Nematodes - Teaching Demo

An Introduction to the
Nematodes
Christian Gallardo, MD
Helminths
• Three phyla:
– Annelida (Segmented Worms)
– Nemathelminthes (Roundworm)
• Nematoda
– Plathyhelminthes (Flatworms)
• Cestoda (Tapeworms)
• Trematoda (Flukes)
Nematodes
• Free living and parasitic
• More than 80,000 are parasitic to
vertebrates
• 2mm (Strongyloides stercoralis) to a
meter ( Dracunculus medinensis)
• Sexes usually separate, male smaller than
female
Morphology
– Elongate cylindrical worm
– Symmetrical bilaterally
– Body
• Outer, hyaline, noncellular cuticle
• Subcuticular epithelium
– Four longitudinal cords – dorsal, ventral
and 2 lateral
» Carry nerves and excretory canals
• Layer of muscle cells
Morphology
– Alimentray tract
• Simple
• Mouth: surrounded with lips, some may have
teeth or plates
• Esophagus
• Intestine: flattened tube, straight course up to the
rectum
– No circulatory system
• Hemoglobin, glucose, proteins, salts and
vitamins
– Nervous system
• Ring or commisure of connected ganglia
surrounding the esophagus
• Sensory organs: Labial, cervical, anal, and
genital regions
Morphology
– Male reproductive organ
• Porterior 3rd of the body
– Testis, vas deferens, seminal vesicle,
and ejaculatory duct
• Accessory copulatory apparatus
– 1 or 2 ensheated spicules –
Gubernaculum
– Copulatory Bursa: winglike
appendedages
– Female reproductive organ
• Single or bifurcated tube
– Ovary, oviduct, seminal receptacle,
uterus, ovejector, and vagina
– 20 – 200,000 eggs
Physiology
– Excretory system
• 2 lateral canals that lie in the lateral
longitudinal cords
– 2 Longitudinal muscles – for sinuous movement
• Thigmotropism – penetration of the skin by

the hookworm larvae
• Methods of obtaining food
– Sucking with ingestion of blood (Ancyclostoma)
– Ingestion of lysed tissues and blood (Trichuris)
– Feeding Intestinal content (Ascaris)
– Ingestion of nourishment from the body fluids
(filarial worms)
Physiology
• Anaerobic – metabolic process
– Glycogen content is high
– Major portion expended in the production of
large number of ova
• Resist digestive juices and tissue invaders
– Afforded by the cuticle and elaboration of
antienzymes
• Life Span:
– Trichinella spiralis: 4-16 weeks
– Enterobius vermicularis: 1-2 months
– Ascaris lumbricoides: 12 months
– Persist for at least 14 years
INTESTINAL HELMINTHS
• Ascaris lumbricoides (roundworm)
• Trichinella spiralis (trichinosis)
• Trichuris trichiura (whipworm)
• Enterobius vermicularis (pinworm)
• Strongyloides stercoralis (Cochin-china
diarrhea)
• Ancylostoma duodenale and Necator
americanes (hookworms)
Ascaris lumbricoides
(Large intestinal roundworm)
• Epidemiology
– Annual global morbidity: 1 billion/ year
– Mortality: 20,000/ year.
– Occur at all ages,
– More prevalent: 5 to 9 years age group.
– The incidence is higher in poor rural
populations
• Morphology
– Female: 22 – 35 cm; Male: 10 – 31 cm
– Smooth finely straited cuticle
– Conical anterior and posterior extremities
– Ventrally curved papilatted posterior extremity
(male)
– Terminal mouth with three oval lips with
sensory papillae
– Paired reproductive organs – posterior 2/3rd in
(female)
– Single long tortuous tubule(male)
• Eggs
• Symptoms
– Usual infection: 5 -10 worms – unnoticed by
host
– Routine stool examination
– Vague Abdominal Pain
– Eosinophilia
– Loeffler’s Syndrome – migrating Ascaris larvae
• Diagnosis
– Identification of eggs (40 to 70 micrometers by
35 to 50 micrometers) in the stool.
