What is the management approach for patients with ascariasis?

Management of Ascariasis

For uncomplicated ascariasis, a single dose of albendazole 400 mg, mebendazole 500 mg, or ivermectin 200 μg/kg is recommended as first-line treatment with cure rates exceeding 95%. 1

Diagnosis

• Stool examination: Microscopy of concentrated stool samples or fecal PCR to identify characteristic eggs 2
• Clinical presentation: Often asymptomatic but may present with:
  • Abdominal pain
  • Diarrhea
  • Gastrointestinal obstruction (particularly in children)
  • Biliary obstruction (in adults)
  • Loeffler's syndrome during larval migration (fever, urticaria, wheeze, dry cough) 2

Treatment Algorithm

First-line Treatment (Uncomplicated Ascariasis)

• Any of these single-dose options:
  • Albendazole 400 mg orally (100% cure rate) 3
  • Mebendazole 500 mg orally (98% cure rate) 4
  • Ivermectin 200 μg/kg orally 2, 1

Special Populations

1. Pregnant women:

   • Generally defer treatment until after delivery unless urgently needed 1
   • If treatment necessary, consult specialist for risk-benefit assessment

2. Children:

   • Same medications are effective with weight-adjusted dosing 1

3. Co-infections:

   • With hookworm: Prefer albendazole or mebendazole 1
   • With strongyloides: Prefer ivermectin 1
   • With trichuris: Prefer mebendazole 1

Complications Management

1. Intestinal obstruction:

   • Initial conservative management with IV fluids, nasogastric decompression
   • Consider surgical intervention if conservative management fails 5
   • Administer anthelmintic after resolving acute obstruction

2. Biliary complications (cholangitis, cholecystitis, pancreatitis):

   • ERCP for extraction of worms from biliary tree
   • Surgical intervention may be required in severe cases 6

3. Loeffler's syndrome (pulmonary migration):

   • Symptomatic treatment with bronchodilators if needed
   • Consider corticosteroids for severe symptoms
   • Anthelmintic treatment 7
   • For empirical treatment of unidentified organism causing pulmonary symptoms, consider single dose ivermectin 200 μg/kg and albendazole 400 mg 2

Follow-up

• Clinical improvement should be seen within days of treatment
• Stool examination 2-4 weeks after treatment to confirm parasitological cure 1
• Consider treating household members to prevent reinfection 1

Prevention

• Health education about personal hygiene
• Improved sanitation and proper disposal of human excreta
• Discontinuing use of human fecal matter as fertilizer 6
• In endemic areas, consider mass deworming programs 6

Common Pitfalls

1. Failure to treat household contacts leading to reinfection
2. Overlooking nutritional status in heavily infected individuals
3. Inadequate follow-up to confirm cure
4. Missing co-infections with other helminths that may require different treatment approaches
5. Failure to consider complications such as intestinal or biliary obstruction in symptomatic patients

The high efficacy and safety profile of single-dose anthelmintic therapy makes ascariasis one of the most treatable helminthic infections, with the main challenge being prevention of reinfection in endemic areas.