Ascaris/Ascariasis

Ascaris is a genus of parasitic nematodes. The infection, ascariasis, is most often caused by A. lumbricoides. Transmission occurs primarily via ingestion of water or food contaminated with Ascaris eggs. Most patients with ascariasis are asymptomatic. If symptomatic, characteristics typically follow 2 phases, which correlate with the migration of the parasite through the body. The early phase may include cough, dyspnea, and wheezing. The late phase typically includes abdominal discomfort, bloating, nausea, and intermittent diarrhea. Heavy infections can cause intestinal obstruction and growth impairment in children. A diagnosis is made by recovering a full-grown parasite from the patient’s stool or by finding eggs in the patient’s stool during a microscopic examination. Management includes anthelmintic therapy with albendazole, mebendazole, or pyrantel pamoate.

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General Characteristics and Epidemiology

General features of Ascaris

Ascaris is a genus of parasitic nematodes (roundworms).

Adults: 

  • Features:
    • Striated cuticle
    • 3 small lips
    • Apical mouth
    • Lifespan: 1–2 years
  • Males: 
    • Diameter: 2–4 mm
    • Length: 15–30 cm long
    • Ventrally-incurvated end
  • Females: 
    • Diameter: 3–6 mm
    • Length: 20–50 cm 
    • Straighter end
    • Can lay up to 200,000 eggs per day

Eggs: 

  • Oval
  • Thick, lumpy outer shell
  • Unfertilized eggs are not infective.

Clinically relevant species

Ascariasis is caused by: 

  • A. lumbricoides (most common)
  • A. suum

Epidemiology

Ascariasis is one of the most common parasitic infections in humans.

  • Approximately 1 billion people are infected worldwide.
  • Majority of cases occur in:
    • Asia
    • Africa
    • South America
    • Rural > urban
    • Tropical, wet climates
  • Children > adults

Pathogenesis

Reservoirs

A. lumbricoides:

  • Humans
  • Eggs in soil

A. suum:

  • Pigs
  • Humans

Transmission

  • Fecal–oral route (A. lumbricoides and A. suum)
  • Ingesting uncooked pig or chicken liver (A. suum)

Life cycle

  • Embryonated eggs are ingested through contaminated food or water.
  • Larvae hatch → penetrate the intestinal mucosa
  • Larvae are carried through the portal system → systemic circulation → pulmonary circulation → lungs 
  • Larvae mature over 1–2 weeks in alveoli.
  • Migration up the trachea → coughed up and swallowed into the GI tract
  • Within the intestines, larvae mature into adult worms → females lay eggs
  • Eggs are excreted in feces → embryonate in the soil → cycle continues
Ascaris-Lifecycle diagram

Diagram summarizing the life cycle of Ascaris lumbricoides

Image by Lecturio. License: CC BY-NC-SA 4.0

Pathophysiology

Effect of larvae migration in the lungs → Löffler syndrome:

  • Respiratory symptoms
  • Eosinophilic pneumonitis 

Effect of adult worms in the GI tract:

  • Competition for nutrients and impaired absorption → malnutrition (particularly in children)
  • A tangled mass of worms in heavy infections → bowel obstruction
  • Aberrant migration → obstruction of: 
    • Biliary tract → cholecystitis
    • Pancreatic ducts → pancreatitis
    • Appendix → appendicitis

Clinical Presentation

General

  • Incubation period: 4–16 days after ingestion
  • Most patients with ascariasis are asymptomatic.
  • Symptomatic disease can present in 2 stages:
    • Early phase (pulmonary stage)
    • Late phase (intestinal stage)

Early phase

Symptoms of Löffler syndrome include:

  • Fever
  • Cough
  • Blood-tinged sputum 
  • Dyspnea
  • Wheezing
  • Substernal chest pain
  • Urticaria

Late phase

  • Abdominal pain
  • Bloating
  • Nausea and vomiting
  • Anorexia
  • Intermittent diarrhea
  • Adult worms passed in the stool

