Blok 10

Nematoda Intestinal
Dr.rer.biol.hum. dr. Erma Sulistyaningsih, M.Si
Department of Parasitology
Faculty of Medicine, University of Jember
Helminths

Aschelminthes
1. Nematoda (round worm)

Platyhelminthes (Flatworms)
2. Cestoda (tape worm)
3. Trematoda (flat worm = fluke)
Nematoda (roundworm)

General characteristic:
- Cylindrical and unsegmented
- The size is range from a few mm to > 1 m in length.
- Dioecious: Both male and female representatives exist. Male < female in
size. Functional sexual organs are present.
- Body development is rather complex: cuticle, a complex nerve cord,
well-developed digestive system (mouth, oesophagus, intestine, anus).
- Three ways of adult female infections:
- Ingestion of eggs
- Skin penetration of eggs or larvae
- Insect vectors transmission of eggs or larvae
Nematoda (roundworm)
• Intestinal
• Ascaris lumbricoides
• Enterobius vermicularis (Pinworm)
• Trichuris trichiura (Whipworm)
• Ancylostoma duodenale (Hookworm)
• Necator americanus (Hookworm)
• Strongyloides stercoralis
• Blood and tissues
• Trichinella spiralis
• Wuchereria bancrofti
• Dracunculus medinensis
• Brugia spp
• Loa loa
• Oncocerca volvulus
• Mansonella spp
 Intestinal nematodes
Adult worms in the
the intestine
Larvae pass
through lungs
trichuris
enterobius

Larvae enter Eggs

bloodstream Eggs ingested
ascaris

strongyloides
hookworm Larvae hatch
Larvae penetrate
from eggs
through intact skin
 1. Ascaris lumbricoides

Female Male
• Most common helminth
with over a billion infested a
year.
• Prevalent in areas where
sanitation is poor and
human waste is used as
fertilizer.
• Large: 25-45 cm in length.
• Infection occurs when
parasite eggs are eaten with
uncooked food or when
soiled fingers are put into
the mouth.
Morphology

• Adults - males are 15 to 30 cm long,

with strongly curved tails; females are 20
to 35 cm long, with straight tails.
• Eggs - one female produces 200,000
per day. The egg has an outer shell
membrane which is heavily mamillated.
This layer is sometimes rubbed off in
passage down the fecal stream. Infertile
eggs often appear longer, and thinner
shelled.
Life Cycle
 Pathogenesis
There are two phase in ascariasis:
1. The blood-lung migration phase of the larvae:
The larvae may cause a pneumonia (low fever, cough, blood-tinged sputum,
asthma).
Large numbers of worms may give rise to allergic symptoms. Eosionophilia is
generally present.
These clinical manifestation: Loeffler’s syndrome.
2. The intestinal phase of the adults.
The presence of a few adult worms in the small intestine lumen: no
symptoms, vague abdominal pains or intermittent colic, especially in children.
A heavy worm burden can result in malnutrition.
Wandering adults may block the appendical lumen or the common bile duct
and even perforate the intestinal wall.
Complications of ascariasis, such as intestinal obstruction, appendicitis,
biliary ascariasis, perforation of the intestine, cholecystitis, pancreatitis and
peritonitis, etc., may occur.
Signs and Symptoms
Major pathology and symptoms:
• Pneumonia associated with
migration of larvae in the lungs.
• Obstruction of the intestines,
appendix, or common bile duct.
• Vomiting and abdominal pain.
• May cause malnutrition in children
with heavy infections or poor diet.
• Some infections are
asymptomatic.
 Diagnosis
The symptoms and signs are for reference only.
The confirmative diagnosis depends on the recovery and
identification of the worm or its egg.
1. Ascaris pneumonitis: examination of sputum for Ascaris larvae is
sometimes successful.
2. Intestinal ascariasis: feces are examined for the ascaris eggs.
• direct fecal film: is the first choice, simple and effective. The
eggs are easily found using this way due to a large number of
the female oviposition, approximately 240,000 eggs per worm
per day.
• brine-floatation method:
• recovery of adult worms: when adults or adolescents are found
in feces or vomit and tissues and organs from the human
infected with ascarids , the diagnosis may be defined.
Prevention and Treatment
• Pirantel pamoat 10 mg/kgBB dosis tunggal
• Mebendazole 500 mg dosis tungga atau 100 mg 2x/hari selama hari
berturut-turut
• Albendazole 400 mg dosis tunggal (sekali saja), tetapi tidak boleh
digunakan selama hamil.
• Levamizole are effective.
• Sanitary disposal of feces.
• Hygienic habits (mencuci tangan sebelum makan, makan sayuran yang
dicuci bersih/dimasak).
• Health education.
• Pengobatan masal 6 bulan sekali di daerah endemik atau di daerah yang
rawan askariasis.
2. Enterobius vermicularis (Pinworm)

