The spirurida: Dracunculus and others

Cephalic structures are bilaterally symmetrical, and esophagus is divided

into anterior muscular and posterior glandular parts. The normal location in
.the host is the esophagus or stomach or in the tissue or tissue spaces

There are two suborders

Camallanina with two superfamilies, the Camallanoidea and *

Dracunculoidea

Spirurina with ten superfamilies, including the Filarioidea and six others in *
.which there are representatives among the parasites of man

SUBORDER CAMALLANINA
Superfamily Drancunculoidea
They have extreme sexual dimorphism and complete atrophy of anus in
.adult female

Drancunculus medinensis
)The guinea worm, medina worm, serpent worm or dragon worm (

Geographical distribution

.Egyptian priests regarded infection as important clinical entity

Distribution includes Nile Valley, Africa, Iran, India, korea

Morphology

It is cylindrical, creamy white, cuticle is smooth

Size: male 4cmΧ0.5mm, mature female about 4cm, gravid female one
meterΧ1.5mm one of largest nematodes (distended uterus full of first
stage larva)
Anterior end is blunt round, no lips and posterior end is coiled (recurved
.ventrally) in both male and female

Mouth:

 buccal capsule is reduced into cuticular ring

 small, triangular
 surround by quadrate prominence (sclerotized plate)
 surround by inner circle of six well developed papillae( two lateral
single and two ventral, two dorsal twinned) and outer circle of four
double papillae (at level of amphids)

Lateral pair of cervical papilla behind nerve ring

Esophagus is cylindrical, anterior muscular and posterior glandular

Intestine is atrophied, compressed by coiled uterus

Anus is atrophied in adults

Male

 ten pairs of caudal papillae (four preanal, six postanal)

 two unequal spicules, gubernaculum

Female

 ovary, oviducts, uteri are paired

 vagina is unpaired
 vulva is equatorial or slightly postequitorial

Gravid female

 ovaries is postfunctional
 uteri are highly coiled, distended masses filled with rhabditiod larvae
and occupying the greater part of the body
 vulva is atrophied and not seen
larva of medina worm

 wiry, vermiform, non sheathed

 striated cuticle
 tail is pointed, long filariform (1/3 of entire body length)
 anterior end is rounded, rhabditiform oesophagus

Life cycle

At end of prepatent period, about 12 months after infected cyclops is

swallowed, cephalic end of worm approaches the skin and a papule is
formed in the dermis; this changes into a blister within 24 hours, or may
enlarge for several days before the blister develops.

These lesions usually appear on the distal portion of the limbs. Eventually
the blister ruptures.

On contact with fresh water, a loop of worm's uterus, prolapsed through a

ruptured anterior part of its body wall or through its mouth, brusts open
and discharges a swarm of motile first stage rhabditoid larvae. This process
is repeated until entire brood has been discharged.

It moves stiff motion, briskly coiling and uncoiling the body. It has no active
means of gaining entrance into intermediate host.

If an appropriate species of cyclops is present in water, some larvae are

ingested and on reaching copepod's midintestine, break through softwall
and come to lie in celomic cavity. More than 5 or 6 larvae usually cause
death of cyclops.

In suitable species, larvae proceed to undergo metamorphosis with loss of

striated cuticula in about 8 days and development of delicate enveloping
sheath 2 days later. Subsequently they become quiescent and show no
inclination to leave copepod.
Infection by ingestion of infected copepod in unfiltered water, on arrival in
duodenum, larvae migrate through wall of digestive tract and reach loose
connective tissue, usually retroperitoneal, where they develop into adults.

Paratenic hosts such as tadepoles and frogs are important means of

transporting infected larvae of dracunculus species up the food chain, thus
facilitating transmission to definitive hosts.

In animal, adult matures in 3 weeks. D.insignis in raccoon needs 2months.

Reservoir hosts infection is not epidemiologically important.

