SHIFA UNIVERSITY

Helminthes

Course : Medical parasitology

Chapter : 6

lecturer : Faisal Abdi Jama

 Helminthes

Nemathelminthes Platyhelminthes

Nematodes Trematode
Cestodes
round worms s (flukes)
tape worms
3-3
 Nematodes

word "nematode" came from a Greek word nema

that means "thread".
Characteristics of Nematodes
o Long cylindrical body.
o No segmentation
o Males and females separate.
o Females larger then male. Similar to each other
but vary in size
Nematodes of the large intestine
• Trichuris trichiura - Whipworm
• Enterobius vermicularis – Pinworm

Nematodes of the Small intestine

• Ascaris lumbricoides
• hook worm
• Strongyloides stercoralis
 Intestinal nematodes

Infection via orally

• Ascaris lumbricoides (round worm)

• Enterobius vermicularis ( Pin worm)
• Trichiuris trichiura ( Whip worm)
Ascaris lumbricoides Round worm
 Morphology -

•Sexes are separate.

•Female - 20 - 40 cm

•Male - 15 - 30 cm with curved tails

•Number of eggs female reproduce per
day - 200,000
• Life cycle :

Host : only human.

Infective stage : embryonated eggs containing larvae.

Mode of transmission : ingestion of embryonated eggs

from the contaminated soil, food, water.
Phases : 1. Migratory phase.

2. Intestinal phase.

3. Development in soil phase.

 Pathogenesis & clinical features

Depends on
• Effect of larval migration
• effects due to adult worm
• worm load
•The host immune response
•Nutritional deficiencies due to the
presence of adult worm
• Pathogenesis :

1. Affect due to migrating larva : 2nd week, after

ingestion of eggs Larva migrate into lungs and
cause pneumonitis, hypersensitivity Non
productive cough, Chest discomfort and fever.
.2. Affect due to Adult worm :
The larvae mature into adult worms in your small
intestine, and the adult worms typically live in the
intestines until they die. In mild or
moderate ascariasisthe intestinal infestation can
cause: Vague abdominal pain. Nausea and vomiting.
ii) Symptomatic :
In the intestine it liberates enzymes and
Protection from digestion by host intestinal ferments

Robbing of nutrients-
a) malnutrition and growth retardation,
b) vit.-A deficiency,
c) PEM ( protein energy malnutrition) in
hyperinfected children
d) lactose maldigestion.
3. Intestinal complication –
a) bowel obstruction (by forming tangled mass),
- abdominal distantion, rebound tenderness, vomiting.
b) GIT perforation ( intestinal hallow ulcer )
c) Intussusception ( Intestinal blockage ).
4. Extraintestinal complication -
- appendix : appendicitis.
- pancrease : pancreatitis.
- biliary tree : biliary colic (blocking the cystic
duct), cholecystitis ( inflammation of the
gallbladder.)
- liver : abcess.
- esophagus : coming out though mouth and nose.

a) ectopic ascariasis : migrate to pharynx and

block eustachian tube.
5. Allergic menifestation :

 release of body fluid

 Typhoid like fever.
 Urticaria(outbreak of swollen, pale red bumps on the
skin.
 Angioneuratic edema (swelling of the lower layer of skin
and tissue).
 Conjunctivitis
 Irritation in upper respiratory tract.
Migrate out of the anus or come out the mouth or nose
 Effect of Ascariasis on Growth & Nutrition

• Protein Energy Malnutrition [PEM]

Due to consumption by the worm

Act as a mechanical barrier to absorb
nutrients
• children with 13-40 worms loose 4g protein/day
from a daily intake of 35-50g
• Kwashiorkor – swelling due to low albumin
• Vitamin A deficiency – Night blindness
• AFFECTS NORMAL GROWTH & EDUCATIONAL
DEVELOPMENT
• Laboratory diagnosis :

A. Detection of the parasite :

1. Egg detection : - both fertilized and unfertilized
eggs can be detected.
2.Adult worm detection
i) occasionally found in stool or sputum by naked eye.
ii) X-ray of GIT
iii) detect adult worm in extraintestinal sites.

B. Serology : antibody detection

• Treatment :

A. Antiparasitic drugs : any one of the followings-

1. Albendazole 400mg once 200mg in children

< 2years
2. Mebendazole 100 gm twice daily for 3days, or
500mg once.
3. Ivermectine 150-200mg/kg once.
4. Nitazoxanide.
5. Pyrantel pamoate – in pregnancy.
Enterobius vermicularis
 Introduction

 It is first described by Leuckart, in 1865.

