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School of Medicine PARASITOLOGY

o Larvae harbored in the tissues of animals can be

M.04 OXYUROIDEA, ASCARIDOIDEA: Toxocara transferred from host to host with no growth and
(Part 3) development occurring until a susceptible definitive host
Dr. Gallardo| October 03, 2019 is reached.
o Toxocara are also prolific parasites: can lay up to 10,000
eggs per day
OUTLINE

I. Toxocara species
II. General Life Cycle
III. Life Cycle in Humans
IV. Epidemiology
V. Pathology and Symptomatology
VI. Clinical Diagnosis
VII. Laboratory Diagnosis
VIII. Treatment
IX. Prevention

I. TOXOCARA SPECIES

• Genus Toxocara
o Distinct cervical alae just like Enterobius
o Prominent lips with fine ridges just like Ascaris
o Esophagus with distinct posterior ventriculus bulb
o Species known to cause disease in man:
1. Toxocara canis: the dog ascaris
2. Toxocara cati: the cat ascaris
o The disease they cause is known as Ascariasis; They are
also Ascaris worms but not the Ascaris lumbricoides
because they are Ascaris worms of dogs and cats
o Disease: Toxocariasis

II. GENERAL LIFE CYCLE

● DEFINITIVE HOSTS:
o Dogs (T. canis) and cats (T. cati) - where entire life cycle
occurs
o Puppies and kittens (less than 5 weeks old), not the
adult pets
● ACCIDENTAL/ABBERANT HOST: Humans • Toxocara spp. can follow a direct (one host) or indirect
● In comparison to Ascaris that humans are the only host (multiple host) life cycle. Unembryonated eggs are
● INFECTIVE STAGE: EMBRYONATED EGG shed in the feces of the definitive host (canids: T. canis;
felids: T. cati).
o Eggs are passed out unembryonated, unicellular,
undergoes 1st molt becomes embryonated that is • LIFE CYCLE:
infective.
1. Eggs embryonate over a period of 1 to 4 weeks in the
environment and become infective, containing third-
Toxocara, unembryonated Toxocara, embryonated egg stage (L3) larvae.
egg
2. Following ingestion by a definitive host, the infective
eggs hatch and larvae penetrate the gut wall. In
younger dogs (T. canis) and in cats (T. cati), the larvae
migrate through the lungs, bronchial tree, and
esophagus, where they are coughed up swallowed
into the gastrointestinal tract; adult worms develop and
oviposit in the small intestine.
3. In older dogs (>5 weeks), patent (egg-producing)
infections can also occur, but larvae more commonly
become arrested in tissues. Arrested larvae are
reactivated in female dogs during late gestation
and may infect pups by the transplacental (major)
and transmammary (minor) routes in whose small
● PARATENIC / TRANSFER HOSTS intestine adult worms become established.
o Can be humans, and other mammals including the older 4. In cats, T. cati larvae can be transmitted via the
dogs/cats (because the definitive hosts are the puppies transmammary route to kittens if the dam is infected
and kittens), birds during gestation, but somatic larval arrest and

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reactivation does not appear to be important as in T. circulation and the lymphatics

canis.
5. Toxocara spp. can also be transmitted indirectly
through ingestion of paratenic hosts. Eggs ingested by
suitable paratenic hosts hatch and larvae penetrate the
gut wall and migrate into various tissues where they
encyst
6. The life cycle is completed when definitive hosts
consume larvae within paratenic host tissue, and the
larvae develop into adult worms in the small intestine.
o Gray, elevated, circumscribed granulomatous area
o 4mm in diameter
o Microscopic picture: eosinophils, lymphocytes, epitheloid
cells, and foreign body giant cells surrounding the larvae
o Extensive hepatic parenchymal necrosis with Charcot-
Leyden crystals (also seen in Ascariasis, Capillariasis, and
parasitic infection caused by Fasciola).

