ASCARIS LUMBRICOIDES

• Giant round worm/Giant intestinal roundworm

• Soil transmitted helminth

FEMALE MALE
• 22-35cm in length • 10-31cm in length
• Posterior end is straight • Posterior end is curved ventrally
• Paired reproductive organs in the posterior 2/3 • Reproductive organ is a single, long, torturous
• Produces 200,000 eggs per day; decreases with tubule
increasing worm load

• Adults reside in but do not attach to the mucosa of the small intestine
• Produces Pepsin inhibitor 3 that protects worms from digestion and phosphorylcholine
• Bile-stained
• Infertile eggs – thin shell and irregular mamillated coating filled with refractile granules
• Fertile eggs
o Has a thick, transparent, hyaline shell with a thick outer layer as a supporting
structure
o Delicate vitelline, lipoidal, inner membrane which is highly permeable
o Ovoid mass of protoplasm which will develop into larvae in about 14 days
• Infective stage – fully embryonated egg
o Hatch in the lumen of the small intestine
o Larvae migrate to the cecum or proximal colon and then penetrate the intestinal wall
• In the lungs
o Undergo molting before it migrates into the larynx and oropharynx
o Hepato-tracheal migration takes place in about 14 days
o Development of egg-laying adult worms takes about 9-11 weeks after egg ingestion
o Larvae may case sensitization which lead to lung infiltration, asthmatic attacks, &
edema of the lips
o Eosinophilia is present in larval migration
o Lactose intolerance and Vitamin A malabsorption present
• Life span: 1 year
• Eggs
o Deposited in the soil takes 2-3 weeks to develop into infective stage (embryonation)
o Only infective when ingested
o Survive in moist shaded soil for a few month to about 2 years; longer in temperate
regions
• Larvae undergo 2 molts to reach the 3rd stage
• Infections are asymptomatic
• Irritation of the intestine by the mechanical and toxic action of the adult explains pathology
• 10-20 worms may not show symptoms
• Discovered by stool examination or spontaneous passing of worms in the feces
• Heavy infection
o Bowel obstruction
 o Intussusception
o Volvulus
• Ectopic ascariasis – may be vomited or regurgitated, escape through the nostrils, or
inhaledinto the trachea; invades gallbladder, liver, pancreatic duct, and appendix
• Invade bile ducts through the Ampulla of Vater
• Acute intestinal obstruction – children are more prone because of the smaller diameters of
the intestinal lumen and heavy worm burden
• Loeffler syndrome or Acute transient pneumonitis – dry cough, dyspnea, wheezing, and
mild fever
• Biliary ascariasis experience severe colicky abdominal pain d/t movement of the worms
inside the biliary tract
• Acute appendicitis or Pancreatitis - worms may lodge into the appendix or occlude the
pancreatic duct
• Acute peritonitis or Chronic Granulomatous Peritonitis – penetration through the
intestinal wall into the peritoneal cavity
• Biting or pricking of the intestinal mucosa for food may irritate nerve endings in the
mucosa and result in intestinal spasm leading to intestinal obstruction
• A child need not to harbor hundreds of Ascaris adults to produce intestinal
obstruction
• Dx – stool sample
o Direct fecal smear – less sensitive compared to kato techniques
o Kato thick smear
o Kato-katz technique – provides quantitative dx in terms of intensity of helminth infxn
in eggs per gram of stool; useful in monitoring treatment
o Concentrations – Formalin-ether/ethyl acetate
o Tramway sign – radiologic dx; adults appear in parallel tracts of filling the defects in
the SI using contrast media
§ “Bull’s eyes” sign in sonography of abdomen
• Tx – single dose; tablet taken after a meal
o Albendazole – bind to the parasites’ b-tubulin resulting in disruption of parasite
microtubule polymerization
o Mebendazole – bind to the parasites’ b-tubulin resulting in disruption of parasite
microtubule polymerization; DOC
o Pyrantel pamoate
o Ivermectin
• Children less than 1 yo and pregnant women in their first tri should not take albendazole
and mebendazole
• Socio-economic factors > physical factors
• Surveillance and monitoring are important
o Monitoring is recommended every 2 years
o Reinfection is usually observed 4 mos post-treatment
o Full reinfection appears at 6 or 7 mos post-treatment
o Reinfection in communities with poor environmental sanitation take place
immediately after deworming
• WASHED
 o Water
o Sanitation
o Hygiene
o Education
o Deworming

