Ascariasis


Article Author:
Daniela de Lima Corvino


Article Editor:
Shawn Horrall


Editors In Chief:
David Tauber


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
1/12/2019 8:50:44 PM

Introduction

Approximately one billion people in the world are infected with Ascaris lumbricoides, and more than 60,000 people die from the disease annually. It affects mostly tropical and subtropical countries around the world, and it is frequently documented in Sub-Saharan Africa, Latin America, China, and East Asia. Unfortunately, it is a neglected tropical disease that causes an estimated loss of 1.2 to 1.5 disability-adjusted years.[1][2][3]

Etiology

Ascaris lumbricoides, a soil-transmitted large nematode, causes Ascariasis. The female adult can reach up to 20 cm to 30 cm in length, and adult male up to 15 cm to 20 cm. The nematodes are pink/yellow/white roundworms. The female worms are thicker and have a straight rear end. The male worm is more slender with a ventrally incurvated rear end with two retractile copulating spicules. The average life of the adult parasite is one year, after which it dies, and it is spontaneously eliminated as it evacuates through the digestive tract. This is the reason why spontaneous cure of disease can happen if there is no reinfection. Adult worms do not multiply in the human host.[4][5]

Epidemiology

Ascariasis is one of the most common human parasitic infections. It is found worldwide. Ascariasis has been a disease that has affected the world population for centuries. It was described in ancient Egypt papyrus and has been identified in Egyptian mummies from around 800 B.C. Even Hippocrates and Aristotle, described the helminth. This disease has been described in children and adults in tropical and subtropical areas with poor sanitation and poor personal hygiene and in places where human feces are used as fertilizer. There is a higher risk of infection in nonendemic areas due to the increased rate of migration and travel.[6][7]

Pathophysiology

Infection occurs when the host ingests eggs found in stool-contaminated soil. Once in the duodenum, larvae are released and enter the circulation via the enteric mucosa. Once in the capillaries (venous, arterial or lymphatic), it reaches the liver via the portal vein and then the lungs within the first week. In the lung, they damage the alveolar membrane and mature in the alveolus. Eventually, the larvae are expectorated and swallowed reentering the gastrointestinal tract. Once in the lumen of the small intestine, the larvae mature to adult worms in about 20 days. When the adult female and male worms are present, they copulate, and the female can produce approximately 200,000 eggs per day. They are later eliminated in the feces to the soil. In the appropriate conditions of a moist, shady, and warm environment the eggs mature to infective form in two to eight weeks and remain viable for up to 17 months. They can be ingested and restart the infective cycle.[5][8][9]

History and Physical

Patients infected with ascariasis can be asymptomatic, only showing long-term manifestations of growth, retardation, and malnutrition. If symptoms are present, abdominal pain, bloating, nausea, vomiting, anorexia, intermittent diarrhea are the most common manifestation. If the number of larvae passing through the lung is significant, pneumonitis and eosinophilia can be seen (also known as Loeffler syndrome), symptoms include wheezing, dyspnea, cough, hemoptysis, and fever. In superinfection, adult worms can migrate to tubular structures like the biliary and pancreatic system causing cholecystitis, cholangitis, pancreatitis, small bowel obstruction, volvulus, appendicitis, and intussusception. Children are more susceptible to complications than adults.

Evaluation

A female worm can produce up to 200,000 eggs a day. This makes retrieval from stool exam easier. The best diagnostic test is still the stool exam for ova and parasites, searching for large oval brown trilayered eggs with a mamillated coat. It is important to note that stool can be negative, while the worm migrates and matures (approximately one month). Only when worms are mature, do they start secreting eggs. Therefore, identification is easy. Sometimes an adult worm can be seen in the stool or coming out of the rectum, but can also be coughed up or passed in the urine. A complete blood count can show eosinophilia during the active migration phase from the intestine to the lungs and larvae can be found in the sputum. Abdominal x-rays can be sensitive but not specific when a whirlpool sign is present. Ultrasound and CT scan can be used to identify worms in the biliary duct and gallbladder. Endoscopic retrograde cholangiopancreatography (ERCP) can be used for diagnosis and treatment.[10]

