Tropis 2019 Tissue Helminth

DURING
LECTURE/DISCUSSION
5/17/2019 S. Wahyuni/lecture/tissue helminth 1

Tropical Medicine
Tissue Helminth
Sitti Wahyuni, MD, PhD

sitti.wahyuni@med.unhas.ac.id
Parasitology Dept
Faculty of Medicine Hasanuddin University

Objectives (2x 50 minutes)
After finishing these lecture student are able to:
1. Know the disease caused by the parasite, the host
and the geographic distribution
2. Understand the life cycle, mode of transmission, and
infective stage of the parasites
3. Understand the pathomechanism of the disease and
the symptoms
4. Recognize the morphology of the each life stage the
parasites and the key identification for diagnosing the
disease
5. Know how to prepare human speciment for diagnosing
the diseses caused by the parasite
6. Understand the risk and how to prevent the infection

Tissue helminth
1. Brugia spp
2. Wuchereria bancrofti
3. Schistosoma sp
4. Ankylostoma sp
5. Toxocara sp
6. Trichinella sp
7. Fasciola hepatica
8. Fasciolopsis buski
9. Capillaria hepatica

• A 32-year old female presented to the orthopaedic out-patient
department with complaints of a painless swelling over the
lateral aspect of her left upper arm for five months.
• No antecedent history of injury or trauma.
• No history of similar swelling elsewhere in the body or of
constitutional symptoms associated.
• On examination: A 2x2.5cm non-tender,
immobile swelling which was firm in
consistency and adherent to the skin, not
warm to touch.
• There were 2-3 lymphnodes, non-tender, in
the left axilla.
• The systemic examination was normal.
• Haematological investigations were normal.
• Thin smear of clear fluid taken by
fine needle aspiration cytology
(FNAC): ; slender colourless thread
like larvae with blunt head and tail
tip free of nuclei were identified
which raised the suspicion of W.
bancrofti
• Treatment: Oral Diethylcarbamazine
100mg 2x1for 21 days.
• Tremendous decrease in the swelling at the end of four weeks
• There was disappearance of the axillarylymphadenopathy at
the end of three months. The patient was closely followed-up
for two years and showed no signs of recurrence.

Wuchereria bancrofty
&
Brugia sp.

• Disease: kaki gajah/ lymphatic filariasis
• Host
– Definitive host:
• humans: W. bancrofti and B. timori
• human & animals: B. malayi
– Intermediate host: masquitos
– urban W.bancrofti: Culex quenquefasciatus
– rural W.bancrofti: A. farauti & A. punctulatis
– nocturnally B. malayi (Sulawesi): Anopheles barbirostris
– sub-periodic B.malayi (Sumatra & Kalimantan): Mansonia
spp. nocturnal B timori : A. barbirostris
• Transmission: Mosquito bite
• Habitat
– Adult: Lymphonods & lymphatic vessel
– Microfilaria: Blod stream and visceral
Epidemiology
• Affect 120 million people over 80 tropics & subtropics
countries; 44 million have visible signs of disease 76
million have preclinical infection
• WHO: global elimination of filariasis byn2020
• Indonesia: Prev. 0-70%
• Health Minister & UI (1983): mf prev. has declined to 0-
19,6%
• WHO (2000): Endemic in 22 of 27 provinces;150 million
people at risk of infection; the highest prev. in South East
Asia

Mosquito breeding site

Clinical manifestation
• spectrum of clinical and parasitological manifestations in
endemic area
– normal/ asimptomatic amicrofilaraemics
– Microfilaraemics
– Chronic obstructive disease
Tropical pulmonary eosinophilia (TPE)

• A relatively unusual manifestation of infection
• Microfilariae are generally absent from the circulation
• Hypereosinophilia, elevation of anti-filarial antibodies
(lgE) & pulmonary symptom such as bronchial asthma

• Acute lymphangitis/lymphadenitis:
– Often occur in chronic patients
– Caused by dying or degenerating adult worms
– Bacterial or fungal superinfections in limbs with
compromised lymphatic dysfunction play a significant
role
• Chronic Bancroftion filariasis
– main clinical manifestation: hydrocele
– can be accompanied by lymphoedema (elephantiasis) of
the whole arm/legenlargement of vulve/breast
• Chronic Brugian filariasis
– lymphoedema (elephantiasis) of leg below the knee or
arm below the elbow
– hydrocele has seldom been recorded
Clinical manifestation
It is an old disease…….
Diagnosis
• Detection of microfilariae
microscopically
• Antigen detection assays
• Molecular Diagnosis
• USG detection of adult worms
• Antibody assays