TRICHURIS TRICHIURA
• Whipworms
• Soil-transmitted helminth
• Classified as Holomyarian – somatic muscles in cross-section appear small, numerous,
and closely packed in a narrow zone

FEMALE MALE
• 35-50mm in length • 30-45mm in length
• Blunt posterior end • Slightly shorter than female
• Paired reproductive organs in the posterior 2/3 • Coiled posterior end
• Produces 3,000 to 10,000 eggs per day • Single spicule and retractile sheath
• Produces 60M eggs in 2 years

• Worms have attenuated anterior 3/5 traversed by a narrow esophagus resembling a

string of beads
• Thick and stout posterior 2/5 contains the intestine and a single set of reproductive
organs
• Eggs
o 50 to 54 um by 23 um
o Unsegmented fertilized ova at oviposition
o Lemon or football-shaped with plug-like translucent polar prominences and bipolar
plugs at each end
o Yellowish outer and a transparent inner shell
o Fertilized eggs are unsegmented at oviposition and embryonic development takes
place outside the host
o More susceptible to desiccation
• Larvae
o Escape and penetrate intestinal villi where they remain in for 3-10 days
o Inhabit the cecum and the colon
 o Secretes a pore-forming protein, TT47, that allows them to imbed their entire-whip-
like portion into the intestinal wall
o Females lay eggs which are passed out through the feces and deposited into the soil
o Embryonated within 2-3 weeks
o Swallowed eggs go to the small intestine undergo 4 larval stages to become worms;
takes 12 weeks
o No heart-lung migration
• Petechial hemorrhages – caused by anterior portions embedded in the mucosa
o Predisposes to Amebic dysentery as it causes ulcers that is suitable for E. histolytica
• Lumen of the appendix may be filled with worms that may lead to appendicitis or
granuloma formation
• Infections
o Over 5,000 eggs/g is symptomatic
§ Heavy infection found throughout the colon and rectum
§ Anemia correlated to blood loss 0.8-8.6mL/day
o 800 eggs – anemia in children
• Trichuris dysentery syndrome – manifested by chronic dysentery and rectal prolapse
• No lung migration – good prognosis
• Dx – possible only in heavy chronic infxn
o Direct fecal smear with a drop of saline
o Kato thick smear method – uses 20-60mg of stool sample; highly recommended
o Acid-ether & formalin-ether/ethyl acetate concentration
• Tx
o Mebendazole 100mg BID x 3 days
o Mebendazole 500mg OD x 3 days – highest cure rate
o Mebendazole 200mg BID X 20 days – DOC TINA LECTURE
o Albendazole may be used as an alternative drug
o Preventive chemotherapy through mass drug administration
§ Mebendazole 500mg OD
§ Albendazole 400mg OD
o Albendazole in combination with Ivermectin
• Children aged 5-15yo are most frequently infected

CAPILLARIA PHILIPPINENSIS
• Pudoc worm
 • Zoonotic; Soil-transmitted helminth
• May be associated with protein-losing enteropathy, electrolyte imbalance, & intestinal
malabsorption
• Natural host – Fish-eating birds
• Belongs to the superfamily Trichinelloidea
o Thin filamentous anterior end & slightly thicker and shorter posterior end

FEMALE MALE
• 2.3-5.3mm in length • 1.5 to 3.9mm in length
• Vulva is located at the junction of anterior & • Spicule is 200-300um long w unspined sheath
middle thirds
• Produce peanut-shaped eggs with striated shells
and flattened bipolar plugs
• Larviparous or ovo-viviparous

