Guest guest Posted November 11, 2008 Report Share Posted November 11, 2008 Interesting that this article did not mention Ivermectin (Stromectol) for treatment of round worms. I believe that this is also used to treat round worms, especially Strongyloides (I don't know which of the Stronglooides), maybe all. Parasitic diseases are becoming increasingly common all over the world due to lowered immunity and illnesses. It is a worldwide problem, but especially in areas where there is little to no good sanitation. Stool testing is a terrible way to find parasites and rarely successful. There are blood tests which are more effective in finding certain parasites, including Strongyloides. Linda -------------- Original message ---------------------- " Apurva Tamhane " <backyardheaven > Hookworms > AUTHOR AND EDITOR INFORMATION > > Author: David R Haburchak, MD, Program Director, Professor, Department of > Internal Medicine, Division of Infectious Disease, Medical College of > Georgia > > David R Haburchak is a member of the following medical societies: Infectious > Diseases Society of America > > Editors: Pranatharthi Haran Chandrasekar, MD, Director of Infectious Disease > Fellowship, Professor, Department of Internal Medicine, Harper Hospital, > Wayne State University School of Medicine; Francisco Talavera, PharmD, PhD, > Senior Pharmacy Editor, eMedicine; Ronald A Greenfield, MD, Professor, > Department of Internal Medicine, Section of Infectious Diseases, University > of Oklahoma College of Medicine; Eleftherios Mylonakis, MD, Clinical and > Research Fellow, Department of Internal Medicine, Division of Infectious > Diseases, Massachusetts General Hospital; Burke A Cunha, MD, Professor of > Medicine, State University of New York School of Medicine at Stony Brook; > Chief, Infectious Disease Division, Winthrop-University Hospital > > Author and Editor Disclosure > > Synonyms and related keywords: hookworms, hookworm, nematodes, nematode > infection, Ancylostoma duodenale, A duodenale, Necator americanus, N > americanus, Ascaris species, helminthiasis, Trichuris species, Strongyloides > species, hookworm infection, hookworm infestation, ground itch > > > [image: Healthverve] <http://www.healthverve.blogspot.com> > > > [image: Healthverve] <http://www.healthverve.blogspot.com> > > > > INTRODUCTION > > Background > > Hookworms represent a widespread and clinically important human nematode > infection. Prevalence figures indicate that the roundworms Ancylostoma > duodenale and Necator americanus infect 576-740 million people and that they > cause anemia in approximately 10% of those infected. Hookworms may persist > for many years in the host and impair the physical and intellectual > development of children and the economic development of communities. > > Hookworm infection is acquired through skin exposure to larvae in soil > contaminated by human feces. Adults, especially agricultural workers, are at > equal or higher risk of exposure than children. Soil becomes infectious > about 9 days after contamination and remains so for about 2 weeks. > Individual hookworm treatment consists of iron replacement and anthelmintic > therapy. Community eradication has proven difficult, even with intensive, > yearly, school-based programs. Despite this, successful control and > eradication of hookworms is a worthy goal for new methods that would offer > huge economic and social benefits to much of Africa and Asia. > Pathophysiology > > Necator and Ancylostoma adults are roundworms that range in length from 5-13 > mm. Females release thousands of eggs into stool daily. In sandy moist soil, > eggs hatch and must molt twice before developing into third-stage larvae. > > Third-stage larvae are 500-700 µm long and are capable of rapid penetration > into normal skin, most commonly of the feet. Transmission occurs after 5 or > more minutes of skin contact with soil that contains viable larvae. They > puncture and feed on mucosal capillaries in the jejunum. Ground itch at the > site of penetration is more common with Ancylostoma species than with > Necator. > > The larvae burrow into venules and embolize the lungs, where they break into > alveoli. A mild and usually asymptomatic alveolitis with eosinophilia > ensues. (Hookworm is one of the causes of the pulmonary infiltrates and > eosinophilia [PIE] syndrome, along with Ascaris and Strongyloides