Ascariasis by Giant Intestinal

Worms

Dr. Lwidiko E. Mhamilawa

 Contents
• Introduction
• Classification
• Morphology
• Life cycle
• Pathogenesis
• Clinical manifestation
• Diagnosis
• Treatment
• Epidemiology
• Prevention and control
• References
 Introduction
• Ascaris is a genus of parasitic nematode
• It is the largest nematode (round worms) parasitizing the
human intestine
• One species, Ascaris lumbricoides, affects humans and
causes the disease ascariasis.
• Another species, Ascaris suum, typically infect pig –
ascaris equorum,the equine round worm,is also
commonly called Ascarid
 Cont…
• Ascaris suum, also known as the large roundworm of
pig, is a parasitic nematode that cause ascaris in pig

• Ascaris lumbricoides, an intestinal roundworm, is one of

the most common helminthic human infections worldwide.

• Highest prevalence in tropical and subtropical regions,

and areas with inadequate sanitation. in humid and warm
climates, and areas where poverty, poor hygiene
 Cont…
• Ascariasis occurs in rural areas of the southeastern
United States. In United States, ascariasis is the third
most frequent helminth infection,
• Ascaris lumbricoides is the largest intestinal nematode of
man
• It has been estimated that 1.5 billion cases of infection
globally and 65,000 deaths occur due to A. lumbricoides.
 Classification
Kingdom Animalia

Phyllum Nematoda

Class Chromadorea

Order Ascaridida

Family Ascarididae

Genus Ascaris

Species Ascaris lumbricoides

 Mophology
• Ascaris lumbricoides is the largest intestinal nematode of
humans. Adult Females are 20 to 35 cm long thickness
2-6mm; Adult males are smaller 15 to 30 cm long
thickness 2-4mm
• Three types of eggs may appear in form: fertilized,
unfertilized, and decorticated.
Ø Fertilized egg : oval, transparent shell / unsegmented
embryo •
Ø Unfertilized egg : longer and narrower
Ø Decorticated eggs : smooth & oval
 Cont…
q Adult ascaris lumbricoides(Female)

• Females are
20 to 35 cm long
thickness 2-6mm
 Cont…
q Adult Ascaris lumbricoides (male)
Male are smaller
15-30cm long
with thickness 2-4mm
 Cont…
Fertilized eggs are
oval in shape, measuring
40×60 μm Mammillated
Albuminous coat or
covering on outer shell
 Cont…
• Unfertilized egg
of A. lumbricoides
- Unfertilized eggs are larger,
measuring 60×90 μm and
more elongated in shape,
have a thinner shell, and
are poorly organized internally
 Cont…
q Decorticated, fertile
egg of A. lumbricoides
• The egg is termed
decorticate if the external
albuminous layer is absent
decorticated eggs have a colorless shell with gray or black
internal material..
 Life cycle
• Adult worms live in the lumen of the small intestine,female
may produce approximately 200,000 eggs per day, which
are passed with the feces
• Unfertilized eggs may be ingested but are not
infective. Fertile eggs embryonate and become infective
after 18 days to several weeks
• Depending on the environmental conditions (optimum:
moist, warm, shaded soil). After infective eggs are
swallowed
 Cont…
• The larvae hatch , invade the intestinal mucosa, and are
carried via the portal, then systemic circulation to
the lungs
• The larvae mature further in the lungs (10 to 14 days),
penetrate the alveolar walls, ascend the bronchial tree to
the throat, and are swallowed
• Upon reaching the small intestine, they develop into adult
worms . Between 2 and 3 months are required from
ingestion of the infective eggs to oviposition by the adult
female.
• Adult worms can live 1 to 2 years. Source: CDC’s Parasite
and Health Page about intestinal ascariasis
Life cycle-Diagram
 Pathogenesis
q Larva in the Lung

• Destroy the capillaries-Hemorrhage

• Migration of inflamation cells which lead to Ascaris

pneumonitis/loefflers syndrome

• Lung tissue destroyed lead to secondary bacteria

infection
 Cont…
qLarvae in general circulation
• When symptoms do occur, they relate either to the larval
migration stage or to the adult worm intestinal stage.

• Heavy infections with Ascaris are frequently believed to

result in abdominal discomfort, anorexia, nausea and
diarrhea passing of worms from the rectum or the mouth,
 Clinical feature
q The migrating larvae
• Larvae in the lung condition is known as Ascaris
pneumonia/loefflers syndrome that characterized by
grade fever,cough,urticaria, eosinophillia,blood tinged
sputum which contain larva
q Larva general circulation
• Larva can pass through pulmonary circulation into
systemic circulation and filtered to various organ
• Symptoms depend on the site of localization and number
of larva example in kidney –Nephrotic syndrome
 Cont…
q Complications
• Intestinal obstruction
• intussusception
• Obstruction of intra and extra hepatic bile duct
• Peritonitis due to intestinal obstruction
• Chlonic pancreatic
• Pneumonia,bronchitis and asthma
• Malnutriation
Cont…
 Lab -Diagnostic
q Direct examination of faeces or following concentration
technique

