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    Ascariasis (Ascariases)

    Ascaris infection in X-ray image- Duedenal worms - in the first portion of the bowel after the stomach (South Africa) (16238958958)[1]

    Ascariasis is the most common intestinal helminthic (parasitic worm) infection in humans caused by a nematode, Ascaris lumbricoides (Ascaris), that very rarely also infects the hepatobiliary system or pancreas.

    This disease stems from the following process: infectious.

    Presentation

    In the early stages of ascariasis, pulmonary symptoms including cough, dyspnea, wheezing, rales, tachypnea and urticaria and chest pain, may be observed. In certain countries, such as Saudi Arabia, the pulmonary symptoms are seasonal. Patients with an intestinal obstruction caused by Ascaris (usually children) may present with abdominal pain, distension, nausea, diarrhea, colic and anorexia. Ascariasis patients with cholangitis, pancreatitis and appendicitis (usually adults) may have nausea, vomiting, jaundice, fever and severe radiating abdominal pain [12]. If Ascaris have colonized the liver parenchyma, abscesses may occur [13]. The most common nutritional deficiencies caused by Ascaris are protein and vitamins A and C. Some prospective studies indicate a link between Ascaris-related nutritional deficiency and growth and developmental delays in children.

    Entire body system
    Vietnamese
    • A recent Vietnamese study found that adult women living in rural areas, especially those exposed to human night soil and living in households without a latrine, were at surprisingly high risk for ascariasis. [12] In regions with soil-transmitted diseases[emedicine.medscape.com]
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  • respiratoric
    Cough
    • […] or bowel obstruction (in severe cases) Pneumonia (in rare cases) Transmission Parasitic eggs are ingested and hatch into larvae, which travel through the body and can cause pulmonary symptoms such as coughing and wheezing.[sabin.org]
    • If there are symptoms, they may include: Bloody sputum (mucus coughed up by the lower airways) Cough, wheezing Low-grade fever Passing worms in stool Shortness of breath Skin rash Stomach pain Vomiting or coughing up worms Worms leaving the body through[medlineplus.gov]
    • However, some individuals may develop mild symptoms, including: Abdominal discomfort Persistent cough, resulting from the parasites moving through the body An individual may swallow the larvae/worms when a cough erupts, or cough-up larvae/worms Migration[dovemed.com]
    • During this stage, pulmonary symptoms such as coughing (even coughing up worms) may occur.[akronchildrens.org]
    • Early respiratory symptoms of coughing, wheezing, hemoptysis, and fever are caused by the passage through the respiratory tract.[medical-dictionary.thefreedictionary.com]
    Dry Cough
    • When the larvae are migrating through the lungs, they may cause a fever, dry cough, wheezing, and sometimes asthma.[humanillnesses.com]
    • Known as Loeffler's syndrome, it gives rise to dry cough, high fever and bronchial asthma.[antimicrobe.org]
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  • gastrointestinal
    Abdominal Cramps
    • People may have no symptoms or may have fever, coughing, wheezing, abdominal cramps, nausea, and vomiting.[merckmanuals.com]
    • Short stature Pulmonary eosinophilia Symptoms There may be possibility that people who have ascariasis do not develop symptoms,But transfer of larvae via the lungs can lead to fever, coughing, and wheezing.There may be some abdominal cramps , a blockage[streetdirectory.com]
    • Intestinal infection may result in abdominal cramps and obstruction.[medical-dictionary.thefreedictionary.com]
    • In heavy infections, however, abdominal cramps occur, and occasionally a mass of worms can block the intestines, causing pain, vomiting, and bloating.[humanillnesses.com]
    • The signs and symptoms of the nematode infection by Ascaris lumbricoides may include the following: Abdominal discomfort Abdominal cramping Abdominal swelling (especially in children) Fever Coughing and/or wheezing Nausea Vomiting Passing roundworms and[medicinenet.com]
