History

Fact Explanation
Cough, dyspnoea, wheeze and chest pain. When migrating through the lungs, Ascaris larvae secrete allergenic substances which stimulate the activation of the IgE mediated immune response which in turn lead to pathophysiological changes in the lung such as airway inflammation and bronchial hyper reactivity [1].
Colicky abdominal pain, abdominal distension, nausea and intermittent diarrhoea. Due to small bowel obstruction, commonly as a result of large numbers of entangled worms. A worm bolus could also result in volvulus and intussusception which could cause bowel ischemia and infarction [2].
Dark urine, pale stools, yellowish discoloration of eyes, radiating right hypochondrial and epigastric pain, and fever. Due to invasion of the biliary tree by the adult worm causing biliary colic, pyogenic cholangitis, chloecystitis, pancreatitis and formation of biliary stones [3].
References
  1. COOPER P.J. Can intestinal helminth infections (geohelminths) affect the development and expression of asthma and allergic disease?. Clinical & Experimental Immunology[online] 2002, 128: 398–404.[viewed 13 April 2014] Available from: DOI: 10.1046/j.1365-2249.2002.01908.x
  2. MORA Nimfa C. Teneza, Eric A. LAVERY and Helen M. CHUN. Partial Small Bowel Obstruction in a Traveler. Clin Infect Dis.[online] 2006, vol 43 (2): 256-258. [viewed 13 April 2014] Available from: DOI:10.1086/505179
  3. GONZALEZ A.H., V. C. REGALADO and J. VAN DEN ENDE. Non-invasive management of Ascaris lumbricoides biliary tract migration: a prospective study in 69 patients from Ecuador. Tropical Medicine & International Health[online] 2001, 6: 146–150. [viewed 13 April 2014] Available from: DOI:10.1046/j.1365-3156.2001.00657.x

Examination

Fact Explanation
Tachypnoea; rhonchi and crepitations on auscultation of the lungs. Due to the pathophysiological changes of the lung similar to asthma, as result of Ascaris larvae migrating through the lung [1].
Urticaria Due to the IgE mediated allergic response brought about by the parasite [2].
Fever; right hypochondrial and epigastric tenderness; icterus Due to parasitic invasion of the biliary tree [3].
Abdominal distension Due to partial or complete intestinal obstruction caused by the parasite [4].
Bitot spots (vitamin A deficiency), gum bleeding (vitamin C deficiency), low lean body mass (protein deficiency) and other features of nutritional deficiency. Due to nutrient absorption and blocking of the absorbing surface of the intestinal mucosa by Ascaris worms as well as reduced voluntary food intake [5].
References
  1. COOPER P.J. Can intestinal helminth infections (geohelminths) affect the development and expression of asthma and allergic disease?. Clinical & Experimental Immunology[online] 2002, 128: 398–404.[viewed 13 April 2014] Available from: DOI: 10.1046/j.1365-2249.2002.01908.x
  2. ZHENG Ping-Ping, et al. Esophageal space-occupying lesion caused by Ascaris lumbricoides. World J Gastroenterol[online] April 2012, 18(13): 1552–1554. [viewed 13 April 2014] Available from: DOI: 10.3748/wjg.v18.i13.1552
  3. GONZALEZ A.H., V. C. REGALADO and J. VAN DEN ENDE. Non-invasive management of Ascaris lumbricoides biliary tract migration: a prospective study in 69 patients from Ecuador. Tropical Medicine & International Health[online] 2001, 6: 146–150. [viewed 13 April 2014] Available from: DOI:10.1046/j.1365-3156.2001.00657.x
  4. MORA Nimfa C. Teneza, Eric A. LAVERY and Helen M. CHUN. Partial Small Bowel Obstruction in a Traveler. Clin Infect Dis.[online] 2006, vol 43 (2): 256-258. [viewed 13 April 2014] Available from: DOI:10.1086/505179
  5. JARDIM-BOTELHO A., et al. Age patterns in undernutrition and helminth infection in a rural area of Brazil: associations with ascariasis and hookworm. Tropical Medicine & International Health[online] 2008, 13: 458–467. [viewed 13 April 2014] Available from: DOI: 10.1111/j.1365-3156.2008.02022.x

Differential Diagnoses

Fact Explanation
Colonic obstruction. Constipation is a prominent feature apart from abdominal pain, abdominal distension and vomiting [1].
Biliary colic due to gall stones. Frequent episodes of right hypochondrial pain radiating to the inferior angle of the right scapula [2].
Acute pancreatits. Epigastric pain radiating to the back associated with risk factors such as alcohol abuse, gall stone disease, etc. [3]
Bronchial asthma. Diurnal variation is characteristic with regard to airway inflammation and bronchial hyperreactivity [4].
References
  1. SCHILLER L.R. The therapy of constipation. Alimentary Pharmacology & Therapeutics[online] 2001, 15: 749–763.[viewed 14 April 2014] Available from: DOI: 10.1046/j.1365-2036.2001.00982.x
  2. TOMIDA S., et al. Long-term ursodeoxycholic acid therapy is associated with reduced risk of biliary pain and acute cholecystitis in patients with gallbladder stones: A cohort analysis. Hepatology[online] 1999, 30: 6–13. [viewed 14 April 2014] Available from: DOI:10.1002/hep.510300108
  3. BLAMEY S.L., et al. Prognostic factors in acute pancreatitis. Gut[online]1984, 25:1340-1346 [viewed 14 April 2014] Available from: DOI: 10.1136/gut.25.12.1340
  4. GANNONA P.F.G., D.T. NEWTONB, C.F.A. PANTINB and P.S. BURGEA. Effect of the number of peak expiratory flow readings per day on the estimation of diurnal variation. Thorax[online] 1998, 53:790-792 [viewed 14 April 2014] Available from: DOI: 10.1136/thx.53.9.790

