worms in general, individual susceptibility, complementary medicine approaches, of which there's very little in the research. And then I started thinking, "Gosh, who else is this affecting?" And then that opens up a whole new chapter that I've been delving into over the last couple of years.  
Andrew: So they were non-responsive to…the usual thing that people get off the shelf is mebendazole.  
Rachel: So what the classic story was, and it's much broader than this, but to go back to the inception of my fascination, my morbid fascination with worms, was really that I had a series of families coming in, in dire straights really, because their kids didn't present with itchy bottoms. Maybe they did, but that was such a minor concern. 

What these children were presenting with were often growth/behavioral disorders. So nothing… They weren't on the spectrum, there was nothing like that. But the instability of the mood was drastic in a lot of situations. The sleep disorders were extreme. And mum and dad are sitting there, saying, "We don't understand. No one else in the family has these. We're absolutely certain. We've wormed everybody." But it wouldn't matter how many doses we give this child, whether it's a girl or a boy. The worms never go away. Or they go away, but just really briefly.” But, often, by the time they'd come to see me, it was completely non-responsive to the over-the-counter worming agents.  
Andrew: What about immune response in the child? What about . . . you know, is it because they were poorly fed, is it because they were malnourished? 
Rachel: Yeah, great question. Great question. I think some of the biggest myths…because we're talking about good, old-fashioned threadworms here. Or you know, some people refer to it as pinworm. 

Andrew: Yeah. 

Rachel: Its real name is Enterobius vermicularis. And when we…I think one of the biggest myths about that is, A) it only happens to kids; B) it only happens to dirty kids; or, C) it only happens in poor regions. And all of those are absolute nonsense. 

These are kids that were well fed, incredibly well cared-for and didn't necessarily have immune compromise in other areas. Not at all. That's not to begin with, shall I say. I'll get to that perhaps a bit later about what chronic worm infestations actually do to the immune system. 

But, no, this is a collection of children that just shouldn't have had this. Should not have had a problem with resolving worms.  
Andrew: Lifecycle? Vector? What was the vector? Where did this greebly come from? 
Rachel: Okay. So one of the other big, completely misunderstood things about threadworms is everyone thinks, "Oh, it's coming from the animals." It's not coming from the animals. 

The only host on the planet that we understand for threadworms is actually humans. We're it. We're it. 

Andrew: Really?

Rachel: You know, and that’s deeply disconcerting because they're looking for somewhere to live. So it's not coming through our pets. It's not coming through the soil. It's not coming through contaminated regions that we live in, so to speak.  

Andrew: Yeah. 
Rachel: There is a discussion about vectors and things like that. There's certainly some relationship with dientamoeba fragilis. But the relationship is the other way around. It's the threadworm eggs that have been found, in many instances, to contain dientamoeba fragilis. So you could actually have recurring d.frag infestations secondary to actually Enterobius infestations. But not the other way around. We think threadworms are just literally hanging around in the environment. Not in the soil, but would be in the environment on things we touch. People would come into contact with. Airborne, because we can inhale the eggs. And they get inside us and they go, "Yippee! I'm home." 
Andrew: So one of the concepts that I vaguely remember was this thing about retroinfection. That if they…God, I hope I got this right. If they swallow the drug, mebendazole, during a phase when the pinworm was outside of the anus, outside of the alimentary tract, that it could live for a few days there. The drugs pass through, metabolise and then the egg goes back into the anus and re-infects. 

Rachel: That’s right. 

Andrew: Is that correct? Okay, good.  
Rachel: Yes, that's right. Yes. 

So one of the things is that…one thing, if we're talking about over-the-counter pharmaceutical worming, one is the details that is often missed by parents and practitioners is you're supposed to do it twice. 

Because it's not even just a matter of the eggs outside of the gastrointestinal tract that are missed. It's that eggs, in general. So the drug is only effective against adult threadworms. It won't actually touch the eggs.  
And the other thing about the drugs, both over-the-counter worming tablets, is that they have 0 to less than 1% uptake. So they're not actually taking up into your bloodstream. They just literally sit within that tube that we affectionately call the gut. And that's where they do their business. 