Detection of microfilariae
• Classic diagnosis of
lymphatic
• Still the golden
standard
• The time accord to
the periodicity
• Two methods: finger
prick & whole blood
filtration

Finger prick method
• The blood is obtained by pricking the

finger with a lancet
• Collect 20-60 ul blood on a slide glass
• Stained with Giemsa's stain
• Screen presence of mf under a light
microscope
• sensitivity of this assay is low
• Time collecting blood is inconvenient
Whole blood filtration
• 1-10 ml blood filtrated to the filter
• The filters: stained and examined in the same
manner as finger prick blood
• Distribution of mf in the periphery non-random,
mf can be missed as they are subject to
periodicity
• The time of blood collection is inconvenient
• Many people object to vena puncture
• Requires skilled personnel & proper precautions

Management

Strategies to reduce transmission
• Treat the infection person

• Decrease human-vector contact
• Reduce the population of mosquito
vectors by insecticides, polystyrene beads
or biocides

Treatment by Diethylcarbamazine
citrate(DEC)
• For the past 50 years has been the primary drug
of choice
• Has excellent microfilaricidal properties
• Demonstrated the rapid decline of mf in the
periphery after treatment
• Have macrofilaricidal potential, if prolonged
treatment is supplied
• A part of individuals seem resistant
• Side effects are recorded

Dosage of DEC
• Standard : 12-14 day course of 6 mg/kg BW

• Meta-analysis of studies : a single dose/a
year for several years equivalently reduce
mf levels
• New opplications : mass administration of
DEC fortified salt
• Combination therapy ivermectin
/albendozole can give 10% better results.
• Have a long-term effects

Current control programs
in Indonesia
• Annual mass drug administration (MDA):
DEC 6 mg/kg + albendazole 400 mg for at
least 4-5 subsequent years.
• Effective in reducing mf prevalence of
B.timori and intestinal helminth infections
in Alor island, East Nusa Tenggara from
26.8% to 3.8%

Schistosoma. sp

Schistosomiasis
(Bilharziasis)
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Causative agent
(blood-flukes) belonging to the class of
trematoda (Platyhelminthes)
• Schistosoma mansoni
• Schistosoma haematobium
• Schistosoma japonikum
• Schistosoma intercalatum
• Schistosoma mekongi

Host
• Devenitive:
human and several animals
• Intermediate: snail
- Biomphalaria
(S. Mansoni)
- Bulinus
(S.haematobium &
S. Intercalatum)
- Oncomelania
(S. Japonikum)
- Tricula (S. Mekongi)
Adult
• Female: 1 to 2 cm long thinner & longer than male

• Female stay in a groove on ventral side (gynaaecophoric
canal) of Male.
• Feed on host erythrocytes and body solutes
• Life span of 5-10 years
• 4-7 weeks post infection the mated adult female starts to
produce eggs (3000 egs/day)
S. mansoni

S. haematobium

S. japonicum

Cercaria
Infective stage of Schistosome

How human get infection?

Patology & clinical manifestation
1. Prepatent
- Cercaria- maturation
- Fever, malaise, headache, lymphadenopaty
- Eosinophilia, inflamation of hepar
2. Acute
- When adult worm produce egg
- nausea, vomit, diare, disuri, hematuri etc
3. Chronic
- Hepar atrofi, hipertensi portal, hidronefrosis

Schistosoma mansoni eggs in
intestinal wall
Schistosoma japonicum eggs in
colon & liver
Schistosoma sp. in liver & bladder
Diagnosis
• Clinical methods
• Parasitological methods
• Antibody detection methods

Clinical diagnosis
• Palpation & USG:
-hepatomegaly
-splenomegali
-periportal hepatic fibrosis
-enlargement of the diameter of the portal
vein.
• Micro-haematuria & leukocyturi: useful indicators

for urinary schistosomiasis and can be
determined with semiquantitative reagen strip
methods (good sensitivity but low specifity)

Parasitological methods
• Stool examination (S. mansoni or S. japonicum)
- simple smear (1 to 2 mg of fecal material)
- concentration procedures (formalin- ethyl acetate
technique)
- Kato-Katz technique (20 to 50 mg of fecal material)
• Urine examination (S. haematobium)

- time for collection between noon-3 PM
- enhanced by centrifugation & examination of the
sediment
- quantification by using filtration through a
Nucleopore® membrane of a standard volume

Antibody detection
• to detect patients who have traveled in
endemic areas
• to whom eggs cannot be demonstrated in
fecal or urine specimens
• sensitivity and specificity vary widely
among the many tests & are dependent on
both the type of antigen preparations used
(crude, purified, adult worm, egg,
cercarial) and the test procedure.

