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The Intestinal Nematodes

The Intestinal Nematodes

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Published by dhainey

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Published by: dhainey on Mar 02, 2009
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09/30/2012

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THE INTESTINAL NEMATODES
Phylum Nematoda
Non-segmented, generally cylindrical
 Tapered at both ends covered by toughcovering=
Cuticle
 
Has complete digestive tract = both oral andanal openings
Separate sexes: Males smaller than femalewormsMale : - single tubule, smaller end consists of testicularcells
-
Extends into a vas deferens and seminal vesicle- Terminates in an ejaculatory duct opening intothe cloacaFemale : - reproductive organs are tubular and lie coiledin the body cavity- Has 2 cylindrical ovaries which expand to theuteri- Uteri may open to the exterior through a singlevulva or there may be a common vagina between thevulva and the uteri- Vulva commonly located near the middle of thebody but varies in position in different species
Majority are free living
Estimated 500,000 species of nematodes
Generally light cream-white color, females appeardarker when filled with dark-colored eggs
Primitive form : mouth surrounded by three lips
Hookworms: buccal capsule with cutting plates orteeth
Anterior portion of digestive tract: Esophagus =muscular form
=
if caliber is uniform –
Filariform
 
=
if expanded posteriorly into a bulb containing avalve mechanism –
Rhabditiform
 
Male nematodes: has a pair of copulatoryspicules, lie in pouches near the ejaculatory ductand may be inserted into the vagina of the female
Stages of life cycle: egg-- larvae which undergoseveral molts--- adults
Filariform type of esophagus: infective stagelarvae
Ascaris = die in about a year in the absence of reinfection Trichuris = live more than a yearHookworm = may persist as long as 8 to 16years
Diagnosis: Demonstration of the characteristicegg in the feces
HELMINTHIC DISEASESASCARIASISEtiology:
Ascaris lumbricoides = largest intestinalroundworm
Most prevalent human helminthiasis
Female worms = 20-35 cm in length= may be as thick as a lead pencil
Male worms = seldom more than 30 cm long= more slender and distinguished by anincurved tail
Both sexes are creamy white, sometimes with apinkish cast and fine circular striations in thecuticle
Mature larva-containing egg = infective stage
Eggs passed in the feces of infected person &mature in 5-10 days under favorable conditions tobecome infective
Female life span = 1-2 years
Produces 200,000 eggs/24 hrs.
Epidemiology:
Promiscuous defecation & use of human manure= unhygienic practices
 
Mode of transmission = hand to mouth; fingerscontaminated by soil contact
 
Eggs remain infective in soil for months
Life Cycle:
Embryonated egg swallowed (infective, containing fullydeveloped larva)
larva escapes from egg in S.I.
tissues and lymphatic vessels and lungs
furtherdevelopment in alveoli
larva from lung
larva in lungpass on to the intestine via trachea, esophagus and
 
stomach
develop maturity
adult in small intestine
eggs passed in feces
unfertilized egg
fertilized egg
swallowed again.
Pathogenesis:
Ingestion of mature egg – larva released from egg– penetrate intestinal wall—Via venous circulationpenetrate the lungs – break through pulmonarytissues to Alveolar spaces – ascend to thebronchial tree & trachea – re-swallowed
Clinical Manifestations:
Morbidity manifested during migration of thelarva thru the lungs = Pneumonitis – occur from 4days to 2 weeks after infection ( asthma attacks)
Pulmonary ascariasis = cough blood stainedsputum and eosinophilia (Loeffler’s-likesyndrome)
Adult worms in the small intestine = vagueabdominal pains, distention & obstruction due tomass of worms in heavily infected individuals
In obstruction = peak incidence 1-6 yrs old;abdominal pain sudden onset, severe, colicky andvomiting
Eosinophilia noted in 10% of patients
Diagnosis:
Direct fecal smear
 
Kato’s thick smear
 
Pulmonary & GI ascariasis complicated byobstruction= based on clinical symptoms & high index of suspicion
 
Fertilized egg: broadly ovoidal, 45 to75 umx35 to50um.
 
