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Dracunculiasis, also known as Guinea-worm disease is a parasitic disease caused by the nematode Dracunculus medinensis.[1] Infection is transmitted to humans by drinking water contaminated with the small crustacean copepods (Cyclops) which contain the larvae of D. medinensis. Humans are the principal definitive host and Cyclops being the intermediate host. The disease is endemic to the rural and poorer areas of the world and is most common in African countries like Chad, South Sudan, Ethiopia, and Mali. Efforts are underway towards global eradication of this disease.[2]

Mature female worms can measure up to 1 meter in length and are 1 to 2 mm wide. Male worms measure 15 to 40mm in length and are 0.4 mm wide.[3]


Dracunculiasis is caused by Dracunculus medinensis which is transmitted to humans by drinking unsafe water containing small crustacean copepods (Cyclops) containing the larvae of D. medinensis. Humans are the principal definitive host, and Cyclops is the intermediate host.


The disease is endemic to the rural and more deprived areas of the world and is most common in African countries like Chad, South Sudan, Ethiopia, and Mali. Guinea worm affects rural area population groups whose livelihood depends on subsistence agriculture. The disease can occur in any age group but frequently presents in young adults between 15 to 45 years. Men and women are equally affected. Transmission of the disease depends on seasonal variation and usually occurs during the rainy season or dry season.

Estimates are that around 48 million people were affected by this disease in Africa, the Middle East, and India in the 1940s. Approximately 3.5 million cases were reported annually in the mid-1980s. Since the start of the Guinea Worm Eradication Program in the 1980s, the number of dracunculiasis cases have significantly decreased and is now at the verge of being eradicated.[4][5] Recent World Health Organization (WHO) reports from October 2018 state that only a few cases have been reports in Chad, South Sudan, and Angola.[6] The goal is to eradicate this disease from the world by the year 2020.[7][8]


After ingestion of cyclops contaminated water,  infected larvae released in the stomach penetrate the mucosa of the stomach and intestinal wall and migrate into the connective tissue. The larvae then mature into adult worms. After maturation and impregnation of the female worms, the male worms die. Female worms fully mature after 9 to 14 months and can measure up to 1 meter in length. Worms migrate through the subcutaneous tissue. Approximately after one year of infection, the female worms are attracted to the cooler surface of the skin and emerge from the skin, usually the feet. Before emerging they form a painful blister at the skin site. Patients usually place or soak their legs in cold water to get relief from the symptoms, and this causes the worm to break from the blister and emerge from the skin. This stage causes itching and pain at the local skin site. During this time the 1st stage larvae are released into the water and are ingested by the Cyclops and undergo two molts to develop into the 3rd stage larvae. Ingestion of Cyclops with 3rd stage larvae contaminated water by humans starts the lifecycle again.

An alternative life cycle was proposed recently involving dogs and fish.[9] After eating raw fish containing guinea worm larvae, dogs can get infected. By eating raw fish, humans can get infected; this reported alternative cycle has made eradication of the disease more challenging, especially in Chad.[10][11]

History and Physical

Patients are usually asymptomatic for approximately one year after infection. Skin erythema and tenderness can present at the site of emergence of the worm. When the adult worm emerges from the skin it can cause blistering and ulceration, edema, pruritus at the location where it comes out. The worms usually emerge at the lower extremities, mainly the feet in 80 to90% of the cases, although, they can emerge from any part of the body. Sometimes more than one worm can emerge from the skin simultaneously. This painful processes of emergence of the worm from the skin can last up to 8 weeks or more.

Systemic symptoms like fever, rash, nausea, vomiting, and diarrhea can develop. An abscess can occur when the worms migrate to other tissue sites like lung, pericardium, spinal cord. When the worms pass through the joints, it can cause joint pain and contractures. Occasionally sepsis can occur due to systemic infections. Cellulitis can occur. If the worm breaks before it is wholly extruded this can lead to severe inflammatory reaction, pain, swelling, and cellulitis. In some cases, the worm can die before it emerges from the skin and it can become calcified and encapsulated, this causes chronic recurrent pain and swelling.


Diagnosis is mainly by clinical presentation. Peripheral eosinophilia can be present in the blood work. Immunoglobulin G4 levels might be elevated.[12] If the worms die before they emerge from the skin, they may calcify and can be visible on x-rays.

Treatment / Management

Anti-inflammatory agents like aspirin and ibuprofen can help decrease pain and swelling. Diphenhydramine can treat itching. Topical antibiotic cream or ointment is an option to prevent secondary bacterial infection at the site where the worm emerges. Systemic antibiotics may be required if cellulitis, sepsis or abscess develops. Wound care is important.

