PARASITOLOGY LECTURE 2 – Nematodes – Dr.

Ng
Notes from Lecture
USTMED ’07 Sec C – AsM

TRICHURIS TRICHIURIA

• also called as whipworm

• incidence of occurrence,
same as Ascaris
• 2nd common intestinal
worm aside from Ascaris
• usually occur in moist,
warm, tropical region of
Asia, Central and South
America, Africa and the
Caribbean Islands

MORPHOLOGY:

• ADULT WORM
o Color: Flesh or pinkish colored slender worms
o Size:
1. Female – 3.5 to 5.5 cm
2. Male = 3.0 to 3.5 cm
Male is smaller than female
3. Anterior 3/5 o f the worm – fine
hair-like structure which forms the
esophagus
LIFE CYCLE OF TRICHURIS TRICHIURIA
Esophagus – is characteristically
embedded in glandular cells called
stichocytes
4. Posterior 2/5 of the worm contain
the intestine and reproductive
organs
Tail end:
Female – straight and blunt
Male – usually curved at 360o
• EGG
o Shape
- Barrel-shaped egg
- thick, smooth
brown egg shell and
2 transparent plugs
protruding from
both poles
o Size – measures 50 to 54
microns by 22 to 23 After copulation in the cecum
microns
1. Fertilized egg

Female worms start to lay eggs w/c are passed out with
feces and deposited in the stool in unsegmented form

2. Embryonated egg

With favorable environmental condition, in 2-3 weeks they

develop into their infective stage with larval stage w/in the
egg (embryonation).

Note:
Whipworms inhabit the large intestine where the entire
whiplike portion is deeply inserted into the wall of large
intestine. Because of this mode of attachment, it is much
harder to expel whipworm than ascaris by anti helmintics

Once the infective embryonated egg is swallowed by the

host, they hatch in the intestine to release the larva and
this larva undergoes 4 larval stages to become adult worm.

• There is no migration phase in the lungs, heart or liver

• It require about 2-3 months from the time the eggs are
swallowed until they are seen in the stool of infected
person
• Each female whipworm can produce 7,000 to 10,000
eggs per day or a total of over 60 million eggs by single
whipworm over an average life span of 2 years

PATHOLOGY AND CLINICAL MANIFESTATION

A. Light infection with trichiuris are asymptomatic and

without clinical significance
B. Symptoms produced by trichiuris are due to worms
 unique mode of attachment on the wall of the large length
intestine where it got its nutrition • smaller than female
- therefore, the degree of clinical • characterized by the
symptoms is related to the intensity of presence of a chitinized
the infection. spicule and a long spicule
sheath extending beyond
• CLINICAL MANIFESTATION the length of worm
1. Diarrhea due to chronic
Hypoalbuminemia impairment of host’s 2 Types of Female worms
Iron Deficiency Anemia nutritional status
a. Typical female – which has 8-10 eggs in utero arranged in a
2. Anemia single row
- due to ulceration of the intestine
b. Atypical female – which has 40-45 eggs in utero arranged in 2
resulting from heavy worm burden
to 3 rows
- Anemia is less frequent than hookworm]
• CAPILLARIA EGGS
3. Prolapse of the anus and the rectum o Color : pale yellow in color with a moderately
- due to frequent loose bowel movement thick, striated shell with flattened bipolar
resulting to the loss of muscle tone of the plugs
anal sphincter o Shape: Peanut-shaped
- could also resort to bleeding thus
aggravates the anemia o Size:: Measures 42 by 20 um
o Development stage – single or 2 segmented
4. Appendicitis stage development
- due to invasion of trichiuris

DIAGNOSIS:

1. Direct Fecal Smear (DFS)

2. Cellophane thick smear method or the Kato thick smear
EPIDEMIOLOGY

In the Philippines
- prevalence of trichiuris is 80-90% almost parallel with
Ascaris LIFE CYCLE OF CAPILLARIA PHILIPPINENSIS
- Most infections are light to moderate and seldom
produce clinical symptoms
- Trichiuris eggs are less resistant to adverse reaction than
Ascaris eggs

TREATMENT

A. Albendazole
- Dose – 400 mgs single dose
B. Mebendazole
- Dose – 500 mgs single dose or 100 mgs twice a day
for 3 days
C. Oxantel-Pyrantel
- Dose – 10-20 mgs per kg/body weight single dose

CAPILLARIA PHILIPPINENSIS

• intestinal capillariasis is a disease characterized by: Adult worms inhabit primarily in the jejunum and are
1. intestinal malabsortion threaded into the mucosa (Larvae and eggs are produced
2. chronic diarrhea by typical and atypical female worms)
3. Borborygmi
• first recognized in the Philippines in 1963 where the first
human case died in PGH
Eggs passed out in the feces embryonate in the fresh
• Origin: Bacarra Ilocos Norte
water in 3 to 5 days
• Order Trichurida
• Prevalence
1. Philippines
- Ilocos Norte Upon ingestion by fresh water fish, hatch in the intestine
- Ilocos Sur of fish. Larvae are found mostly in the gastric mucosa
- Cagayan and Intestines
- La Union
- Pangasinan
- Zambales
- Agusan del Norte When infected fish is ingested the worm’s mature in the
- Leyte host’s small intestine
2. Thailand
3. Japan
4. Iran
5. Egypt In 2 weeks, atypical females start producing larvae then
6. Taiwan grow into mature adult worms

