Parasitic Diseases

in Respiratory System

dr. Wiwien S Utami, M.Sc

Department of Parasitology
 Löffler's syndrome
Loeffler's syndrome is a disease in which
eosinophils accumulate in the lung in response to a
parasitic infection.
•1932 by Wilhelm Löffler
Eosinophilic pneumonia caused by the
parasites Ascaris lumbricoides, Strongyloides
stercoralis and the hookworms
(Ancylostoma duodenale and Necator
americanus)
 Gejala Klinik
Batuk paroksismal
Dispnea
Pleuritis
Demam/sub-febril
Eosinophilic pneumonia
Löeffler 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

Adult Ascaris
worms migrating in
liver
Ascaris causing
intestinal
obstruction.
Acute G.I. Obstruction from Ascaris
 Interesting e mails…

Sent: Monday, April 04, 2005 4:32 PM

To: Patricia.F.Walker@HealthPartners.Com
Subject: health needs
I got your email address from my mother- Linda A.
I am an ELL teacher and have many students from
Liberia. I had a student complain about coughing up a
long white worm as he was eating a lemon at lunch. I
sent him to the nurse at school, as he said this was the
second time it has happened to him. She sent him back
to class saying there wasn't enough to tell anything at this
point. Is there anything you can suggest, or anywhere I
can direct his parents?
Thanks for your help!
Michelle R
Ascaris
(roundworm):
The only
nematode ever
coughed or
vomited up
 Paragonimus westermani
Diastoma pulmonum, Oriental Lung Fluke
(Trematoda Paru)
Distribusi ; Jepang, Korea, Asia
selatan&tenggara, Indonesia
(Indonesia di kep.Solomon, Papua, Jawa,
Sumatra)
Hospes : manusia, kucing, harimau
Host perantara : keong, udang air tawar
Paragonimus westermani
 BENTUK : MIRIP BIJI KOPI
 UKURAN : 8 – 16 x 4-8 mm
 KUTIKULA TERTUTUP SISIK ,SPT DURI -
DURI KECIL
 PENGHISAP ORAL > VENTRAL
 FARING PENDEK MEMBULAT
 COECUM TUBULER, TAK BERCABANG
 TESTIS 2 BH, BERLEKUK TAK TERATUR
LETAK BERDAMPINGAN
 OVARIUM, 6 LOBI, DI SBLH ANTERIOR
 KEL.VITELIN GRANULER DI LATERAL BDN
 CACING DEWASA
P. westermani

TELUR
UKURAN : 80-118 X
48-60 µm
BENTUK : LONJONG
OPERKULUM :
KECIL RATA (AGAK
TERTEKAN KE DALAM
TELUR BERISI SEL-SEL GRANULA
Paru dengan P.westermani
PARAGONIMIASIS PARU
Paragonimiasis paru, Ro
DAUR HIDUP Paragonimus westermani
Distribusi geografis Paragonimiasis
GEJALA KLINIK
Batuk kering sampai batuk berdahak
Hemoptysis
Nyeri di paru, pleuritis
Demam ringan
Kista di abdomen: nyeri perut,
distended, diare berdarah
Kista di otak : epilepsi, paresis
 Lung Flukes:
Paragonimus westermani

• Man gets infected

after ingestion of raw
or insufficiently
cooked crabs
harboring the
metacercariae

Prepared by FZHapan
 Lung Flukes:
Pathogenesis and Clinical Manifestations

• Paragonimiasis
– Cough
– Hemoptysis
– Symptoms consistent
with pulmonary
tuberculosis
– Misdiagnosed as PTB

Prepared by FZHapan
 Lung Flukes:
Diagnosis of Paragonimiasis
• Radiographs aid in
diagnosis
• Definitive diagnosis is
based on the finding of
ova in the sputum, stool
or less frequently in
aspirated material from
abscesses or pleural
effusions
• Multi-dot ELISA

Prepared by FZHapan
 Lung Flukes:
Treatment of Paragonimiasis
• Praziquantel
– Drug of choice
– 25 mg/kg body weight
3x a day for three day
• Bithionol
– 15 – 25 mg/kg / day
on alternate days for
a total of 10-15 days

Prepared by FZHapan
 Lung Flukes:
Epidemiology of Paragonimiasis
• Has a global distribution
• In the Philippines
– Leyte
– Sorsogon
– Mindoro
– Camarines
– Samar
– Davao
– Cotabato
– Basilan

Prepared by FZHapan
Pathology and Symptomatology
Adults inhabit lungs, although other organs are
also involved.
Pathological lesions may be classified into 4
stages:
(1)Invading and migrating stage: After excystation
the adolescents penetrate the intestinal wall and migrate to
the lungs.
(2) Suppurative stage. The bleeding and infiltration of
neutrophils and eosinophils surrounding worms form a
capsule, abscess.
 (3) Cystic stage, the cyst wall is formed due to the
progressive fibrosis of the surrounding tissue. The
cystic contents are chocolate or rusty thick fluid with
eggs and Charcot-Leyden crystals, which looks like
sesame paste.
(4) Fibrous-scar stage, the worms are dead or
escape from the cyst. The exudate and pus are
expelled or absorbed and replaced by fibrous-scar
tissue.
 Clinical manifestation:
Paragonimiasis may be classified into 4 types :
(1)Pulmonary type: the symptoms resemble
pulmonary tuberculosis with low fever, loss of
appetite, night sweating, chest pain, loss of weight
and rusty sputum.
(2) Brain type: manifests epilepsy, hemiplegia,
monoplegia,aphasia, visual disturbence and resembles
cerebral cysticercosis
(3)Abdominal type: abdominal pain，diarrhea or
dysentery with blood, mucus and ova in feces.
(4)Subcutaneous type: the wandering and
painless subcutaneous nodules.
Pneumocystis carinii