So you're right. If you've got eggs clinging around the perianal area, they're not going to touch that. If you have threadworm, and I'm leading the witness here, Andrew, if you have threadworm anywhere else in your body cavities, anywhere else, they won't touch that either.  
Andrew: Oh, really? 
Rachel: Yeah, that's right. So one of the classic things that we say is, you know, remember that pharmaceutical drugs need to be taken twice. So they need to be taken the first dose and then the second dose about 7 to 10 days after the first, to catch that second cycle, if you like, to catch those eggs that have now hatched and become adults. But there's a lot more to really preventing retroinfection than that. 

Because autoinfection…it's not just retroinfection. So retroinfection suggests that pathway that you just described. But autoinfection, which is any means by which you keep re-inoculating yourself. So you think about the child who loves putting their finger up their nose. 

Andrew: Yep. 

Rachel: Which is the same finger that's been..

Andrew: Scratching their bottom…

Rachel: … wiping their bottom, that's been scratching their bottom unconsciously during the night. 

So putting their finger up their nose re-inoculates themselves with threadworm. Sucking on their thumbs, chewing their fingernails, all those sorts of things.  
So there's…autoinfection is huge. And we know that this is one of the main reasons why an infestation can become chronic. That it can actually go on for months and years because we're just never getting our head above water in terms of preventing those kinds of re-exposure risks. 

But, again, even in patients who I've seen who have done everything to stop retroinfection and autoinfection, we were still seeing chronic, un-resolving worms. So there's another part to that story.  
Andrew: Well, I have to ask about another drug. So there's mebendazole, but there was also pyrantel. And that's the one that doesn't kill them, but stuns them. 

Rachel: Yes.

Andrew: So do you favour the use of changing the drug or alternating the drug therapy? 
Rachel: Okay. Probably in a big chunk of patients, I find complementary medicine more effective. But we are prescribing for the situation, right? 

If you came to me Andrew, and said, "Here's my child and they have worms. And this is their first experience with worms. What are you going to do about it?" I'd actually say, "Go to the chemist, go get that over the counter…" 

Andrew: Yep. 

Rachel: You know, I wouldn't be saying, "We've got to go the complementary medicine pathway here." And there's a whole reason behind that. 

But if we're talking about the sort of complex, chronic, un-resolving infestations that I'm describing, then complementary medicine has an enormous potential to be the circuit breaker. That's one part of it.  
Do I think that changing up the drugs does much? Not unless you move to a drug that has systemic anti-worming actions. So that's not pyrantel powder. That's not the over-the-counter tablets. It's actually prescription-based anthelmintics that are absorbed from the gut, get into your bloodstream and, therefore will have an anthelmintic action, from… in other parts of the body.  
Andrew: Okay. So you mentioned these unusual signs and symptoms presenting with an infestation. How do you tease them apart? Like, how did you go, "I know what it is"? 
Rachel: Yes. Okay. So it was a ponderous moment where I started to think, "What is it that I'm seeing here? What's this pattern? How do I know how to spot it earlier next time?" 

I think that the symptom picture, you know, we all go "Oh, if they have an itchy bottom, yes, of course, they get it." And if they don't, no, it's not. And that's probably the biggest mistake we make.  
There's this assumption that you can't have worms without pruritus ani and that's completely incorrect. In fact, a large percentage of patients, particularly adult patients who carry the worms chronically, are asymptomatic and they don't have any symptoms. And isn't that worrisome? Because that can be somebody in your house. 

But, right, so I talk about kind of the iceberg effect. The stuff above the water that we all can see, is the pruritus ani, the itchy bottom. We all go, "Well, we get that." Or a secondary infection or dermatitis around the bottom. We get that. And then I think you get to the next level that, the things a lot practitioners will pick up. Maybe it's the nose-picking, the thumb-sucking, the grinding of the teeth during sleep. The really disturbed sleep…and as I've said, that can get quite extreme. 