Complications

  • Malnutrition in children: 
    • Poor weight gain and failure to thrive
    • Short stature
    • Impaired cognitive development
  • Bowel obstruction 
  • Cholecystitis
  • Acute cholangitis
  • Liver abscess 
  • Pancreatitis 
  • Appendicitis

Diagnosis and Management

Diagnosis

Definitive:

  • Microscopic examination of the stool for eggs
  • Presence of worms in the stool

Supporting evaluation:

  • CBC: eosinophilia (more commonly seen in the early phase)
  • Imaging:
    • Chest X-ray: patchy infiltrates → Löffler syndrome
    • Abdominal X-rays: 
      • If concern for bowel obstruction
      • Barium contrast may demonstrate filling defects due to the presence of worms.
    • CT or MRI: 
      • May demonstrate worms in the bowel
      • “Bull’s eye” appearance on a cross-section of the worm
    • Ultrasound: evaluation of hepatobiliary complications
Ascaris infection in X-ray

An abdominal X-ray with barium swallow in a patient with ascariasis:
Adult worms appear in the duodenum as a tangled mass (black areas) within the white of the contrast medium.

Image: “Duodenal worms” by Larry Hadley. License: CC BY 2.0

Management

  • Albendazole (preferred)
  • Mebendazole
  • Pyrantel pamoate

Prevention

  • Wash hands.
  • Wash raw vegetables and fruits.
  • Cook food properly.
  • Sanitize properly.
  • Do not use human or pig feces as fertilizer.

Comparison of Roundworms

Table: Comparison of similar helminths and their associated diseases
OrganismEnterobius vermicularisToxocara canisAscaris lumbricoidesStrongyloides stercoralisTrichinella spiralis
ReservoirHumansDogsHumans
  • Humans
  • Dogs
  • Cats
Pigs
TransmissionFecal–oralFecal–oralFecal–oralSkin contact with contaminated soilEating raw or undercooked meat
Clinical
  • Pruritus ani
  • Abdominal pain and vomiting are less common.
  • Visceral larva migrans
  • Ocular larva migrans
  • Cough
  • Wheezing
  • Hemoptysis
  • Abdominal cramping
  • Nausea
  • Malnutrition
  • Cough
  • Wheezing
  • Abdominal pain
  • Diarrhea
  • Rash
  • Abdominal pain
  • Diarrhea
  • Nausea/vomiting
  • Fever
  • Periorbital edema
  • Myalgia
  • Petechial rash
  • Cough
  • Hepatomegaly
Diagnosis
  • Clinical
  • Cellophane tape test
  • Serology
  • Biopsy
Stool analysis
  • Stool analysis
  • Serology
  • Serology
  • Muscle biopsy
Management
  • Albendazole
  • Mebendazole
  • Pyrantel pamoate
  • Albendazole
  • Mebendazole
  • Albendazole
  • Mebendazole
  • Ivermectin
  • Albendazole
  • Self-limited
  • Albendazole
  • Mebendazole
  • Corticosteroids
PreventionGood hygiene
  • Good hygiene
  • Deworm dogs.
  • Proper disposal of dog feces
  • Good hygiene
  • Clean raw fruits and vegetables before consuming.
  • Wear shoes and protective clothing.
  • Improve sanitation.
  • Proper meat handling
  • Cook meat.

