Celophane

D
Figs 46.20A to E: Enterobius vermicularis: A. Cellophane tape; B. Adult worms (actual size); C. Adult female worm containing
numerous eggs; D. Planoconvex eggs; E. NIH swab method (schematic).
Source: Band C. Head, Department of Microbiology. Meenakshi Medical College, Chennai; D. DPDx Image Library, Centers for Disease Control
and Prevention (CDC), Atlanta (with permission).

CHAPTER 46 Intestinal Helminthic Infections 461

Prevention Man acquires h ed

infection
ing ted
Total prevention is neither realistic nor possible as the soil food and water
with embryonated egg
transmission is so common; aided by autoinfection.
Improving personal hygiene such as proper washing of Rhabditiform
bed clothes, keeping nail short and clean, frequent hand Embryonated egg larva (L,) hatches
containing larva out from egg
washing are the key measures to contain the transmission.

ASCARIASIS
Embryonation
Unembryonated eggs
\Molting
passed in feces Larva penetrates
Ascariasis is an infection of the small intestine caused by intestinal wall
Ascaris lumbricoides. It is the largest nematode parasitizing Venous
the human intestine. It is commonly called as roundworm.
Fertilization circulati atin
It is a soil-transmitted helminth (see the highlight box, Right side of heart
Develops into
De
subsequently in this chapter). adult worm POmonary
Epidemiology Small intestine Lungs
A. lumbricoides is cosmopolitan in distribution, mainly
affecting tropical countries including India. Swallowed Pharynx
» It is estimated that 807-1200 million people are infected Fig. 46.21:Life cycle of Ascaris lumbricojdes.
obally, ofwhich 120-250 milion are
glob:
Transmission typically occurs symptomau
fecally * Development in soil: The fertilized eggs molt twice
contaminated soil and is due to either lack of sanitary become embryonated (carrying L, larvae), which is
facilities or use of human feces as fertilizer infective to man and the life cycle continues. It occurs
* Clay soils are most favorable for the development of within 2 weeks under suitable conditions such as warm
Ascaris eggs (in contrast to moist porous soil required and clay soil, 22-30°C and 40% humidity
for hookworm) The unfertilized eggs cannot develop further, are not
* Risk factors: Children (most important disseminator of infective and disintegrate in some time
the disease) and malnutrition. Ascaris embryonated eggs survive for as long as
15 years as they are highly resistant due to the
Morphology characteristic thick eggshel. ,alipoprotein
Similar to other nematodes, Ascaris exists in three present in the eggshell is re u.te forits resistance
forms: adult, larvae (four stages) and egg. Adult worm is to disinfectants.
cylindrical and measures 15-31 cm. The female worms
liberate two types of eggs--(1) fertilized eggs, and (2) Pathogenesis and Clinical Feature
unfertilized eggs. Pathogenesis caused by Ascaris infection is attributed
to (i) the host immune response, (ii) migration of larva,
Life Cycle (Fig. 46.21) (ii) mechanical obstruction by the adult worms, and (iv)
Ascaris involves only one host (man). Embryonated eggs nutritional deficiencies due to the presence of adult worms.
containing the L, larvae are the infective form. The incubation period is about 60-7o days; however the
* Mode of transmission: Ingestion of embryonated eggs pulmonary symptoms can be earlier.
from the contaminated soil, food and water
Migratory phase: Following ingestion, the eggs hatch Pulmon ary Phase
out to liberate the L, larvae, which molt once to form L,, Iresults from migrating larvae in the lungs, which provoke
The L,larvae penetrate the intestine, reach right side an immune-mediated hypersensitivity response.
of the heart via portal circulation, then enter lungs * Symptoms are observed in the second week after the
via pulmonary capillaries, where they molt once to ingestion of eggs; characterized by non-productive
form L, cough, chest discomfort and fever
TheL,larvaeinthe lungs migrate up to reach pharynx * Eosinophilic pneumonia (Loeffler's syndrome): In
and finally are swallowed to re-enter the intestine. severe cases, patients develop dyspnea and a transient
Intestinal phase: The L, larvae undergo final molt to patchy infiltrates seen in the chest X-ray along with
develop into adult worms in the small intestine transient peripheral eosinophilia.
Following fertilization, the female worms start laying
the fertilized eggs which are passed in the feces. Intestinal Phase
Sometimes, before mating, the female worms may It results due the effect of adult worm in the intestine.
directly lay the unfertilized eggs Asymptomatic: Most people with mild Ascaris infections
Agravid female can lay 2.4 lakh eggs/day. are asymptomatic

462 SECTION5 Gastrointestinal (GI) Infections

Malnutrition and growth retardation: Robbing the Contd.

nutrition from the host may result innchr
chronic malnutrition
and growth retardation (in children <5 years). It is often Unfertilized eggs (Fig. 46.23B)
Elongated, measure 85-95 um x43-47 um
associated with impairment of educational performance, O Albuminous coat is thin, distorted and scanty
language learning, social, gross motor, and fine motor Q Contains an unsegmented, smalll atrophied ovum with
skills in children a mass of disorganized highly refractile granules and no
* Intestinal complications: A large bolus of entangled crescentic space at poles
worms can causeintestinal obstruction, rarelyperforation, O Bile-stained, appear golden brown in saline mount
o Does not float in saturated salt solution
intussus ception, or volvulus. It is usually seen in age
group >5 years and presents as acute pain abdomen Decorticated eggs (Fig. 46.23C)
Sometimes, the fertilized eggs lose the thick mamillated
* Extraintestinal complications: Larger worms can albuminous coat and called as decorticated eggs.
enter and occlude the biliary tree, causing biliary colic,
cholecystitis, pancreatitis, or (rarely) intrahepatic Adult Worm Detection
abscesses. Wandering worms may migrate to pharynx
and can cause respiratory obstruction or may block the Occasionally, adult worms may be detected in stool or
eustachian tube sputum of the patients by naked eye (Fig. 46.24)
* Allergic manifestations like fever, urticaria, * Barium meal X-ray of the GIT may demonstrate the
angioneurotic edema and conjunctivitis may occur due adult worms in the intestine. When two worms are lying
to toxic fluid (ascaron or ascarase) released by the adult parallel, gives trolley car lines appearance in X-ray
worm. * Ultrasound or cholangiopancreatography should be
done to detect the adult worms in extraintestinal sites.
Laboratory Diagnosis Larva Detection
Detection of the Parasite
During the early pulmonary migratory phase, larvae can be