PARASITOLOGY REVIEW MATERIAL the lamina propria, to the

bloodstream and become distributed

Trichinella spiralis throughout the body. Skeletal muscle
● T. spiralis is the smallest human cells are the only in which the
nematode. The adults and larvae live parasites remain inside them after
in the same host, but they have to invasion, growth and development of
change a host to complete their life the larva occurs. T. spiralis is
cycle. The disease that Trichinella infective by the 14th day of infection
spp. cause is referred to as
trichinellosis or trichinosis, a
zoonosis, which is spread by
mammals that kill each other.
Human infections result from eating
raw or undercooked meat.

Morphology
1. Adults; male: 1.5mm, female:
3-4mm, both have a single set of
reproductive organs
2. Juvenile (larva); 124x6 um, one or
more coil in a cyst in the skeletal
muscle fibers

Life Cycle:
1. Infective stage: Encysted larva
2. Habitat: adults in small intestine
II. Life Cycle
(mainly in duodenum and jejunum),
● Infection is initiated by ingesting raw
juveniles in skeletal muscles
or undercooked meats (pork)
3. Route of infection: by mouth
harboring the Nurse cell-larva
4. Life span of female: 1-2 months
complex. Larvae are released from
5. Final host and intermediate host:
muscle tissue by digestive enzymes
person
in the stomach, and then locate to
6. Reservoir host: pigs, cats, dogs,
the upper two-thirds of the small
mice etc.
intestine. The immature parasites
penetrate the columnar epithelium at
the base of the villus. They live
within a row of these cells. Larvae
molt four times, developing into
adults. After mating, adult females
produce newborn larvae which enter
 Disease:
Trichuriasis
Geographical Distribution:
World wide
Definitive host:
Man
Habitat:
Large intestine (caecum)
Pathogenic stage:
● Adult embed their anterior thin
portion into the mucosa and
sub-mucosa
● The life span of the adult is about 3-5
III. Clinical manifestation
years
The process of the pathogenesis may be
● No intermediate host and no
divided into 3 stages:
reservoir host
1. Invading stage (about 1 week):
The damage is mainly found in the
intestine. In this stage, abdominal
I. Morphology
pain, nausea, vomiting, diarrhea and
Adult:
fever may occur
● Looks like whip, cellular esophagus
2. Migrating stage of the juveniles
● The anterior ⅗ is slender
(2-3 weeks): The damage is mainly
● The posterior ⅖ is thick
in the skeletal muscles. In this stage,
● The female worm is 3-5 cm
muscular pain with high fever is
● The male is smaller and has a
main symptoms, especially in active
curved tail and one spicule
muscles. Wandering juveniles may
● Genitalia: one set
also cause pneumonitis, pleurisy,
encephalitis, nephritis and
Egg:
myocarditis etc.
● It is barrel in shape
3. Encysted stage (416 weeks): In
● 50 x 20 um in size
this stage, only muscular pain
● Brownish
present without other symptoms
● Has a translucent polar plug at either
ends
IV. Diagnosis
● The content is an undeveloped cell
● Muscular biopsy
stage
● Examination of left food and
xenodiagnosis;
● Immunodiagnosis: ELISA & IHAT
II. Life Cycle
1. Infective stage: embryonated egg
V. Treatment
2. Infective mode: orally by
● Albendazole and Mebendazole,
consumption of contaminated food
cortisone, analgesics
and drink
3. Diagnostic stage: immature egg
VII. Prevention
● Quarantine of meat
● Avoid eating raw meat and
● Avoid feeding of animals on raw
meat
III. Pathogenesis
● Adult embed their anterior thin
portion into the mucosa and
submucosa —> extensive
inflammation, traumatic &
haemorrhagic effects at points of
attachments —-> secondary
bacterial infection ulcers & abscess
Ascaris Lumbricoides - Fertilized
Egg in Iodine S. stool smear (golden
brown in colour) 60 - 75 x 40 - 50
um, is spherical or oval with
semilunar space and regular
albuminous layer

This leads to the following clinical picture:

● Light infection: Asymptomatic
● Heavy infection: Symptomatic
Abdominal pain, dysentery,
tenesmus
Complications:
● Chronic dysentery
● Rectal prolapse
● Appendicitis
● Anaemia