species.) > Coughing brings the larvae to the mouth, where swallowing transports them to > the intestine. Approximately 5 weeks after skin penetration, adult females > begin to produce eggs. > > Ancylostoma larvae may also infect via ingestion, but they do not migrate > into the body in this instance. This worm may lie dormant in tissues and > later be transmitted through breast milk. Neither worm multiplies within the > host. If the host is not reexposed, the infection disappears after the worm > dies. Necator has a 5-year lifespan; Ancylostoma has a 1-year lifespan. > > Each Necator worm ingests 0.03 mL of blood per day; each Ancylostoma worm > ingests 0.2 mL of blood per day. Subsequent host anemia is proportional to > diet, iron reserves, and worm burden. Threshold worm loads for anemia differ > nationally, with as few as 40 worms producing anemia in countries with low > iron consumption. Severe anemia affects intellectual and physical > development in children and the cardiovascular performance in adults. > > In the 19th century, an autopsy of an Italian tunnel worker who died of > anemia revealed 1500 worms. Before worker sanitation was enforced, epidemic > hookworm infection was common in mines and tunnels in Europe. > > Recent work has suggested that malnutrition and immunocompromise, > independent of anemia, can occur in children and adults with significant > infection. This is the result of a protein-losing enteropathy, with > immunoglobulins among the proteins lost, as a result of worm digestion. This > results in stunted growth, as well as an increased susceptibility to > infections such as malaria and gastrointestinal disease. This protein-losing > enteropathy can also contribute to a more rapid progression of an HIV > infection. > > Apparently, the risk of atopy and dust-mite sensitization is inversely > related to the burden of hookworm infestation in endemic areas. Whether this > relationship is causative in either direction remains undetermined. The > production of interleukin (IL)–5 during primary hookworm infection appears > to enhance eosinophil function in limiting second-episode infection by > invading larvae. Worms, however, also seem to provoke IL-10, IL-4, IL-5, and > IL-13, which shift the cytokine response toward T helper 2 cells rather than > toward T helper 1 cells. Hookworms also appear to secrete an inhibitor or > natural killer cells, thereby suppressing production of gamma-interferon and > the T helper 2 response that would be expected to clear the parasite. The > increased prevalence of atopy, asthma, and food allergy in areas free of > worm infestation has been cited as supportive of the hygiene hypothesis and > even prompted investigation of worms as therapy for such diseases. > > In the search for possible vaccine targets, investigators have ascertained > the existence of hookworm molecular inhibitors of coagulation factors Xa and > VIIa-tissue factor and metalloproteases that degrade hemoglobin and > intestinal mucosal cells. ASP-2, a protein isolated from larval N > americanus, appears necessary for chemokine receptor binding and invasion > and has shown some promise in animal vaccine trials. > Frequency > United States > > Although hookworm infection is now thought to be rare in the United States, > hookworm played an important role in the impoverishment of the South until > the 1930s. Studies performed in the early 1970s indicated prevalence as high > as 14.8% among schoolchildren from rural Kentucky and as high as 12% among > schoolchildren from rural coastal Georgia. Infection and disease are now > most likely to be found in immigrants and refugees from tropical countries. > Occasionally, persons returning from travel abroad present with acute watery > diarrhea with eosinophilia upon return to the United States. > International > > Infection is widely distributed throughout tropical and subtropical areas, > with prevalence in some communities as high as 90%. The disease flourishes > in rural communities with moist shaded soil and inadequate latrines. > Agricultural laborers have traditionally been at high risk of hookworm > infection. Improper disposal of human feces and the common habit of walking > barefoot are important epidemiologic features. However, the use of footwear > has not been shown to affect hookworm prevalence, as the larvae can invade > through any skin surface. > > In 2005, The