PARASITES

CAUSING
NEUROSENSORY COMPLAINT

BLOCK 3.5, APRIL, 2010

TOPIC TREE
SIGNS & SYMPTOMS
NEUROPATHY
TINGLING SENSATION
INVOLUNTARY MOVEMENT
PARALYSIS
PAIN
DECREASE OF CONCIOUSNESS
SEIZURE
EPILEPSY
DIPLOPIA
HEADACHE
DEAFNESS

DISEASE ?

HELMINTH PARASITES ASSOCIATED WITH

SEIZURES IN HUMAN

CESTODES
(TAPEWORM)

Taenia solium
T. Multiceps
Spirometra spp
Echinococcus
(E. granulosus/ E. multilocularis)

NEMATODES
(ROUNDWORM)
TREMATODES
(FLUKES)

Trichinella spiralis
Angiostrongylus cantonensis
Strongyloides stercoralis
Toxocara canis
Schistosoma
(S. mansoni/S. hematobium/
S. japonicum)
Paragonimus
(P. westermani/P. mexicanus)

Garcia,H.H. & Modi, M., 2008. Epilepsia.49 (suppl.6):25-32

Taenia solium cysticercosis

& Neurocysticercosis

=pork tapeworm
Endemic in developing countries
Infection of human CNS by its larvae
(cysticerci)
Important causes of seizures & epilepsy (most
common)

Life cycle, route of infection

Definitive host
Intermediate hosts
Accidental Ingestion
of eggs
Embryos cross
intestinal mucosa

circulatory system

establish &encyst

larva
vesicles/cysticerci

definitive size in 2-3
months

Clinical Features & Diagnosis

Outside CNS
In the CNS or eye
(Neurocysticercosis/NCC)
In brain parenchyma: viable
cyst, rounded small vesicles
with transluscent
membranes

degeneration, vesicular
fluid
opaque & dense,
cyst edges become
irregular & shrink

round, calcareous nodule
with residual calcification

Outside the brain

parenchyma, cyst tends to
grow & infiltrate
Associated with
hydrocephalus &
intracranial hypertension
(rare cases)
Dx:
CT/MRI
Western blot & ELISA : ab in
serum/CNS
Patient with calcified NCC: ?

Hydatidosis

Causal agents:
larval stages of cestodes (tapeworms)
of the genus Echinococcus.

E. granulosus causes cystic

echinococcosis, the form most
frequently encountered;

E. multilocularis causes alveolar

echinococcosis;

E. vogeli causes polycystic

echinococcosis;

Geographic Distribution:
E. granulosus occurs practically
worldwide, and more frequently in
rural, grazing areas where dogs ingest
organs from infected
animals. Sheeps/cattle by
swallowing Taenia-like egg in a dog
faeces

E. multilocularis occurs in the

northern hemisphere, including
central Europe and the northern
parts of Europe, Asia, and North
America. Associated with wild
canine, rodents.

E. vogeli and E. oligarthrus occur in

Central and South America.

Hydatid cyst & alveolar hydatid cyst

the differences:

Clinical Features & Dx

Clinical Features:
Echinococcus granulosus
infections remain silent for years
before the enlarging cysts cause
symptoms in the affected organs.
Hepatic, Pulmonary involvement
Rupture of the cysts can produce
fever, urticaria, eosinophilia, and
anaphylactic shock, as well as cyst
dissemination.
Other organs (brain, bone, heart)
can also be involved, with
resulting symptoms. Brain:
convulsion/mass effect; Eye:
protopsis & chemosis

Laboratory Diagnosis:
ultrasonography and/or other
imaging techniques supported by
positive serologic tests.
In seronegative patients with
hepatic image findings
compatible with echinococcosis,
ultrasound guided fine needle
biopsy may be useful for
confirmation of diagnosis

 Case Report (Hydatid

disease)
India
Adolescent boy with
headache, weakness of
the right side of the body,
impaired vision, difficulty
in speaking, in the last 7
days vomit
Onset was slow, gradually
progressive

