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Hookworm Disease Workup

  • Author: David R Haburchak, MD, FACP; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Feb 24, 2016
 

Approach Considerations

Laboratory findings (eg, complete blood count [CBC]) may be consistent with iron-deficiency anemia. A differential count may reveal eosinophilia (1000-4000 cells/µL). Serologic tests (eg, tests for A caninum) are usually available only in research laboratories.

Stool should be examined for ova and parasites. The examination may demonstrate significant number of hookworm eggs. However, because egg laying may be delayed, stool examination should not be considered a sensitive test for identifying hookworm infection. Stool examinations may have to be repeated.

Progress is being made in polymerase chain reaction (PCR)-based methods for the specific diagnosis of hookworm infection.[31, 32]

Other causes of iron loss and blood loss should be excluded.

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Blood Studies

Anemia is confirmed by CBC and peripheral blood smear results that demonstrate signs typical of iron-deficiency anemia. Microscopy reveals hypochromic, microcytic red blood cells (RBCs).

Upon initial infection, eosinophilia is usually present during the migratory phase before stool findings are positive.[4] Eosinophilia is surprisingly persistent and may be due to attachment of the adult worms to the intestinal mucosa. Peak eosinophil counts are 1350-3828 cells/µL at 5-9 weeks after experimental human exposure to 45-50 infective larvae. Eosinophilia can be a clue to hookworm, as well as Strongyloides infestation, in chronically infected patients.

Eosinophilia (along with raised serum immunoglobulin E [IgE] levels) is uncommon in cases of cutaneous larva migrans but is almost universally present in cases of eosinophilic enteritis.[33]

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Stool Examination

The diagnosis is confirmed with direct microscopic analysis of fecal samples to verify the presence of hookworm eggs. The specimen is fixed in formalin and prepared as a wet mount.[4, 15]

During early infection, results of stool studies may be normal; in rare cases, the worm or larvae may be present in the fecal sample. In patients with mature infection, eggs may be seen during stool examination. If eggs are not seen, the likelihood of clinically significant infection is very low. When infection is suspected, stool should be evaluated promptly because eggs hatch into infective larvae within 24 hours.

Direct microscopic stool examination usually reveals ovoid eggs with thin colorless shells, measuring approximately 60 ´ 40 µm (see the image below). Under basic light microscopy, the eggs of N americanus and those of A duodenale appear morphologically similar. Larvae and adult worms can be distinguished by rearing filariform larvae in a fecal smear on a moist filter paper strip for 5-7 days (ie, Harada-Mori filter paper strip culture).

Hookworm eggs examined on wet mount. Eggs of Ancyl Hookworm eggs examined on wet mount. Eggs of Ancylostoma duodenale and Necator americanus cannot be distinguished morphologically. Image courtesy of Division of Parasitic Diseases, Centers for Disease Control and Prevention (CDC).

Distinguishing between N americanus and those of A duodenale is not critically important for choosing the type of anthelmintic drug to use, except that arrested larvae of A duodenale can enter breast milk and cause vertical transmission; these arrested larvae can also reactivate after initial treatment and again cause intestinal disease without reinfection.

Although hookworm eggs are easily distinguished from the eggs of other helminths, rhabditiform larvae are occasionally seen in old stool specimens (see the image below). Differentiating the larvae of Necator or Ancylostoma organisms from those of Strongyloides organisms requires attention to the unique morphologic features, particularly the relatively short buccal cavity and prominent genital primordium of Strongyloides larvae.

Hookworm rhabditiform larva (wet preparation). Ima Hookworm rhabditiform larva (wet preparation). Image courtesy of Division of Parasitic Diseases, Centers for Disease Control and Prevention (CDC).

Various methods (eg, ether concentration or Kato-Katz thick smear) can be used for quantitative assessments. The worm burden may be estimated by counting the number of eggs per gram of stool, multiplying by the daily stool weight, and dividing the result by 25,000. A worm burden of less than 25 is generally subclinical; a burden of more than 500 worms is clinically significant.

