Pediatric Ascariasis Treatment & Management
- Author: William H Shoff, MD, DTM&H; Chief Editor: Russell W Steele, MD more...
Medical Care
Pulmonary disease
Most cases are asymptomatic.
Most symptomatic cases are mild and self-limited (days) and do not require therapy.
Bronchospasm can be managed with conventional therapy.
Severe cases can be managed with systemic steroids and oxygen supplementation.
Partial small bowel obstruction
In the absence of signs of toxicity (eg, fever, tachycardia, protracted vomiting, peritoneal signs), persisting abdominal pain, or a palpable mass in the same site for more than 24 hours, several conservative management strategies, including supportive care, have proven efficacious. Some of these strategies are as follows:
Intravenous fluids and nasogastric tube with or without an antispasmodic (antimuscarinic)
Intravenous fluids, nasogastric tube, and antibiotics (eg, metronidazole, aminoglycoside, penicillin) with or without an antihelminthic after resolution of symptoms
Saline enema with or without an antispasmodic: Saline enemas are effective in children because 80% have an incompetent ileal-cecal sphincter.
Racine or mineral oil (15-30 mL via nasogastric tube) in conjunction with an antihelminthic: A low dose is used to allow worm death over few days. Several reports note that administration of antihelminthics in patients with partial bowel obstruction can precipitate complete obstruction.
Gastrografin (15-30 mL) via nasogastric tube: The hyperosmolar action results in increased fluid around worms, which favors their separation.
In the presence bowel obstruction, persisting or worsening abdominal pain, or sepsis, surgical intervention is warranted (see Surgical Care).
Hepatobiliary and pancreatic ascariasis
This typically manifests as biliary colic, acalculous cholecystitis, ascending cholangitis, pancreatitis, or hepatic abscess. Ascariasis is a common cause of these conditions in endemic countries.
Aggressive antibiotic therapy for suspected infection and early ERCP to remove the worms are highly efficacious together in the treatment of HPA. During ERCP, worms are sometimes observed to be moving into and out of the duct orifices. Worms are directly removed; when they are out of reach, they can be flushed out with rapid injection of 5-10 mL of diluted dye (eg, 10% Urograffin) into the duct. The entire worm must be removed because fragments lead to infection, granulomas, or stone formation.
After abdominal symptoms improve, antihelminthics can be administered. In one series, the ERCP complication (cholangitis, hypotension) rate was 6%.[13]
Surgical Care
In endemic regions, ascariasis is a major etiology for conditions that require acute surgical intervention, including the following:
- Intestinal obstruction
- Appendicitis
- Volvulus
- Intussusception
- Ischemic bowel
- Hepatobiliary obstruction (if ERCP has failed or is unavailable)
- Failure of conservative management of partial bowel obstruction
- Severe abdominal pain or tenderness with signs of toxicity
- Persisting or worsening abdominal pain
- Severe abdominal pain with a palpable mass in the same site for longer than 24 hours
Surgical procedures used in the management of the bowel obstruction secondary to ascariasis include the following:
Milking the worms through the ileo-cecal valve: This is recommended for a worm bolus in the distal ileum. Milking proximal boluses may cause damage to the bowel. This process has been facilitated by oral administration of mineral oil (15-30 mL).
Enterotomy to remove the bolus if milking is unsuccessful
Segmental resection of damaged bowel with or without temporary ostomy, as needed: Anastomosis should be 2-layers and end-to-end to prevent residual worms from migrating through the anastomosis into the peritoneal cavity, which has been reported.
Consultations
Surgeon
Any patient with acute abdominal pain and tenderness suggestive of an acute surgical process warrants a surgical consultation. If a double-contrast (ie, oral and intravenous dye) CT scan can be performed and the patient is not toxic or septic, the consultation may be deferred until the results of the scan are available. If the patient is toxic or septic, the surgical consultation should take place immediately.
Critical care specialist
Any patient who appears to be septic may qualify for early goal-directed therapy.
GI specialist
Any patient who is diagnosed with HPA or in whom a high index of suspicion for this diagnosis is noted warrants an immediate GI consultation for emergent ERCP. This procedure is often both diagnostic and therapeutic, with removal of the offending worm and relief of the obstruction.
