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INTESTINAL NEMATODES

ASCARIS LUMBRICOIDES
Giant intestinal round worm
Ascariasis intestinal
Loefflers syndrome pulmonary
Cosmopolitan; endemic in the tropics
and subtropics
1.3B infected; 73% in Asia exposed
Prevalent: 5 9 yrs old m=f
Areas of poor sanitation; crowded; feces
used as fertilizer

A. lumbricoides
Adult:
Male 10-31cm; female 22-35cm
Smooth finely striated cuticle
Conical anterior/posterior extremeties
Ventrally curved posterior end of male
with 2 spicules
Paired reproductive organs in female;
single in male

A. lumbricoides
Egg:

a.

Fertile eggs: 45-70um x 35-50um

Outer coarsely mammilated albuminous


covering
Thick transparent hyaline sheath/shell with
thick outer layer
Delicate vitelline lipoidal inner memberane
(impermeable)
B. Infertile eggs: 88-94um x 39-44um; with
refractile granules

Morphology

Cylindrical with tapered ends


Whitish streak

Female

Male

20-40 cm

15-30 cm

Fertilized Egg
Broadly ovoidal with thick shell
Vitelline membrane

Albuminous coat

75 cm

Unfertilized egg with no outer mamillated layer (decortic

Unfertilized egg.
Prominent mamillations
of outer layer.

Fertilized egg.
The embryo can be distinguished
inside the egg

Egg containing a larva, which will be infective if ingeste

A female may live in the intestine for 12 to


18 months and has a capacity of producing
25 million eggs at an average daily output
of 200,000.
Eggs are resistant to chemical disinfectant
and survive for months in sewage, but are
killed by heat (40C for 15 hours).
Complete development of larva requires 18
days

Pathology:
Immune reaction of host
Mechanical effects of adult worms
Effects of adult worms on the host
nutrition

Clinical presentation:
1. migrating larvae: lungs: Loefflers pneumonitis;
Loefflers syndrome transient pulmonary
symptoms accompanied by eosinophilia

2. adult worm in the small intestine


Mild
Intermittent GI problems
Chronic infection: villi atrophy; elongation of
crypts; round cell infiltrates in the lamina propria

Nutritional impairment
Growth impairment

3. allergic response
4. complications: Obstruction

Intussusceptions

Ectopic migration

Laboratory Diagnosis:
Stool examination
Direct fecal smear
Kato technique / cellophane thick method
Kato Katz technique or Modified Kato
technique

Ancillary methods
CBC
Chest X-ray

Treatment:
Supportive
Specific
Albendazole: 400mg single dose
Mebendazole: 500mg single dose
Pyrantel palmoate: 10mg/kg (max. 1gm
- Piperazine citrate: 150mg/kg initially,
followed by
65mg/kg at 12hrs
intervals for erratic worm migration

Enterobius vermicularis
A.k.a pinworm, seatworm or society
worm
Cosmopolitan distribution
An urban disease of children in
crowded environment.
Adults may get it from their children.

MORPHOLOGY

Curved posterior end

Pointed posterior end

Cephalic alae
8-13 mm

2-5 mm

Lop-sided/ Plano-convex/
D-shaped
Colorless shell
50-60 m

LIFE CYCLE

Embryonated are ingested

Hatched in the duodenum

Matures in the ileum

Adults reach cecum and col

Gravid female migrate


to the perianal region
to deposit eggs

Embryonated eggs - infective stage


A gravid females contains more than 10,000
eggs
Eggs mature in an oxygenated, moist
environment and are infectious 3 to 4 hours
later.
Man-to-man and auto infection are common.
Man is the only host.

Enterobius vermicularis adults in section of appendix

Symptoms
Enterobiasis is relatively innocuous and
rarely produces serious lesions.
The most common symptom is perianal,
perineal and vaginal irritation caused by the
female migration.
The itching results in insomnia and
restlessness.
In some cases gastrointestinal symptoms
(pain, nausea, vomiting, etc.) may develop.