Treatment / Management

Even mild cases of Ascaris infection should be treated to prevent complications from parasite migration, however, during active migration through the lungs; medical therapy is not indicated, secondary to the increased risk of pneumonitis. Medical therapy with albendazole 400 mg as a single dose is the drug of choice; the second line of treatment is mebendazole 100 mg twice a day for three days or 500 mg as a single dose or ivermectin 100 microgram/kg to 200 microgram/kg once. In pregnancy, piperazine 50 mg/kg/day for five days or 75 mg/kg one dose or pyrantel pamoate (11 mg/kg up to a maximum of 1 g) is administered as a single dose; the latter is the drug of choice. Medical therapy will target adult worms, which is the reason why treatment should be repeated after one to three months, to give time to larvae that can be present to mature to adulthood and be susceptible to therapy. Alternative agents include nitazoxanide and levamisole.[11][12][13]

If the partial occlusion is present, place the nasogastric tube, give nothing per mouth, give intravenous fluids and piperazine. If complete occlusion, the patient may need laparotomy for enterotomy for extraction of worms, but if necrosis is found, they may need resection and reanastomosis. Once the surgery is performed, and intestinal transit is restored, medical anti-parasitic treatment should be given to kill any residual eggs.

Prognosis

Studies from Asia and Africa reveal that single dose treatment with albendazole results in cure rates of over 95% with a gradual reduction in eggs over the next few weeks in 995 of cases.

However, patient relocation is vital to prevent recurrence. there is also a great need to improve basic sanitation and provide clean drinking water in these areas.

Many communities are now being targeted for improvement in socioeconomics to help reduce the burden of ascariasis.

Avoiding contact with manure, wearing proper shoes and education are vital in preventing ascariasis.

Complications

  • Bleeding per rectum
  • bowel obstruction
  • Appendicitis
  • Hepatobiliary disease
  • Pancreatic pseudocyst

Postoperative and Rehabilitation Care

  • To ensure that children do not have Failure to thrive, they should have vitamin A supplementation.
  • Retreatment in 3-6 months is recommended in endemic areas if the stool ova still persist.
  • Compliance with drug therapy is necessary to eradicate the disease.

Deterrence and Patient Education

Education, providing fresh water and improving sanitation are a must.

Pearls and Other Issues

The life span of an adult worm is two years. They do not multiply in the host. If there is no reinfection by ingestion of fecal-contaminated food, the patient can clear the infection without treatment. This is why the first line of management should be an education in good hygiene and public health. Hand hygiene is of unmeasurable importance to prevent the infection with Ascaris lumbricoides. In areas of high endemicity, early diagnosis and treatment are important to prevent acute complications, and in the long term, prevent malnutrition, cognitive disabilities, and loss of productive years. 

Enhancing Healthcare Team Outcomes

Many programs have been started by the WHO to help diagnose and manage ascariasis. However, this parasite affects close to 1.2 billion people and a multidisciplinary approach is the only way to fight the infection. Besides infectious diseases, the primary care provider including nurses and pharmacists play a vital role in the education of the patient and their families on sanitation, washing food, and the importance of clean water.[11][14] (level II)

Outcomes

Ascariasis needs to be tackled on a broader spectrum rather than just healthcare. There is a need for improved farming practices, food, and personal hygiene and the availability of clean drinking water. Also of importance is to remove cultural perceptions and improve compliance with medications. Ascariasis has enormous morbidity and affects many organs in the body. While the mortality rates are unknown, the numbers are not minuscule. The WHO has stepped in and is working with a multidisciplinary group of healthcare workers to lower the burden of this parasite.[15][16] (level III)


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Ascariasis - Questions

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How is Ascaris lumbricoides transmitted?

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Which of the following infections is perhaps the most common globally?



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An Egyptian male is undergoing anesthesia for surgery of his appendix. Just after induction of anesthesia, a large parasite is seen wriggling in the oral cavity. This parasite is most likely which of the following?



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The mother of four children ages 3 to 8 years has roundworms. Mebendazole is to be administered. What advice should be given?



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Which of the following parasites has been associated with bile duct obstruction?



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Which of the following medications is the most appropriate treatment for ascariasis?



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Which of the following is true of ascariasis infection in the gastrointestinal tract?



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After an appendectomy, the pathology report shows a light-colored, 20.5-cm long roundworm and bile-stained, knobby eggs consistent with Ascaris. How was this infection acquired?



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A 26-year-old traveling nurse, with no significant past medical history, presents to the emergency department complaining of abdominal bloating for 1 week, nausea, and one episode of emesis. A physical exam is unremarkable. She reports recent travel to Africa where she was living with an indigenous population. She returned about a month ago and reported having a mild episode of coughing and low-grade fever that resolved on its own. Her CBC shows mild anemia and elevated eosinophils. Stool exam for ova a parasite it showed multiple brown, oval mammilated tri-layered eggs. What is the best treatment?