– Outline of the worm in Upper GI series
• Treatment and Prevention
– Mebendazole, 200 mg (Adults); 100 mg
(Children) for 3 days is effective
– Piperazine Citrate, 75mg/kg/day
– Good hygiene is the best preventive measure
– Sanitary disposal of feces and health education
– Night soil not be used unless treated with
chemicals
• Special Considarations”
– Isolation is unnecessary
• Proper disposal of stool and soiled linen
– NG suctioning, provide good mouth care
– Washing of hands
– Inform of patient of adverse effect of drug
• Piperazine – CI on seizure disorder
• Mebendazole – adbominal pain and
diarrhea
Trichinella spiralis
(Trichinosis)
Trichinella spiralis (Trichinosis)
• Epidemiology
– Related to the quality of pork and consumption of
poorly cooked meat
– Autopsy surveys: 2 percent infected/ population is
infected
– Mortality is low
• Morphology
– Female: 3.50mm x 0.06 mm, Male: 1.50mm x
0.04mm
– A slender anterior end with a small, orbicular,
nonpapillated mouth
– Posterior end bluntly rounded in the female
– Ventrally curved with two lobular caudal appendages
in male
– A single ovary with vulva in the anterior fifth in
the female
– Long narrow digestive tract
– Larvae: spearlike burrowing tip at tapering end:
80 – 120 microns and grows up to 900 to 1300
microns
• Life Cycle
– Infection occurs by ingestion of larvae, in poorly
cooked meat.
– Invade intestinal mucosa and sexually
differentiate within 18 to 24 hours.
– The female, after fertilization, burrows deeply in
the small intestinal mucosa, whereas the male
is dislodged (intestinal stage).
– On about the 5th day eggs begin to hatch in the
female worm and young larvae are deposited in
the mucosa
– They reach the lymphatics, lymph nodes and
the blood stream (larval migration).
– Larval dispersion occurs 4 to 16 weeks after
infection.
– The larvae are deposited in muscle fiber and, in
striated muscle, they form a capsule which
calcifies to form a cyst.
– In non-striated tissue, such as heart and brain,
the larvae do not calcify; they die and
disintegrate.
• Persist for several years.
– One female worm produces approximately
1500 larvae.
– Man is the terminal host. The reservoir includes
most carnivorous and omnivorous animals.
Symptoms
Trichinosis Symptomatology
Circulation
Intestinal Brain and
and Myocardium
mucosa meninges
muscle
Edema, peri- (10-21
(24-72 (14-28
(10-21
orbital days) Headache
hrs) Chest pain, days)
days)
conjunctivit (supraorbit
tachycardia
Nausea, is, photo al), vertigo,
, EKG
vomiting phobia, tinnitus,
changes,
diarrhea, fever, chill, deafness,
edema of
abdominal sweating, mental
extremities
pain, muscle apathy,
, vascular
headache. pain, delirium,
thrombosis
spasm, coma, loss
.
eosinophili of reflexes.
• Diagnosis
– Early in infection, serologic test: NEGATIVE
– Serum levels of muscle enzymes (CPK, LDH)
– Muscle Biopsy – most definitive diagnosis
• 3rd to 4th week best time to do biopsy
– Mebendazole: 1000mg/day for 10-14 days
– Oral prednisone: 20 – 40mg daily
– Elimination of parasite in hogs
– Adequate cooking of meat products
• Larvae are killed at 55C to 77C
Trichuris trichiura
(whipworm)
Trichuris trichiura (whipworm)
• Epidemiology
– A tropical disease of children (5 to 15 yrs) in
rural Asia (65% of the 500-700 million cases)
– Seen in the South Americas,
• concentrated in families and groups with
poorer sanitary habits.
– Distribution coextensive with A. lumbricoides
• Morphology
– Attenuated whip like anterior, three fifths
traversed by a narrow esophagus resembling a
string of beads
– A more robust posterior, 2/5th containing the
intestine and a single set of reproductive
organs
– Male: 30-45mm, Female: 35-50mm
– Bluntly rounded posterior end of the female
– Coiled posterior extremity of the male
• single spicule and retractile sheath
– Eggs: 3000 – 10000/ day
• Lemon shaped with pluglike translucent
polar prominences (lantern shaped)
• Life Cycle
– The unembryonated eggs are passed with the
stool
– In the soil, the eggs develop into a 2-cell stage
and an advanced cleavage stage
– Eggs embryonate
– Eggs become infective in 15 to 30 days
– After ingestion (soil-contaminated hands or
food), the eggs hatch in the small intestine
– Release larvae that mature and establish
themselves as adults in the colon
– The adult worms (approximately 4 cm in length)
live in the cecum and ascending colon
• Found anterior portions threaded into the
mucosa.
– The females: Oviposit 60 to 70 days after
infection.
– Life Span: 1 year
– The embryo is killed under desiccation at 37C
within 15 minutes
• Lethal temp: 52C and -9C
• Symptoms
– Worm burden: less than 10 worms are
asymptomatic.
– Heavier infections (e.g., massive infantile
trichuriasis)
• Chronic profuse mucus and bloody diarrhea
• Abdominal pains
• Edematous prolapsed rectum.
