Hookworms

Hookworms are bloodsucking roundworms living in the small intestine. Some common names
for hookworm infections are: ancylostomiasis, necatoriasis, Egyptian chlorosis, tunnel disease,
miners' anemia and brickmaker's anemia. Hookworms are the second most common human
worms (the most common is Ascaris lumbricoides). There are thousands of hookworm species
but only two of them target humans. Necator americanus (necatoriasis) and Ancylostoma
duodenale (ancylostomiasis) infect over one billion people around the globe mostly in tropical
and subtropical climates. Necatoriasis predominates in the Americas (North, Central and South
America) and Australia, whereas ancylostomiasis occurs in the Middle East, southern Europe
and North Africa.

Necator americanus is gray-pink in colour. Male is 5–9 mm and female 10 mm long and about
0.5 mm thick. Usually they live a few years but can live up to 15 years. Females produce up to
10 000 eggs per day. Necator americanus is very similar to Ancylostoma duodenale.
Ancylostoma duodenale males are 5–10 mm and females 10 mm or more in length and 0.5 mm
thick. They live only about six months. Females produce up to 30 000 eggs per day.

The hookworm larvae that start the infection are less than a millimeter long. These third stage,
L3, larvae called filariform live on warm moist soil that has been contaminated with infected
human feces. Upon touch, a tiny filariform larva attaches to the skin and penetrates it. It burrows
through tissue until it reaches a blood vessel or lymphatic duct. It travels in the bloodstream to
the small pulmonary capillaries. It breaks into the lung alveoli and is taken towards the bronchus
and trachea by the movement of microvilli. It is coughed up to the throat and swallowed through
the esophagus to the stomach. After passing the stomach it hooks into the intestinal mucosa in
the small intestine and starts sucking blood. The arrival to the small intestine takes about a week.
Then within a few weeks it develops into an adult and is ready to mate. The produced eggs exit
the body in the feces. Rhabditiform (first stage, L1) larvae hatch in the feces or in warm, moist,
sandy soil within two days. They feed on organic matter and grow rapidly. They molt twice
within 10 days to become filariform (third stage, L3) larvae that are infective. Filariform larvae
can survive up to four weeks in the right conditions (warmth, moisture, shade).

Although most hookworm larvae travel straight to the small intestine, sometimes larval
Ancylostoma duodenale migrate to muscle tissue and become dormant. These sleeping larvae
make up a reserve that can cause infection years after treatment. According to some reports
filariform larvae of Ancylostoma duodenale can cause infection, if ingested. So in theory it is
possible to get infected by accidentally swallowing contaminated dirt. Necatoriasis on the other
hand always requires migration through the lungs.
Infected humans are more often adult men who work barefoot on fields. Hookworm infection is
the most problematic for women and children. Women lose blood with menstrual flow once a
month. They also need extra nutrients for babies. In some developing countries 30 % of pregnant
women are infected with hookworms. Their newborn babies might have low birth weights or
even die. When a woman gives birth, she excretes certain hormones into the bloodstream. The
sleeping larvae (only Ancylostoma duodenale) in the muscles wake up and find their way into the
mammary glands. When the mother breastfeeds her baby, the child gets infected, too.

Hookworms can cause some of the following symptoms:

 anemia (pale skin etc.) and protein deficiency caused by blood loss
 constipation
 congestive heart failure
 decreased rate of growth and mental development in children (caused by protein and iron
deficiency)
 diarrhea
 dizziness
 injury of organs during larval migration
  pneumonitis like symptoms
 dyspnea (shortness of breath)
 excessive coughing during larvae migration
 fatigue (tiredness)
 fever
 loss of appetite
 nausea
 rash or sore and itchy feet after larval invasion
 stomach or chest pain
 vomiting
 weight loss.

Diagnosis of an intestinal hookworm infection is done by identifying hookworm eggs from a

stool sample under a microscope. Another stool sample after treatment is often required to make
sure all hookworms are dead. The infection is usually treated for 1–3 days with medication
prescribed by your health care provider. Some good drugs against hookworms are
benzimidazoles such as albendazole and mebendazole. The drugs are effective and appear to
have only few side effects. Iron supplements may also be prescribed to cure anemia. Despite of
all efforts, the infection might still continue due to awakened dormant larvae or new infections.

Hookworm infection is rarely lethal. In fact, hookworms have been used to cure autoimmune
diseases. In helminthic therapy hookworms are voluntarily swallowed. The parasitic infection
prevents the overly active immune system from destroying tissue focusing only on the foreign
organisms.

Human feces should not be used as fertilizer in agriculture. Do not walk barefoot or touch soil in
areas where hookworms are common. Also if you have cats or dogs, treat them with anti worm
pills regularly.

Cutaneous larva migrans

Animal hookworms Ancylostoma braziliense and Ancylostoma caninum normally parasitize only
dogs and cats. In humans they cause a skin condition called cutaneous larva migrans, creeping
eruption or ground itch. In the canine (or feline) intestine a female hookworm releases eggs
into the stool. The feces land on soil, and rhabditiform larvae hatch and evolve into filariform.
The filariform larvae burrow into human skin and start migrating in the epidermis. They cannot
usually breach the subcutaneous layer and live only up to a few months. They can migrate
several centimeters per day causing itchy red lesions and vesicles on the skin.
Cutaneous larva migrans is usually diagnosed from the signs and symptoms without laboratory
tests. There are no serologic tests for animal hookworm infections for humans. Cutaneous larva
migrans is a self-limiting infection and does not always require treatment. Severe cutaneous larva
migrans infections can be treated with albendazole and surgical removal.

Sometimes larval Ancylostoma caninum is able to penetrate the lower skin layer and migrate to
the small intestine, causing eosinophilic enteritis. It is possible that it can also migrate to the eye
and cause diffuse unilateral subacute neuroretinitis (DUSN). At the early stage of DUSN it
might cause vitritis, visual loss, mild papilledema, and consecutive crops of multiple, evanescent,
deep, gray-white, retinal lesions. After several months there might be widespread, diffuse and
focal depigmentation of the pigment epithelium, retinal arterial narrowing, severe visual loss,
optic atrophy, and electroretinographic changes.

Visceral larval migrans

Migration of larva in the deep tissues

Visceral larva migrans (VLM) is a condition in humans caused by the migratory larvae of
certain nematodes, humans being a dead-end host, and was first reported in 1952. Nematodes
causing such zoonotic infections are Baylisascaris procyonis, Toxocara canis, Toxocara cati,
and Ascaris suum.
They are round worms whose infection is by ingestion of embryonated eggs

Transient larva migration; check on this

Rhabditiform larva of a human hookworm is about 0.3 mm long.

Filariform larva of a human hookworm is about 0.6 mm long.

Prevention and control

Wear protective clothing like shoes

Avoid organic shady places near the home stead

Clears the compound to reduce organic matter

Health education

Treatment of the sick

Proper disposal of stool

Also check out the videos.

Hookworm Quiz

To reveal the answer you need to click the correct option.

How long do hookworms live?

+ A) A few days
+ B) A few months
+ C) A few years

Does cutaneous larva migrans always need to be treated?

+ A) Yes
+ B) No

How does the hookworm larva get into the bowel?

+ A) Skin --> Bloodstream --> Lungs --> Throat --> Stomach --> Small intestine
+ B) Skin --> Bloodstream --> Stomach --> Small int