• Esophagus has rows of secretory cells called Stichocytes

• Entire esophageal structure is called a Stichosome
• Body is divided almost into 2 equal parts
o Anterior – occupied by the esophagus and esophageal glands
o Posterior - intestines
• Anus is subterminal
• Eggs
o Peanut-shaped with striated shells and flattened polar plugs
o 36-45um by 20um
o Passed in the feces and embryonate in soil or water
o Must reach water in order to be ingested
o Hatch in the intestines of the fish and grow into infective larvae
o Atypical – no polar plugs, ovoid, striated
o Typical – peanut-shaped, with polar plugs, striated
• Diagnostic stage: egg
• Incidental hosts: humans
• Diarrhea – 8-10 voluminous stools per day
• Protein-losing enteropathy, hypoalbuminemia, fat and sugar malabsorption, decreased
xylose excretion, low serum L Na Ca, increased IgE, borborygmi
• Parasites DO NOT invade the intestinal tissue but are responsible for micro-ulcers in the
epithelium, compressive degeneration, and mechanical compression of cells
• Homogenous material is seen at the anterior end of the worm
• Intestine show flatted and denuded villi, and dilated mucosal glands
• Lamina propria is infiltrated with plasma cells, lymphocytes, macrophages, and
neutrophils
• Dx – larva and adults
o Direct smear or wet mount
o Stool concentration methods
o Duodenal aspiration
o ELISA – detection of coproantigen
 o Immunoblot assay – for T. spiralis antigen for immunodiagnosis
• Tx
o Electrolyte replacement
o High protein diet
o Mebendazole 300mg BID x 20 days
o Albendazole 400mg OD x 10 days

HOOKWORMS
• Necator americanus and Ancylostoma duodenale
• Soil-transmitted helminths
• Blood-sucking nematodes that attach to the mucosa of the small intestine
• Single or mixed infections
• Have the Meromyarian type of somatic muscle with 2-5 cells arranged per dorsal or
ventral half

Necator americanus Ancylostoma duodenale

• Small, cylindrical, fusiform, grayish-white • Slightly larger
• Buccal capsule has a ventral pair of semilunar • Has a single-paired male or female reproductive
cutting plates organ
• Head is curved opposite to the curvature of the body • Head continues in the same direction as the
which is like a hook at the anterior end curvature of the body
• Buccal spears of filariform larva are conspicuous & • Buccal capsule has 2 pairs of curved ventral teeth
parallel; Sheath in the tail region is conspicuous • Buccal spears of filariform larva are
transverse striations insconspicuous; Sheath in the tail region is
transverse striations
FEMALE MALE FEMALE MALE
• 9-11mm by 0.35mm • Broad, membranous • Adults may live 2-14 • Exhibits a dental
• Larger than males caudal bursa (bursa years pattern
• Adults may live 2-14 copulatrix) with rib-
years like rays (for
copulation) posterior
end
• Exhibits a dental
pattern

• Rhabditiform larvae
o Indistinguishable
o Non-infective; Feeding stage
 o Resemble Strongyloides stercoralis
o Large, attenuated posteriorly, longer buccal cavity
o Genital primordium is smaller in hookworms
o Bulbous esophagus
o Long buccal cavity
o Inconspicuous genital primordium
• Filariform larvae
o Infective; Non-feeding stage
o 700um long
o Straight esophagus (1/4 of the length of the body)
o Curved tail
• Eggs
o Ovoidal
o “Morula ball”
o Bluntly rounded ends
o Single thin transparent hyaline shell
o Unsegmented at oviposition
o In the 2-8 cell stage of division when passed out with fresh feces
• Life cycle
o Direct
o Begins with adult worms copulating when attached to the mucosa of the small
intestines
o Female worms
§ Oviposit into the intestinal lumen
§ Eggs are passed out in the feces
o In the soil, embryo within the egg develops rapidly and hatches 1-2 days into the
rhabditiform larva
o After 7-10 days, the larva undergoes 2 stages of molting and transforms in the
non-feeding filariform larva (L3) – infective stage
o Filariform larvae penetrate the skin and enter the venules

