COMMON INTESTINAL WORMS FOUND IN SOUTHERN AFRICA CESTODES AND TREMATODES #204

Prof. M A Kibel and D Hanslo

QUESTION 1
How do cestode worms differ from the roundworms?

ANSWER 1
As a group they are:

flat worms hermaphrodites (both sexes in same worm) have no body cavity

QUESTION 2
Which species of cestode are important clinically in

Southern Africa?

ANSWER 2
The most important is the pork tapeworm, or Taenia

solium. Others which are also found are Taenia saginata (beef tapeworm) and Echinococcus, the cause of hydatid disease.

QUESTION 3
What do tapeworms look like?

ANSWER 3
They are long worms (up

to 25 meters in length), consisting of flattened segments (proglottids) which get progressively smaller towards the head end, or scolex The scolex is attached to the mucosa of the small intestine with suckers, and/or hooks.

QUESTION 4
Man is the definitive host for Taenia species (the beef

and pork tape worms). What does this mean?

ANSWER 4
It means that adult tapeworms can only survive in the

gut of humans. The eggs are discharged from segments passed in the stools, and these require an intermediate host to complete the cycle. The intermediate hosts are cattle, in the case of T. Saginata, and the pig or other animals (including the dog) in T. Sollum.

Continued...

ANSWER 4 (Contd)
Life cycle of Taenia solium
Eggs ingested by pig Larvae form cysts in pigs muscles Adult worms in gut Eggs and segments passed in stool

Undercooked pork eaten Cysts form in tissues (Cysticercosis)

Child ingests eggs

QUESTION 5
How then is the life cycle completed?

ANSWER 5
Eggs are ingested by the animal (cow, pig or dog) and

the larvae migrate to form cysts (cysticerci) in the muscles of the intermediate hosts. Man eats the flesh of these hosts, (generally beef or pork) , and the cysticerci mature into adult tapeworms in the gut.

QUESTION 6
If a human ingests the eggs, what happens?

ANSWER 6
In the case of the pork tapeworm, cysts can form in the

tissues in the same way, resulting in Cysticercosis. For some reason, beef tapeworm larvae cannot migrate in humans.

QUESTION 7
What are the clinical features of tape worm infestation?

ANSWER 7
In most cases the presence of the adult worm is quite

symptomless segments (proglottids) are merely passed in the stools. There may be symptoms of allergy urticaria or pruritis ani, and a mild eosinophilia in the blood count. They do not feed on the mucosa of the gut and simple absorb nutriment from the bowel contents. Rarely worms can cause obstruction to the bowel, or a segment migrate into the appendix to cause appendicitis.

QUESTION 8
What then is the importance of tapeworm?

ANSWER 8
Cysticercosis is an important health problem in

communities where pigs are allowed to run free, and children pick up the eggs in food, water, dust or dirt, thus developing the cystic form. They are also a danger to themselves by auto-infection that is, transfer of eggs from hand to mouth.

QUESTION 9
Where do the cysts develop?

ANSWER 9
Cysts can develop almost

anywhere in the body beneath the skin, in muscles and heart, in the eye, and, most importantly, in the brain. They do not cause symptoms until they die, swell and calcify usually some years after infection .

QUESTION 10
What are the symptoms of Cysticercosis?

ANSWER 10
The severity increases with the number of cysts present.

The most important effects are caused by cysts in the brain (neurocysticercosis). There are focal or generalised seizures, sometimes with personality changes and other neurological effects. Neurocysticercosis is a common cause of epilepsy in some parts of the country rural areas where pork is commonly eaten.

QUESTION 11
Are there other symptoms of Cysticercosis?

ANSWER 11
When present in the eye they can cause retinal

detachment and loss of vision. Cysts elsewhere are usually benign.

QUESTION 12
How is tapeworm diagnosed?

ANSWER 12
The segments when

found in the stool are typical. The proglottids of T saginata and T solium have slightly different appearances which can be distinguished under a microscope.

Continued...

ANSWER 12 (Contd)
The eggs of tapeworm

are also very characteristic, though the 2 species are identical in appearance.

QUESTION 13
How is the diagnosis of Cysticercosis made?