    Abdominal Pain
    • Laboratory data: Eosinophilia Gallbladder Polyp 52 year old male with sharp right upper quadrant abdominal pain.[sonoworld.com]
    • Symptoms include abdominal pain, constipation and vomiting.[niroginepal.com]
    • The worms can block the intestine or bile duct and this causes abdominal pain.[wikihow.com]
    • Mature worms sometimes block the appendix, biliary tract, or pancreatic duct, producing severe abdominal pain.[streetdirectory.com]
    • If you do have symptoms, you may have vague or off-and-on abdominal pain .[my.clevelandclinic.org]
    Acute Abdomen
    Colic
    • When they are found in a dog's body, it can lead to abdominal swelling (distension), colic, gastrointestinal issues and even intestinal rupture.[petmd.com]
    • But there may be colic or other abdominal symptoms, and occasionally the worms are vomited during their passage through the esophagus.[medical-dictionary.thefreedictionary.com]
    • These worms migrate through CBD, cystic duct and intrahepatic duct leading to biliary colic and cholangitis.[bmcgastroenterol.biomedcentral.com]
    • Ball of worms Filling defects in the biliary system Differential Diagnosis Biliary colic Intestinal obstruction Community-acquired pneumonia Complications Appendicitis Jaundice (if bile ducts are involved) Pneumonia Bowel perforation Mechanical obstruction[learningradiology.com]
    • Presentation forms of BA are biliary colic (56%), acute cholangitis (25%), acute cholecystitis (13%), acute pancreatitis (6%), and, rarely, hepatic abscess or haemobilia [ 1 ].[hindawi.com]
    Diarrhea
    • If the body's immune system can't fight the worm infection, then more of them grow and increase the likelihood of uncomfortable symptoms, such as severe abdominal pain and diarrhea. [4] As the diarrhea becomes chronic and the worms irritate the intestinal[wikihow.com]
    • Signs include poor growth, poor coat and diarrhea due to enteritis.[medical-dictionary.thefreedictionary.com]
    • Symptoms include fever, shortness of breath, malnutrition, abdominal swelling and diarrhea .[byjus.com]
    • The symptoms could be: Related to intestine: Abdominal pain, loss of appetite, nausea and vomiting, diarrhea, weight loss, anal itching occur in ascariasis.[niroginepal.com]
    • Liver hemangiomas This was an incidental finding detected on ultrasound in a 30-year-old man with elevated bilirubin and lipase and a history of diarrhea.[sonoworld.com]
    Recurrent Abdominal Pain
    • abdominal pain, 30% with acute cholecystitis , 25% with obstructive jaundice, 25% with cholangitis , only 5% with pancreatitis , 5% with perforated viscus, and 5% with hepatolithiasis.[emedicine.medscape.com]
    Worms in Stool
    • However, as the infection grows, the following symptom may be experienced by the infected person: Cough Bloody Sputum Low-grade fever Worms in Stool or vomit Skin Rash Abdominal Swelling or Abdominal pain Malnutrition and Loss of Appetite Anemia Shortness[healthresource4u.com]
    • However, if you are heavily infected with worms, then it can cause intestinal blockage symptoms and other parasite infection signs, like: bloating skin rash pancreatitis worms in stool vomiting worms nausea & vomiting severe abdominal pain Ascariasis[healthblurbs.com]
    • […] in stool Coughing, sometimes accompanied by coughing up of worms Wheezing Fever & vomiting Loss of appetite Shortness of breath Swelling of the abdomen & severe abdominal pain Malnutrition, anemia and impaired physical growth, particularly in children[sabin.org]
    • Some symptoms may be seen with mild infection are: worms in stool,coughing up worms , appetite loss,fever ,wheezing .[streetdirectory.com]
    • If there are symptoms, they may include: Bloody sputum (mucus coughed up by the lower airways) Cough, wheezing Low-grade fever Passing worms in stool Shortness of breath Skin rash Stomach pain Vomiting or coughing up worms Worms leaving the body through[medlineplus.gov]
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  • Workup