But the disturbed sleep might be that a child or an adult who calls out, who is yelling out during their sleep, having nightmares. It might be that their bedding's all over the place in the morning. You can tell that they've done several somersaults during the night. It's most often going to be flagged as well by an individual who wakes unrefreshed in the morning. So, of course, there are lots of reasons or explanations behind unrefreshing sleep but don't leave worms off your list.  
I think from there, we start to get into the area that practitioners are less probably likely to lead with Enterobius. And that's things like vulval itching. So that's a little girl who talks about a sore vulva or an itchy vulva. A discharge, something from the vagina, vulvovaginitis. Thirty percent of women, not little girls, women who think they've got thrush, on testing, are found to have actually threadworms. 

Andrew: Wow!

Rachel: I know we haven't covered the "how did it get there" so we've got to cover that, Andrew.  
Andrew: Yeah. You've got the proximity of the anus to the vagina. So there is that.  
Rachel: That's all it is. That's all it is. If you think about that proximity between the opening of the vagina and the opening of the anus. And if we think about it, first of all, in little girls, where the distance between those two openings is less than a centimeter, it's a matter of millimeters. 

Andrew: Yeah, yeah. 

Rachel: And you're going, "How hard would it be for a female worm, which is coming out every night at the anus, to lay its eggs in the perianal area…how hard would it be for it to just do that millimeter further and go, 'Uh-oh. I've found myself in another warm, moist place'"?  
And then arguably as well in women, so not just in little girls where the distance is so small, but even in grown women, that distance really, in non-pregnant women, is quite small as well. In pregnancy, of course, that lengthens and extends, but still is only going to be a maximum sort of 4 centimeters. 

So, again, how possible is it that the threadworm is going to migrate completely unintentionally, just trying to do its business and lay its eggs where they can hatch into the genitourinary system? It's huge. 

Andrew: Yeah.

Rachel: We know that these are the most common sites of what we call extra-intestinal infestations. 

Andrew: Right. 

Rachel: So threadworm can survive pretty much anywhere on the body. 
You know, If a child has the eggs on their fingers and then, believe it or not, they scratch the inside of their ear, you can develop threadworm in your ear. There are reported case reports, lots of them.

Andrew: Wow. 

Rachel: In the ear, in the eye, in the nose, in the salivary glands. All over the place there that you've managed to infect yourself with. And, equally, if not more so, because this is actually the most common place that they go to, of course in girls and women, is they take up residence in the genitourinary system. And they survive very, very well there.  
Andrew: So I'm going to guess here that it's squamous cell. I'm just trying to think about what cells it would live in and upon. And I guess it's different from a bacteria. Like you know, you get gonorrhea, chlamydia, they go for columnar epithelium. But this is different, isn't it? This is an organism. So I wonder whether it would be restricted to a cell type? 
Rachel: Yeah. I don't know the answer to that. I really don't. All I know is that they're incredibly flexible in terms of the sort of environment that they can live in and thrive in. They don't just leave and then go off. They're reproducing in those areas.  
Andrew: So, okay, so there's a big conundrum for therapy because, hey, you don't get pyrantel or a mebendazole pessary.  
Rachel: You don't. That's exactly right. And yet, we have these patients, both little girls and mature women, who are going…threadworm just wasn't on their radar. They thought they had thrush. They thought they had, for example, a UTI or even interstitial cystitis. They thought they had pelvic pain associated with ovarian issues and whatever. 