World Health Organization (WHO) estimated that 198 million > individuals in sub-Saharan Africa were infected with hookworms, 149 million > in East Asia/Pacific, 71 million in India, 59 million in other parts of > South Asia, 50 million in Latin America and the Caribbean, 39 million in > China, and 10 million in the Middle East and North Africa. Both Necator and > Ancylostoma species have worldwide distribution, but Necator is more > prevalent in Africa. Co-infection with Ascaris and Trichuris species is > common in many parts of the world. > > Infection is closely associated with poverty; inadequate sanitation, poor > housing construction, and lack of access to essential medications are major > factors in this relationship. As countries develop, these factors improve, > and hookworm infestation decreases.1 > Mortality/Morbidity > > - Adults carry larger worm burdens than children and are generally more > subject to disease. However, the relationship is nonlinear and depends on > diet and activity thresholds. The increasing prevalence of hookworm disease > and higher worm burden among adults in many infected communities, especially > China, suggests that hookworm is immunosuppressive. > - Young women, especially those who are pregnant, and laborers are most > susceptible to symptomatic anemia. Adolescent girls and women of > child-bearing age are particularly at risk for poor outcomes such as > increased maternal mortality, prematurity, low birth weight, and impaired > lactation. Up to 30-54% of moderate to severe anemia among Africa and Asian > women is attributed to hookworm. > - Severe anemia retards childhood development and intellectual > performance. Vigorous labor is possible only with hemoglobin levels of more > than 7 g/dL. > > Age > > - Because infection is usually acquired by walking, handling, or lying in > contaminated soil, hookworm infection is uncommon in young children. Studies > performed in Brazil indicate that the prevalence and intensity of infection > is higher among poorer households. Similar studies in Uganda indicate that, > compared with the spotty geographic prevalence of ascariasis and > trichuriasis, hookworm is more homogeneously distributed.2 > - Recent studies from China and Brazil indicate consistently increasing > prevalence of disease, from 15% at age 10 years to 60% at age 70 years and > older. Egg counts in stool also increase in a similar pattern. These data > suggest the need for a larger control target than infected schoolchildren > and the need to overcome what appears to be an immunocompromised state with > respect to the parasite. > > > CLINICAL > > History > > Most individuals who develop hookworm infection are from known endemic > areas. > > > - Early symptoms of hookworm infection are proportional to the intensity > of exposure. > - Necator produces a local irritation, termed ground itch, at the site of > skin invasion. An intensely pruritic, erythematous, or vesicular rash > usually appears on the feet or hands. This should be distinguished from a > creeping eruption due to skin migration of the cat or dog hookworm > Ancylostoma braziliense. > - Severe infection with either A duodenale or N americanus may produce > pneumonitis (Loefflerlike syndrome) that manifests as cough, fever, and > malaise. > - As worms mature in the jejunum, patients may experience diarrhea, vague > abdominal pain, colic, and/or nausea. These symptoms are more common with > initial exposures than with subsequent exposures. > - Patients with severe iron deficiency anemia may present with lassitude, > headache, palpitations, dyspnea, and edema. > > Physical > > - Skin and pulmonary findings are minimal. > - Signs of iron deficiency anemia are often insensitive. In severe cases, > patients may exhibit pallor, spooning nails, tachycardia, and peripheral > edema. Poor skin texture, edema, and susceptibility to cutaneous infection > suggest possible malnutrition. > > > DIFFERENTIALS > > Eosinophilia > Gastroenteritis, Bacterial > Hemolytic Anemia > Hypersensitivity Pneumonitis > Iron Deficiency Anemia > Plummer-Vinson Syndrome > Pneumonia, Bacterial > > WORKUP > > Lab Studies > > - Direct microscopic stool examination for ova and parasites usually > reveals oval, 60-µm X 40-µm eggs with thin colorless shells that can be seen > 2 months after exposure. Concentration 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 