MEDICAL PARASITOLOGY

PHASMID 2
DR. De Castro / Quiaoit
OLFU • FUMC ½ COLLEGE OF MEDICINE
Ref: Medical Parasitology in the Philippines by: Belizario

• Larva ® similar in all hookworms

HOOKWORMS: o Rhabditiform (L1)
• Necator americanus ® human hookworm § Feeding larva
• Ancylostoma duodenale ® human hookworm § Short and stout
§ Cutaneous larva migrans ® animal hookworm § Directly hatches from egg
o Ancylostoma brasiliense § From CDC…
o Ancylostoma caninum – Rhabditiform (L1) ® hatch from eggs is 250-
o Ancylostoma ceylanicum 300um long and 15-20um wide
THREADWORM: – Long buccal canal and an inconspicuous
• Stronglyloides stercoralis genital primordium
– May or not be found in stool due to delayed
HOOKWORM processing the stool specimen ® if larva is
• Hookworms seen in stool, the must be differentiated from
o Misnomer (no hooks) L1 larva of Stronglyoides stercoralis
o Provided with “plates or teeth” o Filariform (L3)
o 2 genera § Infective larva
§ Necator sp. ® New world (70-80% infection) § Thin and long
– N. americanus § Adult form
§ Ancylostoma ® Old World (20-30% Infections) § From CDC…
– A. duodenale – Infective stage (L3), 500-700um long
– A. brasiliense ® cats – Pointed tail are escheated (1:2 ration in
– A. caninum ® dog length of esophagus to intestine)
– A. ceylanicum ® hamster – Subtle morphological differences exist
o Similar in all hookworms (Egg and Worm) of Necator and between Ancylostoma and Necator at this
Ancylostoma spp. stage
• Egg – L3 larva found in the environment and infect
o The egg of Ancylostoma and Necator cannot be the human host by penetration of the skin
differentiated microscopically ® CDC
o Similar in all hookworms Rhabditiform larva
o Characteristics:
§ Thin-shelled (hyaline membrane)
§ Ovoid / elliptical ® 60-75x35-40 um [not round]
§ Colorless ® not bile stained
o When released by worm in the intestine ® eggs contain an
unsegmented ovum at oviposition
o During passage down in the intestine, the ovum develops
® passed in feces ® the egg contains a segmented ovum
with 4-8 blastomeres
o Single female worm lays about 25,000 to 30,000 eggs in a
day and some 28 to 54 million its life time Filariform larva

• Note: CDC
§ Pointed and unsheathed at
the posterior end of the tail

Note:
• Larva, Eggs and Life Cycle are similar to all hookworm sa
morphology lang ng adult worm lang sila magkakaiba because
of the present of plates and teeth and sizes 😉✌👍
• N. americanus & A. duodenale ® infect only human
• A. brasiliense, A. caninum, A. ceylanicum ® infects animals
§ Able to produce Cutaneous Larva Migrans