    Patients with ascariasis will have large (50-60 µm), brown, trilayered eggs with an uneven mucopolysaccharide coat (if fertilized) in their stool, therefore, stool examination for ova and parasites should be performed. A negative stool exam may mean that patients have been infected for less than 40 days, which is the time needed for the mature Ascaris to reach the gut. Earlier in the infection cycle, during pulmonary migration, Ascaris larvae may be present in sputum which are identified microscopically in wet preparations. Also during this earlier tissue migration phase, complete blood count (CBC) will show eosinophilia but serological tests are not clinically useful for diagnosing ascariasis. During the pulmonary migration of larvae, chest radiographs may capture opacities in the lungs and during the adult phase, abdominal radiographs may reveal a swirl pattern, indicating Ascaris in the gut. Partial and complete intestinal obstruction are identified by narrow-based air fluid levels without distended bowel loops and wide-based air fluid levels with distended bowel loops, respectively, using upright plain film. If hepatobiliary infection is suspected, Ascaris in those regions can be identified with ultrasonography (real time may be used to observe worm movement) and computerized tomography (CT) scans [14] [15]. Ascaris related liver granulomata can be identified in the periportal or subcapsular regions by ill-defined, 3-35 mm nodular or wedge-shaped lesions. Along with imaging modalities endoscopic retrograde cholangiopancreatography (ERCP) can be used to diagnosis Ascaris infection, which look like long filling defects, as well as remove the worms from the biliary tract.

    Laboratory

    Serum
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  • Microbiology
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  • Treatment

    Ascariasis is effectively treated with one dose of 400 mg of albendazole orally. Albendazole also kills whipworms which are commonly observed in patients with ascariasis. Pregnant women should avoid albendazole and take pyrantel pamoate instead. Pyrantel pamoate and other paralyzing agents, including piperazine and ivermectin, should not be administered in cases with intestinal obstruction as the paralyzed Ascaris may complicate surgery. An alternative to albendazole is mebendazole which is not as effective at treating whipworm infections.
    A study performed in Zaire demonstrated a benefit from vitamin A supplementation in the growth and development of malnourished children with ascariasis [16]. Partial intestinal obstruction and biliary ascariasis are effectively treated through conservative means, including nothing-by-mouth (NPO) status until the obstruction resolves through normal peristalsis. A new drug, nitazoxanide, was shown to be 89% effective in treating ascariasis in Mexico offering a potential future alternative treatment [17].

    Prognosis

    The most common fatal complication associated with ascariasis is intestinal obstruction, which occurs in the ileum of infected children and is estimated to cause between 8,000 and 100,000 deaths per year [6]. Additionally, adult Ascaris can release toxins that induce bowel inflammation, ischemia and fibrosis. Biliary complications are more commonly observed in adults, especially those infected with other diseases such as malaria. Upon administration of albendazole, cure rates are 95% in South Africa [11], however, most patients will reacquire the disease unless they relocate or sanitation in their area significantly improves.

