eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Ancylostoma Infection: Follow-up

Author: Vinod K Dhawan, MD, FACP, FRCP(C), Professor, Department of Clinical Medicine, University of California at Los Angeles; Professor of Medicine, Charles R Drew University of Medicine and Science; Chief, Division of Infectious Diseases, MLK-Harbor Hospital
Coauthor(s): Swati Garekar, MBBS, Staff Physician, Department of Pediatrics, Children's Hospital of Michigan; 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
Contributor Information and Disclosures

Updated: May 1, 2008

Follow-up

Further Outpatient Care

  • The recommended procedure is to repeat the stool examination using a concentration technique after 2-3 weeks; positive results indicate the need for retreatment.
  • Complete the entire course of iron therapy to replenish iron stores, even after hemoglobin values return to normal.
  • Be aware that reinfection is common in endemic areas.
  • Dormant extraintestinal larvae of A duodenale may be resistant to currently available anthelminthic agents (which may have poor systemic absorption) and may be responsible for relapse.

Deterrence/Prevention

  • Patients with classic hookworm infection are not directly contagious because the eggs excreted in their feces require a brief period in the soil to develop into infective larvae.
  • Sanitary excreta disposal is the most effective deterrent but is not feasible in many developing countries.
  • Wearing footwear cannot entirely prevent infection because larvae can penetrate any skin surface that comes in contact with contaminated soil. In addition, A duodenale larvae can be ingested.
  • Mass or targeted chemotherapy programs may not control hookworm infection because reinfection is common in endemic areas, and dormant extraintestinal larvae of A duodenale may be resistant to currently available anthelminthic agents.
  • A recent study assessed the health impact of a national control program that targeted schistosomiasis and intestinal nematodes in Uganda, which has provided population-based anthelmintic chemotherapy since 2003.8 Antihelmintic treatment delivered as part of a national helminth control program decreased infection and morbidity among schoolchildren and improved hemoglobin concentration. Deworming with use of anthelmintics (over and above iron supplementation) within antenatal care programs in hookworm-endemic areas may help prevent very low birthweight babies; this benefit may be higher in countries that do not have an antenatal iron supplementation program or in countries where the intensity of hookworm infections is higher.9
  • Immunization with recombinant hookworm Ancylostoma -secreted proteins (ASPs) has been demonstrated to prevent migration of infective larvae through tissues in a murine model of ancylostomiasis. Efforts are underway for eventual development of a vaccine that combines at least 2 hookworm antigens: one that targets the larval stage of the life cycle, and another that targets the adult worm living in the GI tract.10

Complications

  • Heavy parasitism in childhood occasionally leads to acute fulminating anemia with congestive heart failure. This occurs most often in epidemics associated with breakdowns in sanitation as a result of war or famine.
  • In one study, children with helminthiasis (including hookworms and other helminths) and anemia were 8.7 times more likely to have stunted growth and 4.3 times more likely to be underweight than children without anemia and infection.11

Prognosis

  • Classic hookworm disease
    • With appropriate anthelminthic treatment and with iron and diet therapy, recovery from anemia and malnutrition is complete; however, some deficits in intellectual function may persist.
    • Reinfection is very likely in endemic areas and causes the cycle to repeat.
  • Cutaneous larva migrans: Even in untreated persons, larvae die, and symptoms resolve within a few weeks to several months.
  • Eosinophilic enteritis: This promptly responds to mebendazole therapy.

Patient Education

  • Attempt to prevent reinfection by instructing patients to not walk barefoot in endemic areas and to wash hands thoroughly before meals.

Miscellaneous

Medicolegal Pitfalls

  • Reactivated dormant larvae of A duodenale can migrate from tissue to repopulate the intestine or enter breast milk and infect infants.
  • Because of high reinfection rates in endemic areas, drug therapy alone does not effectively decrease incidence of infection.

Special Concerns

  • Children younger than 2 years
    • The infantile form of hookworm infection has significant mortality rates. A fulminant form of acute hookworm infection causing acute GI tract hemorrhage has been described in infants. These infants (often >2 mo) present with melena, abdominal distention, and hypotension, and they may have hematocrit values as low as 0.2-0.3%.
    • No practical method has been found to interrupt vertical transmission of infection.
    • Experience with anthelminthic drugs is limited for children in this age group. The WHO recommends administering half the adult dosage of albendazole or mebendazole in patients with heavy hookworm infections. Determine the dosage of pyrantel on the basis of the child's weight.
  • Pregnancy and lactation: The WHO recommends deworming treatment (eg, albendazole, mebendazole, pyrantel) during the second or third trimester for pregnant women with heavy hookworm infections.
  • Resistance: Recent reports have documented the emergence of resistance to mebendazole and pyrantel pamoate among human hookworm isolates.12,13
 


More on Ancylostoma Infection

Overview: Ancylostoma Infection
Differential Diagnoses & Workup: Ancylostoma Infection
Treatment & Medication: Ancylostoma Infection
Follow-up: Ancylostoma Infection
Multimedia: Ancylostoma Infection
References
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References

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  2. Albonico M, Stoltzfus RJ, Savioli L, et al. Epidemiological evidence for a differential effect of hookworm species, Ancylostoma duodenale or Necator americanus, on iron status of children. Int J Epidemiol. Jun 1998;27(3):530-7. [Medline].