Treatment
• Praziquantle, Metrifonate and
Oxamniquine are currently the drugs of
choice.
• Praziquantle is active against all species
of the parasites.
• Oxamniquine: only efective for S. Mansoni
• Metrifonate is only active agains S.
haematobium.

Effect of treatment
• Treatment failures have occured &

attributed to drud-resistent schistosomes.
• Tolerence to praziquantle treatment of a S.
mansoni infected community was recently
described.
• chemotherapy does not prevent reinfection

control
• Improvement of water and sanitation
facilities
• health education
• integration of the control measure into
existing public health services are a
prerequisite for long –term control
• snail control may be an option in small and
focal situations only.

Trichinella sp

Trichinellosis (trichinosis)
• Caused by nematodes (roundworms) of the
genus Trichinella.
• several other species of Trichinella are:
-T. pseudospiralis (mammals and birds worldwide)
-T. nativa (Arctic bears)
-T. nelsoni (African predators and scavengers),
-T. britovi (carnivores of Europe and western Asia).
5/17/2019 S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas 53

life span in the
small bowel:
4 weeks
•encysted larvae
•remain viable for several years.
female 2.2 mm
males 1.2 mm
Encystment is completed
in 4 to 5 weeks

Clinical Features
• light infections: asymptomatic
• Intestinal invasion: diarrhea, abdominal pain,
vomiting.
• Larval migration into muscle tissues (one week
after infection): periorbital and facial edema,
conjunctivitis, fever, myalgias, splinter
hemorrhages, rashes, & blood eosinophilia.
• Occasional: myocarditis, central nervous system
involvement, and pneumonitis.
• Larval encystment in the muscles: myalgia &
weakness
laboratory finding
• Eosinophilia always associated with T. spiralis
• In severely infected cases, eosinophils may be
as high as 80-95%.
• Overall, the total WBC count is slightly elevated.
• In patients moderately or severely infected with
this nematode, muscle enzymes such as CPK
and LDH are released into the circulating blood
and their presence inthe serum can be another
clue
• ELISA can detect antibodies as early as 12 days
after infection

Diagnosis
• based on clinical symptoms and

eosinophilia
• can be confirmed by specific diagnostic
tests, including antibody detection, muscle
biopsy, and microscopy.
• Trichinosis is definitely diagnosed by the
detection of larvae in the biopsied muscle.

Encysted larvae of Trichinella in pressed muscle tissue sample.
The coiled larvae can be seen inside the cysts.

Larvae of Trichinella, freed from their cysts, typically coiled;
length: 0.8 to 1 mm

Treatment
• Begin as soon as possible

• The decision to treat is based upon symptoms,
exposure to raw or undercooked meat, and
laboratory test results.
• Thiabendazole and mebendazole are useful
(Miyazaki, 1991).
• Albendazole may be effective, but its role is not
yet established (Markell et al., 1999).
• Steroids are used for infections with severe
symptoms

Case report from Korea
• A 35- year-old men residing in Kochang-up was admitted
to Seokyong Hospital
• Complained of high fever, facial and periorbital edema,
and myalgia,
• A common past history of eating raw liver, spleen, blood
and muscle of a badger, Meles meles melanogenys.
• Hematologic and biochemical examinations :
- leukocytosis
- eosinophilia,
- highly elevated levels of GOT, GPT, LDH and CPK.
• symptoms & the laboratory findings: trichinosis?
Sohn, Korean J Parasitol. 2000;38(2):111-5.

Muscle biopsi
(By pressure method using two slide glasses)
• Biopsi of Gastrocnemius
muscle
• After 24 d eating badger
• Roundly coiled
nematode larvae
• Size: 0.775-1.050 x
0.026-0.042 mm

Fig 2. A sectioned larva in the worm cyst of muscle biopsied(H-E stained).
Fig. 3. Enlarged view of Fig. 2, showing the intense inflammatory response
around the nurse cells (arrow
heads)-larva (L) complex (H-E stained).

• Intensity of infection: Muscle biosy digested with pepsin-HCl solution.
• 212 larvae/gram muscle was recovered & then given orally to a ICR
mouse.
• At 50 days after:: a large number of larval T. spiralis was harvested
from the mouse.
• 7 days flubendazole & 3d albendazole the larvae in biopsied muscle
were uncoiled (Figs. 4, 5),

Treatment to the patient
• Helminths eradication: Praziquantel,
flubendazole & albendazole given orally
• Symptoms & other infection: antibiotics
and steroids were administered.
• discharged at 13-34 days post-admission
• What we can learn?:
Trichinellosis not only be found in pig

Ankylostoma sp

Animal Hookworm
Cutaneus Larva Migran
• A condition where animal hookworm infect

human incidentally
• Typically larvae of the animal (cat or dog)
hookworm
- Ancylostoma braziliense
- A. caninum

A. caninum

Eggs in faeces &
hatch in the soil.
Contaminated soil
is typically found
in (sub)tropical
climates.