Diagnosis
Diagnosis is made by finding the
adult worm or eggs in the perianal
area, particularly at night.
Scotch tape or a pinworm paddle is
used to obtain eggs.

Treatment and Control


Two doses (10 mg/kg; maximum of 1g each) of Pyrantel
Pamoate two weeks apart gives a very high cure rate.
Mebendazole is an alternative.
The whole family should be treated, to avoid
reinfection.
Bedding and underclothing must be sanitized between
the two treatment doses.
Personal cleanliness provides the most effective in
prevention.

TRICHURIS TRICHIURA
WHIPWORM
Epidemiology
A tropical disease of children (5 to 15
yrs) in rural Asia (65% of the 500-700
million cases).

Morphology
The female organism is 50 mm long with a
slender anterior (100 micrometer diameter)
and a thicker (500 micrometers diameter)
posterior end.
The male is smaller and has a coiled
posterior end.
The Trichuris eggs are lemon or football
shaped and have terminal plugs at both
ends.

Whip-like

Trichuris trichiura adult male and female

Barrel shaped
Two polar plugs
Yellow brown external layer

Method of transmission: ingestion of infective egg with L1


Life cycle: average of 3,000 20,000 eggs/day
Life span: 1 year

Clinical Presentation
Asymptomatic
Classical trichuriasis with dysentery
syndrome
Chronic trichuriasis ( >1 year)
Growth stunting; malnutrition
Rectal prolapse
Tenesmus
Geophagia
Finger clubbing (anemia; substance
secreted by parasite)
Chronic bloody mucoid stools
Abdominal pain

Pathology:
Anterior portions of the worms
embedded in the mucosa
Resembles ulcerative colitis
Allergy

Laboratory Diagnosis:

Stool examination:
Direct fecal smear
Kato cellophane thick smear
Kato-katz technique: egg
counting to determine cure rate,
egg reduction rate and intensity
of infection
Stool concentration ( acid ether;
formalin ether)

Treatment:
Albendazole: 400 mg single dose
Mebendazole: 500 mg single dose
* 100 mg bid for 3 days
Pyrantel palmoate

HOOKWORMS
Ancylostoma duodenale: OLD world
Necator americanus: NEW world
A. duodenale: Europe; Southwestern Asia
N. americanus: Africa, America
Hookworm infection/ disease
Cosmopolitan, tropical and subtropical
areas
900 million infected
50,000 deaths annually due to anemia

Factors affecting prevalence:

Continuous presence of infection


Defecation habits
Appropriate environmental conditions
- temperature; rainfall; shaded;
sandy soil
Opportunity for infective stage to
come in contact with the skin of man

Morphology:
Adult:
N. americanus : 9-11mm x 0.35mm
: small, cylindrical, fusiform, grayish
: buccal capsule has a ventral pair of
Cutting plate
A.duodenale
: buccal capsule has two pairs of
curved ventral teeth
: bigger than N. americanus

Female

Male

Males are generally smalle


With a dilated posterior pa
bursa copulatrix

Ancylostoma duodenale, adult

Semilunar cutting plates

Necator americanus adult female, anterior end

Scanning electron micrograph of the oral opening of Ancylostoma


duodenale, another species of human hookworm. Note the presence of
four cutting "teeth," two on each side.

Bursa is wide and long


Pair of hair like copulatory spicules
Barbed tip
Bipartite dorsal rays

Necator americanus adult male, posterior end

Larva: resembles larva of S. stecoralis


-usually larger with attenuate posterior
end
-rhabditiform L1
-rhabditiform L2
-filariform L3, viable for 2 weeks

Eggs: bluntly rounded eggs and single thin


transparent hyaline shell
-excreted in the feces in early cleavage
stage, hatch in 1-2 days

Closed mouth
Filiform esophagus
sheathed
Pointed ends
Hookworm filariform larvae
(Infective stage)