Diet
Advise patients with known ascariasis to avoid peppery and spicy foods because they induce increased worm migration.
Bethony J, Brooker S, Albonico M, et al. Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm. Lancet. May 6 2006;367(9521):1521-32. [Medline].
Crompton DW. Ascaris and ascariasis. Adv Parasitol. 2001;48:285-375. [Medline].
Lynch NR, Hagel IA, Palenque ME, Di Prisco MC, et al. Relationship between helminthic infection and IgE response in atopic and nonatopic children in a tropical environment. J Allergy Clin Immunol. Feb 1998;101(2 Pt 1):217-21. [Medline].
Pinelli E, Willers SM, Hoek D, et al. Prevalence of antibodies against Ascaris suum and its association with allergic manifestations in 4-year-old children in The Netherlands: the PIAMA birth cohort study. Eur J Clin Microbiol Infect Dis. Nov 2009;28(11):1327-34. [Medline].
Dold S, Heinrich J, Wichmann HE, Wjst M. Ascaris-specific IgE and allergic sensitization in a cohort of school children in the former East Germany. J Allergy Clin Immunol. Sep 1998;102(3):414-20. [Medline].
Leonardi-Bee J, Pritchard D, Britton J. Asthma and current intestinal parasite infection: systematic review and meta-analysis. Am J Respir Crit Care Med. Sep 1 2006;174(5):514-23. [Medline].
Hunninghake GM, Soto-Quiros ME, Avila L, et al. Sensitization to Ascaris lumbricoides and severity of childhood asthma in Costa Rica. J Allergy Clin Immunol. Mar 2007;119(3):654-61. [Medline].
Cooper PJ, Chico ME, Rodrigues LC, et al. Reduced risk of atopy among school-age children infected with geohelminth parasites in a rural area of the tropics. J Allergy Clin Immunol. May 2003;111(5):995-1000. [Medline].
Schafer T, Meyer T, Ring J, Wichmann HE, Heinrich J. Worm infestation and the negative association with eczema (atopic/nonatopic) and allergic sensitization. Allergy. Aug 2005;60(8):1014-20. [Medline].
Albonico M, Bickle Q, Ramsan M, Montresor A, Savioli L, Taylor M. Efficacy of mebendazole and levamisole alone or in combination against intestinal nematode infections after repeated targeted mebendazole treatment in Zanzibar. Bull World Health Organ. 2003;81(5):343-52. [Medline]. [Full Text].
Hesham Al-Mekhlafi M, Surin J, Atiya AS, Ariffin WA, Mohammed Mahdy AK, Che Abdullah H. Pattern and predictors of soil-transmitted helminth reinfection among aboriginal schoolchildren in rural Peninsular Malaysia. Acta Trop. Aug 2008;107(2):200-4. [Medline].
Luoba AI, Wenzel Geissler P, Estambale B, et al. Earth-eating and reinfection with intestinal helminths among pregnant and lactating women in western Kenya. Trop Med Int Health. Mar 2005;10(3):220-7. [Medline].
Sandouk F, Haffar S, Zada MM, Graham DY, et al. Pancreatic-biliary ascariasis: experience of 300 cases. Am J Gastroenterol. Dec 1997;92(12):2264-7. [Medline].
Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary and pancreatic ascariasis in India. Lancet. Jun 23 1990;335(8704):1503-6. [Medline].
Sherman SC, Weber JM. The CT diagnosis of Ascariasis. J Emerg Med. May 2005;28(4):471-2. [Medline].
Arya PK, Kukreti R, Arya M, Gupta SN. Magnetic resonace appearance of gall bladder ascariasis. Indian J Med Sci. May 2005;59(5):208-10. [Medline].
World Health Organization. Report of the third global meeting on the partners for parasite control: Deworming for health and develpment. Geneva: WHO; November 2004. [Full Text].
World Health Organization. Report of the WHO informal consultation on the use of praziquantel during pregnancy/lactation and albendazole/mebendazole in children under 24 months. Geneva: WHO; April 2002. [Full Text].