ANSWER 13
Usually with the

assistance of imaging techniques. Calcified cysts may be seen in straight X-rays of muscles (as in this case) or skull, but this is only found in longstanding cases.

Continued...

ANSWER 13 (Contd)
Far more sensitive is the

use of the CT scanner, particularly so in neurocysticercosis. As in this slide. It shows numerous small cysts. When cysts die there is an inflammatory response, hence the oedema present round some lesions. Continued...

ANSWER 13 (Contd)
When in or near the

ventricles larger multilocular cysts may form, sometimes causing obstructive hydrocephalus.

QUESTION 14
Are there any other means of diagnosis?

ANSWER 14
Serological tests are available, such as an ELISA test,

which can be used on blood or CSF.

QUESTION 15
What is the treatment?

ANSWER 15
The adult tapeworms - both T saginata and T solium -

can be rapidly eliminated with Praziquantel, as a single oral dose of 10-20 mg/kg. Niclosamide (Yomesan) is also effective (0,5 gm as a single tablet, repeated in one hour).

QUESTION 16
How would you treat neurocysticercosis?

ANSWER 16
There is now general agreement that killing the cysts all

at once is the best line of attack. This can be accomplished with praziquantel in a dose of 50 mg/kg per day in 3 divided doses for 14 days. Albendazole 15 mg/kg per day for 5 days has also been shown to be effective. The administration of corticosteroids controls the brain swelling which can accompany death of the cysts. Anticonvulsant may also be required.

QUESTION 17
What other cestode parasites are of importance in

Southern African children?

ANSWER 17
In terms of severity of

clinical effects, the most important is the tapeworm Echinococcus granulosus. This is a small worm which lives in the intestine of the dog.

Continued...

ANSWER 17 (Contd)
The dog is thus the definitive host. The eggs which are

passed in the dogs stools are eaten by sheep (intermediate host) and the larvae develop into hydatid cysts in the tissues.

ANSWER 17 (Contd...)
The cycle is completed when dogs are fed sheep offal

containing the cysts. Children become infected when they pick up eggs from the dog's fur or from the dog's tongue after licking.

Continued...

ANSWER 17 (Contd...)
Life cycle of Echinococcus (Hydatid)
Adult worm in jejunum of dog Eggs passed in stool Eggs ingested in sheep Larvae form cysts in sheeps flesh

Dog eats sheep offal

Child ingests eggs

Larvae penetrate bowel wall

Cysts form in tissues (liver, lungs, bone, brain)

QUESTION 17
Where do the cysts form?

ANSWER 17
The most common sites

are the lungs and the liver, but any tissue, including bone, may be invaded. When allowed to grow, the cysts become large round swellings, and cause symptoms like a tumour, by pressing on organs. This may take years to develop. The fluid from cysts contain hydatid 'sand' and hooklets.

QUESTION 18
Can there be any more severe symptoms?

ANSWER 18
If fluid is allowed to leak out of the cyst, severe allergic

symptoms can result.

QUESTION 19
How is the diagnosis made?

ANSWER 19
Usually by arranging - straight X-ray, ultrasound of CT

scan - when the appearances are usually very characteristic. A significant eosinophilia is generally present. The most reliable serological test is the 11-RC5 test.

QUESTION 20
How is hydatid treated?

ANSWER 20
By surgical removal whenever possible, special care

being t taken to avoid spilling the contents. In inoperable cases, albendazole has been used in a dosage of 10 mg/kg a day for 8 weeks.

QUESTION 21
Can hydatid disease be prevented?

ANSWER 21
Yes. By:

enforcing regulations against dogs eating sheep offal, and by the regular de-worming of dogs in affected areas with praziquantel every 2 months. Using these measures hydatid disease has been totally eliminated from some regions.

QUESTION 22
Are there any other tapeworms of importance to us?

ANSWER 22
Several other species are common in Southern Africa,

but they seldom cause significant symptoms, and so will not be discussed further here. They are: Hymenolepis species Dipyllidium caninum, and Inermicapsifer madagascariensis. These worms are readily eliminated by praziquantel or niclosamide.

QUESTION 23
What are trematode worms and how do they differ from

the nematode and cestode worms?