 Globally around 209 million people are infected each
year.
 Prevalence is maximum among the school going
children.
 Temperate climate, over crowding, impaired hygiene,
poor personal care are factors promoting infection.

• Habitat :
The adult worm remains attached to the large intestine
(caecum, appendix, adjacent portion of colon) by their
mouth end.
 Life cycle

•Adults live in the large intestine

• females migrate out of the anus for oviposition (laying
of eggs )
• Worm attached to the mucosa of large intestine, they are not
blood suckers
•A gravid female carries about 10,000 eggs.
• It dies after oviposition
•No lung migration of larvae
•No development in the soil. Therefore it is not a soil
transmitted helminthe infection
 • Clinical feature :
1. Asymptomatic.
2. Symptomatic :
- perianal pruritus .
- excoriation of perianal region.
- abdominal pain.
- vulvovaginitis.
- pelvic and peritoneal granuloma.
- chronic peritonitis.
• Pathogenesis :

A. Nocturnal migration of gravid female, fully filled

with eggs, from large intestine to perianal region and
start laying eggs.
Human with hypersensitivity to the secretion of
the worms

Rectal pruritus at night

Continuous scratching of skin

Excoriation of perianal skin

 B. Migration of the worm

1.Invade female genital tract – vulvovaginitis.

2.Entrance into peritonial cavity – formation of
granuloma around eggs or worm which may lead to
chronic pelvic peritonitis.
3. Invade appendix – appendicitis.
4. Others : liver, lungs. (not common)
1 2
• Treatment :
One of the followings –
1. Mebendazole 100mg once.
2. Albendazole 400mg once.
3. Pyrantal pamoate 11mg/kg once (max 1gm).

** the same treatment should be repeated after 2 weeks.

** all the family members, including asymptomatic
reserviors should be treated simultanously.
• Prevention :
1. By improving personal hygiene.
2. Hand washing.
 Introduction
Trichuris trichiura or whipworm, is a parasitic
roundworm that causes trichuriasis when it infects a
human large intestine.
It is commonly known as the whipworm which refers
to the shape of the worm; it looks like a whip with
wider "handles" at the posterior end.
 Life cycle

No lung migration
 Trichuriasis

 Trichuriasis, also known as whipworm infection, is

an infection by the parasitic worm Trichuris trichiura
(whipworm). If infection is only with a few worms,
there are often no symptoms. In those who are
infected with many worms, there may be abdominal
pain, tiredness and diarrhea. The diarrhea sometimes
contains blood.
 Pathology

Few worms – little damage

Heavy infection- spread
throughout the colon to the rectum
causing
• Haemorrhages
• Muco-purulentstools,
dysentery and rectal prolapse “inside out”
Clinical features

Mild infections are asymptomatic

Heavy infection cause blood and mucus
diarrhoea
due to mucosal damage & rectal prolapse
Children may get ‘Trichuris dysentery
syndrome’ resulting in severe diarrhoea,
malnutrition, growth retardation.
 Diagnosis
Finding the characteristic eggs in
stool by direct smear.

Proctoscopy – in cases of dysentery, show

numerous worms attach to the mucosa which is
redden and ulcerated
• Prevention :
1. By improving personal hygiene.
2. Hand washing.
 Intestinal nematodes

Infection via skin penetration

Hook worms- Ancylostoma duodenale

Necator americanus

Tread worm-
Strongyloides stercoralis
Hookworm
 Introduction

Hookworm is an intestinal parasite of humans. The

larvae and adult worms live in the small intestine can
cause intestinal disease. The two main species of
hookworm infecting humans are Ancylostoma
duodenale and Necator americanus.

