HOOKWORM

NECATOR AMERICANUS

Common name: New World (American) hookworm

Disease: necatoriasis, uncinariasis
Geographical distribution: Southeast Asia, Central & South Africa, Central & South America, Philippines
- Tropical and subtropical countries
Epidemiology:
The general prevalence of hookworm infection is determined by:
• Extent of infection in a community environment favorable for the existence & development of the free –
living larvae.
• Adequate source of infection in the human population.
• Sewage disposal & degree of soil contamination.
• Sanitary habit & economic status of the people.

MORPHOLOGY:
- Adult worms are cylindrical, fusiform
- grayish white with cephalic portion curved against the body
- small and has a tendency to go against the general body curvature, hence a hook is formed (S shaped)
- have a small buccal capsule provided w/ a pair of semilunar cutting plates.

male:
- measures 5-9 mm. X 0.3mm.
- The posterior end has a broad membranous caudal bursa with rib- like rays – used for copulation.
- The head is curved opposite to the curvature of the body, like a hook at the anterior end.
- the bursa is longer than broad w/ bipartite dorsal rays w/ a broad base & the mediolateral & posterolateral
rays are close to each other w/ the externodorsal ray separated
- Has a pair of long copulatory bristle which fused distally & has a barbed tip.

• They are provided with long cephalic or amphidial gland that secretes a potent anticoagulant and promotes
the flow of blood.
• The bursa copulatrix is longer than broad with a bidigitate or a bipartite dorsal ray with long slender
copulatory spicules that are fused at the tip to form a delicate barb.

Posterior part of N. americanus(male) showing dorsal ray and spicule. x200

Females:
- measure 9-11mm X 0.35mm
- the vulvar opening is situated either in the middle of the body or somewhat anterior to this position.
Ova:
- 64-76 um X 36-40 um
- they are rectangularly oval in shape, single thin- shelled & colorless.
- When passed w/ stool, they are in the early stages of segmentation - 2 to 8 cell stages.

Hookworm eggs examined on wet mount (eggs of Ancylostoma duodenale

and Necator americanus cannot be distinguished morphologically).

Larval stages:
Rhabditiform larva – hatches from the eggs 24-48 hours.
- Measures about 250 um.
- short & stout w/ a narrow buccal chamber
- Has flask- shaped muscular esophagus occupying the anterior 3 rd of the digestive tract.
- It has an inconspicuous genital primordium & a long tapering posterior end.

Rhabditiform larva Filariform larva:

Filariform larva
- follows the rhabditiform larva after 2 moltings which would require 5-10 days after hatching from the egg.
- Larva is longer & more slender
- mouth closes & esophagus elongates occupying about 25-30% of the body length
- Sheath, which serves as a protective covering is characteristic of the filariform stage
- posterior end is long & tapering.
- This stage is also known as the non-feeding stage & is the infective stage to man, the manner of
transmission is by skin penetration.

Life cycle
Skin penetration by filariform larva - circulation – heart – lungs – trachea – pharynx – swallowed – small intestine
becomes adults, attach to intestinal mucosa – copulation (1 month) – lay eggs – eggs passed out in feces (diagnostic
stage) -undergo cell stages – becomes embryonated – RL hatches – free RL in soil – FL (infective stage)

PATHOGENESIS: Pathology & Symptomatology

Pathogenic stages are the larva & adult
1. Larval lesion– on skin penetration, it produces maculopapules & localized erythema.
Itching is severe called ‘’ground itch’’ or ‘’dew itch’’.
If many migrate thru the lungs, bronchitis or pneumonitis may result in sensitized individuals.
2. Adult lesions
- it is chronic infection w/ no acute symptoms
- Most prominent characteristic in moderate or heavy chronic infection is progressive secondary microcytic
hypochromic anemia of nutritional deficiency disease type due to continuous loss of blood.
- This may lead to cardiac hypertrophy & rapid pulse.

Other signs are dyspnea, weakness, dizziness, anorexia, vomiting, disturbances in sleep & hypoalbuminemia.