In human
• filariform larvae penetrate the skin &
migrate between the stratum germinativum
& stratum corneum.
• after 4,5 Several days, severely itchy
cutaneous lesions appear.
• Typically presents as a creeping eruption
with an erythematous linear or serpiginous
tract with extreme pruritis.
• In other cases, many larvae may penetrate
the skin simultaneously & cause multiple
itchy follicular papules and pustules,
filariform larvae (4-5 days)
↓
(penetrate the skin)
↓
migrate between the stratum germinativum & stratum corneum.
↓
4-5 days)
severely itchy cutaneous lesions
creeping eruption
( erythematous linear or serpiginous tract with extreme pruritis)
In other cases, many larvae may penetrate the skin simultaneously &
cause multiple itchy follicular papules and pustules,

Clinical finding
• Persistent itching folliculitis in a patient who has
recently returned from tropic.
• Histological confirmation is required to make a
definite diagnosis of a hookworm folliculitis in the
absence of the characteristic
• 2-3 days the migratory larvae produce an
intracutaneous tunnel
= creeping eruption
• Treatment should be started based on typical
clinical findings

Creeping eruption “ tunnel”
• narrow, linear, slightly elevated, erythematous,
serpiginous,
• diameter 1-2 mm
• move from a fraction an inch per day but rarely
pass beyond a few inches from the entry
• vesicles form along the tunnels
• The surface is dry and crust
• The itching is intense especially at night
• the scratching may lead secondary infection
• may persist for weeks

Creeping eruption

Creeping eruption
Creeping eruption

• Self-limiting
• But, many infested patients require
treatment to reduce the often debilitating
symptoms,& to prevent or treat
superinfection.
• Treatment :
- local application of thiabendazole
- systemic therapy : albendazole or ivermectin

An itchy holiday
• A 33-year-old woman from the Netherlands
developed an itchy rash on her trunk and upper
legs during her stay in Thailand
• On the first day of her holiday she had been lying
on a sandy beach without a towel.
• Not recall any insect bites or stings.
• Developed an increasing number of small
papules of ± 3mm in which changed colour from
bluish to red and became increasingly itchy.
• No medical or dermatological history & not taking
any medications.
• Her partner was unaffected.

Local GP:
• amoxicillin/ clavulanic acid
• H1-receptor blocker
• No effect.
Netherland GP (4 week later

because of persisting itchy
abdominal and submammary
erythematous papules,with
purpuric lesions:
• Suspected scabies
• Treated her with lindane
• No success.

Netherlands dermatologist
• Lab: leucocyte count :15.2 x 109/l (4.3-10.0), eosinophils
44% (0-5%), Hb 8.3 mmol/l (7.5-10.0), aspartate
transaminase 43 IU/l (<31 IU/l), alanine aminotransferase
(<31 IU/l) and IgE titre 169 kU/l (<100 kU/l).
• Stool : No parasite Skin biopsy:
• eosinophilic infiltrates, no microorganisms.
• The follicular canal did not seem to be affected.
• Interpreted: eosinophilic invasion of the skin as the
consequence of a hookworm infection
• Treated with mebendazole.
• 3-4 week later skin lesions had not improved
• She complained severe itching

Department of infectious diseases
(3 months after onset)
• Physical examination: pink to red papular and
pustular lesions, mainly localised in the pubic
region, trunk and breasts.
• No creeping dermatitis within these cutaneous
lesions.
• Stool test: did not show hookworm.
• Suspected of hookworm folliculitis and
• Treated with albendazole 1000 mg/day for 5
days.
• The pruritic lesions disappeared within 2 weeks.

Toxocara sp

Toxocariasis
• Caused by larvae of Toxocara canis (dog roundworm) &
less frequently of T. cati (cat roundworm)
• Humans are accidental hosts
• Human are infected by ingesting infective eggs in
contaminated soil
• Usually occurs in children
• Only the larval stages occur in the tissues
• The adult worm does not mature in the intestine
• The lesions mostly in liver, brain & lungs.
• Clinical presentations are visceral larva migrans (VLM) &
ocular larva migrans (OLM)*.