1 of 6

• Life cycle: CDC
o Eggs are passed in the stool (1), and under favorable
conditions (moisture, warmth, shade), larvae hatch in 1 to
2 days and become free-living in contaminated soil
o These released rhabditiform larvae grow in the feces and/or
the soil (2), and after 5 to 10 days (and two molts) they
become filariform (third-stage) larvae that are infective (3)
o These infective larvae can survive 3 to 4 weeks in favorable
environmental conditions. On contact with the human host,
typically bare feet, the larvae penetrate the skin and are
carried through the blood vessels to the heart and then to
the lungs. They penetrate into the pulmonary alveoli,
ascend the bronchial tree to the pharynx, and are
swallowed (4)
o The larvae reach the jejunum of the small intestine, where
they reside and mature into adults. Adult worms live in the
lumen of the small intestine, typically the distal jejunum,
where they attach to the intestinal wall with resultant blood
loss by the host (5)
o Most adult worms are eliminated in 1 to 2 years, but the
longevity may reach several years
Note: CDC
• Some A. duodenale larvae, following penetration of the host
skin, can become dormant (hypobiosis in the intestine or
muscle). These larvae are capable of re-activating and
establishing patent, intestinal infections. In addition, infection
by A. duodenale may probably also occur by the oral and the
transmammary route
• A. ceylanicum and A. caninum infections may also be acquired
by oral ingestion
• A. caninum-associated eosinophilic enteritis is believed to result
following oral ingestion of larvae, not percutaneous infection
• N. americanus does not appear to be infective via the oral or
transmammary route
Eggs (stool)
¯ route (eating raw vegetables containing infective
Soil (humid)
[eggs deposited in stool and only survive in
humid soil egg hatched 3 to 4 weeks]
¯
Rhabditiform larva (L1)
[baby larva, feeding larva, not infective,
short and stout
shed 2x]
¯
2x molting stage (L2)
[this correspond to the development of (L3)]
MEDICAL PARASITOLOGY
PHASMIDS 2
¯
Filariform larva (L3)
[longer, elongated, thin and long and pointed end]
¯
Skin penetration (man) ® common area in foot
[this now the MOT]
Note: In human hookworm
• Skin penetration
§ Erythema, itchiness, pinpoint lesion
• Vascular / lymphatic penetration
§ General circulation (asymptomatic)
§ Blood vessel is more commonly penetrated than
lymphatic system ® therefore filariform is commonly
found in blood vessel than lymphatic system
• Pulmonary circulation (alveolar capillaries)
§ N. americanus ® dyspnea, dry cough, chest pain, back
pain (because, N. americanus infects human 70-80%)
§ When N. americanus reaches the alveolar capillaries ®
it clogs and alveolar will rupture ® release of larva ®
mix with secretion ® goes to larynx ® to pharynx ®
swallowed ® blood-streaked sputum (hemoptysis)
• GIT (small intestine)
§ Mucosal layer (maturation, differentiation,
reproduction) ® erosion, ulceration, hemorrhage
® abdominal pain, nauseam diarrhea)
NECATOR AMERICANUS
• “New World” hookworms
• Buccal capsule ® ventral pair of semilunar cutting plates
• Blood-sucking intestinal nematodes and infects human
• They attach to the mucosa of the small intestine
• Found in subtropical and tropical country were single or mixed
infections
• Most common infection 70 to 80%
Parasite Biology
• Small, cylindrical, fusiform, grayish-white
• Female (9-11mm) are larger than males (5-9mm)
• Head is curved opposite to the body
• Buccal capsule – ventral (1) pair of semilunar cutting plates
• Posterior end of the male has a broad caudal bursa with rib-like
rays for copulation
• Only hookworm with buccal plates
• MOT: ® skin
§ Necator – percutaneous
§ Ancylostoma – percutaneous and through the oral
larvae
2 of 6
 MEDICAL PARASITOLOGY
PHASMIDS 2
posterior 3rd of the
body

Adult Worms Ancylostoma spp. Necator spp.

Size Larger and thicker Small and slender
Shape Head bent in Sam direction Head bend in opposite
as body direction
Buccal 4 ventral teeth and 2 2 ventral and 2 dorsal
capsule dorsal knob like teeth chitinous cutting plates
Copulatory 13 rays, 2 separate 14 rays, 2 spicules fused
bursa spicules, dorsal ray single at the tip, dorsal ray split
Caudal spina Present Absent
inf female
Vulval Situated behind the Situated in anterior to
opening middle of the body middle part of the body
Pathogenicity More Comparatively less

Eggs Ancylostoma spp. Necator spp.

ANCYLOSTOMA DUODENALE 1st and 2nd Similar Similar
• “old world” hook worm stage larva
• Buccal teeth – 2 curved ventral teeth Egg/day 15,000 – 20,000 6,000 – 11,000
• Infects human as its definitive host Rate of Faster Slower
development
Pulmonary More common Less common
reaction
Blood 0.2ml/day 0.03 ml/day
loss/worm
Iron loss 0.76 mg 0.45mg
(mg/day)
Male : 1:1 1.5:1
Female ratio
Life span 2-7 years 4-20 years
Parasite Biology
• Slightly larger than Necator
Copulatory Bursa Of Male Species
• Head continuous and the same direction as the curvature of the
Necator spp. Ancylostoma spp.
body
Bursa: long than broad Bursa: broad than long
• Buccal teeth – 2 pairs of curved ventral teeth
Copulatory: fused Copulatory: separated
Dorsal ray: bipartite Dorsal ray: tripartite

Differential Features of Filariform Larva (L3 stage)

Ancylostoma spp. Necator spp.
Ancylostoma duodenale worm Size 720um 650um
Male Female Head Slightly conical Rounded
Size Smaller (8-11mm in length) Larger (10-12mm) Buccal cavity Short, lumen larger Larger, lumen shorter
Copulation Present Absent Sheath Faint cuticular striations Prominent striation
Genital Open in cloaca along with anus Pons at the junction of
opening the middle and

