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Referral and warning signs
When to refer
Refer if: Severe malnutrition or anaemia. Signs of intestinal or biliary obstruction. Suspected Strongyloides hyperinfection. Failure to respond to standard treatment.
Red flags
- Signs of intestinal obstruction (abdominal distension, vomiting, constipation).
- Severe anaemia.
- Severe malnutrition.
- Rectal prolapse.
- Signs of hyperinfection in immunocompromised (sepsis, respiratory distress).
Signs and symptoms
- Often asymptomatic or mild non-specific symptoms.
- Symptoms depend on worm type and burden:
- - Ascariasis (Roundworm): Abdominal discomfort/pain, cough (during lung migration - Loeffler's), malnutrition, passing worms (anus/nose/mouth), intestinal/biliary/pancreatic obstruction (heavy load).
- - Enterobiasis (Pinworm/Threadworm): Intense perianal itching (pruritus ani), especially at night; disturbed sleep; visible small white worms around anus/in stool.
- - Hookworm (Ancylostoma/Necator): Ground itch (dermatitis at penetration site), cough (lung migration), epigastric pain, iron-deficiency anaemia (chronic blood loss), fatigue, pallor, protein malnutrition (heavy load).
- - Strongyloidiasis (Threadworm): Skin rash (larva currens), cough/wheeze (lung migration), abdominal pain, diarrhoea, weight loss. Hyperinfection syndrome in immunocompromised (severe, potentially fatal).
- - Trichuriasis (Whipworm): Often asymptomatic. Heavy load: Frequent bloody/mucoid stools, abdominal pain, tenesmus, rectal prolapse (children), anaemia.
Risk factors
- Poor sanitation and hygiene (faecal contamination of soil/water/food).
- Lack of access to clean water.
- Walking barefoot in contaminated soil (Hookworm, Strongyloides).
- Eating contaminated raw/undercooked food.
- Young age (children often heavily infected).
- Living in endemic areas (tropical/subtropical regions).
Diagnosis
Clinical assessment
Suspicion based on symptoms (anaemia, malnutrition, abdominal pain, itching, passing worms) and epidemiological context.
Differential diagnosis
- Other causes of abdominal pain, diarrhoea, anaemia, malnutrition.
- Allergies (for itching).
Investigations
- Stool Microscopy for Ova and Parasites (O&P): Main diagnostic method. Identifies characteristic eggs of Ascaris, Trichuris, Hookworm. Multiple samples may increase yield. Larvae seen in Strongyloidiasis.
- Scotch Tape Test (for Pinworm): Pressing sticky tape to perianal area first thing in morning, examine tape under microscope for Enterobius eggs.
- FBC: Eosinophilia common with tissue-migrating helminths; Microcytic anaemia in Hookworm/Trichuris.
- Strongyloides serology (if suspected but stool negative).
Diagnostic criteria
Identification of worms, eggs, or larvae in stool or via specific tests.
Management
Non-pharmacological management
- Improve sanitation and hygiene.
- Nutritional support (manage anaemia/malnutrition).
Pharmacological treatment
- Anthelmintic Drugs:
- - Broad Spectrum (Ascaris, Hookworm, Trichuris, Enterobius):
- - Albendazole 400mg PO single dose (Adult/Child >2y); 200mg single dose (Child <2y). (LOC: HC1+)
- - OR Mebendazole 500mg PO single dose (Adult/Child >2y); 250mg single dose (Child <2y). OR 100mg BID for 3 days. (LOC: HC1+)
- (Note: UCG uses <2y dose cutoffs; WHO often uses >1y for 500mg Mebendazole/400mg Albendazole)
- - Strongyloidiasis:
- - Ivermectin 200 mcg/kg PO single dose (repeated after 2 weeks sometimes recommended). (LOC: HC3+)
- - Alternative: Albendazole 400mg PO BID for 7 days (UCG recommends 3 days).
- - Enterobiasis (Pinworm): Treat entire household. Albendazole or Mebendazole as above, repeat dose after 2 weeks.
- Iron Supplementation: For anaemia caused by Hookworm/Trichuris.
- Mass Drug Administration (MDA): Periodic deworming (Albendazole/Mebendazole) for school-aged children in endemic areas (public health program).
Monitoring
Monitor symptom resolution. Repeat stool exam if symptoms persist. Monitor growth/nutrition in children.
Complications
- Malnutrition, growth retardation, cognitive impairment (chronic infections in children).
- Iron-deficiency anaemia (Hookworm, Trichuris).
- Intestinal obstruction (heavy Ascaris load).
- Biliary/pancreatic obstruction (Ascaris).
- Rectal prolapse (heavy Trichuris load).
- Strongyloides hyperinfection syndrome (in immunocompromised).
Prevention
- Improved sanitation (latrine use, proper faecal disposal).
- Access to safe water.
- Personal hygiene (handwashing before eating/preparing food, after toilet use).
- Food hygiene (washing fruits/vegetables).
- Wearing shoes (prevents hookworm/strongyloides skin penetration).
- Regular deworming programs in endemic areas (MDA).
Patient education
- Explanation of worm infection and transmission.
- Importance of taking medication as prescribed (single dose usually).
- Need to treat family members (esp. for pinworm).
- Hygiene and sanitation measures to prevent re-infection.
- Importance of wearing shoes.
- Nutritional advice.
Uganda-specific notes
Intestinal helminth infections are highly prevalent, especially among children. Soil-transmitted helminths (Ascaris, Trichuris, Hookworm) are common. Regular deworming through school health programs is a key control strategy. Albendazole/Mebendazole widely available.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Section 2.4.1