Pathogenesis, pathology and symptomatology
Pathogenesis
Stage 1
Ingestion of larvae till
maturation and penetration of
viscera and deep tissue
Stage 2
Gravid female is moving in
subcutaneous tissue, host
reaction to worm products
 local reaction
 systemic reaction
(type 1 hypersenstivity
reaction)
Clinical picture
No symptoms
Prepatent period is one year
Inspection, palpitation of
serpiginous worm, localized
oedema
Rash, dizziness, nausea, diarrhea
complication
No complication
Worm that fail to reach skin either
1. absorped, calcified (x-ray) with no
apparent effect on host
2. migrate to deeper tissue lead to
complication
a) deep cellulitis
b) chronic arthritis (if calcified worms
beside it)
c) constructive pericarditis
d) subconjunctival abscess
e) extradural abscess
f) quadriplegia due to spinal cord
abscess
g) urogenital effect
h) if worm degenerates, it releases
antigen result in aseptic abscesses
Stage 3
(blister and ulcer formation) 1) Red papule, vesicular 1) Secondary bacterial infection with
 Gravid female in skin, center, indurated margin, abcesses very painful and disability,
anterior end causes 2-7cm especially in lower cellulitis spreading along track of
blister formation. limb (dorsum of worm and septicemia
Papule lead to blister and ulcer metatarsals, soles, ankle) 2) Tetanus
 Rupture and continuous but can occur in upper 3) Arthritis, synovitis, contractures of
discharge of larvae, limb, head, scrotum, trunk, limbs and disability
worm metabolites calf muscle.
Fluid in side blister (no bacteria
but larva, eosinophilia,
neutrophil, mononuclear cells)
and systemic manifestation few
hours before rupture of blister
(erythema, urticarial rash, intense
burning and itching, nausea,
vomiting, dyspnea, syncope,
asthma.
2) Rupture of blister and ulcer
 Intense pain, relived by
immersion in cool water
 Decrease allergic
reaction( continued
discharge of worm's
metabolites together
 motile larvae)
 Secondary bacterial
infection, abcesses
(increase pain, disability)
 If no secondary bacterial
infection, only tiny hole
remains through which
worm protrudes then
healing.
Prognosis

Good except if secondary bacterial infection, suppuration, physical

deformity or septicemia.

Differential diagnosis

Continuous larva migrans, onchocerciasis, calabar swelling of loa loa and

sparganum

Diagnosis

History of reliving in endemic area, drinking suspected water

Clinical presentation: appearance of red itchy papule, rapidly transforms to

painful blister, brusts in 4 days. By placing cool water on ulcer, emerging
larva (under low powered microscope), sometimes emerging female is
disintegrated, drying, flat.

X-ray for calcified worms

Treatment

Worm removed by slowly being wound around a stick except if worm is

accidentally broken and secondary infection occurs. Allergic manifestation
is decreased by using epinephrine.

Four drugs are used nitridazole, thiabendazole, metronidazole and

mebendazole. Action involves suppression of inflammation rather than any
specific effects on adult worm, although 400 to 500mg/day for six days
reported to kill worms directly.

Epidemiology and prevention

Disease transmission depend on

1. Water sources where cyclops breed

2. Direct contact between infected humans and water source
3. Use of this water source for drinking
 4. Possibility of other paratenic hosts

Prevention

1. Infected individuals must not be allowed to bathe or wade in water

used for drinking purposes
2. Persons must be persuaded not to drink suspected water

Suborder spirurina
Including Filarioidea, there are seven superfamilies of spirurina with species
that are found in man. Except in Filareoidea, all are natural parasites of
animals and are rarely found in man.