• After ingestion, the eggs
hatch
• larvae penetrate the
intestinal wall
• carried by the circulation to
a wide variety of tissues
(liver, heart, lungs, brain,
muscle, eyes).
• the larvae do not undergo
any further development in
these sites
• but they can cause severe
local reactions that are the
basis of toxocariasis.
Ascarid granuloma caused by Toxocara
Ascarid granuloma in the liver
Second stage larva of Toxocara canis in liver
Clinical Features
Mostly asymptomatic
Only eosinophilia and positive serology
VLM:
• larvae invade multiple tissues (liver, heart, lungs, brain, muscle)
• cause various symptoms including fever, anorexia, weight loss,
cough, wheezing, rashes, hepatosplenomegaly, and
hypereosinophilia.
• Death can occur rarely, by severe cardiac, pulmonary or neurologic
involvement.
OLM:
• larvae produce various ophthalmologic lesions
• in some cases have been misdiagnosed as retinoblastoma, resulting
in surgical enucleation.
• often occurs in older children or young adults, with only rare
eosinophilia or visceral manifestations.

Laboratory Diagnosis
• Does not rest on identification of the parasite.
• Stool examination would not detect any eggs.
• For both VLM and OLM, a presumptive
diagnosis rests on clinical signs, history of
exposure to puppies, laboratory findings
(including eosinophilia), and the detection of
antibodies to Toxocara.

Microscopy
Cross-section of Toxocara sp. Longitudinal section of a Toxocara sp.

larvae in liver tissue stained with larva in liver tissue stained with H & E.
hematoxylin and eosin

Treatment:
• Antiparasitic drugs in
combination with anti
inflammatory medications.
• Albendazole or mebendazole
Longitudinal section of a Toxocara sp.

Larva in lung tissue stained with H & E.

Capillaria hepatica

Capillaria hepatica
• Parasite of rodents, dogs, and monkeys
• Man is an incidental host
• Infected if eat raw meat of of rodents, dogs, and
monkeys

Life cycle
In a host the ova are deposited in the liver

fully embryonated within 30 days

a new host eats infected liver

the ova hatch in the intestine

the larvae after piercing the intestinal wall migrate to
the liver

become mature in 4 weeks

Pathogenicity
• the accumulations of ova cause an
inflammatory reaction in the liver with the
production of fibrous connective tissue
• in heavy infections extensive tissue
destruction & hepatic cirrhosis
Diagnosis
• microscopic examination of the liver at
post mortem
Fasciola hepatica

Fasciola hepatica
• Classified as trematodes
• The sheep liver fluke
• Parasite of herbivores that
can infect humans
accidentally
• Size F hepatica : up to 30 x
13 mm
• Reside in the large biliary
ducts of the mammalian
host.
• Worldwide distribution

• wet mounts with iodine
• ellipsoidal • distinct operculum in
• size 120-150 x 63 to 90 µm. upper end of the
• have a small, barely distinct eggs in A and B).
operculum
• have a thin shell which is slightly • The operculum can
thicker at the abopercular end. be opened (egg C),
• passed unembryonated.

4 months
genus Lymnae

Clinical Features
• Acute phase
– caused by the migration of the immature fluke through
the hepatic parenchyma
– abdominal pain, hepatomegaly, fever, vomiting,
diarrhea, urticaria & eosinophilia
– can last for months.
• Chronic phase
– caused by the adult fluke within the bile ducts
– symptoms are more discrete and reflect intermittent
biliary obstruction and inflammation.
• Occasionally
– ectopic locations of infection (such as intestinal wall,
lungs, subcutaneous tissue, and pharyngeal mucosa)
can occur.
Laboratory Diagnosis
• Eggs: in the stools or in material obtained by
duodenal or biliary drainage.
• False fascioliasis (pseudofascioliasis) refers to
the presence of eggs in the stool resulting not
from an actual infection but from recent ingestion
of infected livers containing eggs can be
avoided by having the patient follow a liver-free
diet several days before a repeat stool
examination.
• Antibody detection tests are useful especially in
the early invasive stages,.

Tropis 2019 Tissue Helminth

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DURING

5/17/2019 S. Wahyuni/lecture/tissue helminth 1

Sitti Wahyuni, MD, PhD

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Tropical pulmonary eosinophilia (TPE)

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• The blood is obtained by pricking the

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• Treat the infection person

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• Standard : 12-14 day course of 6 mg/kg BW

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• Female: 1 to 2 cm long thinner & longer than male

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Infective stage of Schistosome

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• Micro-haematuria & leukocyturi: useful indicators

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• Urine examination (S. haematobium)

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• Treatment failures have occured &

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• based on clinical symptoms and

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• Begin as soon as possible

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• A condition where animal hookworm infect

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