Oval or ellipsoidal shape


Thin transparent shell
Contains an embryo

Life Cycle

Clinical Presentation:
Cutaneous: ground itch dew itch
Creeping eruption (CLM)
Skin entry of filariform larvae
Pulmonary: Loefflers syndrome
Larval lung infection
Intestinal infection:
Acute heavy
Chronic hookworm

Hookworm Disease
Microcytic, hypochromic anemia from
hookworm infection (+)stool
examination
A. duodenale: 0.2ml blood/worm/day
N.americanus: 0.03 ml/blood/worm/day

Progressive, secondary, microcytic,


hyochromic anemia of iron-deficiency
type due to continous blood loss
Hypoalbuminemia due to loss of
blood, lymph and protein

Laboratory Diagnosis:
A. Stool examination
Direct fecal smear: low yield
Concentration technique;
Zinc Sulfate Centrifugal Floatation
Formalin-Ether Method

B. Stool Culture:
Harada Mori: culture method allowing
hatching of larva from eggs on strips
of filter paper with one end immersed
in water

Treatment:
Mebendazle: 100mg bid x 3days or
500-600mg single dose
Albendazole: 400 mg single dose
Pyrantel palmoate
Thiabendazole

STRONGYLOIDES
STERCORALIS
A.k.a Threadworm
Cochin-China diarrhea
Prevalent in tropical and subtropical
areas with poor sanitation.

Morphology
Has a free-living (rhabditiform) and
parasitic (filariform) form.
The rhabditiform is the feeding larval
stage
The filariform larva is the non feeding
and infective stage

Broadly fusiform
Pointed and curved tail
with 2 spicules

Rhabditiform larva

Delicate looking & slender


Long and capillary esophagus
Closed mouth
Notch or bifid tail

Life cycle

Characterized by three (3) different


phases of development
1. Direct development cycle
2. Indirect development cycle
3. Auto infection cycle cycle
a. External
b. Internal

Direct Development Cycle


Adults worm (upper small intestines)
lay partially embryonated eggs
Rhabditiform larvae are excreted in the feces
Filariform larva (soil)
Penetrates hosts skin
Reach capillaries heart lungs
Migrate in epiglottis swallowed
Matures in the small intestines

Indirect Development cycle

Excreted Rhabditiform larva


mature in soil
Free-living adults copulates
and lays eggs
Free-living rhabditiform larva
Matures into adults Filariform larva

Autoinfection cycle
Rhabditiform larva
in the small intestine
Filariform larva
Penetrates skin
in perianal area
(External)

Penetrates the
small intestine
(Internal)

Capillaries --- Heart ----Lungs


Matures in the small intestine

Pathology
A. Cutaneous stage:
Erythematous, serpinginous, pruritic
skin (creeping eruptions)
Larva currens if multiple
B. Larval form
Pneumonitis

C. Adult:
Honey-comb lesions of the
intestine
Diarrhea and abdominal pain

Laboratory Diagnosis
Stool examination
DFS has low yield (50 eggs/day)
Culture: sand/charcoal technique;
Baermans technique; Harada-Mori culture

Body fluids
Duodenal aspirate: Enterotest
Sputum; urine; ascitic fluid; CSF

Small bowel biopsy


Serology
IFA vs. (f) larva (85-90%)
ELISA

CBC: hypereosinophilia

Treatment:
Abendazole: as drug of choice 400mg
for 3 days
Thiabendazole: 25 mg/kg in 3 divided
doses daily for 3 days

Capillaria philippinensis
Distribution: Philippines & Thailand
Host: Marine mammals- definitive host
fish: ingest eggs >
infective larva in muscles (in 3-4 wks)
Transmission: Ingestion of raw or
undercooked fish

Capillaria philippinensis

Capillaria philippinensis

Capillaria philippinensis
Pathogenesis & Clinical Diease
- adult: burrow in the jejunum wall
- inflammation & villi atrophy
> pain, diarrhea, malabsorption

Capillaria philippinensis
Diagnosis
- eggs in feces
Traetment
- Mebendazole: drug of choice

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