ANSWER 23
TREMATODES (FLUKES) are a family of worms

which have flattened bodies, have a gut, but no body cavity, and a dorsal and ventral sucker. By far the most important members of this family in Southern Africa are the Schistomes. They are so called because the male has a fissure in the body in which he carries the female (see next slide).

Continued...

ANSWER 23 (Contd)

QUESTION 24
What are the most important schistosome worms in

Southern Africa?

ANSWER 24
Schistosoma haematobium and S mansoni are

responsible for SCHISTOSOMIASIS, also known as BILHARZIA. Bilharzia is widespread in Botswana, Zambia, Zimbabwe and Mozambique, and in the North Eastern parts of South Africa, as far South as the Port Elizabeth area. Another schistosome, S matheii, lives in cattle and game, and is thought to infect humans too, perhaps by hybridising with S haematobium. A third member of the genus of great importance is S japonicum, but this is only found in the Far East.

QUESTION 25
Describe the life cycle of S haematobium.

ANSWER 25
This is complex, and requires man as the definitive host,

and certain species of fresh water snails as the intermediate host.

Continued...

ANSWER 25 (Contd)
Life cycle of S haematobium
Eggs laid in portal veins Eggs are passed in urine Child passes urine in water Larvae (miracidia) hatch seek out snail

Cycle continues in snail Larvae (cercariae) emerge, seek out human

Worms mature in portal veins

Larvae (Schistosomulae) circulate

Cercariae penetrate skin

Continued...

ANSWER 25 (Contd)
The adult worms live in the portal veins of the human,

the female lives continuously in amatory union, partially enclosed in the male. The female lays eggs in the plexus of veins around the bladder, and the eggs digest their way through the bladder mucosa to be passed in the urine. The resultant damage to the mucosa, bladder wall and ureters causes the symptomatology of bilharzia.

Continued...

ANSWER 25 (Contd)
When the child urinates in rivers or dams eggs are

passed into the water. The tiny larva, or miracidium, is a good swimmer and must find a snail, which it enters, to complete the next phase of its cycle.

Continued...

ANSWER 25 (Contd)
Another free swimming

larva, the ceraria, leaves the snail, and must find a human within a few hours or it is no longer infective.

Continued...

ANSWER 25 (Contd)
The cercaria penetrates

the skin of the host, sheds its tail, and then enters the blood stream, eventually reaching the portal veins, in which it matures to adulthood The worms can survive there for many years.

QUESTION 26
Is the life cycle of S mansoni any different?

ANSWER 26
The worms prefer the veins of the bowel rather than the

bladder, and the passage of eggs causes damage to the colon, mainly. Eggs are therefore passed in the stool and not in the urine. The human defecates near water, and the eggs, which can survive in the moist stool for some time, are washed by rain into the water source. The rest of the cycle is similar to S haematobium.

Continued...

ANSWER 26 (Contd)
Life cycle of S mansoni
Eggs laid Pass through bowel wall Eggs in stool Eggs washed into water Larvae (miracidia) hatch seek out snail Cycle continues in snail. Larvae (cercariae) emerge seek out human

Worms mature in portal veins

Larvae (Schistosomulae) circulate

Cercariae penetrate skin

QUESTION 27
The clinical features of schistosomiasis may present in

4 stages. What are they?

ANSWER 27
Clinical features of Bilharzia:

Swimmers itch Katayama fever Early egg-laying stage Late egg-laying stage ? malignancy

Continued...

ANSWER 27 (Contd)
Symptoms may be associated with each of 4 stages of

the infection. At the time when the cercariae penetrate the skin an itchy eruption may develop, lasting a few days 'Swimmers' itch'. A similar rash may be caused by other types of schistosome found in birds, in countries where bilharzia is unknown.

Continued...

ANSWER 27 (Contd)
The schistosome larvae (schistosomulae) enter the lymphatic and thence to the blood stream, eventually reaching the portal veins and the liver where they mature into adult worms. This migratory phase may be associated with systemic symptoms due to release of metabolic products of the schistosmes. This has been called 'Katayama Syndrome'.

QUESTION 28
What are the features of the Katayama Syndrome?

