Clinical Manifestations and Pathology

Theoretically, the presence of a single parasite is detrimental in some way to the host. In reality, however, adequately nourished persons with light infections are not likely to suffer discernible ill effects or to exhibit the clinical features associated with hookworm anemia. Children and pregnant women will begin to manifest symptoms of hookworm disease at lower levels of infection, as greater demands on their normal iron stores already exist. Efforts to establish a threshold of infection above which the host might be expected to begin to show signs of hookworm anemia have been frustrated by the inability to control other significant variables such as nutrition and general health in a population large enough to be statistically valid. An otherwise healthy person with a normal daily intake of iron can apparently tolerate several hundred hookworms without patently adverse effects. The likelihood of hookworm disease in an individual varies in direct proportion to the worm burden and in inverse proportion to iron intake.

Hookworm disease shares many of the same clinical symptoms accompanying other kinds of anemia. Persons suffering from severe hookworm infection often have a pale and wan appearance, a tell-tale yellow-green pallor to the skin that helps to explain why the disease was sometimes called "Egyptian chlorosis" or "tropical chlorosis" in the years before the parasite was discovered and described in the medical literature. In children, growth may be sig nificantly retarded. A distended abdomen and pronounced, sharply pointed shoulder blades ("pot belly" and "angel wings" in the American South) were once thought to identify children with hookworm disease, although the same features often accompany malnutrition as well. In pregnant women, hookworm infection increases the likelihood of fetal morbidity. Victims of hookworm anemia, regardless of age or sex, may be chronically sluggish, listless, and easily tired, symptoms that prompted a facetious American newspaper reporter early in the twentieth century to dub hookworm the "germ of laziness." Dropsy, dizziness or giddiness, indigestion, shortness of breath, tachycardia, and in very extreme cases congestive heart failure have also all been associated with advanced hookworm disease. Hookworm sufferers will sometimes eat dirt, chalk, or clay as well.

A diagnosis of hookworm infection can be made easily if ova are detected during a microscopic examination of a fecal smear. Quantitative methods have made it possible to estimate both the total number of eggs based on a quick count in the area under the cover slip and the quantity of hookworms lodged in the intestine. Since the nineteenth century, dozens of anthelmintic drugs have been tried, including thymol, oil of chenopodium, carbon tetrachloride, and tetrachloroethylene. More recently developed hookworm vermifuges include bephenium, mebendazole, pyrantel, and thiabendazole. A regimen combining chemotherapy with the simultaneous administration of iron tablets now seems to be the most effective way to eliminate the parasites and at the same time to restore the hemoglobin to a normal level quickly.

The probability of reinfection is high, however, if a person thus treated continues to walk barefooted on ground contaminated with hookworm larvae. This discouraging realization has bedeviled public health workers since the days of the massive early control programs. Numerous designs for sanitary latrines have come and gone over the years; their construction costs placed them beyond the means of impoverished agricultural workers. Cheaper and less sanitary latrines were often worse than no latrines at all, as they tended to concentrate the locus of infection in a small area where people habitually went to defecate. Reinfection would occur rapidly in such instances, although it would take somewhat longer to reach pretreatment worm burdens.

The problems posed by unsanitary latrines were universal. Other difficulties were specific to certain regions or cultures, though no less imposing for that.

For example, an extensive treatment and control campaign in China in the early 1920s foundered on the age-old practice of fertilizing mulberry trees with human feces, often infested with hookworm ova, acquired in massive quantities from brokers who collected it for that purpose in nearby villages. For centuries, then, the Chinese silk industry had sustained a disease afflicting its workers whose contaminated feces nourished the crop on which their livelihoods depended.

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