Hypoalbuminemia
• due to combined loss of blood, lymph and protein.

Severity of symptoms:
1. Mild (w/ blood compensation)- anemia negligible and lacks symptoms.
2. Moderate (appreciable blood decompensation) symptoms consist of heartburn, flatulence, feeling of
fullness in the abdomen, epigastric pain relieved by eating bulky food or ingesting clay (geophagia),
vasomotor disturbances, dyspnea, low- grade intermittent fever and palpitation
3. Severe (w/ complete decompensation)
– classic picture w/ constipation or diarrhea, dry skin, geophagia intensified, edema around the eyes, “pot
belly” in children, albuminuria, child may be physically & mentally retarded.

Diagnosis:
• Direct fecal smear
• Kato technique or Kato-katz method
• Concentration techniques (Zinc sulfate C.T.)
• Culture (Harada Mori) - to differentiate hookworm from Strongyloides

Treatment:
• Mebendazole and Albendazole (DOC) – preferred in endemic areas
• Flubendazole
• Thiabendazole –topical or systemic is successful for creeping eruption

Supportive treatment:
• Proper nutrition, vitamins, Iron therapy for anemia
• blood transfusion if anemic.

Prevention:
• Treatment of infected individuals.
• Good & sanitary human waste disposal
• Protection of susceptible individuals by wearing shoes, boots or slippers
• Mass chemotherapy
• Health education
ANCYLOSTOMA DUODENALE

Common name: Old World hookworm

Disease: ancylostomiasis
Geographical distribution:
- Southern Europe, North coast of Africa, Northern India, North China, Japan, Chile and the Far East.

Morphology:
Adult worms:
- stout, cylindrical, slightly constricted anteriorly & have a cephalic curvature along the curve of the body.
- Living worms are pinkish or creamy– gray in color
- covered w/ a tough cuticula & provided w/ a pair of lateral cervical papillae.
- have a pair of small teeth (accessory teeth or toothlets) & 2 pairs of big teeth.

Males:
- measures 8-11mm X 0.4 -0.5mm.
- w/ the bursa shorter & broad, the 3 lateral rays are equally separated w/ a tripartite dorsal rays.
- The spicules are separated w/ pointed tips.

Females:
- measures 10- 13mm X 0.6mm
- the vulva situated midventrally at the beginning of the distal 3 rd of the body.
- daily egg output of
A. duodenale: 25,000- 30,000
N. americanus: 9,000

Ova: same as in N. americanus

- 56-60um X 0.34-40um.

Larval stages same as in N. americanus.

Mode of transmission:
- percutaneous
- transmammary
- oral route by eating raw vegetables contaminated with larvae

Note: Life Cycle, pathogenesis, Diagnosis, Treatment, Epidemiology & prevention are the same in all hookworms.

ANCYLOSTOMA CEYLANICUM

- first human case in the Philippines in 1968 from a 53- year old from Ilocos Norte, collected 23 adult worms.
- smaller size species of Ancylostoma.
• Occur typically in cats & their wild relatives in South East Asia, w/ human infection reported in the Phils.
• This is an intestinal parasite which does not produce cutaneous larva migrans.

Males measure about 5mm.

- broader bursa, the lateral rays are curved more, the mediolateral & externolateral rays are more
divergent.

Females measure 7mm. in length w/ vulvar opening posterior to the middle portion.
• They have a pair of small teeth & a pair of big teeth.
ANCYLOSTOMA BRAZILIENSE
Common Name: Cat HW
Disease: cutaneous larva migrans (creeping eruptions)
Geographical distribution:
= present in wild & domesticated feline & canine host in numerous localities throughout the Tropics & Subtropics.