Gnathostoma spinigerum
Adult inhabits gastric wall of carnivores, pigs (wild, domestic), dog and cat

Geographical distribution

Far East, china, Thailand, Japan, USA

Morphology

Body is stout, pink (reddish), transparent

Size: female 2.5-5cm, male 1-2.5cm size is smaller in small sized hosts

Anterior

 Two powerful lips (fleshy), guarding mouth

 Followed by swollen subglobose head (cephalic swelling) (swollen
head bulb) that is covered by rows of spines (according to species )
usually four rows
  This swelling is separated from remainder of body by cervical
constriction

Number, shape, distribution of spines vary according to species

The anterior half is covered with leaf-like spines, posterior half is aspinose
except for few small terminal spines.

Worms are usually curved ventrad at both ends.

Cephalic portion of body is covered with 4-8 transverse rows of sharp,

recurved hooks.

Esophagus: four conspicuous cervical glands are arranged symmetrically

around esoghagus. They fuse into pairs, open through 2 ducts that
perforate lips. These glands hang into pseudocoel from their attachment
near anterior end of esophagus.

The head bulb is divided internally into four hallow areas (ballonets) each
cervical sac has cervical canal which is continuous with ballonet

Male

 Bluntly rounded posterior end

 Pseudobursa provided with 4 pairs of nipple like ventral perianal
papillae
 2 unequal copulatory spicules chitinoid rods with blunt tips

Female

 Posterior end is blunt

 Vulva is postequatorial
 Vagina is long, anterior directed
 Other genital tubes are paired

Eggs

 Ovoid, 70×40μ, brownish

  Transparent, superficially pitted with mucoid plug at one end
 Unembryonated when laid

Life cycle

Adult lives in tumors in stomach wall of cats,dogs

Unembryonated eggs are extruded from lesions in feces into fresh water

Embryonation is complete in 1week

Motile first stage larva (round anterior end with spines) emerges from
eggshell.

It is eaten by species of cyclops ( sensu lato), force its way into hemocele of
crustacean and metamorphosis in 2week into second stage larva (has head
bulb armed with four rows of single pointed spines and two pairs of
cervical glands like adult.

Infected cyclops are eaten by fishes, frogs or snakes, larva develop into
third stage in flesh of these animals. (This is called primary infection)

Other hosts are not suited to be definitive host, including man, may ingest
vertebrate host containing third stage larvae and become infected. This is
called secondary infection since larva undergoes no further development,
such host is paratenic. Third stage larvae may pass from one paratenic host
to another as predator of smaller host becomes in turn prey of a larger.

When suitable definitive host eats either infected second larval or paratenic
host, infection develops to maturity in stomach wall in 6 months
completing the cycle.

Epidemiology

Modes of infection:

 Eating inadequately processed fish containing encapsulated third

stage larva
  Domestic duck, chicken
 Skin penetration during handling of animal flesh in preparation of
food so female more than male
 Direct swallow copepods in drinking water from ponds or streams

Pathogenesis, pathology and symptomatology

In definitive reservoir hosts, in which adult worms are coiled inside tumors
of digestive tract, is referred as gnathostomiasis interna but not in human
(paratenic host).

In human, third stage larvae, with either 4 or 8 cephalic rings of spines,

migrate into tissues, their presence usually evident when they reach
superficial layers. (gnathostomiasis externa) it includes both

1. Development of abscess pockets or indurated nodules with

abscessed centers
2. Formation of deep cutaneous or subcutaneous tunnels in which
worms migrate, causing larva migrans of gnathostomiasis differ from
hookworm (in gnathostomiasis they are usually deeper,
subcutaneous, more frequently in muscle)

The swellings are intermittent migratory, circumscribed, upto several

centimeters in diameter, hard, nonpitting, last for 1to4 weeks. Then they
disappear, appearing new after free interval of 1 week to several months in
new location not far from previous one. Swellings appear most frequently
on upper extremity, shoulder, neck, thorax, face, scalp, abdominal wall,
thigh and dorsum of foot. The lesion is relatively free of discomfort or be
pruritic or painful. Pain may be mild or severe as to disturb sleep.