Discussion:
Cysts usually seen in middle
cerebral artery territory,
contain infective scolices
How to differentiate with:
Brain abcess
Brain tumor
Therapy: ?
Indian Pediatric surgery, Vol 30, 1993

cyst & alveolar types

Hydatid cyst disease

multiple coalescing thin walled cysts
of varying sizes in the right fronto parietal region.
No calcification/solid component was present.
No perilesional oedema
Clinical features: headache, vomiting, visual field
alteration, gait disorder

Alveolar hydatid disease

multiloculated, solid/semisolid mass
with calcification and oedema.
Daughter cyst by external budding
Invade progressively like malignant
tumor

Cerebral Sparganosis
a rare parasitic zoonosis
sparganum, the migrating plerocercoid larva of the cestode,
Spirometra mansoni.
Transmission to humans ?
The majority of human infestations involve the subcutaneous
and muscular tissues
Cerebral involvement is rare

mimics that of a brain tumor. Usual

manifestations include chronic or
recurrent headaches and focal
neurological deficits in addition to
seizures.

The characteristic features CT/MRI: single

or multiple granulomatous lesions that
enhance profusely with contrast,
may calcify, at times demonstrate
hemorrhage within the
lesion/s and, rather peculiarly, change
location on sequential
imaging studies due to migration of the
larva.

Imaging studies that capture the resolving

stage of sparganosis document focal
perilesional cortical and subcortical
atrophy, presumably as a result of focal
inflammatory scarring

( Garcia, H.H, Epilepsia, 49(Suppl. 6):2532, 2008)

Sleeping Sickness

Life cycle

Parasites
Trypanosoma brucei:
T. brucei brucei
T. brucei gambiense
T. brucei rhodesiense

Vectors: Glossina
Geographical distribution

DISEASE
LOCAL EFFECTS
Trypanosomal chancre
2-3 after bite, increases
in 2-3 weeks
T. b. rhodesiense> t.b.
gambiense
Local lymphadenopathy

SYSTEMIC EFFECTS
Parasitemia 12-15 after
bite (early stage)
Parasitemia ~ fever
CNS via choroid plexus
Or by transcytosis
across endothelial cells
to cause a lymphocyte
meningoencephalitis
(late stage)

PATHOGENESIS & CLINICAL PICTURE

BRAIN & Other Organs:
Perivascular infiltration with lymphocytes,
plasma cells, macrophages, morular cells
Microglial dan Astrocyte proliferation may be
associated with neuronal destruction &
demyelination in the brain

T. b. gambiense
Early Stage

Late Stage

Fever, headache, join pains,

or asymptomatic
Winterbottoms sign
Odd skin rashes, pruritus,
thickening of facial tissue
Enlarged spleen (moderate)
Last many months- 2 years
CNS involvement

Disturbed cerebral function

predominate
Behavioural changes
Sleeping disorders
Disturbed speech & motor
function
CNS, extrapyramidal &
cerebral function
Kerandels sign
Death after few month/a year
of CNS involvement

T. b. rhodesiense
More acute & virulen infection than T.
gambiense, fever & siystemic symptoms
prominent
Serous effusions (pleural & pericardial spaces) are
common, myocarditis
Early stage: hepatocellular jaundice, anemia
Liver & spleen enlarged slightly
Lymph gland enlargement (seldom)
Fatal within few weeks of the onset, more likely
because of myocarditis rather than CNS

DIAGNOSIS
Early stage disease

Late stage disease (CNS)

1.
2.
3.
4.
5.

