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N EM ATO D A

Dr. SUHAEMI, SpPD,FINASIM

Phylum N em atoda
Roundworms
In nearly all habitats from poles to

tropics
Over 100,000 species
Tough cuticle covers body
Longitudinal but not circular muscles
Pseudocoelom acts as hydrostatic
skeleton and circulatory system
Complete digestive tract stylet

Dr. SUHAEMI, SpPD,FINASIM

IN TES TIN A L N EM ATO D ES

Ascaris lum bricoides


Giant intestinal

roundworm
Whitish or pinkish worm
More than 1 billion
individuals are affected
70% from Asia
Soil transmitted
helminth
Polymyarian

Somatic muscles are


numerous and project
well into the body cavity

Ascaris lum bricoides


Males = 10-31

cm
Ventrally curved

posterior end with


2 spicules

Females = 22

35cm
Straight, conical

posterior end

Ascaris lum bricoides


Trilobate lips

Ascaris lum bricoides


Unfertilized eggs
Narrower
Longer
Thin shell
Refractile granules

are not organized


Found in the absence
of males

Ascaris lum bricoides


Fertilized eggs
Thick transparent

hyaline shell
Ovoid mass of

protoplasm which
develops into
larvae at about 14
days

Ascaris lum bricoides


Embryonated

eggs
Infective stage
Embryonation

occurs in the soil

Ascaris lum bricoides

Retrieved fromhttp://parasitol.wkhc.ac.kr/image/nema/lifeal.JPG Feb. 2008

Ascaris lum bricoides


Pathogenesis and clininal

manifestations
Ascariasis
Causes varying degrees of pathology
Tissue reaction to larvae
Intestinal irritation to adults
Complications due to intestinal migration

Ascaris lum bricoides


Diagnosis
Direct fecal smear
Kato technique or

Cellophane Thick
smear method
Kato-Katz Technique
Quantitative
Intensity of infection
Per gram of feces

M igration ofW orm s


Larval forms enter blood and lymph

capillaries and travel to heart.


Heart to lungs, coughed up,

swallowed to the intestine


Then the worm can mature to an

adult.
Why such a pattern?

Ascaris lum bricoides


Treatment
Albendazole
Drug of choice
400 mg single dose
200 mg for children under 2 year old
Mebendazole
500 mg single dose
Pyrantel Pamoate
10 mg/kg body weight (max. of 1 g)

N ecator am ericanus
Hookworms that infect man
Soil-transmitted helminths
Blood-sucking
Attach to the intestinal mucosa

N ecator am ericanus
Small, cylindrical,

fusiform, whitish
worm

Female

Larger

(9-11 mm by 0.35mm)

Male

Smaller (5-9 mm by 0.30mm)


Posterior end has a

broad membranous
caudal bursa with riblike rays used for
copulation

N ecator am ericanus
Head
Curved opposite

the curvature of
the body
Like a hook at the
anterior end

Buccal capsule
semilunar cutting

plates

Ancylostom a duodenale
Slightly larger

than Necator
americanus
Head curves in
the same
direction as the
curvature of the
body

Ancylostom a duodenale
Buccal capsule
2 pairs of curved

ventral teeth

Ancylostom a duodenale
Copulatory bursa

of male

N ecator am ericanus
Rhabditiform larva
Resemble

Strongyloides
stercoralis
Larger
More attenuated
posteriorly
Longer buccal cavity
Smaller
genitalprimordium

N ecator am ericanus
Ancylostom a duodenale
Filariform larva
infective stage to

humans

N ecator am ericanus
Ancylostom a duodenale
OVA
Bluntly rounded

ends
Single, thin
transparent
hyaline shell
Unsegmented
during oviposition
2-8 cell stages in
fresh feces

N ecator am ericanus

LIFE CYCLE

N ecator am ericanus
Ancylostom a duodenale
Pathogenesis and Clinical Manifestations
Pathology of hookworm infection involves
The skin, at the site of entry of filariform larva
Maculopapular lesions ground itch or dew itch
Itching, edema, erythema leading to papulovesicular eruption
lasting for 2 weeks

The lung, during larval migration


Bronchitis
Pneumonitis

The small intestine, the habitat of the adult worm

Abdominal pain
Steatorrhea
Diarrhea with blood and mucus
Eosinophilia ( 30% to 60%)