III. LIFE CYCLE IN HUMANS

• Humans are accidental hosts who become infected by

ingesting infective eggs or undercooked meat/viscera of
infected paratenic hosts.
• After ingestion, the eggs hatch and larvae penetrate the
intestinal wall and are carried by the circulation to a wide
variety of tissues (liver, kidneys, heart, lungs, brain,
muscle, eyes). Toxocara larvae in liver tissue.
• While the larvae do not undergo any further
development in these sites, they can cause severe local
• Eosinophilic granulomatous lesions may occur without
reactions (immune response) which is the basis of the
larvae:
clinical manifestations of toxocariasis
o May be seen in practically every organ of the body
o May be due to larval migration through the area
IV. EPIDEMIOLOGY
o May represent the site of death and disintegration of
larva
• T. canis and T. cati – among the most common helminth
• Organs most frequently involved in VLM:
parasites of dogs and cats
o Liver
• Presence of dogs, esp. puppies at home is a high risk factor of
o Lungs
toxocariasis in children
o Heart (cardiac muscles)
• Heavily contaminated soil from parks and playgrounds
o Kidneys
o Serve as usual sources of infection in children
o Skeletal muscles
o Contribute to high rates of infection in dogs (more than 5
o Eyes
weeks old, non-pregnant – may serve as paratenic host)
o CNS (brain, spinal cord)
• Clinical Manifestations of VLM
V. PATHOLOGY AND SYMPTOMATOLOGY
o Seen largely in children 1 to 4 years of age
o History of close contact with the soil, dogs, or cats and of
• 2 main clinical presentations of toxocariasis:
dirt eating (pica)
o Visceral larva migrans (VLM)
o Light infections – asymptomatic
o Ocular larva migrans (OLM)
• Symptomatic:
** Cutaneous Larva Migrans- Strongyloides o Marked persistent eosinophilia (20-80%)
- Normal eosinophil count: 0-7%
VISCERAL LARVA MIGRANS (VLM) o Hepatosplenomegaly
• Clinical syndrome resulting from invasion of human visceral
o Anemia and hyperglobulinemia
organs by larvae of Toxocara spp. and other parasitic
o Gastrointestinal infiltration: Intermittent abdominal pain,
helminths of dogs, cats, and other carnivorous animals.
dermatitis (nodular pruritic skin lesions)
• Larvae may invade any tissue of the body! induce host
o CNS infiltration: neurologic disturbances (seizures)
response such as bleeding, formation of eosinophilic o Pneumonitis & asthma like symptoms (cough and
granulomas and necrosis wheezing), pulmonary infiltration on chest x-ray
• Patients may be asymptomatic (in mild infestation) or may have • Causes of death (because of severe infiltration):
serious disease o Respiratory failure
• Severity of disease depends primarily on: o Cardiac arrhythmia
o Number of larvae invading the tissues: the more
o Brain damage due to intractable seizure
larvae, the more immune response, the more
inflammation
o The particular tissue invaded: heart, lungs, liver--
symptomatology and treatment will differ
o Duration of the infection
o Degree to which the host is sensitized to larval
antigens
• High, sustained blood eosinophilia: most constant and
striking clinical feature
• Characteristic lesion most frequently seen in the liver:
o Liver is the 1st organ usually infected or infested: small
intestine, intestinal wall invasion and enters the portal

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Visceral Larva Migrans.

OCULAR LARVA MIGRANS (VLM)

