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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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• Overview
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• Treatment & Medication
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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.

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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 feces-
contaminated 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.

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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).
• 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
○ Nonproductive cough
○ Dyspnea

○ 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.
○ Passage of worms (from mouth, nares, anus)
○ Diffuse or epigastric abdominal pain

○ Nausea, vomiting
○ Pharyngeal globus, "tingling throat"

○ Frequent throat clearing, dry cough


○ Complications - Biliary and intestinal obstruction, appendicitis, pancreatitis

Physical
• General
○ Fever
○ Jaundice (in biliary obstruction)
○ Cachexia (due to malnutrition)

○ Pallor (anemia)
○ Urticaria (early infection)

• Pulmonary
○ Wheezing
○ Rales

○ Diminished breath sounds

• Abdominal
○ Abdominal tenderness, which may be diffuse (in obstructive infections), or localized
to the right lower (appendicitis) or right upper quadrant (hepatobiliary infections)
○ Peritoneal signs in cases of bowel perforation
○ 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).