Threadworm infection is an intestinal disease, which occasionally spreads tothe skin, caused by a type of parasitic roundworm (helminth). In untreated patients, the disease has a high rate of reinfection caused by worms already present in the body. This type of disease recurrence is called autoinfection. Because of autoinfection, threadworms can remain inside humans for as long as45 years after the initial infestation.
Threadworm infection, which is also called strongyloidiasis, occurs in most countries of the world but is natural to (endemic in) tropical and subtropicalclimates. Strongyloidiasis is less common than other parasitic infections but may affect as much as 25% of the population in some developing countries. In the United States, threadworm infection is most likely to be found among immigrants; returning travelers or military personnel; people who live in partsof Appalachia and the southeastern states; and persons in homes for the retarded and similar institutions.
Human beings are universally susceptible to threadworm infection, although adults and older children are at greater risk of infection than younger children. The disease does not confer immunity. In addition to humans, threadworms can infect dogs, cats, horses, pigs, rats, and monkeys. The roundworm that lives in soil and can survive there for several generations. Mature threadwormsmay grow as long as 1-2 inches (2.5-5 cm). The larvae have two stages in their life cycle: a rod-shaped (rhabdoid) first stage, which is not infective; and a threadlike (filariform) stage, in which the larvae can penetrate intact human skin and internal tissues.
The infection is most commonly transmitted when a person comes into contact--usually by walking barefoot--with soil containing S. stercoralis larvae in their filariform stage. The threadlike larvae penetrate the skin, enterthe lymphatic system, and are carried by the blood to the lungs. Once in thelungs, the larvae burst out of the capillaries into the patient's main respiratory system. They migrate upwards--usually without symptoms--to the patient's throat, where they are swallowed and carried down into the digestive tract. The filariform larvae settle in the small intestine. They mature into adults that deposit eggs that hatch--usually in the intestines--into noninfectiousrhabdoid larvae. The rhabdoid larvae then migrate into the patient's large intestine and are excreted in the feces. The time from initial penetration ofthe skin to excretion is 17-28 days. The rhabdoid larvae metamorphose into the infective filariform stage in the soil.
Threadworms are unique among human parasites in having both free-living and parasitic forms. In the free-living life cycle, some rhabdoid larvae develop into adult worms that live in contaminated soil and produce eggs that hatch into new rhabdoid larvae. The adult worms may live as long as five years.
The signs and symptoms of threadworm infection vary according to the stage ofthe disease as the larvae migrate throughout the body. Patients who suffer from autoinfection may have chronic or intermittent symptoms for years after they are first infected. The filariform larvae usually enter the body throughthe skin of the feet. There may be swelling, itching, and hives at the pointof entry that may be confused with insect bites. Patients with chronic threadworm infection may also develop an itchy rash on their buttocks, thighs, or abdomen.
Although some patients may notice only mild diarrhea and cramps, others may have fever, nausea, vomiting, general weakness, and blood or mucus in their stools. The pain may mimic a stomach ulcer. When the larvae migrate to the lungs and air passages, the patient may have symptoms ranging from a simple dry cough to fever, difficulty breathing, and coughing up blood or pus.
Hyperinfection syndrome is a potentially fatal set of complications resultingfrom the spread of filariform larvae to the lungs and other organ systems. It can include inflammation of the heart tissue, stomach ulcers, perforation of the intestines, blood poisoning, meningitis, shock, and eventual death. Hyperinfection syndrome is most likely to occur in patients with immune disorders or malnutrition, or in those taking anti-inflammatory or corticosteriod medications. It has been reported in only a few AIDS patients.
Threadworm autoinfection in humans follows two patterns. In internal autoinfection, some rhabdoid larvae in the lower bowel develop into filariform larvaethat enter the bloodstream from the intestines and migrate to the lungs. Inexternal autoinfection, the skin around the patient's anus is infected by larvae in the feces.
The doctor is likely to consider a diagnosis of threadworm infection when a patient has the symptoms described earlier and a history of travel or militaryservice in areas where the disease is endemic. A definite diagnosis is madeby finding rhabdoid or filariform larvae in the patient's body fluids. The larvae may be found in fresh stool specimens or in mucus coughed up when the infection has reached the lungs. Because the larvae cannot be detected in the stools of 25% of infected patients, the string test is often performed to confirm the diagnosis. In this test, the patient swallows a weighted string whichis withdrawn after four hours. The digestive juices absorbed by the string are then examined for the presence of threadworm larvae.
Doctors can also use blood tests and diagnostic imaging to support the diagnosis. Between 85% and 95% of patients with threadworm infections will have a measurable level of antibodies in their blood, even though these antibodies donot prevent the disease from spreading. In addition, patients with severe infections often have unusually high levels of white cells in their blood. X rays of the intestines or the chest often help in locating specific areas of inflamed or ulcerated tissue.
Threadworm infections are treated with medications. The drugs most often given are ivermectin, thiabendazole (Mintezol), and albendazole. Ivermectin is generally preferred because it has fewer side effects than thiabendazole. Thesedrugs, which are taken by mouth over a period of 2-7 days, work by preventing the development of eggs and new larvae. Patients with severe infections should be given protein replacement, blood transfusions, and fluids to replace losses from nausea, vomiting, and diarrhea. Patients who are taking corticosteroids should be carefully evaluated if they have symptoms of threadworm infection, because these medications encourage the development of hyperinfection syndrome. The prognosis for complete recovery is good for most patients, except those with hyperinfection syndrome or severe protein loss.
There is no effective immunization against threadworm infection. Prevention of the disease requires careful attention to personal and institutional hygiene in endemic areas, including handwashing after defecating and before handling food. Other precautions include wearing shoes when visiting countries withhigh rates of threadworm infection, and monitoring close contacts of patientsfor signs of infection.