Neurological signs
Cerebrospinal fluid (CSF)
Raised CSF cell count
(5/mm3)
Immunological dx methods
CATT
Routine lab. Findings;serum
& CSF IgM level are high

Demonstration of parasites:
Blood film
Concentration methods
Gland puncture
Bone marrow aspiration
The chancre

Treatment & Control

T. gambiense & rhodesiense

Sleeping sickness control

Early:
Suramin
Pentamidine

1. Detection & treatment of

cases
2. Vector control

Late:
Melarsoprol
Eflornithine

South American trypanosomiasis

(Chagas disease)
Parasites: T. cruzi
Geographical distribution
Triatomine bugs : reduviid, asasin bug, kissing bugs
Para. Multiply in the hindgut of bug as
epimastigots, develop into metacyclic
trypanosomes
Infected trypanosomes excreted in the feces of bug
during feeding
Rubbing feces into a wound/ conjunctiva,
transfusion, congenital infection

Clinical features
Acute

Chronic

Occurs 10-20 years after

infection
Classical manifestation:
1. Cardiac disease
2. Mega-oesophagus,
megacolon, due to
destruction of the intramural
parasymphathetic nerve
plexus
3. small bowel, ureter

Develop in 1/3 individuals

Chagoma
Romanas sign
Febrile reaction
Death occur rarely at this stage
Untreated: asymptomatic low
level para may continue for
many years, 15-40% develop
to chronic Chagas disease

DIAGNOSIS
Parasitological techniques

Treatment

1.
2.
3.
4.

Acute stage:
Nifurtimox
Benzidazole

Microscopy
Culture
Xenodiagnosis
Biopsy

Serological techniques:
IgM, IgG

Chronic stage:
Symptomatic treatment

Control & Surveillance

1. Seroprevalence survey
2. Spraying: pyrethroid insecticides
3. Elimination:
Cracks in mud,
natural material roofing

Parasites similar to Trypanosoma

3 dominant clinical forms:
cutaneous leishmaniasis,
mucocutaneous leishmaniasis,
and visceral Leishmaniasis

ENDEMICITY
in 88 countries throughout Africa,
Asia, Europe, and North and
South America.
12 million cases worldwide, with 1.5
to 2 million new cases each year.
Although the incidence of
leishmaniasis is greater in the Old
World than in the New World, the
U.S.traveler is most likely to
contract this disease in Latin
America (contracted mainly in
Peru and Brazil)
Associated with rural areas and
poverty, but it has adapted to the
urban environment as well.

Visceral Leishmaniasis endemic countries

PATHOGENESIS
CLINICAL SPECTRUMS
DIAGNOSTIC
CONTROL
VECTORS

Venomous Arthropods
Common Sign & Symptoms

Insects
Hymenoptera
Hemiptera
Diptera
Lepidoptera

Painful bite
Tingling sensation
Seizures
Paralysis
Anaphylactic reaction

Others
Arachnids (ticks)
Scorpion
Chilopoda

Hymenoptera
Bees, wasps, ants
Anaphylaxis life threatening
Ovipositor of females has been modified into a
stinger
Yellowjackets (Vespula & Dolicovespula)
Honeybees (Apis)
Fire ants (Solenopsis), harvester ants
(pagonomyrmex)
Paper wasp (polistes), etc

Cases
1st case
1. Painful ant bites at groin
2. Short of breath & dizzy
3. Periorbital & perioral edema
4. cyanosis of the lips, severe
wheezing bilaterally
5. Marked erythema of right groin
& scrotum
6. Tender & enlarged lymph node
in right groin
7. 1 cm red papule
8. Piloerection of surrounding
hairs
Pogonomyrmex (P. rugosus)

2nd case
2-3 month old baby
Ants invaded home &
covering her child in the
crib
Respiratory distress
Solenopsis invicta
Venom: necrosis (alkaloid),
hypersensitive/ anaphylactic
(protein/peptide)

Mandible s

Hemiptera (bugs)
Anaphylactic reactions to
saliva from the bites of
kissing bugs
Species specific
Triatoma rubida (Arizona)
Triatoma protacta
(California)
Painless bite, during sleep,
harmless
fatal