Steps for worm extraction include: Exposing the affected body area to water facilitating the worm migration to the skin.  The wound should then be cleaned. Worm should be slowly pulled out by applying gentle traction to the worm and should make sure to avoid breaking it. The worm is wrapped around a stick like a match stick or a gauze to apply tension and prevent it from going back inside. Topic antibiotics are used to avoid the development of secondary bacterial infections. Gauze and bandage are applied to the affected site. Anti-inflammatory agents like aspirin and ibuprofen can help decrease pain and swelling. All these steps are repeated daily, and it might take up to 8 weeks or more until the worm undergoes successful extraction. The infected patient should be careful to avoid wading as can contaminate the water and the spread of the disease.[13]

No medication is effective against guinea worm disease. Surgical extraction of the worm is the therapy in areas where facilities are available.[14]

Differential Diagnosis

  • Filariasis
  • Cellulitis


Guinea worm disease is rarely fatal. Severe disease usually occurs due to secondary bacterial infections and sepsis. The condition can lead to temporary and permanent disability.[15] Prevention is the only effective method of contracting this disease.


Abscesses can occur when the worms migrate to other tissue sites like lung, pericardium, spinal cord. Occasionally sepsis can occur due to systemic infections and cellulitis. If the worm breaks before it is completely extruded from the skin, this can lead to severe inflammatory reaction, pain, swelling, and cellulitis. In some cases, the worm can die before it emerges from the skin and it can become calcified and encapsulated, this causes chronic recurrent pain and swelling. When the worms pass through the joints, it can cause joint pain and contractures.


Infectious disease

Surgery consultation for surgical extraction of the worm

Deterrence and Patient Education

There is no medicine to treat dracunculiasis, and there is no vaccine to prevent this disease. Infected persons should strictly avoid any contact with drinking water sources to prevent contamination and the spread of the disease. Safe drinking water consumption should be encouraged.

Enhancing Healthcare Team Outcomes

Prevention and management of Guinea worm disease require a multidisciplinary effort involving the physicians, social workers, nurses, and epidemiologists. Community surveillance should be encouraged. Access to safe drinking water sources should be provided. Health education and behavioral change of the endemic communities is vital. Treating the contaminated water sources for vector control should be encouraged.[16]

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Dracunculiasis - References


Dracunculiasis Eradication: Are We There Yet?, Hopkins DR,Ruiz-Tiben E,Eberhard ML,Weiss A,Withers PC,Roy SL,Sienko DG,, The American journal of tropical medicine and hygiene, 2018 Aug     [PubMed]
Human Parasitology and Parasitic Diseases: Heading Towards 2050., Hotez PJ,, Advances in parasitology, 2018     [PubMed]
Why Funding for Neglected Tropical Diseases Should Be a Global Priority., Reed SL,McKerrow JH,, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2018 Jul 18     [PubMed]
WHO leadership is essential for the elimination of NTDs., Savioli L,Daumerie D,, Lancet (London, England), 2018 Dec 23     [PubMed]
Progress Toward Global Eradication of Dracunculiasis, January 2016-June 2017., Hopkins DR,Ruiz-Tiben E,Eberhard ML,Roy SL,Weiss AJ,, MMWR. Morbidity and mortality weekly report, 2017 Dec 8     [PubMed]
Greenaway C, Dracunculiasis (guinea worm disease). CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2004 Feb 17;     [PubMed]
Cairncross S,Muller R,Zagaria N, Dracunculiasis (Guinea worm disease) and the eradication initiative. Clinical microbiology reviews. 2002 Apr;     [PubMed]
Netshikweta R,Garira W, A Multiscale Model for the World's First Parasitic Disease Targeted for Eradication: Guinea Worm Disease. Computational and mathematical methods in medicine. 2017;     [PubMed]
Biswas G,Sankara DP,Agua-Agum J,Maiga A, Dracunculiasis (guinea worm disease): eradication without a drug or a vaccine. Philosophical transactions of the Royal Society of London. Series B, Biological sciences. 2013 Aug 5;     [PubMed]
Cleveland CA,Eberhard ML,Thompson AT,Smith SJ,Zirimwabagabo H,Bringolf R,Yabsley MJ, Possible Role of Fish as Transport Hosts for Dracunculus spp. Larvae. Emerging infectious diseases. 2017 Sep;     [PubMed]
Eberhard ML,Ruiz-Tiben E,Hopkins DR,Farrell C,Toe F,Weiss A,Withers PC Jr,Jenks MH,Thiele EA,Cotton JA,Hance Z,Holroyd N,Cama VA,Tahir MA,Mounda T, The peculiar epidemiology of dracunculiasis in Chad. The American journal of tropical medicine and hygiene. 2014 Jan;     [PubMed]
Bloch P,Simonsen PE,Vennervald BJ, The antibody response to Dracunculus medinensis in an endemic human population of northern Ghana. Journal of helminthology. 1993 Mar;     [PubMed]
Dholakia KJ, Extraction of Guinea-Worm. The Indian medical gazette. 1921 Dec;     [PubMed]
Rohde JE,Sharma BL,Patton H,Deegan C,Sherry JM, Surgical extraction of guinea worm: disability reduction and contribution to disease control. The American journal of tropical medicine and hygiene. 1993 Jan;     [PubMed]
Molyneux D,Sankara DP, Guinea worm eradication: Progress and challenges- should we beware of the dog? PLoS neglected tropical diseases. 2017 Apr;     [PubMed]
Hours M,Cairncross S, Long-term disability due to guinea worm disease. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1994 Sep-Oct;     [PubMed]


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