stool-concentration techniques such as FLOTAC > have some merit over older methods such as ether concentration or the > Kato-Katz thick smear.3 > - Anemia is confirmed by CBC count and peripheral blood smear results > that demonstrate signs typical of iron deficiency anemia. Upon initial > infection, eosinophilia is usually present during the migratory phase before > stool findings are positive. Eosinophilia is surprisingly persistent and may > be due to attachment of the adult worms to the intestinal mucosa. Peak > eosinophil counts are 1,350-3,828 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. > > Imaging Studies > > - Chest radiography may show diffuse alveolar infiltrates during the > migration of the worms through the lung in severe infection. > > > TREATMENT > > Medical Care > > - Albendazole or mebendazole is the drug of choice for hookworm > infection. These drugs provide a short-term cure in 90-95% of children, with > up to a 99% reduction in egg counts. Quarterly retreatment of Zanzibari > preschool children resulted in improved anemia and malnutrition after one > year.4 Concomitant iron supplementation in a recent study in Kenya did not > improve final hemoglobin concentrations in children or adults.5 > - Rapid hookworm reinfection is common in endemic areas and is made > particularly problematic by the high prevalence and worm burden in adults > who are untreated and who continue to contaminate soil. > - Repeated community treatment may result in an emerging drug resistance. > In a Zanzibari population of children treated repeatedly over 5 years, cure > and egg elimination rates both decreased significantly with time.4 This > suggests the need for a renewed emphasis on community-wide sanitation, > education, and, possibly, vaccine development. > - Iron replacement and nutritional supplementation (protein and vitamins) > should be part of the management strategy and may have greater efficacy than > anthelmintics in reducing morbidity in selected populations, such as > pregnant women and patients who are not infected with HIV. Such combined > therapy has been successful in Peru and Brazil, but less so in Kenya.6, 5 > > > > MEDICATION > > Imidazoles are the most convenient and effective drugs to treat hookworm. > Other older agents are also effective but may have lower clearance rates. > Pyrantel pamoate has been effectively used in hookworm infections. Newer > drugs are being sought because of developing resistance in areas with > frequent periodic deworming, such as Java. Unfortunately, the market for new > antiparasitic drugs is small. A promising alternative to albendazole is > tribendimidine, a synthetic drug developed in China.7 > > Drug Category: Benzimidazoles > > These agents are poorly absorbed, relatively nontoxic broad-spectrum > anthelmintics that act by inhibiting tubulin polymerization. They have shown > high clearance rates. > Drug NameAlbendazole (Albenza) DescriptionA single dose of albendazole is > the treatment of choice for hookworm. It has a high eradication rate and is > easy to administer. Adult Dose400 mg PO as single dose Pediatric Dose<24 > months: Balance potential risk of toxicity > >24 months: Administer as in adults ContraindicationsDocumented > hypersensitivity InteractionsCoadministration with carbamazepine may > decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase > toxicity PregnancyC - Fetal risk revealed in studies in animals but not > established or not studied in humans; may use if benefits outweigh risk to > fetus > PrecautionsDiscontinue use if LFTs increase significantly (resume when > levels decrease to pretest values); abdominal pain, nausea, vomiting, > diarrhea, dizziness, vertigo, fever, increased intracranial pressure, and > alopecia may occur > > Drug NameMebendazole (Vermox) DescriptionA 3-day course of mebendazole has > a reported cure rate of 95% and egg reduction rate of 99.9%. Single-dose > therapy is often advocated but may not be as effective as a single dose of > albendazole. Adult Dose100 mg PO bid for 3 d; alternatively 500 mg PO as > single dose Pediatric DoseAdminister as in adults ContraindicationsDocumented > hypersensitivity InteractionsCarbamazepine and phenytoin may decrease > effects; cimetidine may increase levels PregnancyC - Fetal risk revealed in > studies in animals but not established or not studied in humans; may use