9/9/2020 Ascariasis - Infectious Diseases - MSD Manual Professional Edition

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Ascariasis
By Richard D. Pearson , MD, University of Virginia School of Medicine

Last full review/revision Mar 2019| Content last modified Mar 2019

Ascariasis is infection with Ascaris lumbricoides or occasionally Ascaris suum (a closely related parasite of
pigs). Light infections may be asymptomatic. Early symptoms are pulmonary (cough, wheezing); later
symptoms are gastrointestinal, with cramps or abdominal pain due to obstruction of gastrointestinal
lumina (intestines or biliary or pancreatic ducts) by adult worms. Chronically infected children may
develop undernutrition. Diagnosis is by identifying eggs or adult worms in stool, adult worms that
migrate from the nose or mouth, or larvae in sputum during the pulmonary migration phase. Treatment
is with albendazole, mebendazole, or ivermectin.

(See also Approach to Parasitic Infections.)

Ascariasis occurs worldwide. It is concentrated in tropical and subtropical areas with poor sanitation. Ascariasis is the
most common intestinal helminth infection in the world. Prevalence is highest in children aged 2 to 10 years and
decreases in older age groups. Current estimates suggest that 800 million to 1.2 billion people are infected worldwide,
and ascariasis contributes to malnutrition in many of those. In addition, an estimated 2,000 infected people (mostly
children) die each year of bowel or biliary obstruction.
In the United States, most cases occur in refugees, immigrants, or travelers to endemic tropical areas.
Humans are infected with A. lumbricoides when they ingest its eggs, often in food contaminated by human feces.
Infection can also occur when hands or fingers with contaminated dirt on them are put in the mouth.
Humans can also be infected with A. suum, a closely related roundworm of pigs, when they ingest eggs from handling
pigs or from consuming undercooked vegetables or fruits contaminated with pig feces.

Pathophysiology
Ingested A. lumbricoides eggs hatch in the duodenum, and the resulting larvae penetrate the wall of the small bowel
and migrate via the portal circulation through the liver to the heart and lungs. Larvae lodge in the alveolar capillaries,
penetrate alveolar walls, and ascend the bronchial tree into the oropharynx. They are swallowed and return to the
small bowel, where they develop into adult worms, which mate and release eggs into the stool. The life cycle is
completed in about 2 to 3 months; adult worms live 1 to 2 years.

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Ascaris lumbricoides life cycle

IMAGE FROM THE CENTERS FOR DISEASE

CONTROL AND PREVENTION IMAGE LIBRARY.

A tangled mass of worms resulting from heavy infection can obstruct the bowel, particularly in children. Aberrantly
migrating individual adult worms occasionally obstruct the biliary or pancreatic ducts, causing cholecystitis or
pancreatitis; cholangitis, liver abscess, and peritonitis are less common. Fever due to other illnesses or certain drugs
(eg, albendazole, mebendazole, tetrachloroethylene) may trigger aberrant migration.

Symptoms and Signs

Ascaris larvae migrating through the lungs may cause cough, wheezing, and occasionally hemoptysis or other
respiratory symptoms in people without prior exposure to Ascaris.
Adult worms in small numbers usually do not cause gastrointestinal symptoms, although passage of an adult worm by
mouth or rectum may bring an otherwise asymptomatic patient to medical attention. Bowel or biliary obstruction
causes cramping abdominal pain, nausea, and vomiting. Jaundice is uncommon.
Even moderate infections can lead to undernutrition in children. The pathophysiology is unclear and may include
competition for nutrients, impairment of absorption, and depression of appetite.

Diagnosis
Microscopic examination of stool

Identification of adult worms in stool or emerging from the nose, mouth, or rectum

Diagnosis of ascariasis is by microscopic detection of eggs in stool or observation of adult worms in stool or emerging
from the nose or mouth. Occasionally, larvae can be found in sputum during the pulmonary phase, or later in
infection, adult worms may be seen in radiographic studies of the gastrointestinal tract.
Eosinophilia can be marked while larvae migrate though the lungs but usually subsides later when adult worms reside
in the intestine. Chest x-ray during the pulmonary phase may show infiltrates, which in the presence of eosinophilia
leads to the diagnosis of Löffler syndrome.

Treatment
Albendazole, mebendazole, or ivermectin

All intestinal infections should be treated.

Albendazole 400 mg orally once, mebendazole 100 mg orally twice a day for 3 days or 500 mg orally once, or
ivermectin 150 to 200 mcg/kg orally once is effective. Albendazole, mebendazole, and ivermectin may harm the fetus,
and risk of treatment in pregnant women infected with Ascaris must be balanced with risk of untreated disease. Before
treatment with ivermectin, patients should be assessed for coinfection with Loa loa ifCookies
they have traveled to areas of

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9/9/2020 Ascariasis - Infectious Diseases - MSD Manual Professional Edition

central Africa where Loa loa is endemic because ivermectin can cause severe reactions in patients with loiasis and high
microfilarial levels.
Nitazoxanide is effective for mild Ascaris infections but less effective for heavy infections. Piperazine, once widely used,
has been replaced by less toxic alternatives.
Obstructive complications may be effectively treated with anthelmintic drugs or require surgical or endoscopic
extraction of adult worms.
When the lungs are affected, treatment is symptomatic; it includes bronchodilators and corticosteroids. Anthelmintic
drugs are typically not used.

Prevention
Prevention of ascariasis requires adequate sanitation.
Preventive strategies include
Washing the hands thoroughly with soap and water before handling food

Washing, peeling, and/or cooking all raw vegetables and fruits before eating

Not eating uncooked or unwashed vegetables in areas where human feces is used as fertilizer

Not defecating outdoors

Key Points

Ascariasis is the most prevalent intestinal helminth infection in the world.

Eggs hatch in the intestines, and larvae migrate first to the lungs and then to the intestines, where they
mature.

Larvae in the lungs may cause cough and wheezing; masses of adult worms may obstruct the intestines
and single worms may migrate into and obstruct bile or pancreatic ducts.

Diagnose by microscopic examination of the stool; occasionally, adult worms are seen.

Treat with albendazole, mebendazole, or ivermectin; obstructions may require surgical or endoscopic
extraction of the worms.

© 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA)

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