• Cosmopolitan, 30%~50% of the population, more

prevalent in children than adults. Most common where
people live under crowded conditions (large families /
kindergartens / primary school).
• Human is the only host.
• No intermediate host (direct life cycle)
• No larval migration between organs.
 Morphology
Adult
Female: White. 8~13 mm in
size. Fusiform body with a long,
thin, tapering tail. Alae
(cuticular extension of head).
Prominent bulb (esophagus
posterior).
Male: Like female, but about
1/3 to ½ size of female. The
tail is curved. Rarely seen.
Egg
Oval, clear and colorless. 50
to 60 µm in length. Flattened
on one side. Contains a larva.
 Life cycle

molt molt 3 times

Adults Newly laid Infective Larvae Adults
eggs 6h eggs
 The types of infection
• Infection from environment.
• Autoinfection: Female crawl out of anus and release eggs
on the perianal region. Patients feel anus pruritus.
Scratching leads to contamination of hands and nails.
Then by hand-mouth result in reinfection.
• Retroinfection: Some eggs hatch on the perianal skin and
become larvae. They will crawl back into the anus and
mature into adults.
 Clinical manifestation
• Frequently asymptomatic.
• Typical symptom: perianal pruritus (itching and irritation), especially at
night, which may lead to excoriations and bacterial superinfection.
• Occasionally: invasion of the female genital tract with vulvovaginitis and
pelvic or peritoneal granulomas can occur.
• Other symptoms : anorexia, irritability, and abdominal pain, restlessness,
sleeplessness, weigh loss, grinding of teeth, nervousness, and vomiting.

Laboratory diagnosis
• Cellophane (Graham Scotch) tape method or Anal swabs:
microscopic identification of eggs collected in the perianal area,
for diagnosing enterobiasis. This must be done in the morning,
before defecation and washing,
• Detection of adult on anal skin.
Larvae of Enterobius vermicularis on perianal fold
Treatment and prevention

• Pyrantel pamoate pirantel pamoat 10 mg/kgBB dosis tunggal diulang

2 minggu kemudian.
• Mebendazole 100 mg dosis tunggal diulang 2 minggu kemudian.
• Albendazole 400 mg dosis tunggal diulang 2 minggu kemudian.
• Repeated treatment may be necessary for a radical cure
• Pay attention to personal hygiene and eating habits
• Sanitary disposal of clothing, bed linen, and environment
• Health education
 3. Trichuris trichiura (Whipworm)
Manusia merupakan host utama.
Habitat: caecum, colorektum
No extra-intestinal phase
Morfologi:
jantan
• Dewasa: seperti cambuk dengan 2/5 bagian posterior
tubuhnya tebal dan 3/5 bagian anterior lebih kecil
• Cacing jantan memiliki ukuran lebih pendek (3-4cm)
daripada betina dengan ujung posterior yang
melengkung ke ventral.
• Cacing betina memiliki ukuran 4-5 cm dengan ujung
posterior yang membulat. Memiliki bentuk betina
oesophagus yang khas (Schistosoma oesophagus).
• Telur berukuran 30-54 x 23 mikron dengan bentukan
yang khas lonjong seperti tong (barrel shape) dengan
dua mucoid plug pada kedua ujung yang berwarna
transparan
Epidemiologi

• Frekuensinya di Indonesia tinggi, terutama di

daerah pedesaan, 30%-90%.
• Angka infeksi tertinggi ditemukan pada anak–anak.
• Faktor terpenting dalam penyebaran trikuriasis
adalah kontaminasi tanah dengan tinja yang
mengandung telur.
Life cycle Trichuris trichiura
Symptoms

• 90% infections are asymptomatic.