It's correlated with fertility issues. It has been shown to go affect the It has been shown to be a factor in miscarriage. And you're just going, "Wow. We need to wake up to this. That this is their second home, in a lot of cases." And none of the treatments that our patients are going to reach for are going to address that.  
Andrew: So you do you treat, particularly in an area that's quite sensitive, in the vaginal region? You don't want to be looking at things that are going to burn. I don't think that'll get a favorable feedback from your patients. What do you use? 
Rachel: No. Okay. So this is where I was at about eight years ago. I think it was longer, in fact. I think about 10 years ago when I was treating little girls in this situation. And I was going, "Right. Pretty sure they're in the genitourinary system," because you know, you can certainly…I'd read the literature on that and thought, "Right. That's why we can't get rid of them with these OTC products."  
And I thought, "Okay. Where are the herbs?" And then I'd go literature searching. Where are the herbs that work against Enterobius? Because I'll put them in a sitz bath or I'll do something. I'll make pessaries, you know, like I'm going to treat locally because that is the only way to address this. 

And when I went searching for the research that I just assumed was there, Andrew, lo and behold, there is almost nothing. You might think, "Oh, surely, after these years, there have been studies against Enterobius." No. You might think, "What about all those other kinds of anti-parasitic herbs that we're fond of using in other scenarios?" Nope, they haven't been studied. 

Now, that, for me, was like "Oh, gosh. I'm dealing with young girls." I'm asking their parents to do something and the girls to do something that as you say, I don't want it to be uncomfortable. I don't want it to be unnecessarily invasive. And I sure as heck better be effective. And I'm going, "And I have no research to really…in terms of herbal medicine to back me on this." You know, I'm really going, “Uh-oh."  
So one of the things that actually came up in my reading, was, and actually, it came from the throwaway line from an integrative GP that I shared care with at the time on different patients. I said, "Have you ever seen this? Have you ever seen just kids that cannot expel worms?" And as a total throwaway line, he said, "Oh, check out chondroitin sulfate." And I said, "Right. Chondroitin sulfate." And I thought, "Okay. I'm going to go find something on this."  
And what I came across was a collection of studies that had been done in vet science. Because, of course, worms are a big issue in vet science. And they were looking at it in much greater detail than we were looking at in humans about what makes an individual of any species susceptible to infestation. Because the reality is we're all exposed to, say, something like threadworm. But it doesn't hang around for some of us. It just passes through. We just go, "No, thanks," and off it goes out the other end. It doesn't set up shop.  
But in vet science, they were saying, "Okay. Why some have a problem and others not?" And so they looked at this in really exquisite detail and they'd really blown apart a lot of our misunderstandings about what an effective immune response was to worms. Because you probably remember, Andrew, we all were under the illusion, which we now realise is an illusion, that the way that the body resolved a worm infestation was via our eosinophils.  
Andrew: Yeah. Well, that's what I thought.  
Rachel: Yeah. That's the white cell that goes up. You can see it in the blood tests of all these individuals. So we all thought, "Ah. That's the immune system responding. Great. That's the immune system doing its job." 

What the vet scientists and now the scientists in human research are also echoing is that is not an effective immune response. The eosinophils, rather than actually resolving an infestation and helping with the expulsion of the worms, are instead enabling the worms. They're encouraging, if you like, a symbiosis. 
Andrew: So we're being hijacked. 
Rachel: We're being hijacked. Absolutely.  
Andrew: Oh, my God.  
Rachel: Yeah, yeah. Now, I know you and I will get to the point about, "Well, aren't worms good for us?" But we'll get to that, right? 

So what came out of this research, and I'm going to cut it real short because there's just too much detail to go into, but what came out of this research was the real effective immune response isn't with the eosinophils. It actually is really encapsulated in basophils. It's the basophils that do the work. 

And the way that they expel those worms or make the host, if you like, unfriendly to them setting up residence, is they secrete massive amounts of chondroitin sulfate and other GAGs. And I was like, "Oh, okay. Doctor onto something. Doctor not losing his mind. Totally onto something." 
So I started reading up on this. And in these animal studies, they were treating the animals with chondroitin sulfate and saying, "Now, let's feed them worms and see what happens." And when they treated the animals with chondroitin sulfate, the worms wouldn't set up shop. 