– Malnutrition, weight loss and anemia
– Sometimes death.
• Diagnosis
– Stool exam: Lemon shape eggs in feces
– Mebendazole, 200 mg (Adults); 100 mg
(Children) for 3 days is effective
– Highly endemic and may be prevented by
• Treatment of infected individuals
• Sanitary disposal of human feces
• Personal hygiene
• Thorough washing of hands
• Scalding of uncooked vegetables
Strongyloides stercoralis
(Threadworm)
(Threadworm)
• Epidemiology
– Cochin-China diarrhea,
– 50 to 100 million cases worldwide,
– Tropical and subtropical areas with poor sanitation.
– Prevalent in the South and among Puerto Ricans.
• Morphology
– Varies depending on whether it is parasitic or free-
living.
– The parasitic female is larger (2.2 mm x 45
micrometers) than the free-living worm (1 mm x 60
micrometers).
• Colorless semitransparent
(Threadworm)
– The eggs, when laid are 55 micrometers by 30
micrometers.
– Rhabditiform larvae: 225 microns x 16 microns
• Long slender, nonfeeding, infective,
filariform larvae
(Threadworm)
• Strongyloides life cycle: complex
– alternation between free-living and parasitic
cycles
– potential for autoinfection and multiplication
within the host.
– Two types of cycles”
• Free-living cycle:
– The rhabditiform larvae passed in the
stool can either molt twice and become
infective filariform larvae (direct
development) or molt four times
– Become free living adult males and
females that mate and produce eggs
from which rhabditiform larvae hatch.
(Threadworm)
– The latter in turn can either develop into
a new generation of free-living adults or
into infective filariform larvae
– The filariform larvae penetrate the
human host skin to initiate the parasitic
cycle
• Parasitic cycle:
– Filariform larvae in contaminated soil
penetrate the human skin
– Transported to the lungs
» penetrate the alveolar spaces;
– Bronchial tree to the pharynx, are
swallowed and then reach the small
intestine
(Threadworm)
– Small intestine: Molt twice and become
adult female worms
– The females: threaded - epithelium of
the small intestine
» Produce eggs which yield
rhabditiform larvae.
– Rhabditiform larvae
» passed in the stool
» Autoinfection: become infective
filariform larvae : can penetrate
either the intestinal mucosa (internal
autoinfection) or the skin of the
perianal area (external
autoinfection)
(Threadworm)
• Symptoms
– Light infections: asymptomatic.
– Skin penetration causes itching and red
blotches
– During migration: bronchial verminous
pneumonia
– Duodenum:
• Burning mid-epigastric pain and tenderness
• Nausea and vomiting.
• Diarrhea and constipation may alternate.
(Threadworm)
– Heavy, chronic infections
• Anemia, weight loss and chronic bloody
dysentery.
– Secondary bacterial infection of damaged
mucosa may produce serious complications.
• Diagnosis
– Examination of feces and duodenal contents
– String test: duodenal fluid
– Baermann Technique
– ELISA (enzyme-linkedimmunosorbent assay)
(Threadworm)
• Treatment and prevention
– Thiobendazole: 25mg/kg/BID x 3 days
– Alternate: Albendazole and Ivermectin
– Sanitary disposal of human feces
– Protection of the skin from contact with
contaminated soil
Enterobius vermicularis
(Pinworm, Oxyuriasis)
(pinworm, oxyuriasis)
• Epidemiology
– Commonest helminthic infection in the US (18 million
cases at any given time).
– Worldwide: 210 million.
– Urban disease of children in crowded environment
(schools, day care centers, etc.)
– The incidence in whites is much higher than in blacks
• Morphology
– Female:8 mm x 0.5mm; Male: 2mm – 5mm.
– Female:
• Cuticular alar expansion at anterior end
• Prominent esophageal bulb
• Long pointed tail
– Eggs: 60mm x 27mm
• Ovoid
• Asymmetrically flat on one side.
• Life Cycle
– Eggs are deposited on perianal folds
– Self-infection
• Transferring infective eggs to the mouth with
hands that have scratched the perianal area
– Person-to-person transmission
– Enterobiasis may also be acquired through
surfaces in the environment that are
contaminated with pinworm eggs (e.g., curtains,
carpeting).
– Eggs: airborne and inhaled.
• Swallowed -- Ingested eggs.