Albonico M, Stoltzfus RJ, Savioli L. A controlled evaluation of two school-based anthelminthic chemotherapy regimens on intensity of intestinal helminth infections. Int J Epidemiol. Jun 1999;28(3):591-6. [Medline].
Fallah M, Mirarab A, Jamalian F. Evaluation of two years of mass chemotherapy against ascariasis in Hamadan, Islamic Republic of Iran. Bull World Health Organ. 2002;80(5):399-402. [Medline].
Abebe W, Tsuji N, Kasuga-Aoki H. Species-specific proteins identified in Ascaris lumbricoides and Ascaris suum using two-dimensional electrophoresis. Parasitol Res. Sep 2002;88(9):868-71. [Medline].
Akgun Y. Intestinal obstruction caused by Ascaris lumbricoides. Dis Colon Rectum. Oct 1996;39(10):1159-63. [Medline].
American Academy of Pediatrics. Ascaris lumbricoides infections. In: Peter G, ed. Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL: AAP; 1997:142-3.
Ash LR. Ascaris lumbricoides?. South Med J. Jan 2003;96(1):101-2. [Medline].
Bapat SS, Pulikot AM. Hepato-cerebral complications in ascariasis. Indian Pediatr. Apr 2001;38(4):431-2. [Medline].
Beckingham IJ, Cullis SN, Krige JE. Management of hepatobiliary and pancreatic Ascaris infestation in adults after failed medical treatment. Br J Surg. Jul 1998;85(7):907-10. [Medline].
Beitia AO, Haller JO, Kantor A. CT findings in pediatric gastrointestinal ascariasis. Comput Med Imaging Graph. Jan-Feb 1997;21(1):47-9. [Medline].
Bennett A, Guyatt H. Reducing intestinal nematode infection: efficacy of albendazole and mebendazole. Parasitol Today. Feb 2000;16(2):71-4. [Medline].
Bergler-Czop B, Lis-Swiety A, Kaminska-Winciorek G, Brzezinska-Wcislo L. Erythema nodosum caused by ascariasis and Chlamydophila pneumoniae pulmonary infection--a case report. FEMS Immunol Med Microbiol. Dec 2009;57(3):236-8. [Medline].
Borges CA, Costa-Cruz JM, Paula FM. Intestinal parasites inside public restrooms and buses from the city of Uberlândia, Minas Gerais, Brazil. Rev Inst Med Trop Sao Paulo. Jul-Aug 2009;51(4):223-5. [Medline].
Brooker S, Clements AC, Bundy DA. Global epidemiology, ecology and control of soil-transmitted helminth infections. Adv Parasitol. 2006;62:221-61. [Medline].
Bude RO, Bowerman RA. Case 20: Biliary ascariasis. Radiology. Mar 2000;214(3):844-7. [Medline].
Carneiro FF, Cifuentes E, Tellez-Rojo MM, Romieu I. The risk of Ascaris lumbricoides infection in children as an environmental health indicator to guide preventive activities in Caparao and Alto Caparao, Brazil. Bull World Health Organ. 2002;80(1):40-6. [Medline].
Cooper PJ, Chico M, Sandoval C, Espinel I, Guevara A, Levine MM. Human infection with Ascaris lumbricoides is associated with suppression of the interleukin-2 response to recombinant cholera toxin B subunit following vaccination with the live oral cholera vaccine CVD 103-HgR. Infect Immun. Mar 2001;69(3):1574-80. [Medline].
Crompton DWT, Nesheim MC, Pawlowski ZS. Ascariasis and Its Prevention and Control. London, England: Taylor & Francis; 1989.
de Silva NR, Brooker S, Hotez PJ. Soil-transmitted helminth infections: updating the global picture. Trends Parasitol. Dec 2003;19(12):547-51. [Medline].
de Silva NR, Chan MS, Bundy DA. Morbidity and mortality due to ascariasis: re-estimation and sensitivity analysis of global numbers at risk. Trop Med Int Health. Jun 1997;2(6):519-28. [Medline].
Gelpi AP, Mustafa A. Ascaris pneumonia. Am J Med. Mar 1968;44(3):377-89. [Medline].
