9.parasit Filariasis-Amoeba (Rev 03.17)

Parasite infection
Gatot Sugiharto, Internist

Internal Medicine Department
Faculty of Medicine, Wijaya Kusuma University Surabaya
GSH - Parasite - 2020 1

THE BURDEN OF SOME MAJOR PARASITIC
INFECTIONS
Parasite Diseases No. people infected Deaths/yr
Plasmodium malaria 273 million 1.12 million
Soil transmitted helminths: 2 billion 200,000

• Roundworm (Ascaris) Pnemonitis, intestinal
obstruction
• Whipworm (Trichuris) Bloody diarrhoea, rectal prolapse
• Hookworm Coughing, wheezing, abdominal
(Ancylostoma and pain and anaemia
Necator)
Schistosoma Renal tract and intestinal disease 200 million 15,000
Filariae Lymphatic filariasis and 120 million Not fatal but 40

elephantiasis million disfigured or
incapacitated
Trypanasoma cruzi Chagas disease (cardiovascular) 13 million 14,000
African trypanosomes African sleeping sickness 0.3 – 0.5 million 48,000

Leishmania Cutaneous, mucocutaneous and 12 million; 2 million 50,000
visceral leishmaniasis new cases/yr
TAXONOMIC CLASSIFICATION OF
HELMINTHS
Sub Phylum Class Genus – examples
kingdom
Metazoa Nematodes Ascaris (roundworm)
Round worms; appear round in Trichuris (whipworm)
cross section, they have body Ancylostoma (hookworm)
cavities, a straight alimentary Necator (hookworm)
canal and an anus Enterobius (pinworm or
threadworm)
Strongyloides
Platyhelminthes Cestodes Taenia (tapeworm)

Flat worms; dorsoventrally Adult tapeworms are found in the
flattened, no body cavity and, if intestine of their host
present, the alimentary canal is They have a head (scolex) with
blind ending sucking organs, a segmented body
but no alimentary canal
Each body segment is
hermaphrodite
Trematodes Fasciolopsis (liver fluke)

Non-segmented, usually leaf- Schistosoma (not leaf
shaped, with two suckers but no shaped!)
distinct head
They have an alimentary canal and
are usually hermaphrodite and leaf
shaped
Schistosomes are the exception.
They are thread-like, and have
separate sexes

FILARIASIS
Epidemiology
• 120m people infected in >80 countries in Africa, Asia,
the Pacific islands and South and Central America
• 40m of those infected are disfigured or severely
incapacitated
• 95% cases due to Wuchereria bancrofti, other species
include Brugia malayi and Brugia timori
LIFE CYCLE
• Wuchereria bancrofti is mainly transmitted by
• Culex mosquitoes in India
• Anopheline mosquitoes in Africa
• B. malayi and B. timori are transmitted mainly by Mansonia
mosquitoes
• Larval forms of the parasite (microfilariae) are taken up by a
female mosquito when it takes a blood meal from a human
infected with adult worms
• The microfilariae develop inside the mosquito
• When the mosquito takes another blood meal the infective
filariform larvae enter the bite wound
• Filariform larvae migrate to the lymphatics and lymph glands
• Larvae develop into sexually mature adult worms over 3-12
months depending on the species of filarial worm GSH - Parasite - 2020 7
Adult worms of B. malayi in section
in a lymph node (source: Univ South
Microfilaria of B. malayi in thick blood film Carolina)
(H&E stain; source: CDC)

PATHOLOGY
• Adult worms live in the afferent
lymphatic vessels and cause severe
disruption to the lymphatic system
• Scrotal damage and massive swelling
may occur when adult Wuchereria
bancrofti lodge in the lymphatics of the
spermatic cord
• Late stage disease is typified by
elephantiasis – painful and disfiguring
swelling of the limbs
• Trauma and secondary bacterial
infection of affected tissues is common GSH - Parasite - 2020 10
SYMPTOMS - SIGNS – 3 STAGES
Asymptomatic stage
• There is internal damage to the lymphatics and kidneys
Acute stage – Filarial lymphangitis