ANSWER 28
Features of Katayama Syndrome. There may be any or

all of the following: Fever and malaise Cough Marked eosinophlilia Liver tenderness, splenomegaly Abdominal discomfort and diarrhoea Joint and muscle pains Urticaria, sometimes anaphylactoid purpura Rarely, encephalopathy, myocarditis

QUESTION 29
What are the other stages?

ANSWER 29
The early egg-laying stage:

Dysuria, frequency and terminal haematuria, in the case of S haematobium infection, Symptoms of dysentery in S mansoni

QUESTION 30
Do these symptoms always occur?

ANSWER 30
No - the majority of infections pass unnoticed. But

bilharzia may be the cause of vague ill health and poor performance at school. It is only in the heavier infections, and in individuals with no prior immunity, that illness is apparent.

QUESTION 31
How long does this process last?

ANSWER 31
Initially the eggs pass rapidly across the mucosa, but

gradually there is more and more reaction of the body's tissues to the eggs. Granulation tissue traps the eggs and results in fibrosis and eventually calcification - the late egg-laying stage. This may take years to develop, but is not uncommonly seen in older children.

Continued...

ANSWER 31 (Contd)
Late egg-laying stage:

chronic urinary obstruction bowel polyps and strictures liver fibrosis carcinoma of bladder, liver

Continued...

ANSWER 31 (Contd)
The earliest signs are

'sandy patches' in the lower part of the bladder - the trigone. Later there may be calcification of the bladder wall and fibrosis of the ureters, leading to obstruction in the flow of urine hydronephrosis. Continued...

ANSWER 31 (Contd)
Changes in the bowel are

usually more subtle, but there can be stricture formation and polyps in the colon.

Continued...

ANSWER 31 (Contd)
Hepatic fibrosis leading to portal hypertension.
Eggs lodging in the lungs and nervous system

(especially the spinal cord) may result in chronic cardiovascular and neurological syndromes. Schistosomiasis has been incriminated as a risk factor in carcinoma of both the bladder and liver.

QUESTION 32
How would you diagnose schistosomiasis?

ANSWER 32
By finding the typical eggs in urine or stool. To confirm

that the disease is active the eggs must be shown to a alive (viable) by seeing the typical movements within the egg. For this reason a fresh preparation of stool or urine must be available (not a stained slide).

QUESTION 33
What species is the

ovum in this slide?

ANSWER 33
S haematobium, because of the spine at the end. The

ovum of S mansoni has a spine on its side.

QUESTION 34
What is the treatment for schistosomiasis?

ANSWER 34
Praziquantel is the treatment of choice for all forms.

And is on the WHO 'essential drug list'. It is both safe and highly effective, in a single dose of 40 mg/kg.

QUESTION 35
Who should receive treatment?

ANSWER 35
This is a more complex problem. In some areas virtually

all members of a village will be affected. The children are the heavy passers of eggs, as resistance gradually builds up in adult life. Since a safe, effective treatment is available, mass treatment of the whole population is now possible, but there are clearly financial constraints to this policy. Treatment can be limited to specific groups, for example: certain age groups, or those with heaviest haematuria or egg load

QUESTION 36
What other measures are there to prevent bilharzia?

ANSWER 36
Preventing snails from becoming infected by:

limiting human access to water in highly infected areas, by building protected canals, etc providing latrines and discouraging urination in, and defecation near natural water Snail control by: eradicating vegetation favouring snail growth biological methods, e.g. snail-eating fish

Continued...

ANSWER 36 (Contd)
special attention to prevent snail breeding in new irrigation schemes snail control by chemical killing has become less popular because of harmful effects on the environment

QUESTION 37
Are there any other trematode worms of importance to

children?

ANSWER 37
There are a number of flukes which can infect the liver,

intestine and lung, but none are common in Southern Africa.

FURTHER READING
GOLDSMID, KIBEL AND MILLS; Helminth

infections. In Forfar and Arneil's Textbook of Paediatrics; 5th edition 1998 pages 1481-1513 COOVADIA & LOENING; Paediatrics & Child Health; 1992; p212 - 217 JEFFREY; Atlas of Medical Helminthology & Prctozoology; 1991; p5

THE END