Intestinal Nematodes:

Hookworms and Strongyloides

Francis Ian L. Salaver, RMT, MD
 General characteristics
• Soil transmitted
• Ascaris lumbricoides – ingestion of embryonated ovum
• Trichuris trichiura – same as Ascaris

• Food-borne
• Capillaria philippinensis – ingestion of encysted larva in raw fish meat

• Larval lung migration

• Ascaris lumbricoides

• Autoinfection
• None
Hookworms
 Hookworms
• Diagnostic stage

• Infective stage

• Mode of transmission?

• Autoinfection? Yes or No?

• Larval lung migration? Yes or No?

 Hookworms
• Diagnostic stage : ova/egg in stool

• Infective stage: filariform larva/ third stage larva/ L3 larva

• Mode of transmission? Skin penetration

• Autoinfection? No

• Larval lung migration? Yes

 General characteristics
• Soil transmitted
• Ascaris lumbricoides – ingestion of embryonated ovum
• Trichuris trichiura – same as Ascaris
• Hookworms – skin penetration

• Food-borne
• Capillaria philippinensis – ingestion of encysted larva in raw fish meat

• Larval lung migration

• Ascaris lumbricoides
• Hookworms

• Autoinfection
• None
 Hookworms

• Ancylostoma duodenale (Old World

Hookworm)
• Necator americanus (New World
Hookworm)
• Characteristics of adult worms
• Small grayish-white
• Anterior end with conspicuous bend or
hook-like appearance
 Hookworms
• Characteristics of adult worms

• Adult female is larger than male

• Posterior end of male has

expansion called caudal bursa for
copulation
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 Necator americanus

• The head is curved opposite

to the curvature of the body
 Ancylostoma duodenale

• The head is continuous to the

same direction as the body
Hookworms
 Hookworms
•Characteristics of adult worms Ancylostoma duodenale Necator americanus

• Buccal capsule
• Ancylostoma duodenale: 2 pairs of
curved teeth

• Necator americanus: Pair of

semilunar cutting plates
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 Compare the spicules

Ancylostoma duodenale – 2 spicules

Necator americanus – FUSED spicule

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 Hookworms

Dorsal ray of Necator

americanus is bifid

Dorsal ray of
Ancylostoma
duodenale is tridigitate
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Thin hyaline shell with embryonic cleavage
Pathogenesis and Clinical Manifestations
 Pathogenesis and Clinical Manifestations
• The pathology of hookworm infection involves:

• (1) the skin at the entry of the filariform larva

• (2) the lung during the larval migration

• (3) the small intestine

 Pathogenesis and Clinical Manifestations
• (1) the skin at the entry of the filariform larva

• Ground itch or dew itch refers to the

inflammatory reaction resulting from invasion
of the skin by the filariform larva

• Itchy and erythematous maculopapular rash

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Ground itch
Ground itch
 Pathogenesis and Clinical Manifestations
• (2) the lung during the larval migration

• Loeffler’s syndrome
• Dry cough, wheeze, dyspnea and fever
• Eosinophilic pneumonia

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 Pathogenesis and Clinical Manifestations
• (3) the small intestine

• Buccal capsule attaches worm to intestinal

wall, saliva contains anticoagulant which
keeps the area bleeding

• Abdominal pain, diarrhea and steatorrhea

• Hookworm feed on blood of humans

• Loss of albumin - hypoalbuminemia
• Loss of iron in hemoglobin – microcytic
hypochromic type of anemia

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 Hookworm Disease
• Ancylostomiasis; Necatoriasis
• Site of entry “ground itch”
• Bronchitis and pneumonitis
• Abdominal pain, steatorrhea, diarrhea
• Eosinophilia
• Chronic infection: microcytic hypochromic anemia of iron
deficiency type, hypoalbuminemia
 Diagnosis
• Direct fecal smear – demonstration of the egg in stool sample
• Kato-katz technique
• Concentration techniques

• Harada-Mori Culture
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 Treatment
• Albendazole – drug of choice
• Mebendazole – alternative drug

• Anemia – iron supplementation

• Hypoalbuminemia – adequate diet
Prevention
Strongyloides stercoralis: Free-living cycle
Strongyloides stercoralis: Parasitic Cycle
 Strongyloides stercoralis
• Diagnostic stage

• Infective stage

• Mode of transmission?

