Hookworm

MAJOR
OBJECTIVES

01 Understand important properties and life cycle

fundamentals of the Hookworm.

02 Appreciate the pathogenesis and clinical

findings/presentation.

03 Become familiarized with the means of laboratory

diagnosis.
 Kingdom: Animalia
Phylum: Nematoda
Class: Secernentea
Order: Strongiloidae
Family: Ancylostomatidae
Genus: Necator/Ancylostoma
Species: Necator
americanus and Ancylostoma
duodenale
 Introduction
• Human hookworm infection is also known as necatoriasis/ancylostomiasis

• The most clinically relevant nematode parasite species causing this infection are
Ancylostoma duodenale,  Necator americanus and Ancylostoma ceylanicum.

• Other hookworm species include Ancylostoma caninum and

Ancylostoma braziliense which are found in dogs but have the ability to infect
humans as well.

• Hookworm, one of the most common roundworms found in humans, is known as

a soil transmitted helminth due to its “Fecal-soil-skin transmission”.
• Necator can only be transmitted through penetration of the skin
whereas Ancylostoma can be transmitted percutaneously, orally, and probably
transplacentally.  When A. duodenale is transmitted orally, the early migrations
of the larvae cause Wakana disease.

• Humans are the definitive hosts for both Necator americanus and Ancylostoma

duodenale.

• Ancylostoma caninum primarily infects dogs, but humans can be dead-end hosts

that prevent the larvae from completing their life cycle.

• The incubation period can vary between a few weeks to many months.
 Epidemiology
• Roughly 576-740 million individuals are infected with hookworm today.

• Necator americanus : Southeast Asia, India, Sub-Saharan Africa and Tropical

America.

• Ancylostoma duodenale : Northern India, Parkistan, China, Middle East and

Northern Africa.

• Impoverished children are disproportionately affected.

Life Cycle
 Types of Hookworm
Diseases
Hookworm infection gives rise to the following 3 clinical entities in humans:

• This is a gastrointestinal (GI) infection characterized by chronic

Classic blood loss that leads to iron-deficiency anemia and protein
hookworm malnutrition; it is caused primarily by N americanus and A
duodenale and less commonly by the zoonotic species A
disease ceylonicum

Cutaneous • This is an infection whose manifestations are limited to the skin; it

is most commonly caused by A braziliense, whose definitive hosts
larva migrans include dogs and cats

Loeffler • Simple pulmonary eosinophilia

syndrome
 Paradigm

EARLY ILLNESS

• due to skin and lung migration

LATE ILLNESS

• correlates with higher worm burden (in GI tract)

Host Response to N. americanus & A duodenale

Host immune responses are triggered by:

 larval invasion of the skin
 larval migration through the circulation and lungs
 worm establishment in the intestine, where adult
worms feed on blood and mucosa while injecting
various molecules that facilitate feeding and
modulate host protective responses.
Hookworm Excretory/Secretory Products

Hookworm ES products, react with host proteins and have

major functions including:
Host invasion and tissue migration
Parasite nourishment and reproduction
Immune modulation
 Hookworm Excretory Products
Na – ASP- 2 May imitate chemokines, cause remarkable neutrophil recruitment 
helps to suppress the host immunity. It also lowers expression of genes
involved in B-cell receptor signaling pathway

Anticoagulants Termed nematode anticoagulant peptides (NAPs), these facilitate blood-

feeding by preventing thrombosis at the intestinal attachment site.

Hookworm platelet HPI inhibit coagulation by hindering the platelet aggregation and their
inhibitors adherence to fibrinogen and collagen.

Proteases Many hookworm proteases have been contributed to the digestion of free
hemoglobin (Hb), thus called hemoglobinases. These hemoglobinases
are mostly attached to the adult worm gut and not secreted in ES
products.
 Cutaneous Larva
Migrans
A pruritic papulovesicular rash (ground itch) may
develop at the site of larval penetration, usually on
the feet. 
• Intensely itchy (pruritic)
• Creeps along for days (serpiginous)
• IgE mediated response to filariform larval
migration
• Increased risk of secondary bacterial infection
• Gradually resolves once larvae enter The migration of the larvae produces a 2-mm to
circulation and migrate to the lungs 4-mm wide, erythematous, elevated, vesicular
serpiginous track.
 Lung Migration

• Usually Asymptomatic

• IgE- mediated immune response to larvae in lungs

• May cause Type 1 hypersensitivity within the alveoli (Loeffler Syndrome)

• Transient cough, wheezing, chest pain, hemoptysis

• Lobar infiltrate on Chest X-ray may mimic bronchopneumonia

• Sputum contains eosinophils or Charcot-Leyden Crystals

 Pulmonary Clinical Manifestation

Dry cough, hoarseness

Retrosternal & thoracic Irritation & stenosis of
& in some cases,
pain trachea
aphonia
 Established GI infection

• The hookworm causes illness primarily by ingestion of the host’s blood leading to iron
deficiency anemia, and iron deficiency anemia generates its own secondary features.

• Intestinal blood loss secondary to hookworm infection is the major clinical manifestation of
hookworm infection. 

• In fact, hookworm disease historically refers to the childhood syndrome of iron deficiency
anemia, protein malnutrition, growth and mental retardation with lethargy resulting from
chronic intestinal blood loss secondary to hookworm infection in the face of an iron deficient
diet.
Hookworms contribute to iron deficiency by actively feeding on blood from
lacerated capillaries in the intestinal mucosa, resulting in:

Significant GI hemorrhaging

Loss of serum proteins

Intestinal inflammation
Adult worms attach to the mucous wall of
the small intestine where they are capable
of softening the wall of intestinal villi and
breaking blood capillaries, mainly feeding
on blood and tissue fragments.

