A patient named Mr. Johnson, 68 years old, has a chief complaint of mu

A patient named Mr. Johnson, 68 years old, has a chief complaint of multiple episodes of vomiting since two days, pain in abdomen on both sides, and dry cough for two days, and associated complaints of loss of appetite for two days. So, what is the cause of the illness and diagnose this disease.

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Diagnosis: Ascariasis (Ascaris lumbricoides infection)

Mr. Johnson's constellation of symptoms - vomiting, bilateral abdominal pain, dry cough, and loss of appetite over 2 days - fits the classic presentation of Ascariasis, an intestinal nematode (roundworm) infection caused by Ascaris lumbricoides.

Why This Diagnosis Fits

Mr. Johnson's Symptom	Ascariasis Explanation
Dry cough (2 days)	Larval migration through the lungs triggers an irritating, nonproductive cough (Löffler's syndrome / eosinophilic pneumonitis)
Vomiting (2 days)	Adult worms in the small intestine cause nausea and vomiting; a large worm migrating up the esophagus can provoke vomiting
Bilateral abdominal pain	Heavy worm burden causes nonspecific abdominal pain; entangled worms can cause small bowel-like cramping
Loss of appetite (2 days)	Characteristic symptom of intestinal worm burden

Causative Agent and Life Cycle

Ascaris lumbricoides is the largest intestinal nematode parasite of humans, reaching up to 40 cm in length. The infection cycle explains all of Mr. Johnson's symptoms:

Infection route: Ingestion of embryonated eggs from fecally contaminated soil, raw vegetables, or water
Gastric phase: Stomach acid dissolves the egg's outer layer; larvae are released into the intestine
Pulmonary migration phase (the key to the dry cough): Larvae penetrate the intestinal mucosa, enter the portal circulation, travel through the liver to the lungs, penetrate alveoli, and ascend the bronchial tree - producing the dry cough, substernal discomfort, and Löffler's syndrome at days 9-12 post-infection
Intestinal phase: Larvae are swallowed back down, mature into adult worms in the small intestine (mainly jejunum), causing abdominal symptoms

The simultaneous presence of pulmonary symptoms (dry cough) AND gastrointestinal symptoms (vomiting, abdominal pain, anorexia) is the hallmark clue that larvae are actively migrating while adults are already established.

Harrison's Principles of Internal Medicine 22E, p. 1858
Robbins & Cotran Pathologic Basis of Disease, block 4
Sleisenger & Fordtran's Gastrointestinal and Liver Disease, p. 1585

Epidemiology

Estimated 730 million people infected globally - the most common helminthic infection in humans
Most prevalent in tropical, subtropical, and humid temperate regions where sanitation is poor
Transmission via fecally contaminated soil (from human feces used as fertilizer, or inadequate sewage treatment)
At age 68, Mr. Johnson may have been exposed through contaminated produce or water - infection outside endemic areas can occur when eggs on transported produce are ingested

Loeffler's Syndrome (Pulmonary Phase)

The dry cough is explained by Löffler's syndrome - a self-limited eosinophilic pneumonitis triggered by the larval migration:

Irritating, nonproductive (dry) cough
Burning substernal discomfort aggravated by coughing
Possible low-grade fever
Eosinophilia in blood (a useful diagnostic pointer)
Chest X-ray may show transient, migratory rounded infiltrates

Investigations to Confirm

Stool microscopy - identification of characteristic oval Ascaris eggs (65 x 45 µm) with a mammillated outer coat; this is the mainstay of diagnosis
Complete blood count - peripheral eosinophilia (prominent in the early transpulmonary migratory phase)
Chest X-ray - may show transient eosinophilic infiltrates (Löffler's infiltrates)
Sputum examination - larvae may occasionally be found during the pulmonary phase
Abdominal ultrasound - if biliary/pancreatic migration suspected; worms may be seen as echogenic, tubular structures
Note: During the early pulmonary phase, stool examination may be negative because the worms have not yet matured in the intestine (takes 2-3 months to complete cycle). Larvae in sputum/gastric aspirates may be the only positive finding at this stage.

Differential Diagnoses to Consider

Condition	Why It's Less Likely
Gastroenteritis (viral/bacterial)	Dry cough is not a feature; cough + bilateral GI symptoms together point away
GERD	Dry cough present but not bilateral abdominal pain + vomiting pattern
Strongyloidiasis	Presents similarly but more common in immunocompromised; also causes skin rash
Acute appendicitis	Pain typically right iliac fossa, not bilateral; no cough
Cholecystitis	Right upper quadrant pain, fever; no dry cough

Treatment

All cases should be treated to prevent potentially serious complications (bowel obstruction, biliary migration, perforation):

Drug	Dose
Albendazole (first-line)	400 mg orally, single dose
Mebendazole	100 mg twice daily x 3 days, OR 500 mg single dose
Pyrantel pamoate	11 mg/kg orally (max 1 g), single dose
Ivermectin	150-200 µg/kg orally, single dose

Supportive care: antiemetics for vomiting, adequate hydration
If partial intestinal obstruction develops: nasogastric suction, IV fluids, instillation of piperazine via NG tube
Complete obstruction requires surgical intervention
Harrison's Principles of Internal Medicine 22E, p. 1859
Sleisenger & Fordtran's GI and Liver Disease, p. 1585

Complications to Watch For

Intestinal obstruction (especially with heavy worm burden)
Biliary ascariasis: worm migration into bile duct causing obstructive jaundice, cholangitis, pancreatitis
Intussusception or volvulus
Malnutrition (worms compete for nutrients)
Peritonitis (from intestinal perforation)

Summary

Mr. Johnson's presentation of dry cough + vomiting + bilateral abdominal pain + loss of appetite over 2 days represents the combined pulmonary-intestinal phase of Ascariasis. The dry cough is Löffler's syndrome from larval lung migration, while the gastrointestinal symptoms reflect adult worm activity in the small intestine. Stool ova examination for Ascaris eggs and a CBC looking for eosinophilia are the next steps. Treatment with a single dose of albendazole 400 mg is curative in most cases.

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