Gelpi AP, Mustafa A. Seasonal pneumonitis with eosinophilia. A study of larval ascariasis in Saudi Arabs. Am J Trop Med Hyg. Sep 1967;16(5):646-57. [Medline].
Hui JY, Woo PC, Kan PS, Tang AP. A woman with ascites and abdominal masses. Lancet. Feb 12 2000;355(9203):546. [Medline].
Inatomi Y, Murakami T, Tokunaga M, Ishiwata K, Nawa Y, Uchino M. Encephalopathy caused by visceral larva migrans due to Ascaris suum. J Neurol Sci. Apr 1 1999;164(2):195-9. [Medline].
Ishiwata K, Shinohara A, Yagi K. Identification of tissue-embedded ascarid larvae by ribosomal DNA sequencing. Parasitol Res. Jan 2004;92(1):50-2. [Medline].
Jat KR, Marwaha RK, Panigrahi I, Gupta K. Ascariasis-associated worm encephalopathy in a young child. Trop Doct. Apr 2009;39(2):113-4. [Medline].
Jones JL, Schulkin J, Maguire JH. Therapy for common parasitic diseases in pregnancy in the United States: a review and a survey of obstetrician/gynecologists' level of knowledge about these diseases. Obstet Gynecol Surv. Jun 2005;60(6):386-93. [Medline].
[Best Evidence] [Guideline] Keiser J, Utzinger J. Efficacy of current drugs against soil-transmitted helminth infections: systematic review and meta-analysis. JAMA. Apr 23 2008;299(16):1937-48. [Medline].
Khuroo MS. Ascariasis. Gastroenterol Clin North Am. Sep 1996;25(3):553-77. [Medline].
Kiafar C, Shah D, Wadas D, Gilani N. Intermittent obstruction of jejunostomy tube due to Ascaris lumbricoides infection. South Med J. Jun 2008;101(6):654-6. [Medline].
Knopp S, Mohammed KA, Simba Khamis I, et al. Spatial distribution of soil-transmitted helminths, including Strongyloides stercoralis, among children in Zanzibar. Geospat Health. Nov 2008;3(1):47-56. [Medline].
Knopp S, Mohammed KA, Simba Khamis I, et al. Spatial distribution of soil-transmitted helminths, including Strongyloides stercoralis, among children in Zanzibar. Geospat Health. Nov 2008;3(1):47-56. [Medline].
Larrubia JR, Ladero JM, Mendoza JL, Morillas JD, Diaz-Rubio M. The role of sonography in the early diagnosis of biliopancreatic Ascaris infestation. J Clin Gastroenterol. Jan 1996;22(1):48-50. [Medline].
Loreille O, Bouchet F. Evolution of ascariasis in humans and pigs: a multi-disciplinary approach. Mem Inst Oswaldo Cruz. 2003;98 Suppl 1:39-46. [Medline].
Mao XQ, Sun DJ, Miyoshi A, Feng Z, Handzel ZT, Hopkin JM. The link between helminthic infection and atopy. Parasitol Today. May 2000;16(5):186-8. [Medline].
Norhayati M, Oothuman P, Azizi O, Fatmah MS. Efficacy of single dose albendazole on the prevalence and intensity of infection of soil-transmitted helminths in Orang Asli children in Malaysia. Southeast Asian J Trop Med Public Health. Sep 1997;28(3):563-9. [Medline].
Norhayati M, Oothuman P, Azizi O, Fatmah MS. Efficacy of single dose albendazole on the prevalence and intensity of infection of soil-transmitted helminths in Orang Asli children in Malaysia. Southeast Asian J Trop Med Public Health. Sep 1997;28(3):563-9. [Medline].
O'Lorcain P, Holland CV. The public health importance of Ascaris lumbricoides. Parasitology. 2000;121 Suppl:S51-71. [Medline].
Ochoa B. Surgical complications of ascariasis. World J Surg. Mar-Apr 1991;15(2):222-7. [Medline].
Ozturk H, Ozturk H, Duran H, Otcu S. [Biliary ascaris-induced obstructive jaundice: a case of acute abdomen]. Ulus Travma Acil Cerrahi Derg. Jan 2009;15(1):88-90. [Medline].