• Larval lung migration?

• Autoinfection??
 Strongyloides stercoralis
• Diagnostic stage: rhabditiform larva and occasionally
filariform larva in stool

• Infective stage: filariform larva

• Mode of transmission? : skin penetration

• Larval lung migration? : Yes

• Autoinfection?? Yes
 General characteristics
• Soil transmitted
• Ascaris lumbricoides – ingestion of embryonated ovum
• Trichuris trichiura – same as Ascaris
• Hookworms – skin penetration
• Strongyloides stercoralis – skin penetration

• Food-borne
• Capillaria philippinensis – ingestion of encysted larva in raw fish meat

• Larval lung migration

• Ascaris lumbricoides
• Hookworms
• Strongyloides stercoralis

• Autoinfection
• Strongyloides stercoralis
Adults: Esophagus intertwined with uterus
 Common names

• Giant intestinal roundworm

• Pinkworm
• Pinworm
• Threadworm
• Whipworm
• Sitworm
• Pudoc worm
 Pathogenesis and Clinical Manifestations
• The pathology of infection with Strongyloides stercoralis involves:

• (1) invasion of the skin by the filariform larva

• (2) migration of the larva through the body

• (3) penetration of the intestinal mucosa by the female adult

 Pathogenesis and Clinical Manifestations
• (1) invasion of the skin by the filariform larva

• Larva currens
• Erythematous serpiginous skin lesion at the site of
entry caused by the rapid moving filariform larva
• Accompanied with pruritus and urticaria

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Ground itch vs Larva currens
 Pathogenesis and Clinical Manifestations
• (2) migration of the larva through the body

• During larval migration phase, the lungs are

destroyed causing lobar pneumonia with
hemorrhage

• Cough and tracheal irritation mimicking

bronchitis

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Strongyloides infection in a cat

www.askjpc.org/wsco/wsc_showcase2.php?id=bDg5MXRqOWd1VUZlOU91QnRRdlVPdz09
Strongyloides infection in a cat

www.askjpc.org/wsco/wsc_showcase2.php?id=bDg5MXRqOWd1VUZlOU91QnRRdlVPdz09
 Pathogenesis and Clinical Manifestations
• (3) penetration of the intestinal mucosa by the female adult

• Light infection does not cause intestinal symptoms

• Moderate infection causes diarrhea alternating with constipation

• Heavy infections produces intractable, painless and intermittent diarrhea

(Cochin-China diarrhea)

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 Chronic strongyloidiasis
• Often asymptomatic

• There could be episodes of vomiting, diarrhea and constipation

• Recurrent asthma is also seen

• Can lead to emaciation, loss of appetite, GIT bleeding, anemia, intestinal

obstruction, and malabsorption leading to cachexia
 Hyperinfection
• Syndrome of accelerated autoinfection that occurs with
immunocompromised patients

• Exacerbation of gastrointestinal and pulmonary symptoms

• Increased number of larvae in stool samples and even in sputum

https://juniperpublishers.com/argh/pdf/ARGH.MS.ID.555741.pdf
Strongyloides ova and larva
Strongyloides stercoralis
rhabditiform larva
 Hookworm
rhabdtiform larva
Strongyloides stercoralis
filariform larva
 Hookworm
filiform larva
 Diagnosis

• CBC - eosinophilia
• Harada-Mori culture
• Duodenal aspirations
• Sputum can be used in cases of
disseminated strongyloidiasis
 Treatment
• Albendazole
• Thiabendazole
• Ivermectin