  3. Gasser RB, Cantacessi C, Loukas A. DNA technological progress toward advanced diagnostic tools to support human hookworm control. Biotechnol Adv. Jan-Feb 2008;26(1):35-45. [Medline].

  4. Jelinek T, Maiwald H, Nothdurft HD, Loscher T. Cutaneous larva migrans in travelers: synopsis of histories, symptoms, and treatment of 98 patients. Clin Infect Dis. Dec 1994;19(6):1062-6. [Medline].

  5. Caumes E, Datry A, Paris L. Efficacy of ivermectin in the therapy of cutaneous larva migrans. Arch Dermatol. Jul 1992;128(7):994-5. [Medline].

  6. de Silva N, Guyatt H, Bundy D. Anthelmintics. A comparative review of their clinical pharmacology. Drugs. May 1997;53(5):769-88. [Medline].

  7. Horton J. Albendazole: a review of anthelmintic efficacy and safety in humans. Parasitology. 2000;121 Suppl:S113-32. [Medline].

  8. Kabatereine NB, Brooker S, Koukounari A, Kazibwe F, Tukahebwa EM, Fleming FM. Impact of a national helminth control programme on infection and morbidity in Ugandan schoolchildren. Bull World Health Organ. Feb 2007;85(2):91-9. [Medline].

  9. Larocque R, Casapia M, Gotuzzo E, MacLean JD, Soto JC, Rahme E. A double-blind randomized controlled trial of antenatal mebendazole to reduce low birthweight in a hookworm-endemic area of Peru. Trop Med Int Health. Oct 2006;11(10):1485-95. [Medline].

  10. Diemert DJ, Bethony JM, Hotez PJ. Hookworm vaccines. Clin Infect Dis. Jan 15 2008;46(2):282-8. [Medline].

  11. Hughes RG, Sharp DS, Hughes MC. Environmental influences on helminthiasis and nutritional status among Pacific schoolchildren. Int J Environ Health Res. 2004;14(3):163-77.

  12. Bennett A, Guyatt H. Reducing intestinal nematode infection: efficacy of albendazole and mebendazole. Parasitol Today. Feb 2000;16(2):71-4. [Medline].

  13. Flohr C, Tuyen LN, Lewis S, Minh TT, Campbell J, Britton J. Low efficacy of mebendazole against hookworm in Vietnam: two randomized controlled trials. Am J Trop Med Hyg. Apr 2007;76(4):732-6. [Medline].

  14. American Academy of Pediatrics. Hookworm infection. In: 2000 Red Book: Report of the Committee on Infectious Diseases. 2000:321-2.

  15. Hochedez P, Caumes E. Hookworm-related cutaneous larva migrans. J Travel Med. Sep-Oct 2007;14(5):326-33. [Medline].

  16. Hotez PJ. Hookworm disease in children. Pediatr Infect Dis J. Aug 1989;8(8):516-20. [Medline].

  17. Hotez PJ, Brooker S, Bethony JM, et al. Hookworm infection. N Engl J Med. Aug 19 2004;351(8):799-807. [Medline].

  18. Hotez PJ, Pritchard DI. Hookworm infection. Sci Am. Jun 1995;272(6):68-74. [Medline].

  19. Kucik CJ, Martin GL, Sortor BV. Common intestinal parasites. Am Fam Physician. Mar 1 2004;69(5):1161-8. [Medline].

  20. Long SS, Pickering LK, Prober CG. Hookworm. In: Principles and Practice of Pediatric Infectious Diseases. 1997:1462-4.

  21. Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 2000:2941-2.

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Further Reading

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Keywords

hookworm infection, hookworm, hookworm disease, Ancylostomatidae, Ancylostoma duodenale, Necator americanus, Ancylostoma caninum, Ancylostoma ceylanicum, Ancylostoma braziliense, cutaneous larva migrans, eosinophilic enteritis, iron deficiency anemia, protein malnutrition, iron deficiency anemia, protein malnutrition, helminthic infections, hookworm anemia, malabsorption, hypoproteinemia, malnutrition, GI hemorrhage, ancylostoma infection, ground itch, dew itch, Wakana disease, melena, leukocytosis, erythema

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Contributor Information and Disclosures

Author

Vinod K Dhawan, MD, FACP, FRCP(C), Professor, Department of Clinical Medicine, University of California at Los Angeles; Professor of Medicine, Charles R Drew University of Medicine and Science; Chief, Division of Infectious Diseases, MLK-Harbor Hospital
Vinod K Dhawan, MD, FACP, FRCP(C) is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Royal College of Physicians and Surgeons of Canada
Disclosure: Pfizer Inc None None

Coauthor(s)

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.

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.

Medical Editor

Michael D Nissen, MBBS, BMedSc, FRACP, FRCPA, Associate Professor in Biomolecular, Biomedical Science & Health, Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory, Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital
Michael D Nissen, MBBS, BMedSc, FRACP, FRCPA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Pediatric Infectious Diseases Society, Royal Australasian College of Physicians, and Royal College of Pathologists of Australasia
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Martin Weisse, MD, Program Director, Associate Professor, Department of Pediatrics, West Virginia University
Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching

Chief Editor

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: None None None

 
 
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