MORPHOLOGY:
PATHOLOGY AND CLNICAL MANIFESTATIONS
• ADULT WORM
o Small worm A. Disease is characterized by:
1. Borborygmi or gurgling stomach
1. Female worm
2. Abdominal pain
• size: 2.3 to 5.3 mm by
3. Diarrhea
length
• larger than male B. Without Treatment the patient may experience
2. Male worm 1. Weight loss
• size: 1.5 to 3.9 mm by 2. Dehydration
 3. Malaise o Matured encysted larvae have digestive tracts
4. Anorexia although the reproductive are not fully
5. Vomiting developed.
6. Anasarca
7. Muscle wasting
8. Cachexia
DIAGNOSIS
C. Other Manifestations
1. Malabsorption of fats and sugar • Clinical Diagnosis
2. Protein-losing enteropathy o History of eating raw or inadequetly cooked or
3. Low level of K, Ca++, Carotene improperly processed meat usually pork
4. Low plasma level of total protein o History of intestinal flu or rheumatic pain
o Marked eosinophilia in blood
D. Death is attributed to massive parasitic infection
resulting to: o Swollen eyelids or severe conjunctivitis
1. Electrolyte loss • Specific Diagnosis
2. Heart failure o Biopsy - free larvae or encapsulated larvae in
3. Septicemia secondary to bacterial infection skeletal muscle
o Xenodiagnosis
• PATHOLOGIC CHANGES o Bachman Intradermal test
a. Atrophy of the crypts of Liberkuhn
b. Flattened villi with lamina propia infiltrated by TREATMENT
plasma cells, lymphocytes and macrophages
• No established specific treatment
DIAGNOSIS: A. Thiabendazole
• by finding characteristic - Dose: 50 mg/kg/body weight
o eggs - Effect:
o larvae - may prevent the appearance of symptoms
o adult worms in stool if given from the second day after
• eggs can readily be seen in a simple fecal smear ingestion of infected meat
o concentration technique acid ether or - greatly mitigate the illness if drug is
formalin ether method given between the fifth and ninth day
after ingestion
B. ACTH or corticosteroid
EPIDEMIOLOGY: - treatment of allergic reaction
C. Mebendazole
- first recognized in 1963 - lethal effect
- 1,800 confirmed cases w/ 108 deaths LIFE CYCLE OF TRICHINELLA SPIRALIS
- male is affected twice than females
- Peak age: 20-49 years old

TREATMENT:

A. Mebendazole
- Dose: 200 mgs twice daily for 20 days
B. Albendazole
- Dose: 400 mgs daily for 60 days

PREVENTION AND CONTROL:

• changing the eating habits from raw uncooked fresh

water fish9 to cooked fish

TRICHINELLA SPIRALIS

• diseases:
a. Trichinosis
b. Trichiniasis
c. Trichinelliasis

MORPHOLOGY

• ADULT WORM
o Small worm
o Size
1. Male – 1.50 mm by 0.04 mm
2. Female – 3.50 mm by 0.50 by 0.06
mm
o Shape
- thread-like appearance
o characteristics
1. Anterior end
o provided w/ a small orbicular,
non-papillated mouth
o in female, Anterior fifth is
provided w/ a single ovary with
vulva and a long narrow
digestive system PATHOGENESIS
2. Posterior end
o Female: bluntly rounded
o Male: ventrally curved with 2 • Pathologic changes and the symptomatology are divided
lobular appendages into 3 stages:
• LARVAE 1. incubation or intestinal phase
o Has a spear-like burrowing tip at its tapering 2. acute or larval invasion
anterior end 3. chronic or encapsulated
o Measures 80-120 h by 5.6 u at birth
1. Intestinal Phase
 - Inflammation of duodenal and jejunal mucosa: Early encapsulation 21 Myocarditis or
a. Malaise encephalitis appear
b. Nausea Intestine practically 23
c. Diarrhea free of adults
d. Abdominal cramps 26 Respiratory symptoms
Encapsulation 1 Month
2. Stage of Muscle Invasion practically complete
a. Fever 2 Fever subsides
b. Facial edema Maximum life of 3 Death from
c. Muscle pain, swelling and weakness worms in intestine myocarditis or
d. Peripheral eosinophilia encephalitis most
likely
• Less common symptoms: Cyst calcification may 6 Slow convalescence
a. headache begin
b. Flushing of face 8 Neurological
c. Conjunctivitis symptoms and
d. Pruritus myocarditis subside
e. Diaphoresis Cyst calcification may 1 year
f. Anorexia be complete
g. Thirst Larvae possibly still 6
viable w/in calcified
• Damage of muscle may cause difficulty in: capsules
a. Eye movement
b. Breathing PREVENTION
c. Chewing
d. Swallowing • smoking, drying and slating of meat are not effective
e. Speech
measures
f. Movement of extremities
A. Refrigeration at 5°F (-15°C) for not less than 20 days
• Myocarditis – appear as early as the second week but - at –10°F (for 10 days)
more ofteh after the third week. - at -20°F for 6 days
- Deep freezing
- Death from myocarditis usually occurs between the
fourth and eight weeks of infection. B. Avoid feeding raw garbage to hogs
- Encephalitis and meningitis may also occur at this C. Extermination of rats around the farms
stage D. Thorough cooking or deep freezing of all pork
3. Stages of Convalescence ENTEROBIUS VERMICUALRIS
- end of the 3rd week of infection where
encapsulation start to be seen • Seatworm or pinworm
• affecting 208 million population
• Habitat
o Cecum
o Appendix
o adjacent portion of ascending colon
o ileum

