HOOKWORMS

Dr Mudenda
 Introduction
• Are parasitic nematodes that live in the small intestine of mammalian
host such as humans, dog or cat.
• Are characterized by the presence of well-defined buccal capsules
bearing cutting plates or teeth.
• Two species of hookworms, commonly infect humans:
• Ancylostoma duodenale
• Necator americanus
• Named hookworm due to cervical curvature.
• Ancylostoma duodenale, also known as the old hookworm is a
common hookworm of humans.
• Necator americanus also known as the New World hookworm is
another cause of hookworm disease in humans.
• They hookworm disease characterized by iron-deficiency anemia &
hypoalbuminemia.
 Epidemiology
• Hookworm infn are the 2nd most common helminth infection after
ascariasis.
• Hookworm disease is prevalent throughout the tropics &
subtropics(warm and moist climate).
• Movement of infected persons has blurred the geographic differences
in the distribution of the two species.
• An estimated 576-740 million people in the world are infected with
hookworm(CDC,2020).
 Necator americanus
• Literally means the ‘American murderer’.

• Geographical distribution-South America, Southern Africa, Southern

India, Northern Australia, Southern States of USA.
Habitat
• Adult worms live in the small intestines, mostly the jejunum, less
often the duodenum & rarely the ileum.
• Are attached to mucosa, but may attach to new sites during feeding.
 Morphology of N. americanus
• Adult worms are slightly smaller than A.duodenale & pinkish or
creamy grey.
• Males are smaller than females being 7–9 mm by 0.3 mm.
• Females being 9–11 mm by 0.4 mm.
• Buccal capsule is smaller with 2 pairs of semilunar cutting plates
instead of teeth like A. duodenale.
• Posterior end of the male has a copulatory bursa which is long &
wide used for attachment to the vulva during copulation.
• Female worms have a vulva placed in the middle & anterior of the
body.
• They have excretory & oesophageal glands for exodigestion, also
secretes anticoagulant.
• Contraction of oesophageal muscles draws blood & anchors worms to
the intestinal wall.
• N. americanus eggs are identical with those of A. duodenale.

• Life cycle is similar to that of A. duodenale

• Necator has a much longer life span of about 4–20 years compared to
Ancylostoma with 2–7 years
 Ancylostoma Duodenale
• Prevalent along the Mediterranean coast of Europe & Africa, northern
India, China and Japan.
Habitat
• similar to americanus mostly the jejunum, less often in the duodenum
& rarely in the ileum.
 Morphology
• Relatively stout and cylindrical worms.
• Appear pale pink or greyish white, however may appear reddish
brown due to ingested blood.
• The body is curved with the dorsal aspect concave & convex ventral
aspect.
• The buccal capsule is reinforced with a hard chitin-like substance
carrying 6 teeth; 4 teeth ventrally & 2 dorsally.
• Male worm is smaller than female worm 8-11 mm in length & 0.4 mm
thick.
• Posterior end of the male is expanded into a copulatory bursa.
• The cloaca into which the rectum & genital canal open is situated
within the copulatory bursa.
• Female worm is larger, 10 to 13 mm long & 0.6 mm thick.
• Female posterior end is conoid with a sub-terminal anus situated
ventrally.
• Vulva opens ventrally at junction of the middle & posterior thirds of
the body.
• Has a vagina leading to two closely coiled ovarian tubes which occupy
posterior & middle parts of the worm.
• During copulation the male attaches its copulatory bursa to the vulva.
Adult worm of Ancylostoma duodenale
(male & female)
 Characteristics of hookworm eggs
• Eggs are identical for both species.
• Oval or elliptical in shape & colorless(Not bile stained).
• Surrounded by a thin transparent hyaline shell membrane.
• The egg contains an unsegmented ovum when released by the worm
in the intestine.
• During passage down the intestine ,the ovum develops(becomes
segmented with 4 or 8 blastomeres).
• A clear space btn the segmented ovum & the egg shell exist.
• A single female worm lays about 10,000–20,000 eggs in a day & with
millions layed during its life time.