IV. Diagnosis:
Detection of eggs in feces
V. Treatment:
Mebendazole 3 days
VI. Prevention & Control:
● Mass treatment
● Sanitary disposal of feces
● Avoid human fertilizers
● Proper washing of vegetables
● Pure water supply
● Health education
● Control of flies
C. Cross Section of Worm
● Outer cuticular covering layer
ASCARIS LUMBRICOIDES: ● Middle syncetial cellular layer with
A-Gross specimens: dorsal & ventral thickenings or cords
● Large size of worm in which dorsal ventral nerve cords
● Female: cylindrical in shape, straight pass
posterior end ● Lateral thickenings or cords in which
● Male: smaller than female with lateral excretory vessels pass
curved posterior end ● Inner muscular layer: divided by the
● Male and female anterior end, with dorsal, ventral & lateral cords into 4
three lips sector
Note: Ascaris lumbricoides adult worm ● Section through the intestine in the
● White, brown reddish or light brown middle
or pink the posterior end of the male, ● Coelomic cavity between muscles
curved with 2 spicules, the female intestines
with straight end ● With male or female reproductive
B-Egg organs
Fertilized:
● Round in shape
● With outer mammillated coat
● Thick transparent middle coat
● Thin membranous inner coat
● Single unembryonated egg
Unfertilized:
● Elongated cylindrical in shape
● With all other characters mentioned
above
 THE FILARIAL NEMATODES -
WUCHERERIA BANCROFTI

Phylum Nematoda (roundworms) filarial PATHOLOGY

nematodes ● Worms take 6-12 months to mature
● Dracunculus medinensis ● Infections will release microfilariae
(dracunculiasis or Guinea worm) for up to 10 years without re-infection
● Wuchereria bancrofti ● Pathology is primarily
(elephantiasis or lymphatic filariasis immune-related
or LF) ● Attacks of adenolymphangitis (chills
● Onchocerca volvulus and fever, tenderness of entire
(river blindness) lymph system)
● Loa loa (eyeworm) ● Lymph system obstruction, chyluria
(lymph in urine)
Wuchereria bancrofti, elephantiasis, or ● Chronic lymphedema with fibrous
lymphatic filariasis (LF) infiltration and thickening of the skin
● Related spp. Brugia malayi and B.
timori cause a small minority of the
world’s cases

The human lymph system:

● Drains fluid from tissue spaces
● Transports fats
● Lymph nodes - defensive wbcs
TROUGH:
● Tonsils
● Right lymphatic duct
● Thymus gland
● Thoracic duct
● Spleen
● Some of the lymph nodes
● Bone marrow
 Intestinal Nematodes and Eosinophilia

Parasitic Helminths
Trematodes (flukes) Soil Transmitted Helminths (STH)
● Venous system: Schistosoma ● Infection rates and burden of disease
● Biliary tract: Clonorchis, Fasciola greatest among conditions of
● Lung: Paraagonimus poverty, poor sanitation
Cestodes (tapeworms)
● Taenia saginata, Taenia solium, H. Guatemalan Children with Soil
nana Transmitted Helminths Infections
Nematodes (roundworm) ● Stunting, anemia, loss of IQ,
● Intestinal diminished school performance
● Blood, lymphatic, subcutaneous ● Many years of lost primary
schooling attributable to STH
1. General facts about Intestinal
Nematodes
2. 4 major intestinal nematodes:
Ascaris, Trichuris, Hookworm and
Strongyloides
● Public health implications
● Lifecycle
● Clinical presentation
● Treatment
3. Trends in Intestinal Parasitism
among Refugees

General facts about Intestinal Nematodes

Frequently nonspecific symptoms
● Often asymptomatic until worm
burden becomes large
● Weight loss, GI discomfort
● Diarrhea or fever from nematodes is
uncommon
Polyparasitism
Burden is greatest in children

● Tropical and subtropical

predominance
● Don’t multiply in host
- 2 exceptions
● Infection limited to life span of worm
unless reinfection occurs
- Lifespan: 2 months - 5 years
- Rare Exceptions:
Strongyloides, C.
philippinensis: autoinfection
Pinworm: self-reinfection