• Ascaris lumbricoides
in stool – Wet mount of stool
examined under microscope
(x40) showing the egg
of ascaris lumbricoides.
 Cont…
q Kato–Katz thick-smear technique
• A faecal sample on scrap paper is pressed through a
small screen and,with a spatula,
• The Kato-Katz technique facilitates the detection and
quantification of eggs that infected subjects pass in their
faeces.
• A thick smear is prepared on a microscopic slide and
helminth eggs are enumerated under a light microscope
 Other Dx
q Endoscopic retrograde cholangiopancreatography

Biliary ascariasis –
Cholangiogram obtained
during endoscopic retrograde
cholangiopancreatography
shows a linear filling defect
(arrow) that was later identified
as an adult Ascaris
lumbricoides worm.
 Other Dx
• Ultrasound — Ultrasound examinations can help to
diagnose hepatobiliary or pancreatic ascariasis. Single
worms, bundles of worms, or a pseudotumor-like
appearance may be seen
• Computed tomographic (CT) scanning or magnetic
resonance imaging (MRI) may also be used to identify
worm(s) in the liver or bile ducts
• Other tests that suggest infection include blood
tests(FBP) that show eosinophilia (the increased
presence of a certain type of white blood cell)
 Treatment
• Pyrantel pamoate — Pyrantel pamoate (11 mg/kg up to
a maximum of 1 g) is administered as a single dose
• Mebendazole — Mebendazole (100 mg BID for 3 days
or 500 mg as a single dose) is an alternative
• Albendazole — A single dose of albendazole (400 mg)
is effective in almost 100 percent of cases,
• Ivermectin — Ivermectin causes paralysis of adult
worms and is approximately as effective as other
available therapies but is not generally used.
Note:Pregnant women recommended to take pyrantel
pamoate
 Cont…

q Surgery
• In cases of heavy infestation, surgery may be necessary
to remove worms and repair damage they've caused.
Intestinal blockage or holes, bile duct blockage, and
appendicitis are complications that may require surgery.
 Epidemiology
• Ascaris lumbricoides cause Ascariasis one of the
Neglegated Soil-transmitted helminths infection of
greatest Public Health Importance

• Most cases occur in tropical and subtropical areas of

Asia, sub-Saharan Africa, and the Americas

• The highest prevalence of ascariasis occurs in tropical

countries where warm, wet climates provide
environmental conditions that favor year-round
transmission of infection.
 Cont…
• It is estimated that more than 1.4 billion people are
infected with A. lumbricoides, representing 25 percent of
the world population
• Transmission is enhanced by the fact that individuals can
be asymptomatically infected and can continue to shed
eggs for years, yet prior infection does not confer
protective immunity
• Age related distribution shows that prevalence reaches a
peak between the ages of 4 and 14 years.
 Cont…
• Transmission occurs mainly via ingestion of water or
food (raw vegetables or fruit in particular) contaminated
with A. lumbricoides eggs and occasionally via inhalation
of contaminated dust.
• Children playing in contaminated soil may acquire the
parasite from their hands. Transplacental migration of
larvae has also occasionally been reported
• In Tanzania Cross-Sectional study done in mbeya,based
on population, Ascaris lumbricoides infection associated
with environmental, socio-demographic and sanitary
factors ,and prevalence was 6.8%,
 Prevention/control
• Avoid ingesting soil that may be contaminated with
human faeces including where human fecal matter
(“night soil”)
• Good sanitation to prevent fecal contamination of soil is
required.
• Wash hands with soap and water before handling food
• An education program advising against the use of
human feces as a fertilizer is also needed in some areas.
 Cont…
• Health education to the community especially children
on how and the importance of washing hands to prevent
infection
q Mass treatment
• Periodic mass treatments with single dose mebendazole
or albendazole for all school-age children(4-14years old)
• This serves the dual function of treating the children and
reducing the overall worm burden in the community.
 References
• Jessika lora from Karimu leder and Peter F Wellers-Up
to date review of ascariasis 2017
• Parasites - Ascariasis.(14 February 2018).Retrieved
from https://www.cdc.gov/parasites/ascariasis/biology.ht
ml
• Worms and Human Diseases, 2nd edition by Ralph
Muller,; Chpt 2.;Pg 65-71
• Parasites - Ascariasis". U.S. Centers for Disease Control
and Prevention. Retrieved 3 March 2016
• Worms and Human Diseases, 2nd edition by Ralph
Muller,; Chpt 2.;Pg 65-71
 Cont…
• A. J. Cooper and T. D. Hollingsworth, “The impact of
seasonality on the dynamics and control of _Ascaris
lumbricoides_ infections,” Journal of Theoretical Biology,
vol. 453, pp. 96–107, 2018.
• E. A. Shiraho, A. L. Eric, I. N. Mwangi et al.,
“Development of a loop mediated isothermal
amplification for diagnosis of Ascaris lumbricoides in
fecal samples,” Journal of Parasitology Research, vol.
2016, Article ID 7376207, 2016.
• Textbook of Medical Parasitology, 6th edition by Panker
CK, (2007); Chpt 6.; Pg 139-144