    Complications

    Acute Pancreatitis
    • In Kashimir region ascarisis is a common condition occuring in every third patient with acute pancreatitis, is second cause of visit in an emergency room and is a reason of around 12,5% of biliary lithiasis.[medtube.net]
    • Presentation forms of BA are biliary colic (56%), acute cholangitis (25%), acute cholecystitis (13%), acute pancreatitis (6%), and, rarely, hepatic abscess or haemobilia [ 1 ].[hindawi.com]
    • These patients usually present with biliary colic (56%), acute cholangitis (25%), acute cholecystitis (13%), acute pancreatitis (6%) and rarely hepatic abscesses (less than 1%) [ 4 ].[bmcgastroenterol.biomedcentral.com]
    • In Damascus, of 300 adults referred for complications of ascariasis between 1988 and 1993, 98% had abdominal pain, 4.3% had acute pancreatitis , 1.3% had obstructive jaundice, and 25% had worm emesis.[emedicine.medscape.com]
    Appendicitis
    • Ultrasound scan is negative for appendicitis but reveals a liver abnormality.[sonoworld.com]
    • Ball of worms Filling defects in the biliary system Differential Diagnosis Biliary colic Intestinal obstruction Community-acquired pneumonia Complications Appendicitis Jaundice (if bile ducts are involved) Pneumonia Bowel perforation Mechanical obstruction[learningradiology.com]
    • Wandering Ascaris may enter the lumen of vermiform appendix causing appendicitis. iv.[biologydiscussion.com]
    • Appendicitis is the inflammation of the appendix.[niroginepal.com]
    • Complications Complications such as intestinal obstruction, appendicitis, biliary ascariasis, perforation of the intestine, cholecystitis, pancreatitis and peritonitis, etc., may occur, in which biliary ascariasis is the most common complication. 19.[slideshare.net]
    Ascariasis
    • Ascariasis is common in Africa and in Southeast Asia.[en.wikipedia.org]
    • Ascariasis facts Ascariasis is a disease caused by a parasite named Ascaris lumbricoides .[medicinenet.com]
    Constipation
    • Symptoms include abdominal pain, constipation and vomiting.[niroginepal.com]
    • […] avoid if intestinal obstruction is present) Ivermectin, nitazoxanide, or levamisole as alternative agents Intestinal surgery to relieve obstruction, if necessary Endoscopic or laparoscopic worm removal Nursing Considerations-Nursing Diagnoses Acute pain Constipation[quizlet.com]
    • Hepatic Lipomas An obese 73 year old woman with history of hypertension, cholecystectomy and hysteroannessiectomy is referred for abdominal sonography due to a complaint of abdominal pain and constipation.[sonoworld.com]
    • With very heavy infestation in growing pigs, the young mature worms can block the intestine leading to vomiting, constipation, jaundice, weight loss and death.[nadis.org.uk]
    • Symptoms include colicky abdominal pain, vomiting and constipation.[afrjpaedsurg.org]
    Eosinophilia
    • A bolus of worms may obstruct the intestine; migrating larvae may cause pneumonitis and eosinophilia.[en.wikipedia.org]
    • Complications Bronchopneumonia may be seen during the pulmonary migrational stage, producing fever, cough, dyspnea, wheeze, eosinophilia, and pulmonary infiltrates (Löeffler syndrome).[unboundmedicine.com]
    • For a discussion of the pulmonary appearances of ascariasis please refer to simple pulmonary eosinophilia .[radiopaedia.org]
    • During the migratory stage of the larvae, eosinophilia and an increase in the serum IgE concentration may be detected.[ebmpracticenet.be]
    Intestinal Obstruction
    Pulmonary Eosinophilia
    • Disease Simple pulmonary eosinophilia Simple pulmonary eosinophilia is inflammation of the lungs from an increase in eosinophils, a type of white blood cell.[scripps.org]
    • Short stature Pulmonary eosinophilia Symptoms There may be possibility that people who have ascariasis do not develop symptoms,But transfer of larvae via the lungs can lead to fever, coughing, and wheezing.There may be some abdominal cramps , a blockage[streetdirectory.com]
    • For a discussion of the pulmonary appearances of ascariasis please refer to simple pulmonary eosinophilia .[radiopaedia.org]
    Roundworm Infestation
    • Travelers are also at risk of getting roundworm infestation in areas where the infection is common.[niroginepal.com]
    • Symptoms become more noticeable when the roundworm infestation grows.[healthline.com]
    • Only the patients of intestinal obstruction with documented evidence of roundworm infestation were included in the study and were followed for one year.[afrjpaedsurg.org]
    Small Bowel Obstruction
    • Most common complication of ascariasis is mechanical small bowel obstruction caused by a large number of worms.[radiopaedia.org]
    Urticaria
    • During the migratory stage of the larvae cough and fever may occur; urticaria may also develop.[ebmpracticenet.be]
    • Hepatic Echinococcus Cyst A 72 year old Italian woman presents with urticaria and a history of vague pain in the right upper quadrant.[sonoworld.com]
    • Clinical features There are two distinct varieties of VLM 1) Systemic or visceral form 2) Ocular form  In a systemic variety the symptoms are those of allergy including urticaria and asthma attacks  Failure to gain weight, arthralgia and myalgia may[slideshare.net]
    • […] cholecystectomy. [7] , [8] Ascaris lumbricoides was found to be equal in incidence to gallstones as an etiological factor for adult biliary disease in areas of endemicity. [7] Aside from the non-specific features of nausea, vomiting, abdominal pain, and urticaria[saudijgastro.com]
    • Urticaria and other symptoms related to hypersensitivity usually occur toward the end of the period of migration through the lungs. 2.[web.stanford.edu]
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  • Etiology

    Ascariasis is the most common helminthic (parasitic worm) intestinal infection in humans caused by the nematode, Ascaris, which typically resides in the jejunum and middle ileum regions of the small intestines [1].