3 of 6
 MEDICAL PARASITOLOGY
PHASMIDS 2
Intestine No gap between With gap in present
esophagus and intestine between esophagus and
intestine
Posterior end Small retractile body in No retractile body
on intestine present
Esophagus Not prominent Prominent
spears
Tail Long and blunt Short and pointed
Note:
Buccal Cavity of Hookworms • N. americanus – 0.15 to 0.25 mL/day/parasite
Necator americanus Buccal plates • A. duodenalis – 0.30 to 0.50 mL/day/parasite
Ancylostoma spp Buccal teeth
A. duodenale 2 even pairs
A. brazilienze 2 uneven pairs
A. ceylanicum 2 pairs in pile
A. caninum 3 pairs

Hookworm Larva
Rhabditiform larva
ü Larva is rhabditoid in shape,
shorter and thicker
ü Open buccal cavity is long
but narrow
ü With rhabditoid or bulbous
esophagus
ü Genital primordium, the
group of cells at the
posterior 3rd of the larva and
compressing the gut
inconspicuous
Filariform larva
ü Longer and slender with
pointed posterior end
ü Mouth is closed and filariform
type of esophagus is about
25% of the body length
ü Larva is enclosed in a tight-
fitting sheath Diagnosis
• Direct fecal smear
§ Will not detect if <400 eggs/gram of feces
• Kato thick or Kato-Katz method
§ Rapid clearance of eggs after 30 to 60 minutes after
glycerin
• Concentrated methods:
§ Zinc sulfate centrifugal flotations
§ Formalin ether or Ethyl acetate concentration method
• Harada Mori
§ Culture method
§ For specie identification

• Filariform larva (L3) ® differentiates the species of hookworm

Pathogenesis and Clinical Manifestation

• Systemic
o Iron deficiency Anemia ® Microcytic, Hypochromic
Anemia (systemic)
o Dyspnea, Loss of appetite, Easy fatigability Treatment
• Intestinal • Albendazole
o Sucking of blood § Larvicidal and ovicidal
o N. americanus – 0.15 to 0.25 mL/day/parasite § 400mg single dose for adult and children below 2 y/o
o A. duodenalis – 0.30 to 0.50 mL/day/parasite • Mebendazole – 500mg ® drug of choice
• Hypoalbuminemia ® due to combined loss of blood, lymph and • Pyrantel Pamoate ® alternative drug
protein • Iron supplement
• Bacterial infection ® underlying pathology of hookworm • Adequate diet
• Bronchitis and Pneumonitis
§ Due to larval migration Prevention and Control
• Small intestine • Regular mass drug administration in school
§ Abdominal pain, steatorrhea, diarrhea with blood and • Water, Sanitation, Hygiene and Education “WaSHEd” approach
mucus with eosinophilia
• “ground itch” or “dew itch” Note: CUTANEROUS LARVA MIGRANS ® animal hookworm
§ Skin at the site of entry of the filariform larva • Caused by:
§ Maculopapular lesions and localized erythema § A. brasiliense
§ A. caninum
§ A. ceylanicum
• Pathology:
§ Skin lesion (map-like erythematous, itchy, pin-
point) penetrate skin up to Dermis

4 of 6
 MEDICAL PARASITOLOGY
PHASMIDS 2
• Life cycle:
§ Filariform larva only
• Treatment:
§ Thiabendazole