If swelling is subcutaneous, there usually sign of inflammation, redness and

pain. They are absent in more common deeper lesions except pain.

Swelling is due to allergic reaction to worm and its products and little
mechanical damage. There is intense cellular infiltration with neutrophils,
small mononuclear and plasma cells and massive number of eosinophils.
Any part is invaded such as mucous membrane of mouth, pharynx,
intestine anus or cervix producing visceral larva migrans. It found in urinary
bladder and expelled from respiratory tract by coughing. It may invade eye
by migration via optic nerves or penetration through sclera.

It may invade central nervous system causing encephalomyelitis through

migration along peripheral nerve into spinal cord to brain. Pain, paralysis,
seizures or coma depend on location of worm. Eosinophils are found in CSF
confused with eosinophilic meningitis by angiostrongylus cantonensis but it
is more severe, fatal course with paralysis or coma and bloody or
xanthochromic CSF.

Diagnosis

Specific by removing worm, intradermal test (0.5ml of 1:50000 saline

solution of antigen prepared from larval or adult, read in 15 minutes. It
support clinical diagnosis when positive), precipitin reaction with patient's
serum, blood picture in patient with edema and leukocytosis with
hypereosinophillia highly suggestive in enzootic areas.

Differential diagnosis

Non migrating type with furunculosis or localized bacterial processes

Migrating type with migrating larvae of hookworms, cutaneous myiasis

Treatment

Incision of lesion and remove larva.

Surgical removal from eye save vision, prevent migration to brain

Prognosis

Good except if involve centeral nervous system

Prevention

Cooking fish or immersion in strong vinegar for 5 hours or longer

Gnathostoma hispidum
Common parasite in stomach wall of wild, domestic pigs in Europe and Asia

It is stouter than Gnathostoma spinigerum, has 12 rings of cephalic spines,

has multidigitate cuticular spines extending to caudal extremity, only one
pair of small ventral alar papillae in male.

It found in progressive linear sweeling of left thenar eminence

Physaloptera caucasica
(Stomach worm)

Geographical distribution

Zaire, Zambia, Zimbabwe, India, Colombia, Chelic (tropical countries)

Definitive hosts are monkeys, occasionally man

Morphology

May be mistaken with immature ascarids

Male up to 5cm×1mm, female up to 10cm×2mm

Cuticular collarette around head, pair of fleshy lips around mouth with
characterized pattern of dental processes and papillae

Male has assymetrical caudal alae, copulatory bursa, unequal spicules with
hooked distal end and transversely bossed perianal cuticle

Female has preequatorial vulva

Egg is thick shelled 60×40μ, mature on laying

Life cycle

Eggs in stool of man or reservoir host

Ingested by coprophagous beetles or cockroached (first intermediate host)

Ingested by second intermediate host or paratenic host (vertebrate host)

Human ingest first, second or paratenic host

Parasite live in digestive tract from esophagus to ileum and liver with
anterior end embedded in wall

Pathology, clinical presentation

Anterior end is embedded in mucosa and byproducts of worm causing

sever necrosis, ischemia, and gangrene of gastro intestinal tract

In resection, ischemic necrosis, eosinophilic granuloma, larva in lumen and

wall of blood vessel

It causes vomiting, severe gastritis (epigastric pain) and eosinophilia

Diagnosis

Formol-ether technique for concentration of feces, examination of

sedimented contents of stomach and duodenum

Treatment

Carbamazine dervatives
Thelazia callipaeda, Californiensis

Oriental eye worm

Geographical distribution

Far East, california, Thailand, Japan

Definitive hosts: parasite of conjunctive of dogs, rabbits occasionally man

Morphology

Creamy white, thread like (0.5-1.5 cm ×0.5 -1mm) with cephalic papillae

Male has recurved posterior end, perianal papillae, gubernaculum and two
spicules

Female has pre-equatorial vulva

Egg is oval, hyaline thin shell (50×35μ) fully embryonated when laid

Life cycle

Intermediate host: Fannia, Musca (transmit infection)

Mode of infection: flies transmit larva either from eye to eye or ingestion of
these arthropods or infected water

Clinical presentation

Adults are present in conjunctival sac (coiled) or migrating over cornea

causing excessive lacrimation, foreign body sensation, keratitis, corneal
opacity, paralysis of lower eye lid muscle, ectropion, conjunctivitis, itching
and pain.