    Epidemiology

    An estimated 25% of individuals worldwide (0.8-1.2 billion) are thought to be infected with Ascaris, with the majority of infected people showing no symptoms. Ascariasis is prevalent in children (2-10 years of age) who reside in developing countries and tropical regions [4] [5]. This disease is perpetuated by contamination of soil by human or animal feces and the number of incidence are highest in children who have other soil-transmitted helminthes infections, such as Trichuris trichiura and hookworm [9]. In 2005 there were an estimated 173 million cases in sub-Saharan Africa, 140 million cases in India, 86 million cases in China, 84 million cases in Latin America and the Caribbean and 23 million cases in the Middle East and North Africa. It is estimated that 60,000 deaths occur per year worldwide due to ascariasis, with most of these mortalities in children [6].

    Sex distribution
    Age distribution

    Pathophysiology

    Adult Ascaris reside in the intestines, are white or yellow and color and can grow to sizes of 15-35 cm long, making them the largest nematodes that infect humans. The life cycle of Ascaris begins in the intestines where eggs produced by females (more than 200,000 per day) may be fertilized by males. These eggs are then released by infected individuals where they will mature if conditions are favorable. According to a Chinese study, the majority of eggs released by infected individuals are fertilized with only a small percentage of unfertilized eggs being released (6-9%). Fertilized eggs may remain viable in soil for 17 months and if conditions are favorable these eggs may become infectious in 5-10 days [7]. In order for the Ascaris life cycle to proceed, fertilized eggs must make their way to the intestines, which is usually achieved through contaminated soil being ingested from hands or food. In the small intestines eggs hatch and the Ascaris larvae will pass through the intestinal wall and travel to the liver on day 4 through the portal system and reach the lungs on day 14. At this stage extreme infections can produce pneumonia but normally the larvae are expectorated and swallowed, where they will go on to the small intestines to complete their maturation into adults which takes about 65 days.

    Broken down food materials in the intestines serve as the main food source for adult Ascaris. This may lead to caloric, protein or vitamin A deficiency, and subsequent growth retardation and increased susceptibility to diseases (eg. Malaria), in children with minimal diets [8]. Ascaris may cause a physical barrier, if they are large enough or become entangled with one another, leading to intestinal, common duct, pancreatic or appendiceal obstructions. The average number of adult Ascaris in infected individuals ranges from four to 16 depending on the age, geography and immunity. The maximum Ascaris lifespan is two years, therefore, those individuals with infections lasting longer than two years must have been re-exposed to contaminated soil [10].

    Prevention

    Appropriate sanitation and hygiene are essential for preventing ascariasis infections. At the individual level this includes thorough hand washing with soap before handling or eating food, washing, peeling and cooking all vegetables and fruits before eating and not defecating outdoors. At the community level this includes improving sanitation and providing effective sewage removal systems. Mass treatments are recommended for communities with high prevalence of ascariasis, however, this strategy only decreases morbidity but not transmission rates, therefore, emphasis should be placed on improved sanitation and hygiene practices.

    Summary

    Ascariasis is the most common helminthic (parasitic worm) intestinal infection in humans caused by the nematode, Ascaris [1]. Ascariasis is more common in developing countries that have inadequate sanitation whose inhabitants are suffering from poverty and overcrowding. Higher infection rates are also observed in tropical and subtropical regions. Ascaris, commonly referred to as round worm, often resides in the jejunum and ileum although the adult worm may travel to the hepatobiliary system or pancreas where it can cause cholelithiasis, acute cholecystitis, choledocholithiasis, acute pancreatitis or ascending cholangitis [2] [3].

    Patient Information

    Ascariasis is the most common intestinal helminthic (parasitic worm) infection in humans caused by the worm Ascaris lumbricoides (Ascaris). Ascaris infections are prevalent in developing countries with poor sanitation and areas with tropical climates. This disease is usually transmitted through food that is contaminated with Ascaris eggs, which are released in the feces of infected individuals. These eggs can survive in soil for months under the right conditions. Once Ascaris eggs are ingested they will hatch in the intestines and release larvae that migrate through blood and lymphatic vessels to the lungs. Once in the lungs, Ascaris larvae mature further and then proceed back to the intestines by way of swallowed sputum. Finally, the larvae mature in the small intestines into adults and this entire process takes 2-3 months. In the intestines mature adult Ascaris can produce and fertilize eggs that will be present in stool.