if > benefits outweigh risk to fetus > PrecautionsAdjust dose in hepatic impairment > > > FOLLOW-UP > > Deterrence/Prevention > > - Community control of hookworm infection is challenging. > - Successful programs have included economic, sanitary, and > mass-treatment components. > - Cost studies comparing various management strategies favor > community-wide, single-dose albendazole chemotherapy at intervals of 18 > months. Some programs have been more intensive, with dosing frequency up to > quarterly in school children. > - > - Community control is difficult unless socioeconomic conditions, > sanitation, education, and the availability of proper footwear > significantly > improve. > - Current WHO recommendations for hookworm infection include periodic > mass therapy to lower the overall worm burden until conditions permit a > multicomponent physical and educational program. Community > leaders should be > trained about WHO recommendations. > - Major efforts are underway to develop an effective vaccine against both > hookworm species.8 These are based on various candidate antigens such as > antithrombotics, proteases, protease inhibitors, and secretory proteins > necessary for larval and adult worms. A hamster model using the Na-ASP-2 > hookworm vaccine has suggested encouraging results in lowering worm burdens > and inhibiting growth delay. The necessity to express worm proteins in > eukaryotic cell systems and the inherent immunosuppressive nature of > hookworm infection make progress challenging.8 > - The combined use of periodic deworming, improved sanitation, and an > at-least partially effective hookworm vaccine is hoped to decrease the > medical, social, and economic burden of anemia due to hookworm in developing > countries. The emergence of benzimidazole resistance is a concern, and new > drugs are being sought. A promising agent is tribendimidine, which was first > synthesized in China in the 1980s; tribendimidine seems equal or superior to > single-dose albendazole in initial trials.7 > - Integrated control of hookworm with control of other helminth > infections can be provided with a package of medicines at a cost of $0.50 > per patient per year.1 Such dual therapy has been shown effective in various > geographic contexts.9 Major partnerships of organizations are coordinating > integrated management through the Global Network for Neglected Tropical > Disease Control.10 Such efforts provide hope to improve the health and > economic development of millions worldwide. > > Prognosis > > - Most patients become reinfected within months unless they are relocated > to an area of significantly improved sanitation. > > > MISCELLANEOUS > > Medical/Legal Pitfalls > > - Failure to recognize, diagnosis, and properly treat the hookworm > infection > > > > REFERENCES > > > 1. Hotez P. Hookworm and poverty. Ann N Y Acad > Sci. 2008;1136:38-44. [Medline]. > 2. Kabatereine NB, Tukahebwa EM, Kazibwe F, et al. Soil-transmitted > helminthiasis in Uganda: epidemiology and cost of control. Trop Med Int > Health. Nov 2005;10(11):1187-9. [Medline]. > 3. Utzinger J, Rinaldi L, Lohourignon LK, et al. FLOTAC: a new sensitive > technique for the diagnosis of hookworm infections in humans. Trans R Soc > Trop Med Hyg. Jan 2008;102(1):84-90. [Medline]. > 4. Albonico M, Bickle Q, Ramsan M, et al. 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]. > 5. Friis H, Mwaniki D, Omondi B, et al. Effects on haemoglobin of > multi-micronutrient supplementation and multi-helminth chemotherapy: a > randomized, controlled trial in Kenyan school children. Eur J Clin > Nutr. Apr 2003;57(4):573-9. [Medline]. > 6. 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[Medline]. > 35. Watkins WE, Pollitt E. " Stupidity or worms " : do intestinal worms > impair mental performance?. Psychol Bull. Mar 1997;121(2):171-91. [Medline]. > 36. Williams-Blangero S, Subedi J, Upadhayay RP, et al. Attitudes towards > helminthic infection in the Jirel population of eastern Nepal. Soc Sci > Med. Aug 1998;47(3):371-9. [Medline]. > 37. Ziem JB, Kettenis IM, Bayita A, et al. The short-term impact of > albendazole treatment on Oesophagostomum bifurcum and hookworm infections in > northern Ghana. Ann Trop Med Parasitol. Jun 2004;98(4):385-90. [Medline]. > > > Quote Link to comment Share on other sites More sharing options...
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