N ecator am ericanus
Ancylostom a duodenale
Epidemiology
Over 900 million people infected
Associated anemia causes 50,000

deaths annually

Ancylostoma duodenale

Necator americanus

N ecator am ericanus
Ancylostom a duodenale
Prevention and Control
Sanitary disposal of human feces
Wearing of footwear
Health education
Treatment of infected individuals
Mass chemotherapy when prevalence is

greater than 50%


Protection of susceptible individuals through
Improved househod income
Improved diet to prevent malnutrition

N ecator am ericanus
Ancylostom a duodenale
Diagnosis

Direct fecal smear

only for heavy infections

Kato Technique

Increases detection rate

Kato Katz Method

Quantitative diagnosis

Zinc Sulfate Centrifugation


Formalin Ether Concentration
Harada-Mori

Allow hatching of larvae from eggs on strips of


filter paper with one end immersed in water

Ancylostom a caninum
Ancylostom a braziliense
Ancylostoma

caninum

Dog hookworm

Ancylostoma

braziliense

Cat hookworm

Both cause creeping


eruptions

N ecator am ericanus
Ancylostom a duodenale
Treatment
Albendazole
Drug of choice
Ovicidal and larvicidal
400 mg single dse in adults and children over 2
years old
Available in chewable tablets or suspension
Not recommended for pregnant women

Mebendazole
500 mg single dose in adults and children
Not recommended for children below 2 years old

Trichuris trichiura
Whipworm
Soil transmitted heminth
Often observed occuring together

with Ascaris lumbricoides due to


similarities in transmission and mode
of distribution
Holomyarian
Somatic muscles are small and closely

packed in narrow zones

Trichuris trichiura

Anterior three-fifths long and whiplike

Posterior two-fifths is thick and


fleshy

Inhabit the large intestine

Insert into the intestinal wall of the


cecum in a pin-fashion

Male
30-45 mm
Coiled posterior end
Single spicule
Retractile sheath

Female
35-50 mm
Bluntly rounded posterior end
Can produce over 60 million ggs
in an average life span of 2 years

Trichuris trichiura
Ova
Passed out

together with
feces
Embroyanation in
the soil (2-3
weeks)
Protuberant
bipolar mucus
plugs
Football in shape

Trichuris trichiura
Pathogenesis & Clinical

Manifestations
trichuriasis

Petechial hemorrhages predisposing to

amebic dysentery
Over 5,000 eggs /g of stool:
symptomatic
Over 20,000 eggs/g : severe diarrhea or
dysenteric syndrome

Trichuris trichiura

Rectal

prolapse
during heavy
infection

Trichuris trichiura

Trichuris trichiura
Diagnosis

Direct fecal
smear
Kato Thick
smear
Kato Katz
Concentration
Techniques
ZnSO4
Formalin Ether

Trichuris trichiura
Epidemiology
Distributed in warm. Moist areas of the

world
20% 30% prevalence in temperate
countries
60% - 85% in tropical countries
Children 5 to 15 years of age are
frequently infected

Trichuris trichiura
Treatment
Mebendazole
Drug of choice
500 mg single dose in light infections
2 3 days of consecutive treatment for moderate
and heavy infections
Contraindicated during early pregnancy and in
hypersensitivity

Albendazole
400 mg single dose
Contraindicated during pregnancy

Enterobius verm icularis


Pinworm or seatworm
Found in the lower ileum and cecum
Cuticular alar expansions : cephalic

alae
Prominent posterior esophageal bulb
Meromyarian
Somatic muscles arranged into 2-5 cells per

dorsal or ventral half

Enterobius verm icularis


Male

2-5 mm by 0.1-0.2 mm
Curved tail with a single
spicule
Dies after fertilizing the
female

Female

8 13 mm by 0.4 mm
Long pointed tail
Uteri of gravid females
are distended with eggs
Gravid female lays 4,
672 to 16,888 eggs/day
(11,105 eggs on
average/day)
Dies after deposition

Enterobius verm icularis


Ova

Assymetrical
D-shaped
Plano convex50-60 um
by 20-30 um
Embryonated when laid
Remain viable within 13
days in moist conditions
Translucent shell