Habitat
Lumen of small intestine ( jejunum and ileum).
Remain attached to the intestinal wall by their mouth
parts.
 Morphology

Females:
9-13 mm long with
egg-filled uterus

Male hookworms:
7-11 mm long
Routes of transmission

 Penetration of skin
 Ingestion of filariform larvae
 Breast milk from mother to
infants( transmammary transmission)
 Transplacental transmission
Life cycle
 Clinical manifestations

Skin manifestations
 Ground itch most important
Observed after 7-10 days.
Seen around feet.
 Intense itching , edema , erythema and rash
 Secondary bacterial infection.
 Respiratory manifestation

 Low grade fever

 Mild cough
 Pharyngitis
 Dyspnoea
 Hemoptysis
 Dyspnoea may be triggered when worms first break
through from venous circulation into lung alveoli.
 Pneumonia with pulmonary consolidation
 Bronchitis
 Intestinal manifestation

 Low grade fever

 Anaemia
 Nausea
 Vomiting
 Diarrhea
 Abdominal discomfort
 Nutritional defects

1. iron deficiency anaemia.

2. folic acid and vit. B-12 deficiency anaemia.
3. If associated with both – dimorphic anaemia.
Laboratory Diagnosis

Direct Methods:
- Stool examination: to find the adult worm or characteristic
hookworm eggs
- Larva- seen if stool is kept at room temperature after 24 hours.
• Treatment :

Antiparasitic : any one of the followings-

1. Albendazole 400mg once.
2. Mebendazole 500mg once.
3. Pyrantel pamoate 11mg/kg for 3 days.

Symptomatic :
1. Oral iron suppliment.
2. Proper nutritional support with protein.
• Prevention :

1. Personal care.
2. School based deworming.
3. Improved nutrition status.
4. Treatment of infected persons.
Strongyloides
stercoralis
 Definition
• Human parasitic disease caused by nematode S. Stercoralis.
• Mostly in tropical,subtropical area and temperate climate
• Affect 30-100 million annually.
• Has two unique life cycle: Free life cycle and Parasitic life cycle.
• Cause by direct contact with contaminated soil and
recreational activities.
• Children highly affected to bad sanitation.
• S. Stercoralis is a 2 mm long intestinal worm
 Strongyloidiasis

 Strongyloidiasis. It is a parasitic disease caused by

nematodes, or roundworms, in the
genus Strongyloides that enter the body through
exposed skin, such as bare feet. Strongyloides is
most common in tropical or subtropical climates.
 Most people who are infected with Strongyloides do
not know they are infected and have no symptoms.
Others may develop a severe form and, if untreated,
become critically ill and potentially die.
 Epidemiology & Risk Factors

 The global prevalence of Strongyloides is unknown, but

experts estimate that there are between 30–100 million
infected persons worldwide.
 Strongyloides is found more frequently in the
socioeconomically disadvantaged and in rural areas. It is
often associated with agricultural activities.
 Mode of infection

 The most common way of becoming infected

with Strongyloides is by contacting soil that is contaminated
with Strongyloides larvae. Therefore, activities that increase
contact with the soil increase the risk of becoming infected,
such as:
1. walking with bare feet
2. contact with human waste or sewage
3. occupations that increase contact with contaminated soil
such as farming and coal mining.
 Pathology
Invasive : Skin Penetration.

Pulmonary: During Cycle or

Immigration. Intestinal: Tissue

Destruction
Disease

 Most people infected with Strongyloides do not know they’re

infected. If they do feel sick the most common complaints are
the following:
1. Abdominal
 stomachache, bloating, and heartburn
 intermittent episodes of diarrhea and constipation
 nausea and loss of appetite
2. Respiratory
 dry cough
 throat irritation
3. Skin
 an itchy, red rash that occurs where the worm entered the
skin
 recurrent raised red rash typically along the thighs and
buttocks.
Clinical Manifestations
 Dermatitis, swelling, itching, larva
currens and mild hemorrhage at the site
where the skin has been penetrated
 Pnuemonia-like symptoms Lofflers
syndrome
 Tissue damage, sempsis and ulcers
 Hyperinfection syndrome has a mortality
rate of close to 90%
 Clinical manifestations

diarrhea, abdominal pain, nausea, and vomiting



 dry cough, dyspnea, throat irritation, wheezing

 Loffler syndrome (eosinophilic pneumonia)

 rash (larva currens)

 Symptoms and Signs of
Hyperinfection
anemia (for example, pale skin) constipation, cough
diarrhea, eosinophilic pneumonitis (during larvae
migration through the lungs)Nausea, vomiting,
weight loss.
Laboratory Diagnosis

 Direct stool smears (larvae)

Serology
imaging ( X- ray )

Treatment
Strongyloidiasis is treated with:
□ Ivermectin.
□ Tthiabendazole.
Thank you….