Morphology:
-the buccal capsule is specifically diagnostic, has a pair of small, very inconspicuous median teeth & a pair of
larger outer teeth.
Males measure 7.75-8 mm X 0.35 mm. w/ a distinct small, almost as broad as long bursa supported by short stubby
rays.
Females measure 9-10.5mm X 0.375 mm

ANCYLOSTOMA CANINUM

Common Name: dog hookworm

Disease: creeping eruption or cutaneous larva migrans
Geographical distribution: Northern Hemisphere, Philippines
Morphology:
Adults: there is a wide buccal capsule to accommodate the 3 pairs of ventral teeth, a diagnostic characteristic of the
species.
Males measure 10mm X 0.4 mm., bursa is flaring, supported by long, moderately slender rays.
Females measure 14mm X 0.6 mm.
Ova: similar to those of A. duodenale but are slightly larger (63.8 X 40 um)
Pathogenesis of A. caninum & A. braziliense
Creeping eruption- a cutaneous lesion commonly resulting from exposure to the unprotected skin of man to
filariform larvae of canine or feline strains of A. caninum.
- also known as plummer’s itch or duck hunter’s itch. This can also be caused by human strains of hookworms (A.
duodenale, N. americanus).

- the filariform larva penetrates the skin but does not pass through the st. germinativum; using the st.
corneum as the floor & the st. granulosum as the roof, they tunnel their ways under the skin; the tunnel
could be linear or twisted
- Itchiness and inflammation at the site of penetration
- skin elevation (papulo-vesicular lesion) at the site of invasion
 - the larva moves a few mm. to a few cm. a day; it could be single or multiple; they usually affect the feet,
arms, back & abdomen; the tunnel becomes dry & crusted.

Treatment: topically, use ethyl chloride spray or dry ice freezing; burning w/ TCA or phenol; use of Thiabendazol.

Prevention:
• Avoid sites where infected dogs & cats may have defecated.
• Eradicate infection in the dogs & cats by periodic antihelminthic treatment.

STRONGYLOIDES STERCORALIS
Common name: threadworm
Disease:
- strongyloidiasis
Cochin– china diarrhea- heavy infection produces intractable, painless, intermittent diarrhea.
• Incidence in the Phils is rare, (5%)
Morphology:
• Strongyloides have 2 phases of development:
1. the free –living or indirect phase
2. the parasitic or direct phase.
 They are known as facultative parasites due to its ability to survive both in a free- living & parasitic
conditions.
 Under favorable condition, the rhabditiform larva molts several times into the free- living adult males &
females which reproduce & multiply in the soil.
 Such existence is indefinite depending upon the environment conditions. When the conditions become
unfavorable to the parasites, the worm follow the parasitic form of development.

Free- living male

- Measures 0.7mm x 0.04 mm
- Smaller than the female
- Has a ventrally curved tail, two copulatory spicules, a gubernaculum but no caudal alae
- Gubernaculum, a gelatinous tissue that pulls the testes through the abdomen, through the inguinal canal in
the groin, and down into the scrotum. The pulling action occurs as the  gubernaculum  is stimulated first to
grow and then to shrink.

Parasitic males:
- have not been reliably identified.
- measures about 0.7 mm, almost identical w/ the free-living males except for the slightly larger buccal cavity
of the latter.
- Posterior end of the parasitic males (which is believed to be the same in the free-living males) is curved
ventrad to the tail.
- It has 2 short equal copulatory spicule & a gubernaculum but no caudal alae.

Parasitic/ filariform females:

- measures about 2.2 mm. X 0.04 mm.
- has a slender tapering anterior end & a conical short pointed posterior end.
- The esophagus is cylindrical extending to the anterior 4 th of the body.
- It has a paired uterus (containing a single file of 8- 12 thin- shelled transparent segmented ova about 50-58
X 30-34 um), oviduct & ovarian tubules.
- Vulvar opening is situated in the posterior 3rd of the worm.

Free- living females

- measures about 1 mm X 0.06mm.
- It has a muscular double- bulbed esophagus and the intestine is a straight cylindrical tube.
 - The reproductive organs are paired. The uteri contain a single column of thin shelled, transparent
segmented ova occupying most of the space along the intestine.
- Lays embryonated eggs, develop into RL after few hours. Feed on organic matter and transforms into free-
living adults, becomes FL in unfavorable environment.