• Egg of Ancylostoma duodenale. A. As seen under microscope; B. Schematic

diagram
• Both species have high fecundity with duodenale laying 10000-25000
eggs/day & Americanus producing 6-9000 eggs/day.
 Life Cycle
• Life cycle is the same for both species.
• Definitive host: Humans are the only natural host.
• Infective form: Is the 3rd stage filariform larva.
• Adult worms inhabit the small intestine by attaching to the mucous
membrane by means of mouth parts.
• Eggs containing segmented ova are passed in feces of infected person
& not immediately infective to humans.
• Embryo develops inside the eggs deposited in the soil under ideal
conditions .
• A rhabditiform larva hatches out of the egg & grows in size by feeding
on bacteria & other organic matter in the soil.
• It then moults twice to become the non-feeding 3rd-stage infective
Filariform larva.
• Infective larva can live in the soil for 5–6 weeks.
 Summary of stages of the life cycle
Stage 1: Passage of eggs from the infected host in faeces
Stage 2: Development in soil
• eggs under the favorable conditions (damp, warm, well-oxygenated
soil) hatch to rhabditiform larva i.e. L1 larva in 48 hours.
• The L1 larva molts twice to develop into a filariform larva(L3) the
infective stage of the parasite.
Stage 3: Entrance to new host
• The L3 larva cast of their sheath and gain entrance into the body by
penetrating the skin.
Stage4: Migration
• The larva are carried by the venous circulation & carried to the Rt
heart into the pulmonary capillaries.
• They break the lung capillaries, enter the alveolar spaces, ascend
upward the bronchial tree to trachea, larynx & ultimately swallowed.
• On entering the esophagus, the larva undergoes a 3rd molt to form 4th
stage (L4 larva) equipped with a buccal capsule for adherence to the
gut wall.
Stage5:  Localization & laying of eggs-In the small intestine, larva
undergo a 4th molt to develop into an adolescent worm.
• Adult worms become sexually mature & start laying eggs after 6 wks
post infection however devt arrest may occur & process may take
longer(6 months or more).
• In some cases, larvae may be swallowed & may develop directly into
adults in the small intestine without a tissue phase.
 Transmission of Hookworm
• Human feces are the only source of infection, routes are:-
1. Cutaneous route – Penetration of the skin by infective filariform
larva in the unshod state or bare hands e.g farmers/Miners.
2. Oral route – swallowed filariform larvae thru contaminated
vegetables or fruits become infective without lung passage(Tissue
phase is bypassed) .
3. Cases of transmammary/transplacental transmission has been
reported for Ancylostoma.
• Galactogenic hookworm infection not demonstrated in human
hookworm except only suggested by high neonatal hookworm
incidence.
 Pathogenesis
Pathogenicity of adult worm
• Pathological changes are caused by the attachment of adult worms to
the intestinal walls.
• The attachment leads to mechanical disruption of the intestinal mucosa.
• The parasites penetrate the blood vessels & suck the blood to get the
nutrition.
• These worms cause considerable loss of blood & tissue.
• Ancylostoma can suck abt 0.2 ml/day of blood while Necator suck abt
0.03 ml per day.
• Excessive blood loss due to heavy & prolonged worm infection leads to
hypochromic microcytic anemia.
• Pathogenicity of infective larva:
• The infective filariform larva at the site of skin penetration produce a
local reaction called ground itch.
•  This allergic manifestation is more severe in Necator infection
•  In previously sensitized host, it can lead to secondary bacterial
infections.
• Migration of large no. of larva, through the lung produces minute
hemorrhage & infiltration of leucocytes resulting in the entrapment of
the larva in lung tissue.
• Both eosinophilia and leukocytosis occur at this stage.
 Clinical manifestation
• The clinical symptoms depend on the site where the worms are present
and their burden.
1. Skin manifestation
• Hookworm related cutaneous larva migrans (HrCLM) is caused by
migration of larva in the epidermis.
• Ground itch is the early clinical manifestation during the penetration of L3
larva on the skin believed to be due to allergic components of the larva.
• Lesions are characteristically seen in & around feet particularly btwn toes.
• It is associated with intense itching, edema, erythema & rash.
• The associated secondary bacterial infection is more common during this
stage.
• Cutaneous larva migrans commonly caused by animal hookworms
than human e.g. A.braziliense,A. caninum etc.