– Larvae: Small intestine
– Adults: Colon
– The time interval from ingestion of infective eggs to
oviposition by the adult females is about one month
– Life span: 2 months
– Gravid females migrate nocturnally outside the anus
• oviposit while crawling on the skin of the perianal
area
– The larvae contained inside the eggs develop in 4 to
6 hours
– Retroinfection
• The migration of newly hatched larvae from the
anal skin back into the rectum, may occur but the
frequency with which this happens is unknown
(pinworm)
• Symptoms
– Relatively innocuous and rarely produces serious
lesions.
– The most common symptom: perianal, perineal and
vaginal irritation caused by the female migration.
• Insomnia and Restlessness.
– Gastrointestinal symptoms (pain, nausea, vomiting,
etc.)
– Mother Complex
• The conscientious housewife's mental distress,
guilt complex, and desire to conceal the infection
from her friends and mother-in-law is perhaps the
most important trauma of this persistent, pruritic
parasite.
(pinworm)
• Diagnosis
– Finding the adult worm or eggs in the perianal area,
particularly at night.
• Scotch tape / pinworm paddle
– Made upon the morning before bathing or
defecation
• Treatment
– Pyrental Pamoate: 2 doses (10 mg/kg;
maximum of 1g each) two weeks apart
• Very high cure rate.
– Alternative: Mebendazole.
– The whole family should be treated, to avoid
reinfection.
(pinworm)
– Bedding and underclothing must be sanitized
between the two treatment doses.
– Personal cleanliness provides the most
effective in prevention.
Necator americanes and
Ancylostoma duodenale
(Hookworms)
• Epidemiology
– More than 900 million people worldwide
– Cause daily blood loss of 7 million liters
– Ancylostomiasis
• Most prevalent hookworm infection
• Second only to ascariasis in infections by
parasitic worms.
– N. americanes (new world hookworm)
• Most common in the Americas, central and
southern Africa, southern Asia, Indonesia,
Australia and Pacific Islands.
– A. duodenale (old world hookworm)
• Dominant species in the Mediterranean
region and northern Asia.
• Morphology
– Small cylindrical, fusiform, grayish white
nematodes.
– Female: 9 – 13mm, Male: 5 – 11mm
– Thick cuticle
– Bursa
• Broad, translucent, membranous caudal
bursa with riblike rays at the posterior end of
the male
• Used for attachment to the female during
copulation
– N. americanes
• Buccal capsule is conspicious
• Dorsal pair of semilunar cutting plates
• Concave dorsal median tooth
• Deep pair of triangular subventricular
lancets
– A. duodenale
• 2 ventral pairs of teeth
– Egg
• Sinle thin transparent hyaline shell
• 2 – 8 cell stages division in fresh feces
• Life cycle
– Eggs are passed in the stool
– Under favorable conditions (moisture, warmth,
shade), larvae hatch in 1 to 2 days.
– Rhabditiform larvae grow in the feces and/or the soil
• After 5 to 10 days (and two molts) they become
become filariform (third-stage) larvae that are
infective.
– Infective larvae can survive 3 to 4 weeks in favorable
environmental conditions.
– On contact with the human host, the larvae penetrate
the skin
• Carried through the veins to the heart and then to
the lungs
– Filariform penetrate pulmonary alveoli
– Ascend the bronchial tree to the pharynx, and are
swallowed
• Reach the small intestine, where they reside and
mature into adults.
– Adult worms live in the lumen of the small intestine, where
they attach to the intestinal wall with resultant blood loss by
the host.
– Most adult worms are eliminated in 1 to 2 years, but
longevity records can reach several years.
– Some A. duodenale larvae, following penetration of the host
skin, can become dormant (in the intestine or muscle).
– A. duodenale infection
• may probably also occur by the oral and
transmammary route.
– N. americanus infection
• requires a transpulmonary migration phase.
Table 2. Clinical features of hookworm disease
Site Symptoms Pathogenesis
Local erythema, Cutaneous invasion
Dermal macules, papules and subcutaneous
(ground itch) migration of larva
Bronchitis, Migration of larvae
pneumonitis and, through lung,
Pulmonary
sometimes, bronchi, and
eosinophilia trachea
Anorexia, epigastric Attachment of adult
pain and gastro- worms and injury
Gastro- intestinal
intestinal to upper intestinal
hemorrhage mucosa
Iron deficiency,
anemia,
Hematologic hypoproteinemia, Intestinal blood loss
edema, cardiac
failure
• Diagnosis
– Identification of hookworm eggs in fresh or
preserved feces.
– Species of hookworms cannot be distinguished
by egg morphology.
• Treatment and control
– Mebendazole, 200 mg, for adults and 100 mg
for children, for 3 days is effective.
– Sanitation is the chief method of control:
sanitary disposal of fecal material and
avoidance of contact with infected fecal
material.

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An Introduction to the

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