Differential Diagnosis

  • Pneumonia: infection of the lung parenchyma most often caused by a bacteria or virus. Patients present with fever, dyspnea, and productive cough. Chest X-ray findings usually show lobar consolidation; however, multifocal infiltrates can be seen in some cases. Management usually involves empiric antibiotics, which can be tailored if the causative organism is identified. Antivirals are used in cases where a viral cause is suspected.  
  • Asthma: an inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. Unlike ascariasis, the condition is chronic. Patients typically present with wheezing, cough, and dyspnea. The diagnosis is confirmed with a pulmonary function test showing a reversible, obstructive pattern. Management includes bronchodilators and inhaled corticosteroids for control of inflammation. Biologic agents may be used for severe, persistent asthma.
  • Allergic bronchopulmonary aspergillosis (ABPA): a hypersensitivity reaction to Aspergillus. Patients may have symptoms of airway obstruction such as dyspnea, wheezing, productive cough, and fever. Bronchiectasis and pulmonary fibrosis may occur if left untreated and eosinophilia may be seen. The diagnosis is made with imaging, IgE levels, skin-prick testing, and serology. Management includes steroids and antifungal therapy.
  • Gastroenteritis: inflammation of the stomach and intestines, which is commonly caused by bacteria, virus, or parasite infection. Clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Diagnostic testing with stool analysis or culture is not always required but can help determine the etiology in certain circumstances. The majority of cases are self-limited; therefore, management is typically supportive. Antibiotics are indicated in severe cases.
  • Acute cholecystitis: inflammation of the gallbladder resulting from sustained gallstone impaction of the cystic duct. Patients present with colicky, upper abdominal pain, nausea, and vomiting. Inflammation of the gallbladder and gallstones is seen on ultrasound or CT. Adult worms are not seen on imaging, which rules out ascariasis. Management includes IV fluids, antibiotics, and cholecystectomy. 
  • Acute pancreatitis: inflammation of the pancreas. Patients present with sudden-onset, severe epigastric pain, which is typically sharp and radiates to the back. The diagnosis results from characteristic abdominal pain, lipase elevation, or imaging revealing pancreatic edema. Management includes bowel rest, pain control, and IV fluid hydration.

References

  1. Centers for Disease Control and Prevention (2018). Parasites – Ascariasis. Retrieved April 28, 2021, from https://www.cdc.gov/parasites/ascariasis/biology.html
  2. Crompton DW. How much human helminthiasis is there in the world?. J Parasitol. 1999 Jun. 85(3):397–403. http://reference.medscape.com/medline/abstract/10386428
  3. Albonico M, Ramsan M, Wright V, et al. Soil-transmitted nematode infections and mebendazole treatment in Mafia Island schoolchildren. Ann Trop Med Parasitol. 2002 Oct. 96(7):717–26. http://reference.medscape.com/medline/abstract/12537633
  4. Luoba AI, Wenzel Geissler P, Estambale B, et al. Earth-eating and reinfection with intestinal helminths among pregnant and lactating women in western Kenya. Trop Med Int Health. 2005 Mar. 10(3):220–7. http://reference.medscape.com/medline/abstract/15730505
  5. Tietze, PE; Tietze, PH (March 1991). “The roundworm, Ascaris lumbricoides”. Prim Care. 18 (1): 25–41. https://pubmed.ncbi.nlm.nih.gov/2011640
  6. Mishra PK, Agrawal A, Joshi M, Sanghvi B, Shah H, Parelkar SV. Intestinal obstruction in children due to Ascariasis: a tertiary health center experience. Afr J Paediatr Surg. 2008 Jul-Dec. 5 (2):65–70. http://reference.medscape.com/medline/abstract/19858669
  7. Leder, K., and Weller, P.F. (2020). Ascariasis. In Baron, E.L. (Ed.), UpToDate. Retrieved April 28, 2021, from https://www.uptodate.com/contents/ascariasis
  8. de Lima Corvino, D.F., and Horral, S. (2021). Ascariasis. [online] StatPearls. Retrieved April 28, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK430796/
  9. Pearson, R.D. (2020). Ascariasis. [online] MSD Manual Professional Version. Retrieved April 28, 2021, from https://www.msdmanuals.com/professional/infectious-diseases/nematodes-roundworms/ascariasis
  10. Haburchak, D.R. (2018). Ascariasis. In Chandrasekar, P.H. (Ed.), Medscape. Retrieved April 28, 2021, from https://emedicine.medscape.com/article/212510-overview#showall
  11. The Australian Society for Parasitology Inc. (n.d.). Ascaris. Retrieved April 28, 2021, from http://parasite.org.au/para-site/text/ascaris-text.html

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