I was like, "Okay. This is as close as I've got to the best research right now for these poor little girls." And I had some little boys at that time, too, in practice, that were chronically infested. And I thought, "Well, chondroitin sulfate’s safe. I'm going to give it a go." Now, it wasn't the only thing I did but I'm absolutely convinced that it was one of the most important things that I did was giving these individuals chondroitin sulfate. 
So there is a question, of course, Andrew, as to why would you have an individual who doesn't make enough for themselves and so on and so forth. But that's probably beyond the scope of this discussion. But I can tell you that we resolved the worms. In each and every case, we resolved the worms. Yes.  
Andrew: This is really interesting to me in that I remember some research done by Samantha Coulson, Dr Samantha Coulson. On work with regards to chondroitin sulfate. Basically, we got it wrong that we think it's something for the joints. But, I mean, I actually found a diagram which details how our body absorbs and digests, if you like, chondroitin and makes these downstream molecules that, eventually, they'll help our joints. But, initially, they are metabolised by our gut. 

Rachel: Absolutely.

Andrew: So what you said, it surprised me, but the more I'm thinking about it, the more I'm thinking this is a gut-healing response.  
Rachel: Yeah. And that immune response is really complex. It's a multi-step sort of process. And GAGs are…I mean, the gut is one of the primary producers of GAGs. We thought of it in terms of tight junctions and things like that. 

But now, this is really painting the scene, as you said for GAGs is actually the immune response in the gut, a really important immune response. 

It really, really turns my assumptions and my training on its head. And I thought it was all good in theory, to begin with, but I really needed the proof in my clients. And then when I could get the proof over and over and over again, I was like, "Right. Yeah. Let's tear out those pages. Let's rewrite those sections in the textbook and let's all understand the truth about Enterobius, in all its wonderful color." 
Andrew: I remember a paper, and I think it was Greek? But it actually looked at a positive response from children infected or immune responses from children infected with pinworms. And I think we need to be clear on this, about the botanical…when I say the botanical name, that's a plant. The binomial nomenclature. The actual organism that we're talking about. So we're talking about Enterobius vermicularis, correct? 
Rachel: Yes, that's right. 
Andrew: Yeah. Because some countries call threadworm and pinworm another thing. 

Rachel: That’s right. 

Andrew: But I think what they saw in this paper was a decrease in allergies. Now, this comes back to we think about eosinophils. This comes back to, not a stimulatory response of eosinophils at all.  
Rachel: No. Look, this is…I mean, this is so interesting because as I've been mentoring people and bringing this to their to attention or speaking at conferences, of course, the first sort of protestation I get is, "Hang on. Worms are good for us?" And I go, "Ooh. Hmm. You might want to specify what you mean when you say, 'worms are good for us.' That would be like saying bacteria are good for us." Well, there are a lot of species. There are a lot of strains. 

So there is a lot of interest in this area about where the helminths are part of good gut digestion. 

Andrew: The ‘old friends’ yeah. 

Rachel: Yeah. And, as you say, even going beyond that and saying, "Do they actually have some immunomodulatory actions that are absolutely desirable?" So the answer is, yes, sort of, in some ways.  
Andrew: In a person where it's not causing an issue. You have an infection of them and there's an infection.  
Rachel: That's right. So that's the first thing. Like I said to you, you bring your kid in to see me and go, "This is the first time they've had worms," I go, "Great. Go treat that. End of story." 

Because do I think Enterobius is evil for all individuals? No, not at all. And there is some literature. There was a paper published last year by Yang, which looked at the microbiome of kids without threadworms, or without Enterobius, kids with Enterobius and then kids after treatment of Enterobius. And they actually found that kids without the threadworms actually had the lowest microbial diversity in their gut. The kids with Enterobius obviously had better diversity. Interestingly enough, the kids after treatment for Enterobius had even better diversity. 

Andrew: Oooh.