Diagnosis

Worm are seen, felt while crossing over cornea (creamy white thread like).
Removal with forceps and identification under microscope
Treatment

Removed by forceps after topical anesthesia

Prognosis

On removal of worm from conjunctiva , irritating symptoms disappear but

superficial opacity of cornea resulting from scarification produced by worm
may be permanent.

Prevention

Care not to ingest suspected arthropods or raw drinking water

Congylonema pulchrum
Scutate thread worm, filaria labialis

Geographical distribution

.Man cases reported in Europe, Far East, USA

Cosmopolitan parasite of ruminants, pigs, bears, monkey and occasionally

from man

Morphology

Species affecting man, pigs are smaller than that affecting ruminants

Long, thin, male (6cm×0.3mm), female (12cm×0.5mm)

Esophagus is filariform

Anterior end is covered by numerous bosses or scutes, typically arranged in

8 longitudinal series, two each in four submedian fields. There is pair of
small lateral cervical papillae one on each side about 0.1 to 0.2 mm from
anterior extremity. Just posterior to papillae is pair of cervical alae, extend
distal almost as far as scutes. Excretory pore opens in to small crater like
prominence near junction of anterior muscular and posterior glandular
.portion of esophagus
Male: caudal end is asymmetrically alate, typical perianal pattern of
papillae, copulatory spicules are dissimilar, gubernaculum resembles
.midiron with short handle

Female caudal end asymmetrically bluntly conical, vulva is thick walled,

slightly protuberant, situated some distance in front of subterminal anus,
.vagina is long, extending cephalad to equatorial plane

Egg is transparent, thick shelled, broadly ovoid, embryonated when laid.

Eggs ingested by various species of dung beetles or cockroaches

(intermediate host) in intestine of which they hatch. They burrow into
.haemocele of insect hosts and encapsulated

.The definitive host including man infected by swallowing infected insect

Larvae become free of capsule and migrate within wall of stomach or

.duodenum up to esophagus or buccal cavity

Pathology, symptomatology

Maturing and adult worm migrate through mucosa and submucosa of

.buccal cavity cause damage

Lips, gums, hard and soft palate, tonsil and angle of jaw are site from which
worms were recovered

Most common to seen actively migrating in submucosa

Patients know their presence or may remove it by slight traction with

fingers

May accompanied by pharyngitis and stomatitis, reflux esophagitis or only

local irritation resulted may with spitting of blood

Esophagoscopy may reveal migrating maturing and adult worm erosive

patches on mucosa, from which blood is oozing. Biopsy revealed eggs in
.tunnel of mucosa similar to recovered from expectorated blood
No neoplasm, but in Gongylonema neoplasticum, G.orientale produce
neoplasm

Diagnosis

Discovery of migrating thread like worms in buccal mucosa identified under

microscope

Oesophagoscopy

Treatment

Removal by fingers or needle inserted under portion of worm in its tunnel

Genus Rictularia

Parasite of rodent and bat.

Adult has two subventral rows of spines or cuticular combs

Egg is thick shelled, mature

Reported once in histopathological section of appendix

Genus Cheilospirura

Reported from ovoid tumor on lower palpebral conjunctiva causing chronic

catarrhal conjunctivitis and keratitis

Genus Spirocerca

It causes intestinal obstruction, located by x-ray film in terminal ileum with

complication of peritonitis in infant.

Intermediate host is coprophagous beetles

Larva migrates transplacentally to fetus, in digestive tissue they develop to

maturity