Outer albuminous
covering for mechanical
protection
Inner lipoidal membrane
for chemical protection

Enterobius verm icularis

Enterobius verm icularis


Pathogenesis and Clinical

Manifestations

Enterobiasis or oxyuriasis
Familial disease
Pruritus perinei et periani
Other complications

Appendicitis
Vaginitis
Endometriosis
Salpingitis
peritonitis

Enterobius verm icularis


Epidemiology

Temperate and tropical regions


208.8 million are infected
Prevalence
29% among schoolchildren in private schools
56% among schoolchildren in private schools
Only nematode infection that cannot be controlled

through sanitary human waste disposal


Infection
Inhalation
Ingestion

Retroinfection

Enterobius verm icularis


Prevention and Control
Personal cleanliness ang hygiene
Chemotherapy for familial cases
Use of showers rather than bath tubs
Boiling of bed sheets, night wear,

blankets, etc.

Enterobius verm icularis


Diagnosis
Finding the adult

worm
Finding ova in
stool (only in 5%
of infected
individuals)
Finding ova in
scotch tape swabs

Enterobius verm icularis


Diagnosis
Graham s Scotch

Adhesive Tape
Technique
Cellulose Tape
Technique
Very sensitive and
specific

Enterobius verm icularis


Treatment

Pyrantel pamoate

Drug of choice
10 mg/kg with a second dose 2 to 4 weeks later

Albendazole

Alternative drug

400 mg single dose


Chewable tablets

Mebendazole

500 mg single dose


Chewable tablets

Strongyloides stercoralis
Free-living females
Parasitic females
Free living males
Parasitic males have not reliably been
identified
Only species naturally pathogenic to
humans
other species infect mammals and
birds

Strongyloides stercoralis
Rhabditiform larva
Feeding
225 um by 16 um
Elongated esophagus

with pyriform
posterior bulb
Slightly smaller tha
hookworm larva
Shorter buccal
capsule
Larger genital
primordium

Strongyloides stercoralis
Filariform larva
Infective
Non-feeding and

slender
550 um in length
Notched tail

Strongyloides stercoralis
Ova
Clear, thin shelled
Similar to

hookworm but are


smaller

Strongyloides stercoralis

Strongyloides infections of
humans can be fatal in two
situations.

individuals who are


immunosuppressed
(artificially or by other
disease) are susceptible to
a disseminated, and usually
fatal, Strongyloides
infection.
In addition in areas of New
Guinea Strongyloides is the
causative agent of 'Swollen
Baby (or Belly) Syndrome'
in which young infants
develop massive
Strongyloides infections
which are fatal unless rapid
treatment is given.

Strongyloides stercoralis
Pathogenesis and Clinical

Manifestations

Strongyloidiasis
3 phases of infection
Invasion of the skin by filariform larvae
Erythema
Pruritic hemorrhagic papules

Migration of larvae inside the body


Lobar pneumonia (lungs)

Penetration of intestinal mucosa by female worms

Strongyloides stercoralis
Epidemiology
50 to 100 million people are infected
Frequently found among male children

(7 14 years old)
More of fecally-transmitted worm rather

than soil-tranmitted

Strongyloides stercoralis

Strongyloides stercoralis
Diagnosis
Eosinophilia
Duodenal

aspiration
Small bowel
biopsy
Concentration
techniques
Harada Mori
Culture
Baer mann funnel

Strongyloides stercoralis
Diagnosis
Eosinophilia
Duodenal

aspiration
Small bowel
biopsy
Concentration
techniques
Harada Mori
Culture
Baer mann funnel

Strongyloides stercoralis
Treatment
All infected individuals must be treated
Albendazole
Drug of choice
400 mg for 3 consecutive days for adults and children
over 2 yeas of age
Eradicate up to 80% of infection
Thiabendazole
50mg/kg (max. of 3 g/day) in 2 divided doses daily for 2
consecutive days after meals
Contraindicated in pregnant women and those with

hypersensitivity to the drugs

Capillaria philippinensis
Tiny nematode in small intestines
Thin filamentous anterior end
Slightly thicker and shorter posterior

end
Esophagus has rows of secretory cells
called stichocytes
Stichosome refers to the entire
esophageal structure