• Symptoms in heavy infection:
Physical Weakness, Anemia
• Stunted Growth, Cognitive Deficits
• Stool frequency (12+/day), nocturnal stooling
Trichuris dysentery syndrome (bloody diarrhea)
• Trichuris colitis
• Rectal prolapse
Diagnosis

• Diagnosis ditegakkan dengan menemukan telur

cacing di dalam tinja.
Pengobatan dan Pencegahan

• Mebendazol 100 mg 2 x sehari selama tiga hari berturut-turut atau

dosis tunggal 500 mg
• albendazol 400 mg 3 hari berturut-turut. Tidak boleh digunakan
selam kehamilan.
• Pencegahan trikuriasis = ascariasis
• buang air besar di jamban
• mencuci dengan baik sayuran yang dimakan mentah (lalapan)
• Pendidikan tentang sanitasi dan
• kebersihan perorangan seperti mencuci tangan sebelum makan.
 4. Hookworm
Necator americanus - The New World hookworm
Ancylostoma duodenale - The Old World hookworm

• Hookworms are named for the dorsal curve in their anterior end.

• Hookworms are quite small, Necator americanus is only 11mm long.

• However, because they feed on blood a heavy infection can produce
severe anemia.

http://www.virginmedia.com/images/hookworm.jpg
Global Distribution
Morphology
• Rhabditiform larvae - long buccal cavity,
indistinct genital primordium.
• Filariform larvae - lose oral structures &
have sharp pointed tails.
• Adults
Hookworm rhabditiform larva
• males: 7 to 11 mm long with a copulatory
bursa;
• females: 8 to 15 mm long.
• Eggs - 55 to 70 x 35 to 40 microns; very
Hookworm filariform larva
thin shell; usually seen in the 8 - 32 stage
of cleavage.

Hookworm egg
N. americanus and A. duodenale
• Female: 9-11 mm x 0.4 mm
• Male: 7-9 mm x 0.3 mm
• 9000 eggs/day, eggs have 3-5 years
survival
• Smaller than A. duodenale
• Buccal capsule set with two
crescent-shaped cutting plates on
ventral side
• Ingests 30 µl blood/day
• Female: 10-13 mm x 0.6 mm
• Male: 8-11 mm x 0.4 mm
• 20,000 eggs/day, eggs have 1 year
survival
• Posterior end has an umbrella-
shaped bursa with riblike rays
• Buccal capsule set with symmetric
pair/two pirs of sharp teeth/curved
teeth on ventral side.
• Ingests 260 µl blood/day
Life cycle
 Pathology
• Infection occurs after a larva hatches from an egg and penetrates
the skin of a person.
• It makes its way to the lungs, coughed up and swallowed and
travels to the intestines.
• Hookworms do not permanently attach in one spot, but move
around the gut and reattach when they are ready to feed.
• Hookworms have evolved sophisticated anti-clotting factors that
keep platelets from clumping and forming a clot while the
hookworm is feeding …. When it releases, a clot forms and the
tissue can recover……. hookworms prevent hemophilia developing
in their hosts, which would be fatal for the hookworm.
Major pathology and symptoms
• Skin Infection : Serpent-like tunneling at site of
penetration may occur (cutaneous larva migrans);
stinging, burning, itching, pruritus, papulovesicular rash
- can last up to 2 weeks
• Lung Infection: pneumonia, a sore throat and / or bloody
sputum.
• Ingestion: throat soreness, hoarseness, nausea,
vomiting
• Heavy intestinal infections: enteritis, anemia, weakness,
and loss of strength due to the anemia.
• Chronic infections anemia, weakness, weight loss and
gastro-intestinal symptoms.
• Nutritional and disease factors are commonly seen in
endemic areas. Children may exhibit stunted growth and
intellectual development.
• Blood loss can be up to 100 milliliters/day.
Associated Morbidities

• Anemia, iron deficiency.

• Hypoproteinemia, edema.
• Mental, physical, growth retardation.
• Immunocompromised.

• Complicates malaria, HIV, etc.