• Pathology
o Skin as the site of entry – produces macupaploular lesions and localized
erythema; “Ground itch” or “Dew itch”; lasts for 2 weeks
o Lung in larval migration – bronchitis or pneumonitis; larvae produce minute
hemorrhages with eosinophilic and leukocytic infiltration
o Small intestine as the habitat – abdominal pain, steatorrhea, diarrhea with blood,
eosinophilia
o Infxn is chronic, px don’t show acute symptoms
o A. duodenale > N. americanus blood loss
o Chronic/heavy infection results in progressive secondary microcytic
hypochromic anemia of the iron-deficiency type
o Hypoalbuminemia
o Prognosis is good
o Cellular immune response is primarily mediated by eosinophils, mast cells, and
Th2 cells
 o Polyvalent IgE antibodies proved protective roles
• Dx
o Depends on the identification of ova (2-8 cell stages) in the feces
o Differentiation by observing the buccal capsule
o Direct Fecal Smear – for heavy infxn
o Kato thick smear/Kato-Katz technique – increased detection rates d/t more stool
samples; provide quantitative dx no. of helminth eggs
o Concentration methods – zinc sulfate centrifugal flotation and formalin
ether/ethyl acetate concentration method
§ Increase in sensitivity
§ FLOTAC has higher sensitivity for dx
o Culture methods – Harada-Mori allow hatching of larvae from eggs strips of filter
paper with the end submerged in water; for species identification
o Molecular approaches – for secretory/excretory coproantigens
§ PCR-based detection of hookworm DNA
§ ELISA
• Tx
o Albendazole 400mg OD adults & children >2 yo
o Mebendazole 500mg OD adults & children
o Iron for anemia
o Pyrantel pamoate
o Adequate diet for hypoprotenemia
• Epidemiology
o Environment – damp, sandy or friable soil with decaying vegetation, temp of 24
to 32C
o Ancylostomiasis is both percutaneous and oral
o A. duodenale remains dormant in the intestine or muscles resulting in longer
incubation period
o Cutaneous larva migrans – animal hookworms; “creeping eruption”; causes
Serpiginous tunnel
• Prevention
o Human hookworm vaccine – Sabin vaccine
o Antihelmenthic drugs + Vitamin A + Micronutrients

STRONGYLOIDES STERCORALIS
• Threadworm
• Free-living rhabditiform and parasitic filariform stages
• Only species which is naturally pathogenic to humans

FEMALE MALE
• 2.2mm by 0.4mm • Free-living
• Colorless, semi-transparent, finely striated o 0.7mm by 0.04mm
cuticle o Ventrally curved tail
• Slender tapering anterior o 2 copulatory spicules
• Short conical pointed tail o Gubernaculum
• Short buccal cavity has 4 distinct lips o No caudal alae
• Long slender esophagus extends to the anterior
fourth of the body
• Intestine is continuous to the subterminal anus
• Vulva is located 1/3 of the body from the
posterior end
• Uteri contains a single file of 8-12 thin-shelled,
transparent, segmented ova 50-80um by 30-
34um
• Parthenogenic/Parthenogenic
• Free-living
o 1mm by 0.06mm
o Muscular, double-bulbed esophagus
o Intestine is straight cylindrical tube

• Rhabditiform larva
o 225um by 16um
o Elongated esophagus with pyriform posterior bulb
o Shorter buccal capsule
o Larger genital primordium
o Feed on organic matter; Feeding stage
• Infective Filariform larva
o Non-feeding
o Slender
o 550um in length
o Distinct cleft at the tip of the tail
o Formed from rhabditiform larva in unfavorable environment – infective to
humans
• Eggs
o Rarely seen in the stool specimen
o Clear thin shell
o 50-80um by 30-34um
• Free-living forms – found in the soil
• Life cycle
o Begins when filariform larvae enters through the skin
o Larvae develops into adults in 1 month while in the duodenum
o Eggs hatch into rhabditiform larvae
o Autoinfection occurs with rhabditiform larvae pass down the large intestine and
develop into filariform larvae
• Pathology
o 3 phases of acute strongyloidiasis
§ Invasion of the skin by F larvae – erythema and pruritic elevated
hemorrhagic papules
§ Migration of larvae through the body – lobar pneumonia with
hemorrhage; cough and tracheal irritation
§ Penetration of intestinal mucosa by adult female worms – found in the
pylorus to the rectum; greatest numbers found in the duodenal and
upper jejunal regions; may exhibit leukocytosis and eosinophilia
 o Migration & penetration may happen simultaneously – hyperinfection
o Moderate infection – diarrhea alternating with constipation
o Heavy infection – intractable, painless, intermittent diarrhea (Cochin China
diarrhea)
o Autoinfection
§ Some rhabditiform larva develop into filariform larva in the bowel and
reinfect the host
o Hyperinfection – accelerated autoinfection
o Chronic strongyloidiasis
§ Often asymptomatic
§ May cause anal pruritus, urticaria, larva rashes, recurrent asthma and
nephritic syndrome
• Dx
o Finding of unexplained eosinophilia may be a clue
o Baermann funnel gauze method
o Harada-Mori culture – one of the most successful methods in parasite
identification; uses pothyethylene bags or tubes
o Nutrient agar plates
o Others: Beale’s string test, duodenal aspiration, and small bowel biopsy
o Disseminated strongyloidiasis – larvae may be found in sputum or urine samples
• Tx
oAlbendazole or Thiabendazole
oIvermectin provides the best result for chronic uncomplicated strongyloidiasis
oHigher doses given for longer periods may be necessary
o3 drugs are used for hyperinfection or disseminated disease singly or in
combination
o Egg reduction rate cannot be determined because eggs are not passed out in
the feces but are oviposited in the intestine and other tissues of the host
• Epidemiology – people remain infected for more than 30 years even after leaving
endemic areas