Soil Transmitted Helminths (STH) =

Geohelminths
● Part of development occurs in the
soil
● Average 3-4 weeks in soil until
infective
● Infection via eggs in contaminated
soil (Ascaris, Trichuris) or skin
penetration (hookworm)
Ascaris Lumbricoides
● 1/8th the world’s population infected
● Largest of nematodes infecting
humans
● Adult habitat: small intestine
(jejunum)
● Obligatory extra-intestinal migration
(eosinophilia)
● Lifespan: 1-2 years
● Intensity of infection greatest in
children, ages 5-10 years
Ascaris Lumbricoides
● Eighty-nine hookworms and 81
Ascaris. This demonstration induced
many to apply for treatment (brazil)
Geographic prevalence highest in warm,
wet climates.
● 1 adult female = 200,000 eggs/day
● Pre-patency: 2 months
● Pneumonitis: 4-16 days after
infection, short duration (~3 weeks)
Loeffler Syndrome (Pneumonitis)
● Transverse sections of Ascaris
larvae in pulmonary alveoli
Ascaris Lumbricoides
● Larval phase: eosinophilia,
pneumonitis
● Adult phase:
- Malnutrition, impaired
physical growth
- Mild abdominal discomfort
—-> small bowel obstruction
(in children, few as 60
worms)
- Wandering ascaris: biliary
tract obstruction, cholangitis,
pancreatitis, liver abscess
● Treatment: Albendazole x 1 dose
WHIPWORM: Trichuris Trichiuria
● Adult habitat: caecum, colorectal
● No extra-intestinal phase
● Lifespan: 1-3 years
● 90% infections are asymptomatic
● Symptoms with heavy infections
- Intensity of infection peaks
by age 10
Clinical Features:
● Asymptomatic
● Physical weakness, Anemia
● Stunted Growth, Cognitive Deficits
● Stool frequency (12=/day), nocturnal
stooling
● Trichuris dysentery syndrome
● Trichuris colitis
● Rectal prolapse
Treatment:
● Albendazole x 3 days
The Human Hookworms
● Necator americanus
● Ancylostoma duodenale
HOOKWORM: Necator americanus &
Ancylostoma duodenale
● One - tenth world’s population
infected
● Significant cause of anemia &
protein malnutrition
● Adult habitat: small intestine
● Lifespan:
● ~1 year (A. duodenale)
● ~3-5 years (N. americanus)
● Worm burdens do not decline in
adult years
HUMAN HOOKWORM INFECTION
● ~600 million cases worldwide (rural
poverty >>> urban slums)
● 44 million pregnant women infected
● Iron-deficiency anemia: Physical &
Intellectual Retardation
● Necator americanus is the
predominant hookworm species
HOOKWORM-BLOOD LOSS
Adult worms injure their host by causing
intestinal blood loss:
● Anticoagulants, Hemolysins and
Hemoglobinases
● 30 to 200 uL blood per hookworm
● Intestinal blood loss and iron
deficiency anemia
Adult Hookworm in Situ (1cm)
● Adult size: 0.5 - 1 cm
● Daily eggs per worm: 5 - 20,000
HOOKWORM
Clinical Features:
● Ground-itch → dry cough, wheezing
(1-2 weeks later) in primary infection
● Abdominal discomfort
● Progressive iron-deficiency anemia
● 40 - 160 worms associated with Hgb
< 11 g/dL
● Failure to thrive, extreme fatigue
● IQ loss
Treatment:
● Albendazole x 1 dose
 At-Risk Populations for Hookworm
Disease
● Women and children: Low Iron
Stores
● Children:
- Physical growth stunting
- Cognitive deficits and
intellectual retardation
● Women of child-bearing age
- Puberty
- Menstruation
- Pregnancy
● Increased Maternal Mortality
(anemia)
● Low Birthweight
● Infant Mortality

School Based Deworming

In 2001, (WHO) adopted a resolution aimed
at the “deworming” of 75% of all at-risk
school-age children by 2010, Prevention
and;
● Improvements in iron, Hgb status
● Improved cognition, educational
achievement
● Reduction in school absenteeism
● Reduction in community helminth
transmission of ascariasis &
trichuriasis

CONTROL
● Anti-helminthic drugs:
- 50 million tablets of
mebendazole donated per
year by Johnson & Johnson
- Albendazole available from
GlaxoSmithKline for 2c per
pill
● Currently no vaccine exists for
ascariasis or trichuriasis
● Human Hookworm Vaccine Initiative
(HHVI): Phase I trials Strongyloidiasis Hyperinfection:
Strongyloides Stercoralis
STRONGYLOIDIASIS: Strongyloides Hyper-Infection:
stercoralis ● Intestinal perforation
● Worldwide prevalence: ~100 million ● Hemorrhagic pneumonia
● Adult habitat: duodenum, jejunum ● Shock, sepsis, gram-negative
● Lifespan: unknown, Ongoing meningitis
autoinfection ● Eosinophilia may be limited

Strongyloidiasis - Clinical Presentation Pre-departure treatment for intestinal

● Asymptomatic eosinophilia
● Abdominal pain
● Dermatitis - larva currens
● Pulmonary infiltrates with
eosinophilia
● Dissemination with sepsis
parasites in US bound refugees
● Since May, 1999 CDC has
implemented empiric treatment with
single dose albendazole 600 mg for
all refugees departing from sub
Saharan Africa, and for selected
groups, such as Hmong arriving
from Thailand in 2005
 When is the ideal time to check stool O & P
in returning traveler?
● 2 month

General Truths about NEMATODES

● Polyparasitism
● Burden greatest in children
- Except hookworm,
Strongyloides
● Don’t Multiply in Host (2 exceptions)
● Eosinophilia = tissue invasion
- Larval stages or
strongyloides

What is the most likely worm to be coughed

or vomited up?
● Ascaris
Which worm infection do you always want
to treat?
● Strongyloides
Which worm’s burden of illness increases
through your late childhood and early
adulthood years?
● Hookworm
Which worm infection is most likely to
mimic colitis?
● Trichuris
Which nematode is the most likely to be the
cause of eosinophilia in an
immigrant/refugees from africa who has
been in america x 9 months?
● Strongyloides