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Ascaris Lumbricoides (Ascariasis), Pediatric

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Ascaris Lumbricoides (Ascariasis), Pediatric

Basics

Description

Epidemiology

Ascaris lumbricoides is a large parasitic nematode (roundworm), 15-40 cm in length, which infects humans via eggs found in soil.

Children commonly acquire this infection from playing in dirt contaminated with Ascaris eggs.

Ascariasis should be considered in the differential diagnosis when a patient presents with pneumonia, peripheral eosinophilia, and/or intestinal obstruction in returned traveler or resident from an endemic area.

Surgery or endoscopic retrograde cholangiopancreatography may be required for severe intestinal or biliary tract obstruction.

Warn parents about passage of worms in stool with treatment.

  • Geographic distribution: South America, sub-Saharan Africa, China, and East Asia
  • All ages may be affected; however, children are more frequent hosts owing to oral behavior and tend to have a higher worm burden.
  • Ascariasis is more common where sanitation is poor and population is dense.
  • Eggs are viable in the soil for more than 6 years in temperate climates.
  • It is the most prevalent helminth infection in the world.
  • ~1/6 of the world's population is infected.
  • 8-15% of infections are symptomatic.120-220 million casesMostly moderate and heavy worm loads
  • 120-220 million cases
  • Mostly moderate and heavy worm loads

General Prevention

  • Sanitary disposal of human excrement, not using human feces as fertilizer, and hand washing has the potential to eliminate this infection.
  • In communities with high transmission of Ascaris, community-wide mass drug delivery of anthelmintics is effective in controlling morbidity.

Pathophysiology

  • Fertilized eggs are ingested from soil contaminated with human feces.
  • Larvae hatch in the small intestine and migrate to cecum and colon.
  • Larvae invade the mucosa into the venous system and travel to the portal circulation, inferior vena cava, and finally, pulmonary capillaries.
  • During migration through the pulmonary vessels, an eosinophilic response is evoked.
  • Larvae penetrate the alveoli, are expelled by coughing, and swallowed back (days 10-14).
  • Larvae become adult worms in the small intestine (day 24).
  • Female worms excrete up to 200,000 eggs per day.
  • Ingestion to excretion takes 2-3 months.
  • Once in soil, fertilized eggs require 2-3 weeks of incubation in soil to become infectious and restart cycle.

Etiology

Commonly Associated Conditions

  • This infection may be associated with other soil-transmitted helminths:Hookworm (Necator americanus, Ancylostoma duodenale)Trichuris trichiuraStrongyloides stercoralisToxocara canis
  • Hookworm (Necator americanus, Ancylostoma duodenale)
  • Trichuris trichiura
  • Strongyloides stercoralis
  • Toxocara canis

Diagnosis

History

  • Gastrointestinal symptoms include the following:Abdominal distentionPainNauseaDiarrheaDecreased appetite
  • In the chronic phase, ascariasis is associated with the following:Growth stuntingCognitive delays
  • Severe respiratory symptoms during the pulmonary migratory stage, when larvae cause an inflammatory response (L ¶effler syndrome), characterized by the following:DyspneaCoughFeverShifting pulmonary infiltratesEosinophilia
  • Severe presentation during the intestinal phase, when symptoms are due to the presence of worms:PainObstruction (2 per 1,000)Peritonitis from perforationBiliary colic, hepatitis, or pancreatitis from blockages due to worms
  • History of passage of large worms in the stool or vomitus is suggestive of ascariasis.
  • History of wheezing may precede passage of worms by 2-3 months.
  • Abdominal distention
  • Pain
  • Nausea
  • Diarrhea
  • Decreased appetite
  • Growth stunting
  • Cognitive delays
  • Dyspnea
  • Cough
  • Fever
  • Shifting pulmonary infiltrates
  • Eosinophilia
  • Pain
  • Obstruction (2 per 1,000)
  • Peritonitis from perforation
  • Biliary colic, hepatitis, or pancreatitis from blockages due to worms

Physical Exam

  • Chest: may have rales or wheezing if Ascaris larvae are in the lungs
  • AbdomenDistendedAuscultate and palpate for signs of obstruction or perforation.
  • Distended
  • Auscultate and palpate for signs of obstruction or perforation.