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An 17 year old male with no significant past medical history presents with severe vomiting, abdominal pain, fever, and mild jaundice. He recently immigrated from a south American country. He tells you that 4 months ago he was treated for ascariasis with albendazole. There is concern for intestinal obstruction. Abdominal X ray shows a whirlpool sign and a CT scan confirms the presence of partial obstruction with no clear signs of intestinal necrosis. He is passing gas and is hemodynamically stable. What is the best next step for management?



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An immigrant from Central America presents with nausea, vomiting, and abdominal pain. He claims that for the past month he has not been feeling well. In the last few days, he has lost his appetite, and his abdomen is distended. Plain abdominal x-rays reveal that he has dilated loops of bowel with multiple air-fluid levels. There is no air in the rectal area. The infectious disease expert indicates that his stool samples were positive for a parasite in the past. Which parasite is known to present with such x-ray findings?



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Ascariasis - References

References

Fahim SM,Das S,Gazi MA,Mahfuz M,Ahmed T, Association of intestinal pathogens with fecal markers of environmental enteric dysfunction among slum dwelling children in the first two years of life in Bangladesh. Tropical medicine     [PubMed]
Darlington CD MBBS, MS,Anitha GFS MBBS, MD, Ascaridial Volvulus: An Uncommon Cause of Ileal Perforation. Iranian journal of medical sciences. 2018 Jul     [PubMed]
Zakzuk J,Casadiego S,Mercado A,Alvis-Guzman N,Caraballo L, Ascaris lumbricoides infection induces both, reduction and increase of asthma symptoms in a rural community. Acta tropica. 2018 Jul 21     [PubMed]
Adu-Gyasi D,Asante KP,Frempong MT,Gyasi DK,Iddrisu LF,Ankrah L,Dosoo D,Adeniji E,Agyei O,Gyaase S,Amenga-Etego S,Gyan B,Owusu-Agyei S, Epidemiology of soil transmitted Helminth infections in the middle-belt of Ghana, Africa. Parasite epidemiology and control. 2018 Aug     [PubMed]
Sharma M,Somani P,Prasad R,Jindal S,Pathak A, Biliary ascariasis: mimicker of biliary stent. VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy. 2017 Jul     [PubMed]
Sklyarova VО, [Epidemiological features of parasitary invasis in women of reproductive age with disorders of reproductive health]. Wiadomosci lekarskie (Warsaw, Poland : 1960). 2018     [PubMed]
Claus PE,Ceuppens AS,Cool M,Alliet G, Ascaris lumbricoides: challenges in diagnosis, treatment and prevention strategies in a European refugee camp. Acta clinica Belgica. 2018 Feb 19     [PubMed]
Sharma A,Jariwala P,Kaur N, Biliary ascariasis presenting with gangrenous perforation of the gall bladder: report of a case and brief review of literature. Tropical doctor. 2018 Jul     [PubMed]
Bradbury RS,Harrington H,Kekeubata E,Esau D,Esau T,Kilivisi F,Harrington N,Gwala J,Speare R,MacLaren D, High prevalence of ascariasis on two coral atolls in the Solomon Islands. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2018 Apr 1     [PubMed]
Ghosh G,Shah S,Maltz C, Ascariasis Diagnosed by Wireless Capsule Endoscopy. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2018 Jun     [PubMed]
Wright JE,Werkman M,Dunn JC,Anderson RM, Current epidemiological evidence for predisposition to high or low intensity human helminth infection: a systematic review. Parasites     [PubMed]
Bharti B,Bharti S,Khurana S, Worm Infestation: Diagnosis, Treatment and Prevention. Indian journal of pediatrics. 2017 Nov 11     [PubMed]
Silber SA,Diro E,Workneh N,Mekonnen Z,Levecke B,Steinmann P,Umulisa I,Alemu H,Baeten B,Engelen M,Hu P,Friedman A,Baseman A,Mrus J, Efficacy and Safety of a Single-Dose Mebendazole 500 mg Chewable, Rapidly-Disintegrating Tablet for {i}Ascaris lumbricoides{/i} and {i}Trichuris trichiura{/i} Infection Treatment in Pediatric Patients: A Double-Blind, Randomized, Placebo-Controlled, Phase 3 Study. The American journal of tropical medicine and hygiene. 2017 Dec     [PubMed]
Mara D, Water- and wastewater-related disease and infection risks: what is an appropriate value for the maximum tolerable additional burden of disease? Journal of water and health. 2011 Jun     [PubMed]
Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet (London, England). 2016 Oct 8     [PubMed]
Olds GR, Deworming the world. Transactions of the American Clinical and Climatological Association. 2013     [PubMed]

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