ENTEROBIUS VERMICULARIS
• Human pinworm
• Causes enterobiasis or oxyuriasis
• Characterized by perianal itching or pruritis ani
• Occasionally causes complications in ectopic areas
• Classified as Meromyarian – based on the somatic muscles where there are 2-5 cells
pero dorsal or ventral half
• Most common helminth parasite identified in temperate regions
• Adult worms
o Cuticular alar expansions at the anterior end
o Prominent posterior esophageal bulb
o Small worms measure 8-13mm by 0.4mm & has a long pointed tail

FEMALE MALE
o 8-13mm by 0.4mm o 2-5mm by 0.1-0.2mm
 o Long pointed tail o Curved tail
o Uteri are distended with eggs o Single spicule
o Dies after laying eggs o Cephalic alae
o Gravid worms migrate down the intestinal o Rarely seen because they die after
tract and exit through the anus to deposit copulation
eggs in the perianal skin in the evening
hours

• Rhabditiform larva
o 140-150um by 10um
o Characteristic esophageal bulb
o No cuticular expansion on the anterior end
• Eggs
o Asymmetrical
o One sided flattened and the other end convex
o Length: 50-60um by 20-30um
o Size: 55 by 36um
o Translucent shell
§ Outer triple albuminous covering – for mechanical protection
§ Inner embryonic lipoidal membrane – for chemical protection
o Tadpole-like embryo inside that fully matures outside the host within 4-6h
o When ingested, contains 3rd stage larva and hatches in the duodenum and passes
down the SI into the cecum
o Resistant to disinfectants but succumb to dehydration in dry air within a day
o In moist conditions, remains viable for up to 13 days
o Airborne eggs can infect at a distance via inhalation
• Adult worms
o Found in the cecum and adjacent portion of the SI & LI
• Pathogenesis
o Relatively innocuous parasite are rarely produces any serious lesions
o Mild catarrhal inflammation may result from attachment
o Mechanical irritation and secondary bacterial infection may lead to inflammation
of the deeper layers of the intestines
o May cause appendicitis, vaginitis, endometritis, salpingitis, and peritonitis d/t
aberrant worm migration
o Children may experience insomnia d/t the pruritus
o Entry into the peritoneal cavity may result in the formation of granuloma around
eggs or worms
• Dx – Graham’s scotch adhesive tape swab (perianal cellulose tape swab)
• Tx
o Mebendazole 100mg PO OD
o Albendazole 400mg PO OD
o Pyrantel pamoate 11mg/kg PO OD as a secondary drug of choice
o Cure can only be considered after 7 perianal smears on consecutive days using
scotch-tape swab method
o Egg reduction rate is difficult to determine because eggs are collected from the
perianal area instead of the feces
• Epidemiology
o The only intestinal nematode infection that cannot be controlled through sanitary
disposal of feces
o Route of infection is through peri-oral and respiratory route (anus included for
retroinfection)
• Epidemiology
o The only intestinal nematode infection that cannot be controlled through sanitary
disposal of feces
o Route of infection is through peri-oral and respiratory route (anus included for
retroinfection)