In most cases, stool-concentration techniques are unnecessary, because most individuals with clinically significant infection excrete a large number of eggs. Eggs are easily detectable in unconcentrated specimens at levels of 1200/mL or higher. However, such techniques may be helpful for diagnosis of minimal infections expected during control programs. Because the intensity and prevalence of hookworm infection decrease with public health intervention, newer concentration methods (eg, FLOTAC) have some advantages over older methods.[34]

In cases of cutaneous larva migrans, stool examination is not indicated, because the diagnosis can be made clinically and because the larvae remain confined to the skin in almost all cases. In cases of eosinophilic enteritis, no eggs are found, because adult A caninum worms do not produce eggs in human hosts.

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Other Studies

In cases of severe infection, chest radiography may show diffuse alveolar infiltrates during the migration of the larvae through the lung. Once infection is established in the gut, imaging studies are not helpful.

In cases of eosinophilic enteritis, colonoscopy may reveal ileal and colonic ulceration and, occasionally, adult hookworms.

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Contributor Information and Disclosures
Author

David R Haburchak, MD, FACP Professor of Medicine, Medical Director of Physician Assistant Program, Department of Medicine, Section of Infectious Diseases, Medical College of Georgia at Augusta University

David R Haburchak, MD, FACP is a member of the following medical societies: American College of Physicians, American Society for Microbiology, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Vinod K Dhawan, MD, FACP, FRCPC, FIDSA Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Infectious Diseases, Rancho Los Amigos National Rehabilitation Center

Vinod K Dhawan, MD, FACP, FRCPC, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Pfizer Inc for speaking and teaching.

Christopher M Watson, MD, MPH Assistant Professor, Department of Pediatrics, Uniformed Services University of the Health Sciences; Adjunct Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine

Christopher M Watson, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Medical Association, Association of Pediatric Program Directors, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

Disclosure: Nothing to disclose.

Basim Asmar, MD Director, Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Michigan; Professor, Department of Pediatrics, Wayne State University School of Medicine

Basim Asmar, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Anika Baxter Tam, MD Staff Physician, Department of Emergency Medicine, New York University / Bellevue Hospital

Disclosure: Nothing to disclose.

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Department of Internal Medicine, Director of Infectious Disease Fellowship, Harper Hospital, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Swati Garekar, MBBS Staff Physician, Department of Pediatrics, Children's Hospital of Michigan

Swati Garekar, MBBS is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Aaron Hexdall, MD Assistant Professor, Director of the International Emergency Medicine Initiative, Department of Emergency Medicine, Tufts University School of Medicine, Baystate Medical Center

Disclosure: Nothing to disclose.

Patrick W Hickey, MD, FAAP Assistant Professor of Pediatrics and Preventive Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Department of Pediatrics, Division of Pediatric Infectious Disease, Walter Reed Army Medical Center

Patrick W Hickey, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society of Tropical Medicine and Hygiene, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Ashir Kumar, MD, MBBS, FAAP Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS, FAAP is a member of the following medical societies: American Association of Physicians of Indian Origin and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mark Louden, MD Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine

Mark Louden, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Progressor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Adult hookworm attached to duodenal mucosa.
Ground itch associated with penetration of skin by hookworm larvae.
Life cycle of hookworm. Image courtesy of Division of Parasitic Diseases, Centers for Disease Control and Prevention (CDC).
Hookworm egg. Image courtesy of Patrick W Hickey, MD.
Hookworm rhabditiform larva. Image courtesy of Division of Parasitic Diseases, Centers for Disease Control and Prevention (CDC).
Hookworm filariform larva. Image courtesy of Division of Parasitic Diseases, Centers for Disease Control and Prevention (CDC).
Adult Ancylostoma duodenale worm. Anterior end with mouth parts visible. Image courtesy of Patrick W Hickey, MD.
Adult Necator americanus worm. Anterior end with mouth parts visible. Image courtesy of Patrick W Hickey, MD.
Hookworm eggs examined on wet mount. Eggs of Ancylostoma duodenale and Necator americanus cannot be distinguished morphologically. Image courtesy of Division of Parasitic Diseases, Centers for Disease Control and Prevention (CDC).
Hookworm rhabditiform larva (wet preparation). Image courtesy of Division of Parasitic Diseases, Centers for Disease Control and Prevention (CDC).
 
 
 
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