• Characterised by bouts of fever, redness, pain, swelling
and tenderness of the lymph nodes and ducts
Chronic stage
• Usually results in elephantiasis as a result of chronic
lymphoedema
• There is a massive overgrowth of tissue resulting in
severe deformities
Elderly male with massive • The legs are often affected and result in inability to
hydrocoele, and elephantiasis of walk
the leg. Also has nodules in the • The scrotum is often affected in men and the breasts
groin due to onchocerciasis and vulva in women
(source: WHO/TDR/Crump) GSH - Parasite - 2020 11
FILARIASIS STAGE

• Microscopic examination of Giemsa stained thick blood films for the
presence of microfilariae
• W. bancrofti shows marked nocturnal periodicity, so it’s best to
collect blood samples between 10pm and 1 am
• Serology test
Diagnosis
•Rapid diagnosis and treatment of infected individuals
•Mass drug administration to at risk communities
•Vector control: eliminate mosquito breeding sites through
improved sanitation and enviromental management
•Personal protection against mosquito bites by insecticides, bednets
and repellants
Prevention and control

TREATMENT
Diethylcarbamazine (DEC) rapidly kills microfilariae and adult worms
• ivermectin 400 ug/kg single dose

• combination of DEC and albendazole
Dose : 6 mg/kg in 3 divided dose, given in full dosage over 3 weeks (repeated yearly)
Release of antigens from dying microfilaria causes allergic-type reactions – add an

antihistamine and aspirin to treatment regimen
Other treatment options are

AMEBIASIS
Entamoeba histolytica
 Pseudopod-forming, non-flagellated protzoa
 Most invasive parasite of the Entamoeba group
 Only member that causes: Amebic colitis & liver abscess
 Life Cycle consists of:
(1) Infectious cyst & (2) Invasive trophzoite
 Trophozoites adhere to colonic mucin and epithelial
cells  kill host epithelial & immune cells  tissue
destruction
TROPHOZOITES OF ENTAMOEBA HISTOLYTICA (TRICHROME STAIN).
TWO DIAGNOSTIC CHARACTERISTICS: TWO OF THE TROPHOZOITES
HAVE INGESTED ERYTHROCYTES, AND THE NUCLEI HAVE TYPICALLY A
SMALL, CENTRALLY LOCATED KARYOSOME
CLINICAL MANIFESTATIONS:
Intestinal
Amebic Colitis
amebiasis
Acute Fulminant
or Necrotizing
Colitis

INTESTINAL AMEBIASIS
 Patients with chronic, non-dysenteric

intestinal amebiasis may complain for
months to years of abdominal pain,
flatulence, intermittent diarrhea,mucus in
the stools, and weight loss
 Chronic non-dysenteric intestinal
amebiasis has been mistakinly diagnosed as
ulcerative colitis

AMEBOMA
 Segmented mass of granulation tissue in the cecum or

ascending colon
 Occurs in 0.5% to 1.5% of patients with intestinal amebiasis
 Tender palpable abdominal mass
 Concuurent amebic dysentery present in 2/3 of patients
 “Apple-core” lesions on barium enema study
 Lesions resolve with anti-amebic chemotherapy
 Intestinal constriction occurs in the colon in <1% of patients

AMEBIC COLITIS
 Sign or Symptom % of Patients Affected
 Symptoms > 1 wk Most patients
 Diarrhea 94-100
 Dysentery 94-100
 Abdominal pain 12-80
 Weight loss 44
 Fever >38oC 10
 Heme (+) stool 100
 Immigrant from or traveler
to endemic area >50
 Prevalence (male/female) 50/50
ACUTE FULMINANT OR
NECROTIZING COLITIS
 Unusual (about 0.5% of cases)
 A complication that occurs more frequently in patients
inappropriately treated with corticosteroid
 Abdominal pain, distension, and rebound tenderness are present in
most patients
 Indications for surgery:
 Failure of response to anti-amebic drugs after intestinal
perforation/abscess formation
 Persistence of abdominal distention after institution of anti-
amebic Rx
 Toxic megacolon

AMEBIC LIVER
ABSCESS
 Develops in about 10% of patients with invasive E.