Case:
Heart rate increasing, felt
hot, consciousness, seizure
Kissing bug were found in bed
Types of allergic reactions:
Localized intensely pruritic
urticaria at the site of bite
or anaphylaxis
Relatively uncommon: bed bug
(Cimex lectularius)

Class: Arachnids ; Ordo: Acarina

Ticks & Mites
TICKS (Sengkenit):
FAMILY ARGASIDAE (soft ticks):
Ornithodorus moubata
Argas
Otobius

FAMILY IXODIDAE (hard ticks):

Dermacentor
Riphicephalus
Boophilus
Haemophysalis
Amblyoma sp

MITES (Tungau):

Sarcoptes scabiei
Leptotrombidium
Dermatophagoides

Human cases of tick paralysis caused by

the genera Ixodes , Dermacentor ,
and Amblyomma have been reported
from Australia, North America,
Europe, and South Africa

What should we learn:

Morphology
Species identification
Life cycles
Their role as vectors
Medical Problem caused
Pathogenesis :
tick paralysis
treatment

Dermacentor andersoni
Rocky mountain spotted fever
(Rickettsia ricketsii) in USA, Canada,
Mexico, South Amr.

Dermacentor variabilis/
American dog tick

 The life cycle of ticks involves four

stages: the egg, larva, nymph,
and adult. All are capable of
feeding on blood.
Life cycle may involve one, two,
or three hosts. A three-host cycle
is typical with a life span of about
2 years.
Eggs hatch into tiny six-legged,
punctate larvae, which molt into
eight-legged nymphs with a
diameter of 1 to 2 mm after a
blood meal. Nymphs molt to
adults, which are about the size
of a human little fingernail.

The disorder usually occurs in spring

and summer when nymphs and
adults are actively feeding
Paralytic syndrome has been related
to such attempts by the ticks to
obtain a blood meal
toxin
secreted during feeding
First symptom:
Numbness in feet & legs, difficulty in
standing & walking
Hands & arms can be affected next,
tongue, throat muscle
speaking &
swallowing

Class: Arachnids
Ordo: Acarina
Ticks & Mites
Ticks:
Ixodidade (hardtick)
Argasidae (soft tick)
Male & female:
bloodsucking
Major vectors of various
pathogens
Toxins (some)
paralysis
Allergic reaction

Examples:
Australian paralysis tick
(Ixodes holocyclus)
Ixodes pacificus
(North America)
Rhiphicephalus
Ixodes ricinus

SCORPIONS
Usually is not serious:
pain, tenderness,
swelling, discoloration
Anaphylactic reaction
The common striped
scorpion:
Centruroides vittatus
Sculptured scorpion:
C. Exilacauda (can be fatal
in children)

SPIDERS
Cutaneous anesthesia after
spider bite
Eg: Loxosceles reclusa (brown
recluse spider),
Commonly known to cause
cutaneous necrosis,
ulceration and others:
fever, macular rash,
pyoderma
gangrenosum,
hemolysis, renal failure,
death

Gross et al, 1990. Southern Medical Journal,

Vol 83, No 11

SPIDERS

Bite sites: pin prick, two red marks

may appear, minor swelling.

Female Black widow spider

Nocturnal
Aggressive to defense egg sacs,
etc
Eating male after mating
Morphology:
Hourglass shape
Red/white mark on top of
abdomen

Pain (1 to 3 h), continuing for up to 2

days, and can spread from a bitten
limb into the abdomen or back.

Cramping or rigidity (abdominal

muscles)

other possible symptoms including

nausea, vomiting, shaking, profuse
perspiration, and labored speech and
breathing, possibly progressing to a
weak pulse, clammy skin,
unconsciousness, and convulsions.

Symptoms often diminish after about

a day and are gone after several days.
Death
very rare.

CHILOPODA (centipedes)
Multi segmented
Flat-body
A pair of venomous claws
Painful bites
Anaphylactic-like reaction