    Most patients with ascariasis will not display any symptoms and if symptoms arise they are usually a result of the worms presence in the lungs or intestines. When the Ascaris larvae are traveling through the lungs, patients may experience coughing, wheezing, fever and sometimes blood in their sputum. Worms in the intestines may cause abdominal cramps and in severe cases an abundance of worms can partially or completely block the intestines. Intestinal blockage is more common in children that reside in areas with poor sanitation and can result in nausea, vomiting, abdominal swelling and pain. Intestinal blockage is the main cause of death due to complications from ascariasis.

    Ascariasis is most commonly diagnosed by identifying the eggs in a patient’s stool sample. Adult worms may be identified in the intestines through ultrasonography, computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP). Ascariasis is effectively treated with oral administration of the prescription drugs albendazole, mebendazole or ivermectine. Pregnant women may be given alternative medications.

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    References

    1. Mahmoud Adel AF. Intestinal nematodes (round worms) In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone; 1990: 2135–42.
    2. Ochoa B. Surgical complications of ascariasis. World J Surg. 1991; 15(2):222-7.
    3. Gomez NA, Leon CJ, Ortiz O. Ultrasound in the diagnosis of roundworms in gallbladder and common bile duct. Report of four cases. Surg Endosc. 1993; 7(4):339-42.
    4. Bethony J, Brooker S, Albonico M, et al. Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm. Lancet. 2006; 367(9521):1521-32.
    5. Walker M, Hall A, Basáñez MG. Individual predisposition, household clustering and risk factors for human infection with Ascaris lumbricoides: new epidemiological insights. PLoS Negl Trop Dis. 2011; 5(4):e1047.
    6. World Health Organization Staff. Water related diseases: ascariasis. World Health Organization. http://www.who.int/water_sanitation_health/diseases/ascariasis/en/. Published 2013. Accessed 2015.
    7. Peng W, Zhou X, Gasser RB. Ascaris egg profiles in human faeces: biological and epidemiological implications. Parasitology. 2003; 127:283-90.
    8. Le Hesran JY, Akiana J, Ndiaye el HM, et al. Severe malaria attack is associated with high prevalence of Ascaris lumbricoides infection among children in rural Senegal. Trans R Soc Trop Med Hyg. 2004; 98(7):397-9.
    9. Geissler PW, Mwaniki D, Thiong F, et al. Geophagy as a risk factor for geohelminth infections: a longitudinal study of Kenyan primary schoolchildren. Trans R Soc Trop Med Hyg. 1998; 92(1):7-11.
    10. Dold C, Holland CV. Ascaris and ascariasis. Microbes Infect. 2011; 13(7):632-7.
    11. Saathoff E, Olsen A, Kvalsvig JD, et al. Patterns of geohelminth infection, impact of albendazole treatment and re-infection after treatment in schoolchildren from rural KwaZulu-Natal/South-Africa. BMC Infect Dis. 2004; 4:27.
    12. Louw JH. Biliary ascariasis in childhood. S Afr J Surg. 1974;12(4):219-25.
    13. Lloyd DA. Massive hepatobiliary ascariasis in childhood. Br J Surg. 1981; 68(7):468-73.
    14. Wani I. Gallbladder ascariasis. Turk J Gastroenterol. 2011; 22(2):178-82.
    15. Schulman A, Loxton AJ, Heydenrych JJ, et al. Sonographic diagnosis of biliary ascariasis. AJR Am J Roentgenol. 1982; 139(3):485-9.
    16. Donnen P, Brasseur D, Dramaix M, et al. Vitamin A supplementation but not deworming improves growth of malnourished preschool children in eastern Zaire. J Nutr. 1998; 128(8):1320-7.
    17. Galvan-Ramirez ML, Rivera N, Loeza ME, et al. Nitazoxanide in the treatment of Ascaris lumbricoides in a rural zone of Colima, Mexico. J Helminthol. 2007; 81(3):255-9.

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    Media References

    1. Ascaris infection in X-ray image- Duedenal worms - in the first portion of the bowel after the stomach (South Africa) (16238958958), CC BY 2.0

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