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      Ghost tablets mimicking intestinal parasite

      brief-report
      a , a , b , *
      The Brazilian Journal of Infectious Diseases
      Elsevier

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          Abstract

          A 67-year old man and a 71-year old woman consulted for the repeated shedding of bean-sized elements in their stools. Although not suffering from gastrointestinal complaints, both patients were worried and feared to be infested by intestinal parasites. The attending physicians suspected of helminth infection and ordered parasitological examinations of the fecal elements. Submitted samples contained cuboid structures of yellowish to brown color, measuring approximately 2.5 × 1.0 × 1.0 cm (Fig. 1). Due to the soft consistency and lack of internal structures, we suspected that the amorphous elements represented so called “ghost tablets”, which are the remainders of long-acting medications. On request, both patients confirmed to recent prescription of extended release (XR) metformin. These formulations have to be swallowed whole and can remain intact during gastrointestinal transit. According to the product information, they can present as soft, hydrated masses in feces, which does not affect the efficacy of the drug. Ghost tablets appear in up to 54 % of those taking XR metformin 1 and, in patients with psychiatric disorders, might lead to anxiety and paranoia, especially if caretakers are unaware of the phenomenon. 2 Due to the lack of information and education regarding this harmless side effect, the topic is frequently discussed in internet forums or medical lay press articles.3, 4, 5 In Chile and other countries with endemic tapeworm infections, ghost pills might cause additional confusion, since their size and shape might resemble Taenia proglottids. In our parasitology laboratory, several of such samples have been submitted in recent years, all representing metformin XR formulations. Physicians should inform patients using metformin XR about this harmless side effect to avoid unnecessary anxiety and exams. Infectious diseases specialists and microbiologists should be familiar with the phenomenon of ghost tablets in patients reporting the shedding of suspicious stool elements. Fig. 1 Macroscopic appearance of metformin XR remainders (ghost tablets) as soft amorphous masses in fecal samples mimicking parasitic elements. Fig. 1 Conflict of interest The authors declare no conflicts of interest.

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          Most cited references3

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          Assessment of efficacy and tolerability of once-daily extended release metformin in patients with type 2 diabetes mellitus

          Aims To determine prospectively the efficacy, tolerability and patient satisfaction of an extended release formulation of metformin (metformin XR) in hospital based outpatients with type 2 diabetes mellitus currently treated with standard metformin. Methods Patients on immediate release standard metformin either alone or combined with other oral agents were switched to extended release metformin XR 500 mg tablets and titrated to a maximum dose of 2000 mg/day Measurements to include glucose and lipid control, blood pressure, body weight, waist circumference, C-reactive protein, adverse events and patient satisfaction were recorded at baseline, three and six months. Results Complete data were obtained for 35 of the 61 patients enrolled to the study. At three and six months no changes were reported for any of the cardiovascular risk factors except for lipids where there was a modest rise in plasma triglycerides. These effects were achieved with a reduced dose of metformin XR compared to pre-study dosing with standard metformin (1500 mg +/- 402 vs 1861 +/- 711 p = 0.004). A total of 77% of patients were free of gastrointestinal side effects and 83% of patients stated a preference for metformin XR at the end of the study. Ghost tablets were reported in the faeces by the majority of the patients (54.1%). Conclusions Patients switched to extended release metformin XR derived the same clinical and metabolic benefits as for standard metformin but with reduced dosage, fewer gastrointestinal side effects and a greater sense of well being and satisfaction on medication.
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            Curse of the ghost pills: the role of oral controlled-release formulations in the passage of empty intact shells in faeces. Two case reports and a literature review relevant to psychiatry.

            Orally taken tablets in different formulations continue to have a central role in the treatment of various psychiatric and medical conditions. In order to improve compliance, reduce the frequency of taking medications and minimize the peaks and troughs associated with certain immediate-release formulations, pharmaceutical companies have developed a number of novel methods of delivering oral solid dosage medications in the form of controlled-release (CR) formulations. Some CR formulations have been associated with pharmacobezoars and false-positive findings on certain physical investigations. Though CR drugs are commonly used in psychiatry, clinicians appear to have a limited understanding of how they are released for absorption once ingested. Some have insoluble parts that are excreted in faeces as 'ghost pills'. Due to lack of awareness of this phenomenon to both patients and the physicians, anxiety has ensued in some patients. Some clinicians have been puzzled or have been dismissive when faced with curious patients wanting to know more after they had observed tablet-like looking structures in faeces. We present two cases from our clinical setting and a few drawn from the World Wide Web to highlight the role of CR medications and their association with the ghost pill phenomenon. The mechanisms involved in drug release relevant to psychiatry medications are also briefly reviewed. The ghost pill phenomenon occurs with certain CR medications. This is a normal and expected outcome related to drug-release mechanisms of some of these products. It is inevitable that some patients will see what looks like tablets or capsules in faeces. Raising awareness of this phenomenon among clinicians would facilitate discussions and information sharing at the initial process of medication prescribing. Awareness among patients and carers would also help to allay anxiety.
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              What causes white specks in my poop?

              C. Sissons (2024)
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                Author and article information

                Contributors
                Journal
                Braz J Infect Dis
                Braz J Infect Dis
                The Brazilian Journal of Infectious Diseases
                Elsevier
                1413-8670
                1678-4391
                14 November 2019
                Nov-Dec 2019
                14 November 2019
                : 23
                : 6
                : 462-463
                Affiliations
                [a ]Universidad del Desarrollo, Facultad de Medicina Clínica Alemana, Clínica Alemana, Laboratorio Clínico, Santiago, Chile
                [b ]Universidad del Desarrollo, Facultad de Medicina Clínica Alemana, Instituto de Ciencias e Innovación en Medicina (ICIM), Santiago, Chile
                Author notes
                [* ] Corresponding author at: Laboratorio Clínico, Clínica Alemana, Av. Vitacura 5951, Santiago, Chile. tweitzel@ 123456alemana.cl
                Article
                S1413-8670(19)30472-6
                10.1016/j.bjid.2019.10.006
                9428199
                31734173
                d83b435b-262e-43aa-a985-9f33d1f8bc82
                © 2019 Sociedade Brasileira de Infectologia. Published by Elsevier España, S.L.U.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 17 September 2019
                : 17 October 2019
                Categories
                Clinical Image

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