Rachel: Yes. So there are all these sort of…it's too simplistic to say worms are good or Enterobius is fine. It's a symbiote or something like that. As you say, my first exception is, I say, “not if this child is presenting with a problem.” And not if this…I should stop saying ‘children.’ Not if this adult. I'm seeing a lot of these in adults. Not if this adult is presenting with a problem. I would no sooner tell those families that Enterobius is a symbiote or a commensal and just get over it, than walk in front of a truck. 

These people were living a horrible experience with their kids. And who's going to argue with them that the helminth doesn’t need to be eradicated? It does. It's got on top of this child. So that's a really important section. 

And I think that there has been, first of all, this general sort of concept that worms could be beneficial and worms could be good for our immune system, in particular lowering T helper 1 and T helper 17 cell lines. And this is speculated to potentially lower risks of autoimmunity in the future. And also to reduce the severity of current autoimmune presentations. 

The stuff on allergies is totally at sixes and sevens, Andrew. There is as much research saying it is allergies as there is saying that it actually promotes allergies. Because if your response to a worm infestation is to make eosinophils, that's going to increase your allergic response, right? 
Andrew: My old concept was that it would, therefore…sorry. That it would react with the eosinophil and, therefore, the…and I'm going to be really vague here. But, if you like, the energy given to the eosinophilic reaction would be taken up by that infection. But that's not necessarily the case.  
Rachel: Not necessarily. The research is so complex and so catchy because it depends on…I won't go into it, but the research is all over the place. They've used different worming agents, they've used different follow-up times. As I've said, some studies have shown reduced allergy development in those kids when their pregnant mums were treated for worms and some have shown increase. 

So I really don't think we can, at this point, say worms are good, full stop. And that we don't entirely know what worms are going to do for the immune system. So this whole idea that they increase T helper 2, lower T helper 1, T helper 17, we've kind of established that. And it's not just Enterobius, of course. It's a range of worms that do that.  
But worms are immunosuppressive. This is one of the absolute accepted truisms about worms. 

Andrew: Yeah. 

Rachel: So what does that mean for somebody who does have a chronic infestation? I said to you before about these kids. You said, "Did they have immune problems?" I said, "Well, not to begin with." 

But if you're carrying a chronic worm infestation, their impact on your white cell replication and the cell line proportions is to induce a hyporesponsiveness to defending yourself against bacteria. And you go, "Okay. I can see a little bit of a problem for some individuals." 
Andrew: I guess my issue with it is if you are instigating or wanting to use any helminth therapy when the human is the vector, i.e. it's a sideline thing that passes in and out but doesn't live in you. Then, okay, let's potentially look at that. But if you've got something where the human is the host, you'd better have a good terrain. 

And this, to me, is what you're talking about. It's got to do with the terrain and how that person can handle or ward off an organism passing through, setting up shop and becoming an infection and causing problems.  
Rachel: That's right.  
Andrew: What interests me, though, is the therapy, chondroitin. So if you're talking about vulval infection and things like that, how versatile have you used it? 
Rachel: Okay. This is very interesting. 

Look, as I've said, the approach, it has to be multi-pronged. So I don't give them chondroitin and we're done. There's a raft of other things that we do, not just in terms of actual ingestives, but there's a lot of educating that we do about how to prevent all of those sort of re-exposure pathways and all of those sorts of things as well. 

When I was asking myself that same question, Andrew, I'm like, "Okay. So I use chondroitin sulfate and that seems to get rid of them quite convincingly." I'm like, "Well, how does that get…does that really get into the genitourinary system? Is that what I've changed there as well? Have I increased GAGs in the GU?"  
So let's go back one step. You said chondroitin sulfate actually has poor bioavailability, which it does. Okay, so it's not a molecule that we find very easy to absorb. So the percentage that actually gets into the system and gets to those other tissues is quite low. So I'm going, "Well, am I really making a difference in the genitourinary system of these girls?"  
Then, my research took me down the line of do GAGs belong in the genitourinary system?

