Ascariasis

Causal Agent:
Ascaris lumbricoides is the largest nematode (roundworm) parasitizing the human intestine.  (Adult females: 20 to 35 cm; adult male: 15 to 30 cm.)
Life Cycle:

Adult worms live in the lumen of the small intestine.  A female may produce approximately 200,000 eggs per day, which are passed with the feces .  Unfertilized eggs may be ingested but are not infective.  Fertile eggs embryonate and become infective after 18 days to several weeks , depending on the environmental conditions (optimum: moist, warm, shaded soil).  After infective eggs are swallowed , the larvae hatch , invade the intestinal mucosa, and are carried via the portal, then systemic circulation to the lungs .  The larvae mature further in the lungs (10 to 14 days), penetrate the alveolar walls, ascend the bronchial tree to the throat, and are swallowed .  Upon reaching the small intestine, they develop into adult worms .  Between 2 and 3 months are required from ingestion of the infective eggs to oviposition by the adult female.  Adult worms can live 1 to 2 years.
Geographic Distribution:
The most common human helminthic infection.  Worldwide distribution.  Highest prevalence in tropical and subtropical regions, and areas with inadequate sanitation.  Occurs in rural areas of the southeastern United States.
Clinical Features:
Although infections may cause stunted growth, adult worms usually cause no acute symptoms.  High worm burdens may cause abdominal pain and intestinal obstruction.  Migrating adult worms may cause symptomatic occlusion of the biliary tract or oral expulsion.  During the lung phase of larval migration, pulmonary symptoms can occur (cough, dyspnea, hemoptysis, eosinophilic pneumonitis - Loeffler’s syndrome).
Laboratory Diagnosis:
Microscopic identification of eggs in the stool is the most common method for diagnosing intestinal ascariasis.  The recommended procedure is as follows:

1. Collect a stool specimen.
2. Fix the specimen in 10% formalin.
3. Concentrate using the formalin–ethyl acetate sedimentation technique.
4. Examine a wet mount of the sediment.

Where concentration procedures are not available, a direct wet mount examination of the specimen is adequate for detecting moderate to heavy infections.  For quantitative assessments of infection, various methods such as the Kato-Katz can be used.  Larvae can be identified in sputum or gastric aspirate during the pulmonary migration phase (examine formalin-fixed organisms for morphology).  Adult worms are occasionally passed in the stool or through the mouth or nose and are recognizable by their macroscopic characteristics.
Diagnostic findings

• Microscopy
• Macroscopy
• Morphologic comparison with other intestinal parasites

Treatment:
The drugs of choice for treatment of ascariasis are albendazole* with mebendazole, ivermectin*, and nitazoxanide as alternatives.  In the United States, ascariasis is generally treated for 1-3 days with medication prescribed by a health care provider.  The drugs are effective and appear to have few side effects.  For additional information, see the recommendations in The Medical Letter (Drugs for Parasitic Infections).
* This drug is approved by the FDA, but considered investigational for this purpose.