2. Pulmonary manifestation
• It is associated with low grade fever, mild cough dizziness &
hemoptysis.
• Pneumonia with pulmonary consolidation is seen in persons with
severe infection.
 3. Intestinal manifestation
• Acute intestinal symptoms such as abdominal pain, nausea,
vomiting & hemorrhagic diarrhea are observed.
• Chronic hook worm disease is characterized by blood loss &
iron-deficiency anemia.
• Anemia is associated with fatigue, pallor, tachycardia &
dyspnea on exertion.
• Hypoproteinemia may cause edema and there can be sign of
malabsorption and malnutrition.
• The severity of the disease varies with the worm burden and the
amount of blood lost.
• Severe hookworm anaemia commonly leads to cardiac failure.
• Mental & physical development is retarded in children.
• Hookworm disease is related to worm burden.
5 eggs/mg feces – No clinical disease.
20 egg/mg feces – associated with significant Anaemia.
50 eggs/mg feces – Represent massive infection.
 DIAGNOSIS OF HOOKWORM
1. Demonstration of eggs in feaces.
• Egg counts give a measure of the intensity of
infection.
• Modified Kato-Katz smear technique is a useful
method for quantitative estimation of eggs in stool.
2. Charcot-Leyden crystals in feaces – in prepatent
period
3. Free larvae in stored feaces – to be differentiated
from other larvae
4. Culture of eggs – Harada-Mori test & Coproculture
5. Blood examination reveals microcytic,
hypochromic anemia and eosinophilia.
 6. Occult blood test
• occult blood in the stool gives a position reaction in case of
hookworm infection
• Charcot-Leyden crystals are often found in the stool.
 Diagnosis of Hookworm

Harada-Mori test-tube fecal culture for the diagnosis of hookworm and other intestinal
nematode larvae. The cultures shown here are 3 days old, and by the upward flow and
evaporation of water, the fecal film has been leached and the soluble elements have been
deposited in the dark zone at the top of the filter-paper strip. The water level (shown by
an arrow) is maintained by periodic replacement. After about 24 hours of leaching, the
odor of feces disappears and is replaced by the aroma of damp soil. (From Beaver, P.C.,
Malek, E.A., and Li.ttle, M.D. 1964. J. Parasitol., 50:664-666.)
 Treatment

• Mebendazole is a drug of choice- oral, 100 mg twice daily for 3 days

• Others anti parasitic drugs are- pyrantel pamoate, thiabendazole,
Albendazole, levamisole
• Treatment of iron deficiency anemia with replacement iron therapy.
• Treatment for Hookworm anaemia
a. Iron therapy
b. Folic acid
c. Parenteral iron – iron dextrose when patients
cannot tolerate iron by mouth or when compliance is
poor.
• Treatment for Cutaneous Larva Migrans
a. oral Thiabendazole
b. Topical Thiabendazole
c. Mebendazole
d. 10% Metriphonate in petroleum
jelly - topically
 Ancylostoma ceylanicum
• Males are 8mm & females 10mm in size
• Two large teeth, each with a small one on each
side of the middle line.
• Found in domestic cats, wild cats, dogs & man to a
lesser extent in SE Asia, Phillipines, Taiwan & India
• Does not cause larva migrans in man
• Causes intestinal infection in man and needs to be
distinguished from N. americanus & A.duodenale
Ancylostoma ceylanicum Cont.
6. Small bursa , as wide as it is long supported
by short lateral rays
Ancylostoma brazilliense
• Found in wild and domestic Cats and dogs in Brazil
Phillipines, India, Thailand, Ceylon, Indonesia,
New Guinea
• Males – 8mm, Females – 10mm with distinct
angular bend at level of vulva
• Buccal capsule with pair of inconspicuous
median teeth and a pair of outer larger teeth.
Ancylostoma caninum
• Is a dog parasite
• Human parasite in the Phillipines, L3found in
skeletal muscle of man in Louisiana.
• Males – 10mm, Females – 14mm
• Large buccal capsule – 3prs ventral teeth
• Bursa supported by slender rays
• Eggs slightly larger than A.duodenale
• Oesophageal ( amphidial) glands produce
proteolytic enzymes
Other hookworms
1. A. turbaeformi
2. A. malayanum
3. A. ceylonicancylostoma
4. Uncinaria stenocephala -dogs
5. Bunostomum phlebotomum - cattle
 Prevention

• Sanitary disposal of human feces

• Treatment of infected persons.
• Use of sanitary latrines & use of foot wear.
• Health education with improved nutrition supplemented with the
dietary iron.
 Factors promoting endemicity of hookworms are as
follows:-
1. Continuous infection in the human population
2. Promiscuous defecation ensuring that ova are
deposited in favorable soil for extrinsic
development
3. Appropriate conditions – sandy and humus soil
4. Opportunity for the infective larvae to come in
contact with bare skin.
5. Prolonged dry and cold seasons are
unsatisfactory for the extrinsic development.
6. Defecation habits and use of night soil in
agriculture ensures inoculation of soils for
human exposure.
7. Temperature is major factor in determining
geographical distribution
• Necator eggs and larvae tolerates higher
temperatures than those of Ancylostoma
• Necator is warm climate hookworm
• Ancylostoma is cooler climate hookworm