Diagnosis
• Recovery and identification of eggs
(rarely larvae) in the feces.
• Cannot differentiate Hookworm
species by egg appearance.
• To determine if a significant infection:
count the number of eggs on a direct
smear of the unconcentrated
specimen.
• 5 eggs per smear indicates a light infection
• 20 or more eggs is clinically significant;
• 100 or more is indicative of a very heavy
infection.
Treatment and Prevention

• Pirantel pamoat 10 mg/kg BB per hari selama 3 hari

• Mebedazole 500 mg dosis tunggal atau 100 mg 2 x sehari selama
3 hari berturut-turut
• Albendazole 400 mg dosis tunggal, tetapi tidak boleh digunakan
selama hamil.
• Sulfas ferosus 3 x 1 tablet untuk orang dewasa atau 10 mg/kg
BB/kali (untuk anak) untuk mengatasi anemia
• Sanitary disposal of night soil.
• Individual protection (penggunaan alas kaki)
• Health education
5. Strongyloides stercoralis (Threadworm)
Morphology:
• Rhabditiform larvae – 220 x 15 um, short buccal cavity; large,
prominent genital primordium. Diagnostic stage
• Filariform larvae – 600 x 20 um, tail has a notch in it, in contrast with
the filariform larva of hookworms. Infective stage
• Must be able to differentiate these from hookworm larvae.
• Eggs hatch in the intestine (not usually passed in stool
specimens). Eggs resemble hookworm eggs, but are
embryonated.

Buccal cavity of rhabditiform larva Notch in tail of filariform larva

Life cycle
 Life cycle
Very complex:
• Infective third stage filariform larvae penetrate skin,
enter the lymphatics or bloodstream.
• Larvae migrate to the lungs, break out of lung capillaries
into alveoli.
• After maturation, larvae travel to the pharynx, are
swallowed, and return to the intestine.
• Larvae mature to adults and attach to the mucosa of the
small intestine.
Strongyloides stercoralis rhabditiform larva
• Parthenogenetic reproduction: Females only - no
parasitic males. Females are capable of unisexual
reproduction, no fertilization required. Produce viable
eggs.
• Eggs hatch in mucosa.
• Larvae: Are passed in feces, live in the soil, mature into a
free-living adult males and females, which produce
eggs; Rhabditiform larvae feed in soil and develop into
infective stage larvae which penetrate the skin; First
stage larvae develop into infective stage larvae in the
Strongyloides stercoralis filariform larva
intestine (autoinfection).
Diagnosis

Diagnosis:
• Recovery and identification
of larvae in the feces.
• Recovery and identification
of eggs in duodenal
drainage.
Major pathology and symptoms
• Skin – allergic reactions; raised, itchy, red blotches at the site of
larval penetration.
• Lungs – pneumonia.
• Intestinal - abdominal pain, diarrhea, vomiting, weight loss, anemia,
eosinophilia. Light infections usually asymptomatic; Heavy infection
- bowel becomes edematous and congested.
• Death occurs in immunosuppressed patients due to heavy
autoinfection.
 D i a g n os i s

• Direct stool smears (larvae)

• Cultivation of stool. (Damp charcoal or Harada-Mori mediums).

• Histological examination of duodenal or jejunal biopsy

specimens obtained by endoscopy can demonstrate adult worms
embedded in the mucosa.

• Eosinophilia, is present in uncomplicated strongyloidiasis, but is

lost in hyper infection

• For population screening in endemic areas, an ELISA for IgG anti-

Strongyloides antibodies is effective.
 Treatment and Control

Strongyloidiasis is treated with:

ž Ivermectin.
žThiabendazole.
ž No public health strategies for controlling are active at
global level

Control:
• Good sanitation with specific care of human waste disposal.
• Mass treatment of Ivermectin drugs shows some progress but
needs further research.
• Setting global health plan.
• Wearing permanent shoes.
• Education Program for community.
Hookworm vs Strongyloides

• While hookworm infection dies out over a period of years after

the patient has moved from an endemic area, strongyloidiasis
may persist for years, due to autoinfection (internal infection).
• In cases with severe diarrhea, Strongyloides eggs may be
present in stool specimens. Strongyloides eggs contain well-
developed larvae. Hookworm eggs do not have well developed
larvae until passed from the body and mature for one to two
weeks in the soil.
Terima kasih atas perhatiannya ……

Semoga bermanfaat!!!