ASCARIASIS

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 Introduction

• Ascariasis is an infection of the small

intestine caused by Ascaris lumbricoides
• It is the largest nematode parasitizing the
human intestine
• It is commonly called as Roundworm
• It is a soil-transmitted helminth Adult worm of A. lumbricoides
Image Source: DPDx Image Library,
Centers for Disease Control and
Prevention (CDC), Atlanta

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 Epidemiology
• A. lumbricoides is cosmopolitan in distribution, mainly affecting
tropical countries including India
• It is estimated that 807–1200 million people are infected globally, of
which 120–250 million are symptomatic
• Transmission: Typically occurs through fecally contaminated soil and is
due to either lack of sanitary facilities or use of human feces as
fertilizer
• Risk factors: Children (most important disseminator of the disease)
and malnutrition

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 Morphology
.
3 forms

Egg Larvae Adult

Unfertilized Fertilized

The canonical nematode life cycle

https://www.cell.com/trends/parasitology

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 Life Cycle

• Host: Ascaris involves only one host (man)

• Infective form: Embryonated eggs containing the L2 larvae are the

infective form

• Mode of transmission: Ingestion of embryonated eggs from the

contaminated soil, food and water
• Migratory phase:
Following ingestion, the eggs hatch out to liberate the L2 larvae

Which molt once to form L3 larvae

Penetrate the intestine, reach the right side of the heart via portal circulation

Then enter the lungs

Molt once to form L4 larvae in the lungs

Migrate up to reach pharynx

Finally are swallowed to re-enter the intestine

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Intestinal phase:
• The L4 larvae undergo a final molt to develop into adult worms in the small intestine
• Following fertilization, the female worms start laying the fertilized eggs which are passed
in the feces
• Sometimes before mating, the female worms may directly lay the unfertilized eggs. A
gravid female can lay up to 2.4 lakhs eggs per day

Development in soil:
• The fertilized eggs molt twice become embryonated (carrying L2 larvae), which is
infective to man and the life cycle continues
• It occurs within 2 weeks under suitable conditions such as warm and clay soil, 22–30°C
and 40% humidity
• The unfertilized eggs cannot develop further, are not infective and disintegrate in some
time
• Ascaris embryonated eggs survive for as long as 15 years as they are highly resistant due
to the characteristic thick eggshell. Ascaroside, a lipoprotein present in the eggshell is
responsible for its resistance to disinfectants

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 Life cycle of Ascaris lumbricoides
Chapter-12 Nematodes—I (Intestinal Nematodes), Essentials of Medical Parasitology 8
Apurba Shastry
 Pathogenesis
• It is attributed to
(i) the host immune response
(ii) migration of larva
(iii) mechanical obstruction by the adult worms
(iv) nutritional deficiencies due to the presence of adult worms.

• The incubation period is about 60–70 days

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 Clinical Features
Pulmonary Phase:
• It results from migrating larvae in the lungs
• Provokes an immune-mediated hypersensitivity response
called Eosinophillic pneumonia (Loeffler’s syndrome)
• Symptoms: Non-productive cough, Chest discomfort,
Fever & Dyspnea
• A transient patchy infiltrates seen in the chest X-ray along
with transient peripheral eosinophilia Pulmonary Infiltrates and
Eosinophilia
https://www.researchgate.net/figure

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Intestinal Phase:
• It results due the effect of adult worm in the intestine
• Asymptomatic: Most people with mild Ascaris infections are asymptomatic
• Malnutrition and growth retardation: Robbing the nutrition from the host may result in
chronic malnutrition and growth retardation. It is often associated with impairment of
educational performance, language learning, social, gross motor, and fine motor skills in
children
• Intestinal complications: A large bolus of entangled worms can cause intestinal
obstruction, rarely perforation, intussusception, or volvulus
• Extraintestinal complications: Larger worms can enter and occlude the biliary tree,
causing biliary colic, cholecystitis, pancreatitis, or (rarely) intrahepatic abscesses
• Wandering worms may migrate to pharynx and can cause respiratory obstruction or may
block the eustachian tube
• Allergic manifestations like fever, urticaria, angioneurotic edema and conjunctivitis may
occur due to toxic fluid (ascaron or ascarase) released by the adult worm

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 Laboratory Diagnosis
Stool examination:
• Both fertilized and unfertilized eggs can be
detected by stool examination by saline and
iodine wet mount
• Concentration techniques by sedimentation
method should be done if direct stool
microscopy is negative to improve detection
• Floatation method for stool concentration is not Saline mount of Eggs of Ascaris
www.laboratorytests.org
preferred as unfertilized eggs do not float on
saturated salt solution
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 Fertilized eggs Unfertilized eggs
Round to oval and smaller Elongated and larger
Surrounded by thick mamillated Albuminous coat is thin, distorted and
albuminous coat scanty
Contains a large unsegmented ovum with Contains unsegmented small atrophied
clear crescentic space at both the poles. ovum and no crescentic space at the
Sometimes the fertilized egg loses this poles
coat and is called as decorticated eggs

Bile-stained appear golden brown in Bile-stained appear golden brown in

saline mount saline mount
Floats in saturated salt solution Do no float in saturated salt solution

Fertilized Decorticated Unfertilized egg

corticated egg fertilized egg

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Image source: www.researchgate.net/figure/Eggs-of-Ascaris-lumbricoides
Adult Worm Detection:
• Adult worms may be detected in stool or sputum of the patients by
naked eye
• Barium meal X-ray of the GIT may demonstrate the adult worms in
the intestine

Larvae Detection: It can be found in sputum or gastric aspirates

during the early pulmonary migratory phase

Antibody detection: (by ELISA and other formats) though sensitive;

cannot differentiate between recent and past infection

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Molecular Method: PCR assay has been developed targeting Ascaris
specific gene in the stool. Multiplex PCR can simultaneously
differentiate Ascaris, Trichuris and hookworm. Real-time PCR can be
used for quantitation of the parasite load in the stool

Eosinophilia is prominent during the early lung stage, but disappears

later

Presence of Charcot-Leyden crystals in sputum and stool, a

nonspecific finding seen in ascariasis

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 Treatment
• Albendazole or Mebendazole is the drug of choice
• In pregnancy, Pyrantel Pamoate is safe

Prevention
• The use of human feces, or “night soil,” for fertilization of crops
should be avoided as it is an important source of Ascaris (mainly) and
other helminthic infections

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 Reference
• Essentials of Medical Microbiology (4th Edition) –Apurba S. Sastry
• Essentials of Medical Parasitology (2nd Edition) –Apurba S. Sastry

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Thank you!

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