Ova
- measures about 50-58 um x 30-34 um.
- With clear, thin shell
- Similar to HW ova but SS ova is smaller

Larval Stages

Rhabditiform larva:
- measures 175 – 225um X 16 um
- has a short & wide buccal cavity and larger genital primordium.
- It has an elongated muscular esophagus with a pyriform posterior bulb
- Slightly smaller than HW RL and less attenuated posteriorly.

Filariform larva:
- w/ a characteristic club-shaped anterior portion
- 550 um long, has post-median constriction & a posterior bulb.
- It has a very long conspicuous genital primordium located ventrally.
- Similar to HW FL but usually smaller with a distinct cleft at the tip of the tail.
- The posterior end is sharply attenuated.
- long, delicate organism w/ a long esophagus occupying about 40% of the body length.
- A fork posterior end and a notched caudal end.

Filariform or parasitic female: 2.2mm X 0.04 mm

parasitic male - none
Free-living filariform female: 1mmX 0.06mm
Free-living filariform Male: 0.7mm X 0.04mm

• This is characteristic of this stage & specie which help in differentiating it from hookworm.
• It is infective to man & many remain viable in the soil for several weeks.

Ova:
 50-58um, partially embryonated when laid, thin shelled transparent ovoidal ova which usually hatches in
the tissues.

Life cycle:

Direct/ Parasitic LC - primarily responsible for human infection since it requires parasitic phase for its continuation

Skin penetration by FL
reaches cutaneous venules
circulation – heart - lung migration – swallowed
develop into adult male and female in duodenum and upper jejunum (1 month)
copulate – eggs laid – becomes RL after few hours
RL in feces - RL in soil
unfavorable condition in soil RL becomes FL
skin penetration
Indirect or Free-living LC
Adult female lays embryonated eggs

Parasitic LC RL after few hours

Skin penetration feed on organic matter

FL transform into adult male and female

Unfavorable condition in the soil favorable condition in the soil

lay eggs

RL larva

Adults

Autoinfection- reinfection w/o living the host.

2 TYPES:
• External autoinfection – when rhabditiform larvae transforms to filariform larvae in the anal mucosa to
reach the superficial vessels & initiate reinfection by internal route; also associated w/ radiating perianal
‘’creeping eruption‘’
• Superinfection or hyperinfection or simply autoinfection occurs in the GIT when rhabditiforms become
filariform & penetrates the mucosa to reach the mesenteric vessels & enter portal circulation.

Autoinfection LC
RL

Enters large intestine and becomes FL

Penetrates perianal area
anus invades the mucosa

Circulation circulation

starts another parasitic cycle

w/o leaving the host
Pathogenesis & Symptomatology:
Filariform larva – when it penetrates the skin, produces petechial hemorrhages, congestion & edema, violent
pruritus at site of skin penetration.
- In the lungs, delay in larval migration due to host response, they mature in the lung parenchyma & invade
the bronchial epith. causing destruction & consolidation of the lungs (strongyloides pneumonitis).
- In autoinfection, they penetrate the colon & go to venous circulation carrying w/ them microorganisms in
the intestine (E. coli) resulting to bacteremia & septicemia.

Adult- by mechanical or chemical irritation, produce intestinal disturbances like severe diarrhea, abdominal pain,
severe infection, paralytic ileus.
- They also produce hypereosinophilia.
Diagnosis:
1. Modified Harada-Mori culture method
2. Beale’s string test
3. Duodenal aspiration
4. Small bowel biopsy
- demonstration of rhabditiform larva & adults in stool.
5. lungs- demonstration of adult & larva from sputum & bronchial washing

Treatment:
1. albendazole- drug of choice
400mg x 3 consecutive days
2. Thiabendazole

Additional notes- intestinal strongyloidiasis differs from the hookworm infection in that it causes an immediate
inflammatory irritation of the intestine, whereas the hookworm causes symptoms when anemia occurred.

Prevention and control

- Same as HW

Capillaria philippinensis