histolytica infections
 Few patients have concurrent dysentery – most report
dysentery within the preceding year
 Occurs in any age group
 Patients with a more chronic illness (2-12 weeks of
symptoms) commonly present with hepatomegaly and
weight loss

AMEBIC LIVER ABSCESS
 Sign or Symptom % of Patients Affected

 Symptoms > 4 wks 21-51
 Fever 85-90
 Abdominal tenderness 84-90
 Hepatomegaly 30-50
 Jaundice 6-10
 Diarrhea 20-33
 Weight loss 33-50
 Cough 10-30
 Immigrant from or traveler
to endemic area >50
 Prevalence (male/female) 50/50 in children; 90/10 in
adults GSH - Parasite - 2020 30
GROSS PATHOLOGY OF LIVER CONTAINING AMEBIC ABSCESS

LABORATORY FINDINGS AND DIAGNOSIS
 Differential Diagnosis of Amebic Dysentery:

 IBD
 Ischemic colitis
 Other infectious causes of bloody diarrhea
 Diagnostic Tests:
 EIA is best for specific diagnosis of amebiasis (Sensitivity &
specificity of assay on stool >95%)
 Colonoscopy remains important to evaluate for other causes
 Serology for antibodies: IHA
 Positive in: 88% amebic dysentery, 70-80% liver abscess, 50% of
general population

LABORATORY FINDINGS AND DIAGNOSIS
 Differential Diagnosis of Amebic Liver Abscess:

 Pyogenic abscess
 Echinococcal cyst
 Hepatoma
 Diagnostic Tests:
 Ultrasonography
 CT
 MRI
None differentiate amebic from pyogenic abscess
Diagnosis is frequently a diagnosis of exclusion
AMEBIC LIVER ABSCESSES

TREATMENT
Asymptometic amebiais:
 Luminal agent (paromomycin, diloxanide
furate, or iodohydroxyquin)
 Amebic Colitis: Metronidazole & a luminal
agent
 Amebic Liver Absces : Metronidazole & a
luminal agent

PREVENTION
Prevention of E. hisolytca transmission requires disruption of the

fecal-oral spraed of amebic cysts
• Risk of traveling to endemic areas

• Safeguards to prevent ingesting colonic organisms
Individuals should be advised regarding:
Because humans and primates are the only known reservoirs of E. histolytica, a
successful vaccine Could potentially eliminate this disease

9.parasit Filariasis-Amoeba (Rev 03.17)

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Parasite infection

Gatot Sugiharto, Internist

GSH - Parasite - 2020 1

Soil transmitted helminths: 2 billion 200,000

Schistosoma Renal tract and intestinal disease 200 million 15,000

Filariae Lymphatic filariasis and 120 million Not fatal but 40

Trypanasoma cruzi Chagas disease (cardiovascular) 13 million 14,000

African trypanosomes African sleeping sickness 0.3 – 0.5 million 48,000

Platyhelminthes Cestodes Taenia (tapeworm)

Trematodes Fasciolopsis (liver fluke)

GSH - Parasite - 2020 4

GSH - Parasite - 2020 9

Acute stage – Filarial lymphangitis

GSH - Parasite - 2020 12

Prevention and control

Diethylcarbamazine (DEC) rapidly kills microfilariae and adult worms

• ivermectin 400 ug/kg single dose

Release of antigens from dying microfilaria causes allergic-type reactions – add an

Other treatment options are

GSH - Parasite - 2020 23

 Patients with chronic, non-dysenteric

GSH - Parasite - 2020 24

 Segmented mass of granulation tissue in the cecum or

GSH - Parasite - 2020 25

GSH - Parasite - 2020 28

 Develops in about 10% of patients with invasive E.

GSH - Parasite - 2020 29

 Sign or Symptom % of Patients Affected

GSH - Parasite - 2020 31

 Differential Diagnosis of Amebic Dysentery:

GSH - Parasite - 2020 33

 Differential Diagnosis of Amebic Liver Abscess:

GSH - Parasite - 2020 35

GSH - Parasite - 2020 36

Prevention of E. hisolytca transmission requires disruption of the

• Risk of traveling to endemic areas

Individuals should be advised regarding:

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