Albuminoid outer covering Thick yellowish inner shell
Infertile eggs: longer, narrower than fertile eggsMeasures 90 x 40 umBoth inner shell and albuminoid coat are thinIf albuminoid coat is absent – may resemble Trichostrongylus eggs
Can also be diagnosed through radiography =worm-shaped radioluscent areas in a barium-filled intestine
Treatment:
Albendazole = a nitroimidazole that bindsirreversibly to tubulin, blocking microtubuleassembly and inhibiting glucose uptake by theworm= 400mg p.o. single dose (200 mg forchildren <2 years old)= drug of choice
Mebendazole 100 mg BID for 3 days or 500 mgonce
Pyrantel pamoate 11 mg/kg single dose
Piperazine salts (citrate, adipate or phosphate)= causes neuromuscular paralysis & rapidexpulsion of the parasite; used for intestinal &biliary obstruction; given 50-75 mg/kg for 2days
Surgical treatment for severe obstructive cases
Prevention:
 Treating human feces before it is used as fertilizer
Providing hygienic sewage disposal facilities
Deworming every 3-6 months
ENTEROBIUS VERMICULARIS
Pinworm
 
Affects 10% of pediatric population
 
Spread is facilitated by crowded indoor living intemperate climates but also common in thetropics
 
Male : inconspicuous, 2-5 mm long and not morethan 0.2 mm wide
 
Female : 8-13 mm in length and 0.5 mm in width
 
Light yellowish whiteDistinguished by a long thin, sharply pointedtail
Inhabit the cecum and adjacent portions of thelarge and small intestines
 
Female worms, when fully gravid, migrate downthe intestinal tract to pass out the anus anddeposit their eggs
 
 The worms may migrate several inches out of theanus, depositing eggs as they crawl or liberatingmasses of them as the worms dry and literallyexplode
 
 
Eggs are fully embryonated and are infectivewithin a few hours of the time they are deposited
 
Eggs live longest under conditions of fairly highhumidity and moderate temperature
 
Reinfection of the patient by contamination of thehand is common and makes control of theparasite very difficult
 
Development of adult worm = 6 weeks
 
Familial outbreaks : Infection throughcontaminated clothing and beddings
 
Eggs may survive for some days in dry dust
 
Airborne eggs may infect persons at somedistance
 
Retrofection = a type of autoinfection, involveshatching of the embryonated eggs after theirdeposition in the perianal area and subsequentmigration back into the rectum and largeintestine
 Life Cycle:
Mature egg ingested by human
egg hatch inthe duodenum
larva develops to maturity in S.I.
proceed to L.I. (final habitat)
adult in largeL. I. (male and female)
Diagnosis:
 
Recovery of the characteristic eggsMethod: Scotch Tape Swab Technique
Suspected in children with pruritus ani
Occasionally, adult female worms seencrawling in the perianal region or in thefeces
Females do not ordinarily oviposit untilthey leave the intestinal tract
Eggs: 50-60 um in length, 20-32 inbreadthTranslucent shell of moderate thicknessFlattened on one side = flattening, consequentreduction in diameter and thicker shell – differentiatesfrom hookworm eggs
Symptoms:
Pruritus ani = migration of the female wormsfrom the anus
In small children, worms may invade the vaginaafter leaving the rectum producing a localirritation
Local itching may interfere with the sleep of children or adults = worms migrate from the anusduring the resting hours
Pathogenesis:
Considered as a commensal
Attachment of the adult worms to the intestinalwall may produce some inflammation
Invasion of the appendix can also be expected asa cause of appendicitis
Entrance into the peritoneal cavity via the femalereproductive system may result in formation of granulomas around eggs and worms = chronicpelvic peritonitis
Occasionally reported in other sites: Liver andlungs
Treatment:
Albendazole = DOC= single dose of 400mg or 200 mg inchildren < 2 y.o.= should be repeated in 2 weeks to kill anyworms that migrated and hatched from eggs present atthe time of initial treatment
Pyrantel pamoate = single dose of 11 mg/kg bodyweight and repeated in 2 weeks
HOOKWORM INFECTIONS:ANCYLOSTOMA DUEDENALE
Old World hookworm
Adults : - grayish white or pinkish

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