Roundworm Infection

Estimates suggest that one quarter of the world's population is infected with the intestinal roundworm Ascaris lumbricoides.  The vast majority of infected people are asymptomatic.  Patients who are newly infected may have pulmonary symptoms (e.g. cough, wheezing) and eosinophilia due to larval migration through the lungs.  Later, abdominal symptoms may develop because of the mechanical effects of the relatively large adult worm.  Patients in this later stage do not demonstrate eosinophilia.

The adult A lumbricoides is a large, cream-colored worm.  Adult males are 6-12 inches (15-30cm) in length, and adult females are 8-14 inches (20-35cm) in length.  Adult worms can live in the small intestine for 6 months or longer.

Incidence; Causes and Development; Contributing Risk Factors

In the US, occurrence is uncommon.  Approximately 4 million people in the United States are infected, mostly in the rural southeast.  In developing countries, more than 1 in 4 people are infected (e.g. Southeast Asia [73% infected], Africa [12%], Central/South America [8%]).

The roundworm life cycle begins when eggs from adult female worms living in the intestine are passed out with feces.  These eggs then contaminate the soil and, and in warm moist conditions, will develop to the stage where they can become infective.  These eggs are then swallowed, for example on fruits or vegetables that have been watered with water containing contaminated soil.  Once they are in the intestine (specifically, the duodenum), the eggs hatch into larvae which penetrate the wall of the intestine and enter blood or lymph vessels and end up in the lungs.  There they continue to grow and develop, before moving to the throat, to be swallowed back down to the intestine.  Here the worms grow and develop to maturity and start producing eggs.

Children, because of their habits (e.g. directly or indirectly consuming soil), are more commonly and more heavily infected than adults.  Males are more likely to be infected because boys, it is believed, eat more dirt than girls do.

Signs and Symptoms

Most patients are asymptomatic.  To become infected, a patient needs to consume soil contaminated 2-3 weeks before with infected feces.  Infected patients are not directly contagious.  Symptoms can be broken down into 2 categories: early (larval migration) and late (mechanical effects).

Early (4-16 days after egg ingestion) symptoms of the tissue-migratory phase include fever, cough, wheezing.  Late (6-8 weeks after ingestion) GI symptoms resulting from mechanical irritation include vague abdominal complaints (i.e. cramping, nausea, vomiting); small bowel obstruction (mostly in children); pancreatitis (secondary to worm migration); cholecystitis (secondary to worm migration); appendicitis (less common, secondary to worm migration).

Physical signs include passage of adult worm(s) from mouth or anus; wheezing (early infection); mild abdominal tenderness (established infection).

Diagnosis and Tests

Adult females lay about 200,000 eggs per day, making diagnosis by stool examination easy.

Treatment and Prevention

Conventional treatment generally involves the use of drugs (Mebendazole/Vermox, Albendazole/Albenza, Piperazine citrate), and prevention is based mainly on good personal hygiene and food handling techniques.

Complications

Infection with A lumbricoides is very rarely fatal, but death may occur because of mechanical intestinal obstruction.  Worm passage (from above or below) may cause significant consternation in patients and/or parents.