THREADWORM
• Similarities with hookworm: 📢📢📢
Life stages • Egg, larva, adult
Forms of larva • Rhabditiform, filariform
Infective stage • Filariform larva (L3)
Mode of transmission • Skin penetration • Filariform larva
Habitat • Small intestine o Infective stage
o Non-feeding, slender
• Differences with Hookworms: 📢📢📢 • Strongyloides Eggs:
Buccal cavity • No teeth, no plates o Clear thin shell and similar to hookworm eggs but
Life cycle • 4x mothing smaller
• Pulmonary circulation • Life cycle: CDC
• Exhibit auto-reinfection o The Strongyloides stercoralis life cycle is complex,
alternating between free-living and parasitic cycles and
• Manifests hyper infection
involving autoinfection
Diagnostic stages • Egg + Rhabditiform (L1)
o In the free-living cycle: Rhabditiform larvae are passed
Population affected • Adult; institutionalized in the stool of an infected definitive host (1), develop
into either infective filariform larvae (direct
STRONGLYLOIDES STERCORALIS development) (6) or free-living adult males and
• Rhabditid nematode (Threadworm/Roundworm) females (2) that mate and produce eggs (3), from which
• Major causative agent for human strongyloidiasis rhabditiform larvae hatch (4) and eventually become
• Host ® human infective filariform (L3) larvae (5) . The filariform larvae
• Characterized by free-living rhabditiform and parasitic filariform penetrate the human host skin to initiate the parasitic
stages cycle (see below) (6). This second generation of
• No teeth or plates filariform larvae cannot mature into free-living adults
• With autoinfection (life cycle) and must find a new host to continue the life cycle.
• Relatively rare in the Philippines o Parasitic cycle: Filariform larvae in contaminated soil
• 1.2% out of 4,208 stools examined using Hara-Mori culture penetrate human skin when skin contacts soil (6), and
migrate to the small intestine (7). It has been thought
Parasite Biology that the L3 larvae migrate via the bloodstream and
• Filariform / Parasitic female lymphatics to the lungs, where they are eventually
§ 2.2mm, colorless, semi-transparent, with finely striated coughed up and swallowed. However, L3 larvae appear
cuticle capable of migrating to the intestine via alternate routes
§ Short buccal cavity with 4 indistinct lips (e.g. through abdominal viscera or connective tissue). In
§ Long and slender esophagus the small intestine, the larvae molt twice and become
§ Produce eggs by Parthenogenesis ® able to produce adult female worms (8) . The females live embedded in
without partner 😳😳😳 the submucosa of the small intestine and produce eggs
• Free-living female via parthenogenesis (parasitic males do not exist) (9) ,
§ 1mm which yield rhabditiform larvae. The rhabditiform larvae
§ Muscular and double-bulbed esophagus can either be passed in the stool (1) (see “Free-living
• Free-living male cycle” above), or can cause autoinfection (10)
§ 0.7mm
§ 2 copulatory spicules, but no caudal alae
• Parasitic male
§ Have not been identified
• Strongyloides Rhabditiform Larva (L1)
§ Diagnostic stage
§ Elongated esophagus with a pyriform posterior bulb
§ Shorter buccal cavity
§ Larger genital primordium

Comparison Of Rhabditiform Larva (L1)

Hookworm
(N. americanus & A, duodenale)
Larger
Longer buccal cavity
Smaller genital primordium
Threadworm/Roundworm
(Strongyloides stercoralis)
Smaller
Shorter buccal cavity
More prominent genital
primordium

5 of 6
 MEDICAL PARASITOLOGY
PHASMIDS 2
Note: CDC • Ivermectin – chronic cases , also for animal infection
• Rhabditiform larvae in the gut become infective filariform • Egg reduction cannot be determined
larvae that can penetrate either the intestinal mucosa or the
skin of the perianal area, resulting in autoinfection. Once the Prevention and Control
filariform larvae reinfect the host, they are carried to the • Health education on hygiene
lungs, pharynx and small intestine as described above, or • Treat infected individual
disseminate throughout the body. The significance of
autoinfection in Strongyloides is that untreated cases can END
result in persistent infection, even after many decades of
residence in a non-endemic area, and may contribute to the
development of hyper infection syndrome.

Pathogenesis and Clinical Manifestation

• Threadworm or roundworm
o it doesn’t suck blood, but it dissected the intestinal
layer (mucosal, submucosa, marcularis) ® results in
inflammation and may be fibrotic
o Produce hyperinfection ® liver [common site], kidney,
heart, brain
• 3 phases:
o Invasion of the skin by filariform larvae
o Erythema, pruritic elevated hemorrhagic
papules
o Migration of larvae through the body
o Lobar pneumonia ® Loeffler syndrome
o Penetration of the intestinal mucosa by adult female
worms
o Duodenum and upper jejunum
• Diarrhea alternating with constipation
• Cochin China Diarrhea
o Numerous episodes of water and bloody stools,
intermittent
• Light infection – good prognosis
• Moderate and heavy infection
o High mortality rates due to massive invasion of tissue by
adult larvae

Diagnosis
• Goal ® finding 1st stage larva on feces or duodenal fluid
• Unexplained eosinophilia
• Harada-Mori culture ® for identification
• Duodenal aspiration
• Small bowel biopsy

• String Test

Note: Diagnosis
• Egg + Rhabditiform larva (L1) and adult form ® may see in
stool
• Filariform larva (L3)® seen in circulation [never found in
stool]

Treatment
• Mebendazole ® DOC
• Albendazole or Thiabendazole ® alternative

6 of 6