Investigations - for Diagnosis

Fact Explanation
Stool examination for fertilized ova. Fertilized ova of the adult worm are unequally excreted over days and patchily distributed in stool, so stool smears should be examined over several days [1].
Full blood count revealing eosinophilia. Secondary eosinophilia due to tissue invasive parasitosis [2].
Ascaris larvae in sputum. Due to migration of larvae through the lungs in the pulmonary phase [3].
Transient pulmonary infiltrates on chest X ray. Occurs during pulmonary migration of Ascaris larvae [4].
Multiple air fluid levels on erect abdominal X ray. Due to intestinal obstruction caused by the worms [5].
Ultrasound scanning of the biliary tree. It has the ability to demonstrate the presence of biliary ascariasis with findings such as bile duct dilatation and by directly visualizing worms within the biliary tree [6].
References
  1. KNOPP Stefanie, et al. Diagnosis of soil-transmitted helminths in the era of preventive chemotherapy: effect of multiple stool sampling and use of different diagnostic techniques. PLoS neglected tropical diseases. [online] 2008, 2(11): e331. [viewed 15 April 2014] available from: DOI: 10.1371/journal.pntd.0000331
  2. TEFFERI A., M.M. PATNAIK and A. PARDANANI. Eosinophilia: secondary, clonal and idiopathic. British Journal of Haematology[online] 2006, 133: 468–492. [viewed 15 April 2014] available from: DOI: 10.1111/j.1365-2141.2006.06038.x
  3. MORA Nimfa C. Teneza, Eric A. LAVERY and Helen M. CHUN. Partial Small Bowel Obstruction in a Traveler. Clin Infect Dis.[online] 2006, vol 43 (2): 256-258. [viewed 13 April 2014] Available from: DOI:10.1086/505179
  4. KUNST H., et al. Parasitic infections of the lung: a guide for the respiratory physician. Thorax [online] 2011, 66: 528-536 [viewed 13 April 2014] Available from: DOI: 10.1136/thx.2009.132217
  5. GANGOPADHYAY A.N., et al. Conservative treatment for round worm intestinal obstruction. The Indian Journal of Pediatrics. [online] December 2007, Vol 74(12): 1085-1087. [viewed 15 April 2014] available from: DOI: 10.1007/s12098-007-0202-z
  6. DAS C., J. KUMAR, J. DEBNATH and A. CHAUDHRY. Imaging of ascariasis. Australasian Radiology [online] 2007, 51: 500–506.[viewed 15 April 2014] available from: DOI: 10.1111/j.1440-1673.2007.01887.x

Investigations - Screening/Staging

Fact Explanation
CT scan of the abdomen. To identify complications of biliary ascariasis such as cholangitis and hepatic abscesses [1].
References
  1. DAS C., J. KUMAR, J. DEBNATH and A. CHAUDHRY. Imaging of ascariasis. Australasian Radiology [online] 2007, 51: 500–506.[viewed 15 April 2014] available from: DOI: 10.1111/j.1440-1673.2007.01887.x

Management - General Measures

Fact Explanation
Bronchodilator therapy. This reduces the bronchospasm brought about by the hypersensitivity reaction towards the Ascaris larvae which occurs during the pulmonary larval migration phase [1].
Nutritional supplimentation. Due to nutrient absorption and blocking of the absorbing surface of the intestinal mucosa by Ascaris worms as well as reduced voluntary food intake [2].
References
  1. LAU Susanna Kar Pui, et al. Ascaris‐induced eosinophilic pneumonitis in an HIV‐infected patient. J Clin Pathol [online] Feb 2007, vol 60(2): 202–203. [viewed 15 April 2014]. Available from: DOI: 10.1136/jcp.2006.037267
  2. JARDIM-BOTELHO A., et al. Age patterns in undernutrition and helminth infection in a rural area of Brazil: associations with ascariasis and hookworm. Tropical Medicine & International Health[online] 2008, 13: 458–467. [viewed 13 April 2014] Available from: DOI: 10.1111/j.1365-3156.2008.02022.x

Management - Specific Treatments

Fact Explanation
Albendazole 400mg single oral dose. It is a benzimidazole and acts by binding to parasite beta tubulin inhibiting its polymerization and impairing glucose uptake [1].
Pyrantel pamoate. Non-benzimidazole anthelminthics act on the parasite neuromuscular pathways and paralyze them [2].
Endoscopic retrograde cholangiopancreatography (ERPC). For the endoscopic removal of worms in diagnosed biliary ascariasis [3].
References
  1. VENKATESAN P. Albendazole. Journal of Antimicrobial Chemotherapy [online] 1998, 41(2): 145–147. [Viewed 15 April 2014] Available from DOI: 10.1093/jac/41.2.145
  2. HORTON J. Albendazole: a review of anthelmintic efficacy and safety in humans. Parasitology. [online] 2000, Vol 121(1): S113-S132. [Viewed 15 April 2014] Available from DOI: 10.1017/S0031182000007290
  3. DAS C., J. KUMAR, J. DEBNATH and A. CHAUDHRY. Imaging of ascariasis. Australasian Radiology [online] 2007, 51: 500–506.[viewed 15 April 2014] available from: DOI: 10.1111/j.1440-1673.2007.01887.x