Generally, the extent of hookworm

infection may be categorized as
o Light (< 100 worms)
o Moderate (100-500 worms)
o Heavy (500-1000 worms)

19
Each Necator worm ingests
0.03 mL of blood daily
Each Ancylostoma worm
ingests 0.15-0.2 mL of blood
daily
 Protein Losing
Enteropathy

Loss of
Hypoproteinemia
immunoglobulins

Increased Rapid
Weight progression of
loss Anasarca Edema susceptibility to
infection an HIV
infection
Clinical Manifestations of the GI Tract

• Iron deficiency anemia causing pallor, dyspnea, weakness,

tachycardia and lassitude

• Abdominal pain and distention (Colicky epigastric pain)

• Diarrhea

• Occasional melena

• Weight loss

• Growth retardation in the fetus

• Severe anemia, heart failure & anasarca in children

Summary of Clinical Manifestations of
Hookworm Disease
Cutaneous Larva Migrans (Ground itch)
• Creeping eruptions
• Serpiginous, pruritic, 1 to 5 cm tunnels beneath the skin
• Linked to zoonotic Ancylostoma braziliense 

Pulmonary Eosinophilia (Loeffler Syndrome)

• Type-1 hypersensitivity reaction within the alveoli
• Irritation of the pharynx, coughing, dyspnea, hoarseness

Iron-deficiency anemia – Intestinal blood loss

• Abdominal pain, diarrhea, weight loss
• Severe anemia and anasarca in children
Laboratory Diagnosis
of Hookworm
Flowchart Summarizing Laboratory
Diagnosis Of Hookworm
 Direct methods of Laboratory
Diagnosis
(Demonstration of eggs)

• Demonstration of characteristic thin-shelled, oval segmented

hookworm eggs in feces by direct wet microscopy or by
concentration methods is the best method of diagnosis.

• The eggs of A.duodenale and N.americanus cannot be

differentiated microscopically.
Hookworm eggs in an unstained wet mount, taken at 400x Hookworm egg in a wet mount
magnification. under UV fluorescence microscopy;
image taken at 200x magnification.
 Hookworm
Rhabditiform Larvae

Hookworm rhabditiform larvae (wet preparations)

Differentiation of Rhabditiform Larvae of
Hookworms & Strongyloides stercoralis

A short buccal cavity distinguishes the Strongyloides rhabditiform larvae (B) from the
rhabditiform larvae of hookworm (A), as it is generally longer in hookworms.
 Direct methods of Laboratory
Diagnosis
(Demonstration of adult)

Image A Image B
 Adult Hookworms

Ancylostoma duodenale Necator americanus

 Buccal Capsule of Adult
Hookworm

Image A: Adult worm of A. duodenale. Image B: Adult worm of N. americanus.

Anterior end is showing cutting teeth. Anterior end showing mouth parts with
cutting plates.
 Copulatory Bursa of Male
Adult Hookworm

Image A: A.duodenale Image B: N.americanus

 Direct methods of Laboratory
Diagnosis
(Stool Culture)
Using the Harada-Mori filter paper culture (HMFPC):
carried out to demonstrate third stage filariform larvae which helps in distinguishing
A. duodenale and N. americanus.
 Filariform/L3 Larva Of Hookworms

N. americanus third-stage Close-up of the posterior end of a

filariform/L3 larva filariform (L3) of N.americanus

Filariform larvae, L3 of A. duodenale in iodine stain

obtained from agar plate culture
 Indirect methods of
Laboratory Diagnosis
(Blood Examination)
• Microcytic Hypochromic Anemia
• Eosinophilia
 Indirect methods of
Laboratory Diagnosis
(Stool Examination)

• Occult Blood (Benzidine Test-blue

colour positive for occult blood.)

• Charcot Leyden cells

 Indirect methods of
Laboratory Diagnosis
(Chest X-Ray)

• Bronchitis/ Bronchopneumonia/
Löffler Syndrome
 Treatment

• The most practical and effective drug is

albendazole (400 mg single dose) or
mebendazole (500 mg once).

• Pyrantel pamoate (11 mg/kg × 3 days) is also

effective and can be used in pregnancy.

• Oral administration of iron can correct the

anemia.
 Prevention

• Prevention of soil pollution with feces and

proper disposal of night soil and use of
sanitary latrines.

• Use of footwear to prevents entry of larva

through the skin of the foot. Gloves give
similar protection to the hands of farm
workers.

• Treatment of patients and carriers, preferably

all at the same time, limit the source of
infection.
 References
• Ghosh S. Panikers textbook of medical parasitology. Jaypee
Brothers Medical Publis; 2017.
• John DT, Petri WA, Markell EK, Voge M. Markell and Voges
medical parasitology. St. Luis: Saunders Elsevier; 2006.
• CDC - DPDx - Intestinal Hookworm [Internet]. Centers for
Disease Control and Prevention. Centers for Disease Control and
Prevention; 2019 [cited 2020May15]. Available from: https://
www.cdc.gov/dpdx/hookworm/index.html
• Hookworms (Necator americanus and Ancylostoma spp.)
[Internet]. Clinical Gate. 2015 [cited 2020May17]. Available
from:
https://clinicalgate.com/hookworms-necator-americanus-and-ancy
lostoma-spp
/
 References
• Ghosh S. Panikers textbook of medical parasitology. Jaypee
Brothers Medical Publis; 2017.
• Charcot–Leyden crystals [Internet]. Medical Laboratories. [cited
2020May19]. Available from: http://
www.medical-labs.net/charcot-leyden-crystals-2-1159/
• Akuthota P, Weller PF. Eosinophilic Pneumonias [Internet].
Clinical Microbiology Reviews. American Society for
Microbiology Journals; 2012 [cited 2020May19]. Available
from: https://cmr.asm.org/content/25/4/649