Andrew: Yeah. 

Rachel: Like, "Well, hang on. Is there a reference point for this?" 

Now, what's amazing to me is the increase in volume, the loudness of the research talking about the imperative role of GAGs in the genitourinary system in women. This has got nothing to do with worm research. This has got to do with…you might be aware that GAGs, particularly chondroitin sulfate, are being used in interstitial cystitis. Chondroitin sulfate is used in prolapse.  
It's used…and I'm starting to get into the literature, going, "Oh, my goodness. Here's another world." So my thought is, now, I go, "Oh, yes. GAGs belong there. Our capacity to make GAGs at the gut, in the joints, in the genitourinary system, is this going to be a big determinant of our ability to defend ourselves in this way." 

Can I tell you that giving someone chondroitin sulfate orally increases the GAGs in the genitourinary system? I can't. I can't. I wish I could mention that. I wish I could say I know that that's what's happening. I don't, at this point. But we're exploring new options, new treatment options all the time and new modalities all the time. So watch this space. But I have had good results just through the oral administration.  
Andrew: Oh, so we're not even talking topical application? We're talking oral administration? 
Rachel: Nope. Yeah. And, again, I even said it challenges all these ideas. Like your thing about there will never be bacterial translocations. I've got similar ones. I thought, "How could probiotics ever get into the breast milk?"  

Anyway, it challenges all these ideas that we have that are really simplistic, A) about where GAGs are and where they're important; B) about how we make them and how variable our capacity to make them actually is; and, C) about what the impact is if we're not a good producer of GAGs. I mean, I'm just fascinated about what more this is going to teach us.  
Andrew: Look, this is absolutely fascinating, but I'm going to have to learn a lot more. Where can others learn a lot more? Because there's a lot more to learn.  
Rachel: There is a lot more to learn. Every time I talk about it, I think, "Oh, I think I'm done now. I think people can get what I'm saying. Watch for worms, look again. Understand making discoveries. Off you go." 

But when I realise that my knowledge is built on, as I've said, about 10 years of reading into this and treating this, so I go, "Oh, okay. Yeah, there is a bit. There is a bit to know." So I am speaking at MINDD on this topic, women and worms, at the MINDD conference in May. 

And we also have a resource online called thewormwhisperer.com.au, which is primarily really there for the public. Because, I tell you, the outcry from the public is enormous, in terms of their need for help and the gaps that are there at the moment in terms of getting help. But a lot of practitioners would learn a lot by going on there as well and looking at some of the resources that we have on there also.  
Andrew: And I would definitely urge all of our listeners, please, get onto the website. Click on mindd.org. Look at the seminars and the events that are upcoming because you need to be at the MINDD forum. In 2018, it's the 11th through the 13th of May. You need to get to this to help these kids, in this instance, with behavioral and neurological issues. And you will be speaking, indeed, at this one in 2018, like you did last year. And I've got to say you were one of the key speakers at that event. You were brilliant.  
Rachel: Thank you, Andrew. That's very kind of you.  
Andrew: Well, you were practical. You were pragmatic. You are obviously an expert in clinical practice. But you have this knack for questioning, for uncovering and debunking assumptions and you have, as you say, these many ponderous moments and you give those to us. Thank you so much for joining us on FX Medicine today.  
Rachel: Thanks, Andrew.  

Additional Resources

Rachel Arthur
The Worm Whisperer
Dr Samantha Coulson

Research explored in this episode

Patsantara GG, Piperaki ET, Tzoumaka-Bakoula C, et al. Immune responses in children infected with the pinworm Enterobius vermicularis in central Greece. J Helminthol. 2016 May;90(3):337-41

Yang C, Liang C, Chia-Li L, et al. Impact of Enterobius vermicularis infection and mebendazole treatment on intestinal microbiota and host immune response. PLoS Negl Trop Dis. 2017 Sep; 11(9): e0005963




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