Reeder MM. The radiological and ultrasound evaluation of ascariasis of the gastrointestinal, biliary, and respiratory tracts. Semin Roentgenol. Jan 1998;33(1):57-78. [Medline].
Rodriguez EJ, Gama MA, Ornstein SM, Anderson WD. Ascariasis causing small bowel volvulus. Radiographics. Sep-Oct 2003;23(5):1291-3. [Medline].
Salman AB. Management of intestinal obstruction caused by ascariasis. J Pediatr Surg. Apr 1997;32(4):585-7. [Medline].
Sandouk F, Anand BS, Graham DY. The whirlpool jet technique for removal of pancreatic duct ascaris. Gastrointest Endosc. Aug 1997;46(2):180-2. [Medline].
Sarinas PS, Chitkara RK. Ascariasis and hookworm. Semin Respir Infect. Jun 1997;12(2):130-7. [Medline].
Schulman A. Ultrasound appearances of intra- and extrahepatic biliary ascariasis. Abdom Imaging. Jan-Feb 1998;23(1):60-6. [Medline].
Selimoglu MA, Ozturk CF, Ertekin V. A rare manifestation of ascariasis: encephalopathy. J Emerg Med. Jan 2005;28(1):87-8. [Medline].
St Georgiev V. Pharmacotherapy of ascariasis. Expert Opin Pharmacother. Feb 2001;2(2):223-39. [Medline].
Stephenson LS, Latham MC, Ottesen EA. Malnutrition and parasitic helminth infections. Parasitology. 2000;121 Suppl:S23-38. [Medline].
Tiyo R, Guedes TA, Falavigna DL, Falavigna-Guilherme AL. Seasonal contamination of public squares and lawns by parasites with zoonotic potential in southern Brazil. J Helminthol. Mar 2008;82(1):1-6. [Medline].
Tondon A, Choudhury SP, Sharma D. Hypertonic saline enema in gastrointestinal ascariasis. Indian J Pediatr. Sep-Oct 1999;66(5):675-80. [Medline].
van Riet E, Wuhrer M, Wahyuni S, Retra K, Deelder AM, Tielens AG. Antibody responses to Ascaris-derived proteins and glycolipids: the role of phosphorylcholine. Parasite Immunol. Aug 2006;28(8):363-71. [Medline].
Villamizar E, Mendez M, Bonilla E, et al. Ascaris lumbricoides infestation as a cause of intestinal obstruction in children: Experience with 87 cases. J Pediatr Surg. Jan 1996;31(1):201-4; discussion 204-5. [Medline].
World Health Organization. Control of Ascariasis. 1967. WHO technical report series. [Full Text].
World Health Organization. Prevention and control of schistosomiasis and soil-transmitted helminths. WHO; 2002. WHO technical report series. [Full Text].
Zargar SA, Khuroo MS. Management of biliary ascariasis in children. Indian J Gastroenterol. Oct 1990;9(4):321. [Medline].
| Parasite* | Disease | Prevalence |
| A lumbricoides | Common roundworm infection, ascariasis | 800 million to 1.4 billion |
| T trichiura | Whipworm infection, trichuriasis | 600 million to 1 billion |
| Necator americanus and Ancylostoma duodenale | Hookworm infection | 580 million to 1.2 billion |
| Strongyloides stercoralis | Threadworm infection, strongyloidiasis | 30-300 million |
| Enterobius vermicularis | Pinworm infection | 4-28% of children |
| Toxocara canis and Toxocara cati | Visceral larva migrans and ocular larva migrans | 2-80% of children |
| *All major parasites are found in tropical, subtropical, and temperate climates. | ||
| Minor Parasite | Disease | Distribution |
| Ancylostoma braziliense | Cutaneous larva migrans | Costal regions worldwide |
| Uncinaria stenocephala | Cutaneous larva migrans | Costal regions worldwide |
| Ancyclostoma canium | Eosinophilic enteritis | Australia |
| Ancylostoma ceylanicum | Hookworm infection | Asia |
| Oesophagostomum bifurcum | Nodular worm infection | North America |
| Strongyloides fuelleborni | Swollen belly syndrome | West Africa |
| Ternidens diminutus | False hookworm infection | Southern Africa |

