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Dracunculus medinensis

Dr. Subhash Chandra Parija
MD , PhD, DSc, FRCPath
Dean (Research) , JIPMER

Phylum Nematoda
Class Secernentea
Order Spirurida
Family Dracunculidae
Dracunculus medinensis
Dracunculus medinensis
 Guinea worm, medina worm, or serpent worm
 The traditional symbol for a doctor is the serpent
wound round a stick.
 This has always been supposed to be a snake but a
more serious suggestion is that the creature is the
guinea worm and the sign of a healer is a man who
can get rid of the worm.

Adult worms
 Female
 One of the largest nematodes known
 Milky white, slender worm
 Measure 50-120 cm x 07-1.7 mm
 In anterior end, a minute triangular mouth is
 They are viviparous
 Uterus is filled with thousands of eggs, embryos
and first stage larvae

 Male
 Measures 15-40 mm x 0.4 mm
 Die immediately after fertilizing the females

 First-stage larva
 Unsheathed and coiled with round
anterior end and long slender
filariform tail

 Definitive Host: Humans
 Intermediate Host: Cyclops (Mesocyclops
leuckarti, M. hyalinus)
Life cycle
Life Cycle
 Source: Water containing infected cyclops
 3
Stage larva released in stomach and then reaches
small intestine
 After fertilisation the female migrates into tissues
 On contact with water the female releases large
number of first stage rhabditiform larvae
 The larvae are ingested by cyclops
 In the cyclops it undergoes 2 moults to develop into
third stage larvae
 Cyclops harbouring the third stage larvae infects the
human host and the cycle continues

3 Mandatory Conditions
 Skin of infected persons must come into
contact with water
 Water must have cyclopoid crustacean
 Water must be used for drinking
Pathology and Clinical Signs
 Three major disease conditions can
occur from Dracunculus infection:
1. Emergent adult females cause hot
and painful blisters
2. Secondary bacterial infections
3. Nonemergent worms that die
under skin cause allergic reactions that
could lead to death
 Bacterial infection can cause ulcers and
abscesses to develop, which are very
painful and can cause disability for
extended periods of time
 About ½ of the cases are complicated by
bacterial infection of ulcers
 Application of antibacterial agents to ulcers
is important in case management
 Bacterial infection becomes more serious
when the bacteria are drawn under the skin
by a receding worm
 In parts of Africa, this is the 3
most common
mode of entry for tetanus spores.
 Other complications that can occur are:
synovitis, arthritis, and bubo.

 Sometimes when worms do not
emerge, they begin to degenerate and
release antigens. Which cause aseptic
abscesses, which can also lead to
 Abscesses can be BIG, holding up to ½
Liter of fluid
 More commonly the worms become
 Nonemergent worms can cause
problems within tissues deeper in the
 Although many die and become absorbed
or calcified, without much apparent effect
on the host.
 Chronic arthritis is common if the worm
is calcified alongside or in a joint.
 More serious symptoms, like paraplegia,
result from the worm in the CNS.

Host Immune Response
 Allergic reaction occurs due to the release of
metabolic wastes from the worm.

 This may cause a rash, nausea, diarrhea,
dizziness, and localized edema.

 Reinfection may occur. No immunity.
Clinical manifestations
 Pre-patent period: 10-14 months
 Asymptomatic until the female worm reaches the skin
 Papule which develops into a blister is the first sign
 Blisters are usually found on the legs between the
metatarsal bones, on the sole and on the ankles
 Intense burning pain at the site of blister
 Urticaria, nausea, dyspnoea, giddiness
 Secondary bacterial infection

Geographical distribution
 Once prevalent in 20 nations of Asia and Africa

 But now endemic only in
 Sudan, Mali, Ethiopia (Africa)
 Saudi Arabia, Iran and Yemen (Middle East)

 India was declared free from this disease in 2000 by WHO

 In 2010 - < 1800 cases were reported worldwide

 94% of the cases are found in South Sudan
Asia, Africa, Indonesia
 Parasitic diagnosis
 First stage larvae can be observed in the
discharge fluid
 Adult worm can be detected when it appears at
the surface
 Serodiagnosis

 Imaging methods
 X-ray demonstrates dead and calcified parasites
 Winding the protruding worm on a stick has been a
successful treatment since antiquity.

 Because the worm protrudes only a few centimeters per
exposure to water, this procedure takes, on average,
three weeks to completely remove the worm.

 The worm can also be removed surgically, and some
drugs are used, but the evidence for their effectiveness is

 Thiobendazole or Mebendazole enables rapid emergence
of the worms and quick healing
Control/ Prevention
The most important strategies for the
eradication of Dracunculus have been:
1. Supply of safe drinking water.
 Boiled or filtered water
2. Health education.
3. Early case containment.
4. Vector control.
(Temephos, is a chemical that has low toxicity to
mammals and fish, but kills copepods for 4-5 weeks at a
concentration of 1ppm)
Onchocerca volvulus
 Family Onchocercidae
 Causes „river blindness‟
 Transmitted by female black flies of the
Simulium damnosum complex
 Affects 40 million people mainly in Tropical
Africa and South America.
 Second major cause of blindness in the
Onchocerca volvulus
Onchocerca volvulus
The “black fly”
 Definitive host-Man
 Intermediate host- Female black flies of
genus Simulium
 They are pool feeders and suck in blood and
tissue fluids
Life cycle
Life cycle
 Microfilariae migrate to thoracic muscles of fly
 Develop into filariform (infective stage)
 Infective stage migrate to the mouth parts.
 Extrinsic incubation period is -6 days.
 Life span of adult worm in human host is
about 15 years.
 Life span of microfilariae- 1 year.

Skin snips for
microfilaria with
oculoscleral biopsy
 UN Development Program, World Bank, and
WHO funded the OnchocerciasisControl
Programin 11 West African countries, 1974-
2002 (extended to 2007)
 African Program for OnchocerciasisControl in
19 central African countries, 2000-2010
 Goal: Disease elimination through drug
Control of Onchocerciasis

 Stop black fly transmission of parasite
to humans
 Over time, the human “reservoir”of
parasites decreases
 9-11 year parasite life cycle, 14-20
years of insecticide applications needed
 >35,000 miles of river sprayed weekly

Strategy of Vector Control:
 Ivermectin is the drug of choice.

 DEC causes the Mazzotti reaction- pruritus,
rash, lymphadenopathy, fever, hypotension,
and eye damage.
Loa loa
Loa loa
 Also called 'eye worm‟
 Causes „Calabar swellings‟
 Currently endemic in west and central
 Adult worm- 30-70x 0.3-0.5mm
 Sheathed microfilariae.
 Vector- Chrysops

Calabar swellings
Affecting the conjunctiva
 Adult worm- removal from the skin or
the conjunctiva
 Microfilaria- peripheral blood collected
during the day.
 Treatment – Surgical removal of the
adult worms.