MORPHOLOGY

• ADULT WORMS
o Color: whitish or brownish
o Shape: spindle-shaped
SYMPTOMS
o Size: very small
1. Female: measures 8-13 mm by 0.3
1. Fever subsided to 0.5 mm
2. Muscular symptoms begin to decline 2. Male: 2 to 5 mm by 0.1 to 0.2 mm
3. If there is marked edemaàdiuresis may occur
4. Appetite return to normal
5. Malaise subsided
- myocarditis may still be present at this stage and
physical exertion may precipitate congestive heart
failure
- venous thrombosis and encephalitis
- eventually- when all symptoms subsided, the cyst wall
and larva itself calcify
o Posterior end
Biological Stage Beginning/Onset Clinical Conditions
1. Female: long sharp pointed end
Ingested larvae exist 2-4 hrs GI symptoms
in epithelium 24 2. Male: ventrally curved; has a single
Worms become 30 conspicuous copulatory spicule but
mature and mate lack gubernaculums
Females deposit 6 days
larvae, which invade o Anterior End
skeletal muscles - is a pair of lateral cuticular expansions
7 Edema of face and known as “lateral wings or cephalic alae”
fever - Another feature of pinworm adult is the
Maximum invasion of 10 Fever at max (40- presence of posterior esophageal bulb
muscle fibers 41oC)
11 Myositis and • EGGS
“rheumatic” pains o Size: 50-60 um by 20 to 30 um
Decrease in 14 Eosinophilia and o Shape: elongated, ovoid flattened on ventral
larviposting circulating antibody side giving a letter D appearance
Larvae in muscles 17 o Egg shell composed of 2 layers
fully differentiated 1. An outer thick hyaline albuminous
20 Eosinophilia reaches shell
maximum
 2. Inner embryonic lipoidal membrane • Retroinfection, the eggs hatch in the perianal region and
the larvae migrate back into intestines
LIFE CYCLE OF ENTEROBIUS VERMICULARIS
TREATMENT

A. Mebendazole
- single dose of 100 mg tab for everyone above 2
years of age -à this is repeated after 2 weeks
B. Pyrantel pamoate
- Dose:
o 11 mg/kg orally (maximum of 1 g) as a single
dose
o a second dose should be given after 2 weeks

PREVENTION

1. Personal hygiene
2. Finger nail should be cut short.
3. Handwashing after using the toilet or before meal.
4. Bed linens and clothing of infected person should be
sterilized by boiling.
Adult worms inhabit the cecum where the head attached to
the intestinal wall

-fin-
In gravid female, the uteri packed with eggs and the body audsmartinez@gmail.com
becomes distended which makes the female releases its hold ustmedc3@yahoogroups.com
on the Intestinal wall and migrate down the colon and
out the anus to lay eggs on the perianal and perineal region

Eggs laid on the perianal region become fully matured or

embryonated within 6 hours

When ingested, eggs containing the third stage juvenile

larva hatch in the duodenum, pass down the small intestines
to the cecum and develop into egg laying worm
PATHOGENESIS AND CLINICAL MANIFESTIONS

• Pathogenesis in enterobiasis take 3 forms

1. Pathology at the site of attachment of the worm
2. Pathology due to egg deposition in perianal region
3. Pathology caused by migrating worms

A. At the site of attachment

- minute ulceration and abscesses develop in cecal
mucosa
B. Egg Laying
- intense itching or pruritus in the perianal region
resulting to scratching the area until it is scarified
- can also result to hemorrhages, eczema and
bacterial infection
C. Migrating worm may go beyond the perianal region and
may cause
1. Vulvovaginitis
2. Salphingitis

DIAGNOSIS

• Pinworm infection may be suspected in patient

exhibiting manifestation like pruritus of the perianal
area, restlessness
• Use of Perianal cellulose tape swab or Scotch tape swab
o recovery of D shaped embryonated egg
• Since oviposition take place at night the best time to
take the swab right after the patient awakens or before
taking a bath.

EPIDEMIOLOGY

• Prevalence among regions varies from 10% in rural area

to 75% in crowded urban area
• women are infected more than men
• children are infected more than adult
• infection may occur thru
1. Hand to mouth transmission from scratching
the perianal region or from handling
contaminated objects
2. Inhalation of airborne egg in dust
3. Reinfection through the anus
• The most common mode of transmission hand to mouth
transmission