Diagnostic Tests & Interpretation

  • Microscopic examination of stool specimens will demonstrate the characteristic ascaris eggs (round with thick shell).
  • During the pulmonary phase, may have peripheral eosinophilia and larvae in sputum, but negative stool examinations
  • Serologic tests are unnecessary and are poorly specific to the diagnosis.
  • Chest radiograph, if cough is present
  • Abdominal imaging, if abdominal signs or symptoms of obstruction or perforation

Differential Diagnosis

Treatment

Medication

  • OralAlbendazole400 mg, single doseWHO recommends 200 mg single dose for children <1 year old.Mebendazole100 mg, b.i.d. for 3 days or 500 mg onceIvermectin150-200 mcg/kg, single dose
  • Alternatives (oral):Pyrantel pamoate11 mg/kg to max 1 g per day for 3 daysPiperazine citrate75 mg/kg/24 h for 2 days; maximum, 3.5 gHas been used historically for cases of intestinal obstruction (causes worm paralysis), but it is no longer available in the United States
  • Albendazole400 mg, single doseWHO recommends 200 mg single dose for children <1 year old.
  • Mebendazole100 mg, b.i.d. for 3 days or 500 mg once
  • Ivermectin150-200 mcg/kg, single dose
  • 400 mg, single dose
  • WHO recommends 200 mg single dose for children <1 year old.
  • 100 mg, b.i.d. for 3 days or 500 mg once
  • 150-200 mcg/kg, single dose
  • Pyrantel pamoate11 mg/kg to max 1 g per day for 3 days
  • Piperazine citrate75 mg/kg/24 h for 2 days; maximum, 3.5 gHas been used historically for cases of intestinal obstruction (causes worm paralysis), but it is no longer available in the United States
  • 11 mg/kg to max 1 g per day for 3 days
  • 75 mg/kg/24 h for 2 days; maximum, 3.5 g
  • Has been used historically for cases of intestinal obstruction (causes worm paralysis), but it is no longer available in the United States

Surgery/Other Procedures

Ongoing Care

Follow-up Recommendations

  • Treatment is highly effective.
  • Reexamination of stool specimens 2 weeks after therapy can be considered but is not essential.
  • Reinfection is common in endemic areas and has led to mass drug administration programs.

Prognosis

  • Once intestinal infection is detected and treated, the prognosis is excellent.
  • If obstructive or respiratory complications have occurred, the prognosis is less favorable.
  • The case fatality rate in cases with complications is up to 5%, most from obstruction.

Complications

  • Bronchopneumonia may be seen during the pulmonary migrational stage, producing fever, cough, dyspnea, wheeze, eosinophilia, and pulmonary infiltrates (L ¶effler syndrome).
  • Heavy infestations may cause abdominal pain, malabsorption, and growth failure.
  • Children may experience obstruction (ileocecal), malabsorption, or intussusception.
  • Perforation or migration into the appendix, biliary, or pancreatic ducts may rarely occur.
  • Hepatitis, acute cholecystitis, or pancreatitis can occur. Liver abscess can occur if intrahepatic ducts are obstructed.

Additional Reading

  • American Academy of Pediatrics. Ascaris lumbricoides infections. In: Pickering LK, Baker CJ, Kimberlin DW, et al, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:239-240.
  • Capello M, Hotez PJ. Intestinal nematodes. In: Long S, Pickering L, Prober C, eds. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Churchill Livingstone/Elsevier; 2008:1296-1298.
  • Centers for Disease Control and Prevention. Parasites-ascariasis. http://www.cdc.gov/parasites/ascariasis/. Accessed November 24, 2013.
  • Dold C, Holland CV. Ascaris and ascariasis. Microbes Infect. 2011;13(7):632-637. [View Abstract]
  • Hall A, Hewitt G, Tuffrey V, et al. A review and meta-analysis of the impact of intestinal worms on child growth and nutrition. Matern Child Nutr. 2008;4(Suppl 1):118-236. [View Abstract]
  • O'Lorcain P, Holland CV. The public health importance of Ascaris lumbricoides. Parasitology. 2000;121(Suppl):S51-S71. [View Abstract]
  • World Health Organization. Intestinal worms. http://www.who.int/intestinal_worms/en/. Accessed November 24, 2013.

Codes

ICD09

  • 127.0 Ascariasis

ICD10

  • B77.9 Ascariasis, unspecified
  • B77.0 Ascariasis with intestinal complications
  • B77.81 Ascariasis pneumonia
  • B77.89 Ascariasis with other complications

SNOMED

  • 50982003 Infection by Ascaris lumbricoides (disorder)
  • 1082721000119101 Pneumonia due to Ascaris (disorder)

FAQ

  • Q: What are the long term effects of untreated Ascaris infection in children?
  • A: Growth stunting and cognitive delays are the most common long-term effects of untreated infections. Given the prevalence of this infection in the world, this is a major cause of morbidity in the world.