Capillaria philippinensis
Male

1.5 to 3.9 mm
Has a spicule with an
unspined sheath

Female

2.3 to 5.3 mm
First generation of
female worms lay larvae
to build up the
population
Subsequent generations
produce eggs

Capillaria philippinensis
Ova
Peanut-shaped
Striated shell
Flattened bipolar

mucus plugs
36 um x 45 um x 20
um
Passed out in the
feces
Embryonate in the soil
and water

Capillaria philippinensis

1) Unembryonated eggs deposited in the intestinal lumen of either the avian or


human host are expelled in the feces, whereupon the eggs are released into the
external (usually aqueous) environment.
(2) The unembryonated eggs become embryonated while in the fresh- or
brackish-water.
(3) The embryonated eggs are ingested by fresh- or brackish-water fish. which
serve as the intermediate host for the Capillaria philippinensis. Inside the
intestinal lumen of the fish, the larvae hatch, burrow through the intestinal
mucosa, and permeate the fish's mesenteric and peripheral tissues.
(4) The parasite enters the intestinal lumen of humans, fish-eating birds, and
other animal hosts upon ingestion of raw or undercooked C. philippinensis
infected fish.
(5) The adult worms of Capillaria philippinensis burrow into the intestinal
mucosa (most typically of the jejunum).
(6)While in the intestinal lumen of the human or avian host, the female worms
deposit unembryonated eggs, which are subsequently expelled in the host's
feces. (Albeit a rare occurence, the eggs of Capillaria philippinensis may
become embryonated within the intestine of the human host. The subsequent
release of infective larvae leads autoinfection and hyperinfection. Photos on
this page courtesy of www.dpd.cdc.gov/.../ body_Capillariasis_page1.htm

Capillaria philippinensis

Capillaria philippinensis
Pathogenesis and Clinical Manifestations

capillariasis
Abdominal pains
Gurgling of the stomach (borborygmus)
Diarrhea
Noticeable weight loss, malaise, anorexia, vomiting,
edema
Severe protein losing enteropathy, malabsorption of
fats and sugars
Low electrolyte levels (especially K+)
High levels of IgE
death

Capillaria philippinensis
Epidemiology
First recorded in Northern Luzon, Philippines
2,000 cases documented in the Philippines
Thailand, Iran, Japan, Egypt, Korea, Taiwan,

India
Infection is acquired by eating uncooked
raw freshwater/brackish water fish bagsit

Capillaria philippinensis
Prevention and Control
Discouraging people in endemic areas to

eat raw fish


Good sanitary practices
Avoid washing fecally contaminated
bedsheets in lagoons
Educational programs

Capillaria philippinensis
Treatment

Electrolyte replacement
High protein diet
Antidiarrheal drugs
Antihelminthic drugs
Albendazole
400 mg once a day for 10 days
Drug of choice
Destroys larval stages

Mebendazole
200 mg 2x a day for 20 days

B LO O D A N D TISS U E
N EM ATO D ES

W uchereria bancrofti
Pathogenesis
causes chronic

disfiguring disease
presenting as
lymphedema,
elephantiasis,
hydrocoele

W uchereria bancrofti
Adults worms
Creamy, white ,

long filariform in
shape

Male
2 4 cm in length

Female
8 10 cm in

length

W uchereria bancrofti
Microfilaria
Appear as minute

snake-like organisms
among the red blood
cells
270 um 290 um
enclosed in a sheath
that is longer than the
microfilaria
Central axis shows
dark-staning nuclei

W uchereria bancrofti

Brugia m alayi

Adult worms
Male
13 23 mm
Female
43 55 mm
Indistinguishable
from adult female
W. bancrofti

Brugia m alayi

Microfilaria
177 230 um
Enlosed in a

sheath with
angular
curvatures and
secondary kinks
2 terminal nuclei
at the tip of the
tail

Brugia m alayi
Wuchereria bancrofti

Brugia malayi

Mean length

290 um

222 um

Cephalic space:
breadth

1:1

2:1

Sheath in Giemsa

unstained

pink

nuclei

Regularly spaced;
separately situated

Irregularly spaced
and overlapping

tail

Single row that does


not reach the tails
end

Single row that


reaches the tails end

Terminal nuclei

None

2 nuclei

Appearance in blood
film

Smoothly curved

kinky

Brugia m alayi

W uchereria bancrofti
Brugia m alayi

Epidemiology

More than 1 billion people in over 80 countries are at risk


Over 120 million peole are affected
43 million are seriously affected
In the Philippines:

Camarines Norte
Camarines Sur
Albay
Sorsogon
Mindoro
Palawan
Romblon
Mountain Province
All provincrs of Mindanao

W uchereria bancrofti
Brugia m alayi

Epidemiology
Wuchereria bancrofti
Anopheles minimus var. flavirostris
(principal vector for malaria) ; rural
Culex: urban
Aedes poecilus (abaca and banana plants)
Brugia malayi
Mansonia bonnae

W uchereria bancrofti
Brugia m alayi

Diagnosis

Microscopic finding of
characteristic microfilariae
in wet smears or thick blood
smears
Diethylcarbamazine
provocative test (3mg/kg
single dose) stimulates
microfilariae to come out to
the peripheral circulation
Detection of circulating
filarial antigens
Ultrasonography may
demonstrate live worms in
the lymphatics

W uchereria bancrofti
Brugia m alayi

Prevention an Control
WHO has targeted elimination of

filariasis by 2020
DEC medicated table or cooking salt
Elimination of microfilariae in the blood
Personal protective measures

W uchereria bancrofti
Brugia m alayi

Treatment
Diethylcarbamazine (DEC)
Drug of choice
6 mg/kg body weight for 12 days
Divided doses after meals
Ivermectin
200 to 400 ug/kg body weight in a single
ral dose

W uchereria bancrofti
Brugia m alayi

W uchereria bancrofti
Brugia m alayi

Trichinella spiralis
3 species that can infect humans
Trichinella spiralis spiralis : temperate

regions
Trichinella spiralis nativa : arctic regions
Trichinella spiralis nelsoni : Africa

Trichinella spiralis

Adult worms
Whitish in color
1.5 to 3.5 mm by

0.04 to 0.06 mm

Trichinella spiralis

Female

3.5 mm by 0.06 mm
Single ovary
Oviduct, seminal

receptacle, coiled
uterus, vulva, vagina

Male

1.5 mm by 0.04 mm
Single testis
Posterior cloaca
Pair of caudal
appendages
Pair of papillae

Trichinella spiralis

Larva
80 to 120 um by

5.6 mm at birth
Reaches 900 to
1300 um by 35 to
40 um when it
enters the muscle
fiber
Spear-like
burrowing anterior
tip

Trichinella spiralis
Hosts serve both as final and intermediate

host by harboring the adut and larva stages


Host

Humans
Rats
Dogs
Cats
Pigs
Bears
Foxes
Carnivores/omnivores

Trichinella spiralis

Trichinella spiralis

Pathogenesis
Trichinosis: zoonosis
Self-limiting disease
Patients with approx. 10 larvae: light

infection: asymptomatic
50 to 500 worms: moderate infection:
symptomatic
1,000 larvae: severe: fatal

Trichinella spiralis

Pathogenesis
Clinical manifestations
Incubation and intestinal invasion
Diarrhea or constipation
Vomiting, malaise, nausea, abdominal
cramps, similar to acute food poisoning

Larval migration and muscle invasion


Myalgia, periorbital edema, eosinophilia
-complications: splenomegaly, meningitis,
cerebral lesions

Encystment and encapsulation

Trichinella spiralis

Diagnosis
Based on history

of exposure
Demonstration of
encysted larvae in
muscle biopsy
Biochemical tests
Becks
xenodiagnosis

Trichinella spiralis
Epidemiology
Occurs whenever meat is part of the diet
Human infection: dead end infection

Trichinella spiralis
Prevention and Control
Health education
Cooking of meat at 77 0C, storage at -15

C, for 20 days or -30 0C for 6 days


Smoking, salting, drying meat are not
effective
Meat inspection
Keep pigs in rat-free pens
0

Trichinella spiralis
Treatment
Thiabendazole
25 mg/kg body weight twice a day for 7 days
during the first week of infection expels the adult
worm from the GI tract
No effect on migrating larvae and infections
detected 2 weeks after exposure

Mebendazole
Larvicidal
Given at 20 mg/kg body weight 6-hourly for 10 to
14 days