Ascaris Lumbricoides

Ascaris Lumbricoides Author: Aaron Dora-Laskey, MD, Emergency Physician, Physician Management Group, Dayton, Ohio Coauthor(s): Ugo Anthony Ezenkwele, MD, MPH, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center; Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine Contributor Information and Disclosures Updated: Jul 30, 2009

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Introduction Background Intestinal nematode infections affect one fourth to one third of the world's population. Of these, the intestinal roundworm Ascaris lumbricoides is the most common. While the vast majority of these cases are asymptomatic, infected persons may present with pulmonary or potentially severe gastrointestinal complaints. Ascariasis predominates in areas of poor sanitation and is associated with malnutrition, iron-deficiency anemia, and impairments of growth and cognition.

Adult Ascaris lumbricoides. [ CLOSE WINDOW ]

Adult Ascaris lumbricoides.

Pathophysiology A lumbricoides is the largest of the intestinal nematodes affecting humans, measuring 15-35 cm in length in adulthood. Infection begins with the ingestion of embryonated (infective) eggs in fecescontaminated soil or foodstuffs. Once ingested, eggs hatch, usually in the small intestine, releasing small larvae that penetrate the intestinal wall. Larvae migrate to the pulmonary vascular beds and then to the alveoli via the portal veins usually 1-2 weeks after infection, during which time they may cause pulmonary symptoms (eg, cough, wheezing). During the time frame of pulmonary symptoms, eggs are not being shed, and thus diagnosis via stool ovas and parasites is not possible. Eggs are not shed in stool until roughly 40 days after the development of pulmonary symptoms. After migrating up the respiratory tract and being swallowed, they mature, copulate, and lay eggs in the intestines. Adult worms may live in the gut for 6-24 months, where they can cause partial or complete bowel obstruction in large numbers, or they can migrate into the appendix, hepatobiliary system, or pancreatic ducts and rarely other organs such as kidneys or brain. From egg ingestion to new egg passage takes approximately 9 weeks, with an additional 3 weeks needed for egg molting before they are capable of infecting a new host.

Life cycle of Ascaris lumbricoides. [ CLOSE WINDOW ]

Life cycle of Ascaris lumbricoides.

Frequency United States

In the United States, approximately 4 million people are believed to be infected. High-risk groups include international travelers, recent immigrants (especially from Latin America and Asia), refugees, and international adoptees. Ascariasis is indigenous to the rural southeast, where cross-infection by pigs with the nematode Ascaris suum is thought to occur. (Children aged 2-10 years are thought to be more heavily infected in this and all regions.) International

Worldwide, 1.4 billion people are infected with A lumbricoides, with prevalence among developing countries as low as 4% in Mafia Island, Zanzibar,1 to as high as 90% in some areas of Indonesia. Local practices (eg, termite mound–eating in Kenya2 ) may predispose to ascariasis in some populations. Other risk factors like dog/cat ownership, presence of pets within the house, and a previous history of geophagia have been noted. In some regions, Ascaris infection is thought to contribute significantly to the burden of abdominal surgical emergencies.

Mortality/Morbidity The rate of complications secondary to ascariasis ranges from 11-67%, with intestinal and biliary tract obstruction representing the most common serious sequelae. Although infection with A lumbricoides is rarely fatal, it is responsible for an estimated 8,000-100,000 deaths annually, mainly in children, usually from bowel obstruction or perforation in cases of high parasite burden. Due to similarities in the means of infection, many individuals infected with Ascaris are also co-infected with other intestinal parasites.

Race No racial predilection is known. A genetic predisposition has been described in a study of families from Nepal.3

Sex Male children are thought to be infected more frequently, owing to a greater propensity to eat soil.

Age Children, because of their habits (eg, directly or indirectly consuming soil), are more commonly and more heavily infected than adults. Neonates may be infected by transplacental infection. Frequently, families may be infected and reinfected in group fashion due to shared food and water sources as well as hygiene practices.

Clinical History Most patients are asymptomatic. When symptoms occur, they are divided into 2 categories: early (larval migration) and late (mechanical effects).

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In the early phase (4-16 d after egg ingestion), respiratory symptoms result from the migration of larvae through the lungs. Classically, these symptoms occur in the setting of eosinophilic pneumonia (Löffler syndrome). ○

Fever

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Nonproductive cough

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Dyspnea

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Wheezing

In the late phase (6-8 wk after egg ingestion), gastrointestinal symptoms may occur and are more typically related to the mechanical effects of high parasite loads.

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Passage of worms (from mouth, nares, anus)

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Diffuse or epigastric abdominal pain

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Nausea, vomiting

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Pharyngeal globus, "tingling throat"

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Frequent throat clearing, dry cough

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Complications - Biliary and intestinal obstruction, appendicitis, pancreatitis

Physical •

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General ○

Fever

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Jaundice (in biliary obstruction)

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Cachexia (due to malnutrition)

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Pallor (anemia)

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Urticaria (early infection)

Pulmonary ○

Wheezing

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Rales

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Diminished breath sounds

Abdominal

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Abdominal tenderness, which may be diffuse (in obstructive infections), or localized to the right lower (appendicitis) or right upper quadrant (hepatobiliary infections)

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Peritoneal signs in cases of bowel perforation

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Obstructive symptoms (nausea/vomiting/constipation/distention)

Migrating larvae may transmit other organisms, causing bacterial pneumonia or cholangitis. Rare cases of airway obstruction have also been reported. Other much less common presentations include lacrimal drainage obstruction,4 small bowel intussusception,5 acute interstitial nephritis,6 and encephalopathy.7

Causes

Symptoms are typically associated with early larval migration, heavy intestinal burdens of adult worms, or aberrant worm migration. Worm migration may be stimulated by anesthetic agents, fever, or subtherapeutic anthelmintic treatment, or by use of certain anthelmintics (eg, pyrantel pamoate).