Deadly AIDS Opportunist

Pneumocystis carinii pneumonitis (PCP) is a common
opportunistic disease that occurs almost exclusively
in persons who have profound immunodeficiency.

PCP was and still is the most common life-threatening

opportunistic infection occurring in patients with HIV
disease.
The taxonomy of P carinii has not been established. It is
either a protozoan or a fungus. Recent studies show P
carinii more closely resemble fungi than protozoa.

• rRNA sequences
• thymidylate synthase
• dihydrofolate reductase
• beta tubulin
• mitochondrial DNA
• chitin in the cell wall

O E Eriksson has a treatise which places P

carinii in a new family, Pneumocystidaceae,
and in a new order, Pneumocystidales
(Ascomycota).
 The mode of replication of P carinii has not been
established. However, the stages in its life cycle have
been characterized. Sporozoites excyst through
breaks in the cyst wall and then are termed
trophozoites. The means by which the trophozoite
form progresses to the cyst phase is not known.
Life Cycle
 The portal of entry for P carinii has not been firmly
established; however, because with rare exceptions
the organism has been found only in the lung,
inhalation is a likely mode of transmission. Airborne
transmission has been demonstrated in animals. In
most individuals, the organism is dormant and
sparsely dispersed in the lung, with no apparent host
response (latent infection). In susceptible
(immunocompromised) hosts, the organism occurs in
massive numbers.
With rare exceptions, P carinni causes disease
only when natural mechanisms of host defense
are compromised.
Pneumonitis tends to occur in patients with
impaired cell-mediated immunity, and it is a major
infection in patients with the acquired immune
deficiency syndrome (AIDS).
Severe protein-calorie malnutrition alone may
provoke the disease. Immunosuppressive drugs
used for cancer or organ transplantation render
the individual susceptible to P carinii pneumonitis.
Tachypnea and fever are consistent features of
the pneumonitis, and diffuse bilateral alveolar
disease can be observed by radiography.
Diagnosis requires the identification of P carinii
in pulmonary tissue or lower airway fluids.
Such specimens may be obtained by lung
biopsy, inducement of sputum, bronchoalveolar
lavage, or needle aspiration of the lung. The
Gomori, Giemsa, fluorescence-labelled
antibody, or toluidine blue O stains may be used
to identify the organism.
 Pneumocystis carinii
http://www.doctorfungus.org

• Genus/Species: Pneumocystis carinii • Title: EM Image of Pneumocystis carinii

• Image Type: Microscopic Morphology • Disease(s): Pneumocystis pneumonia

• Legend: An electron micrograph of P. carinii cyst from rat lung tissue.

 Pneumocystis carinii
http://www.doctorfungus.org

• Genus/Species: Pneumocystis carinii • Title: Pneumocystis carinii-infected

• Image Type: Microscopic Morphology Rat Lung Tissue
• Disease(s): Pneumocystis pneumonia
• Legend: An H&E stain of a rat lung infected with P. carinii. It does not show any organisms, but shows the
proteinaceous exudate which results from Pneumocystis infection, and ultimately causes reduced gas exchange.
 Pneumocystis carinii
http://www.doctorfungus.org

• Genus/Species: Pneumocystis carinii • Title: Pneumocystis carinii Silver Stain

• Image Type: Microscopic Morphology Disease(s): Pneumocystis pneumonia

• Legend: A silver stain of P. carinii cysts from rat lung tissue showing the typical 'deflated ball' shape.
 Pneumocystis carinii
http://www.doctorfungus.org

• Genus/Species: Pneumocystis carinii • Title: EM Image of Pneumocystis carinii

• Image Type: Microscopic Morphology Disease(s): Pneumocystis pneumonia

• Legend: An electron micrograph of a P. carinii troph from rat lung tissue, showing its binding
to a type I pneumocyte.
•Four drugs currently available for therapy of P
carinii pneumonitis are:

• pentamidine isethionate
• trimethoprim-sulfamethoxazole
• atovaquone
• trimetrevate

Trimethoprim-sulfamethoxazole is
preferred because of its low toxicity
and greater efficacy.
 Normal Chest X-Ray

Courtesy of Up To Date
 What is pneumonia?
• Infection of the lung
parenchyma
• Causative agents
include bacteria,
viruses, fungi

www.netmedicine.com/xray/xr.htm
PCP PCP

www.netmedicine.com/xray/xr.htm
Information obtained from:

• UTMB Graduate School of

Biomedical Sciences
http://gsbs.utmb.edu
• Dr Fungus
http://www.doctorfungus.org
• HIV Insite
http://hivinsite.ucsf.edu
Ngantuuukk……??