• Result of penetration of the orbit by a single larva
• Various ophthalmologic lesions produced by larvae
(endopthalmitis, choroiditis, iritis, or hemorrhage)
• Usually unilateral
• Clinical manifestations of OLM:
“THE MONSTER WITHIN”
o Manifestations include:
Case Presentation: " Diminished vision
" Strabismus
• 9-year-old, female, Happy Hallow, Baguio City " Leukocoria: whitish pupillary substance
• Chief Complaint: blurring of vision on left eye " Fixed pupil
• HPI: " Posterior retinochoroiditis on fundoscopy
o 10 months PTC: blurring of vision on left eye with eye o May be misdiagnosed as malignant retinoblastoma in some
pain, frontal headache, dizziness, nausea and vomiting
cases because of whitish pupillary reflex called Leukocoria
o 7 months PTC: difficulty in reading from back of class
because of glaring (“masisirap”) o Often occurs in older children or young adults
o 4 days PTC: deviation of left eye towards outward- o Slight eosinophilia or visceral manifestations occur rarely
upward direction
" Consulted at BGHMC Ophthalmology department
" Fundoscopy: Cystic Mass on posterior chamber
of the eye
" Surgical intervention contemplated
" Referred to Pediatric department for medical
management on January 5, 2016
• Past Medical History
o Complete vaccinations as to EPI
o Deworming done every 6 months in school (last
deworming: June 2015)
• Family History: Ocular larva migrans.
o 2nd of 5 siblings
o No history of cancer in family VI. CLINICAL DIAGNOSIS
• Social and Environmental History:
o Lives in a Bungalow-type house, walls made of • Triad:
galvanized iron, floor is bare ground o Marked eosinophilia
o Drinking water from water-refilling station; water for o Hepatomegaly
household purposes from nearby spring
o Hyperglobulinemia
o Congested neighborhood with lots of stray dogs
that litter everywhere • History of exposure to dogs or cats
• Physical Examination: • History of pica
o Physical and neurological examination findings are • Triad seen frequently seen in:
normal except for the eyes o Visceral Larva Migrans > Ocular Larva Migrans
o Inspection of Eyes: (Slight eosinophilia in OLM)
" No ptosis, no eye discharge, no bulbar and
palpebral conjunctival injection, pupils round and VII. LABORATORY DIAGNOSIS
equally reactive to light, left eye deviated
towards supra-lateral area • Diagnosis does not rest on identification of the parasite since
o Visual Acuity: larvae do not develop into adults in humans
" Right Eye: 20/20; Left eye: counting fingers at 2 • Stool examination would not detect any Toxocara eggs: No adult
feet (left eye practically blind) laying the eggs; only larvae
o Fundscopy: • Presence of Ascaris and Trichuris eggs (soil transmitted) in feces,
" Red Orange Reflex (+) on R eye and (-) on L eye indicating fecal exposure, increases the probability of Toxocara
" No hemorrhage and exudate larvae in the tissues
" Cystic, white mass at posterior chamber of
Left eye; Normal R eye ANTIGEN DETECTION TESTS
• DIAGNOSIS: OCCULAR LARVA MIGRANS • Gold standard
• The only means of confirmation of a clinical diagnosis of Visceral
Larva Migrans and Ocular Larva Migrans
• ELISA based on the enzyme immunoassay (EIA) with
larval stage antigens extracted from embryonated eggs or
released in vitro by cultured infective larvae
o Currently recommended serologic test for
toxocariasis
• Stool examination from infected pets may support the

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diagnosis
• Tissue examination for larvae may provide a definitive
diagnosis
o May be negative because of sampling error

VIII. TREATMENT

• Anthelminthic therapy:
o Benzimidazoles: Albendazole, Mebendazole,
Diethylcarbamazine (DEC), Thiabendazole
• Thiabendazole 25 mg/kg bid for 5 days
o Appears to shorten course of the disease
however, not locally available
• Injury to parasite may provoke a more intense inflammatory
response leading to worsening of clinical picture because of
host sensitization
• Corticosteroid therapy
o For severe cases, esp. with prominent allergic
manifestation, when you are dealing with serious
pulmonary, myocardial, or CNS involvement
o For eye involvement

IX. PREVENTION

• Prevention of contact with contaminated soil

• Avoid contact with infected dogs and cats esp. kittens and
puppies
• Periodic deworming of household dogs and cats
• Cover sandboxes when not in use

CHECKPOINT!

1. A 5-year-old female presents with abdominal pain and

splenomegaly. Based on risk factors, parasitic infection is
suspected. Which of the following tests is used to make the
diagnosis of visceral larva migrans?
A. Skin biopsy
B. Casoni Test
C. ELISA for Toxocara
D. Serology for antibody titers

2. A child presents with fever, eosinophilia, abdominal pain, and
mild splenomegaly noted on exam. It is suspected this is
more than the gastroenteritis. The parents report there are
multiple dogs and cats at home. What is the drug of choice?

3. A 4-year-old female from the United States complains of
problems breathing. She likes to eat dirt. She has no past
medical history, travel history, or sick contacts. The patient
has bilateral wheezing and hepatomegaly. The family has a
dog. CBC shows leukocytosis with 55 percent eosinophilia.
Select the best diagnostic test.
A. Bronchoscopy
B. Toxocara ELISA
C. Gastric aspirate for acid fast bacilli stain and culture
D. Urine test for Legionella antigen
1. C
2. Albendazole/Mebendazole
3. B

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