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THE INTESTINAL NEMATODES

♦ Phylum Nematoda
♦ Non-segmented, generally cylindrical
♦ Tapered at both ends covered by tough
covering= Cuticle
♦ Has complete digestive tract = both oral and
anal openings
♦ Separate sexes: Males smaller than female
worms
Male : - single tubule, smaller end consists of testicular
cells
- Extends into a vas deferens and seminal vesicle
- Terminates in an ejaculatory duct opening into
the cloaca
Female : - reproductive organs are tubular and lie coiled HELMINTHIC DISEASES
in the body cavity ASCARIASIS
- Has 2 cylindrical ovaries which expand to the Etiology:
uteri • Ascaris lumbricoides = largest intestinal
- Uteri may open to the exterior through a single roundworm
vulva or there may be a common vagina between the • Most prevalent human helminthiasis
vulva and the uteri
• Female worms = 20-35 cm in length
- Vulva commonly located near the middle of the
= may be as thick as a lead pencil
body but varies in position in different species
• Male worms = seldom more than 30 cm long
♦ Majority are free living
= more slender and distinguished by an
♦ Estimated 500,000 species of nematodes
incurved tail
♦ Generally light cream-white color, females appear
 Both sexes are creamy white, sometimes with a
darker when filled with dark-colored eggs
pinkish cast and fine circular striations in the
♦ Primitive form : mouth surrounded by three lips
cuticle
♦ Hookworms: buccal capsule with cutting plates or • Mature larva-containing egg = infective stage
teeth
• Eggs passed in the feces of infected person &
♦ Anterior portion of digestive tract: Esophagus =
mature in 5-10 days under favorable conditions to
muscular form become infective
= if caliber is uniform – Filariform
• Female life span = 1-2 years
= if expanded posteriorly into a bulb containing a
• Produces 200,000 eggs/24 hrs.
valve mechanism – Rhabditiform
♦ Male nematodes: has a pair of copulatory
spicules, lie in pouches near the ejaculatory duct
and may be inserted into the vagina of the female
♦ Stages of life cycle: egg-- larvae which undergo
several molts--- adults
♦ Filariform type of esophagus: infective stage
larvae
♦ Ascaris = die in about a year in the absence of
reinfection
Epidemiology:
Trichuris = live more than a year
Hookworm = may persist as long as 8 to 16 • Promiscuous defecation & use of human manure
years = unhygienic practices
♦ Diagnosis: Demonstration of the characteristic • Mode of transmission = hand to mouth; fingers
egg in the feces contaminated by soil contact
• Eggs remain infective in soil for months

Life Cycle:
Embryonated egg swallowed (infective, containing fully
developed larva) → larva escapes from egg in S.I. →
tissues and lymphatic vessels and lungs → further
development in alveoli → larva from lung → larva in lung
pass on to the intestine via trachea, esophagus and
stomach → develop maturity → adult in small intestine → assembly and inhibiting glucose uptake by the
eggs passed in feces → unfertilized egg → fertilized egg worm
→ swallowed again. = 400mg p.o. single dose (200 mg for
children <2 years old)
Pathogenesis: = drug of choice
• Mebendazole 100 mg BID for 3 days or 500 mg
• Ingestion of mature egg – larva released from egg
once
– penetrate intestinal wall—Via venous circulation
• Pyrantel pamoate 11 mg/kg single dose
penetrate the lungs – break through pulmonary
• Piperazine salts (citrate, adipate or phosphate)
tissues to Alveolar spaces – ascend to the
bronchial tree & trachea – re-swallowed = causes neuromuscular paralysis & rapid
expulsion of the parasite; used for intestinal &
Clinical Manifestations: biliary obstruction; given 50-75 mg/kg for 2
days
• Morbidity manifested during migration of the
• Surgical treatment for severe obstructive cases
larva thru the lungs = Pneumonitis – occur from 4
days to 2 weeks after infection ( asthma attacks)
Prevention:
• Pulmonary ascariasis = cough blood stained • Treating human feces before it is used as fertilizer
sputum and eosinophilia (Loeffler’s-like • Providing hygienic sewage disposal facilities
syndrome)
• Deworming every 3-6 months
• Adult worms in the small intestine = vague
abdominal pains, distention & obstruction due to ENTEROBIUS VERMICULARIS
mass of worms in heavily infected individuals
• Pinworm
• In obstruction = peak incidence 1-6 yrs old;
• Affects 10% of pediatric population
abdominal pain sudden onset, severe, colicky and
vomiting • Spread is facilitated by crowded indoor living in
• Eosinophilia noted in 10% of patients temperate climates but also common in the
tropics
Diagnosis: • Male : inconspicuous, 2-5 mm long and not more
• Direct fecal smear than 0.2 mm wide
• Kato’s thick smear • Female : 8-13 mm in length and 0.5 mm in width
• Pulmonary & GI ascariasis complicated by Light yellowish white
obstruction Distinguished by a long thin, sharply pointed
= based on clinical symptoms & high index of tail
suspicion • Inhabit the cecum and adjacent portions of the
• Fertilized egg: broadly ovoidal, 45 to75 umx35 to large and small intestines
50um. • Female worms, when fully gravid, migrate down
Albuminoid outer covering the intestinal tract to pass out the anus and
Thick yellowish inner shell deposit their eggs
• Infertile eggs: longer, narrower than fertile eggs • The worms may migrate several inches out of the
Measures 90 x 40 um anus, depositing eggs as they crawl or liberating
Both inner shell and albuminoid coat are thin masses of them as the worms dry and literally
If albuminoid coat is absent – may resemble explode
Trichostrongylus eggs
• Can also be diagnosed through radiography =
worm-shaped radioluscent areas in a barium-
filled intestine

Treatment:
• Albendazole = a nitroimidazole that binds
irreversibly to tubulin, blocking microtubule
Symptoms:
• Pruritus ani = migration of the female worms
from the anus
• In small children, worms may invade the vagina
after leaving the rectum producing a local
irritation

• Eggs are fully embryonated and are infective • Local itching may interfere with the sleep of
within a few hours of the time they are deposited children or adults = worms migrate from the anus
during the resting hours
• Eggs live longest under conditions of fairly high
humidity and moderate temperature Pathogenesis:
• Reinfection of the patient by contamination of the • Considered as a commensal
hand is common and makes control of the
• Attachment of the adult worms to the intestinal
parasite very difficult
wall may produce some inflammation
• Development of adult worm = 6 weeks
• Invasion of the appendix can also be expected as
• Familial outbreaks : Infection through a cause of appendicitis
contaminated clothing and beddings • Entrance into the peritoneal cavity via the female
• Eggs may survive for some days in dry dust reproductive system may result in formation of
• Airborne eggs may infect persons at some granulomas around eggs and worms = chronic
distance pelvic peritonitis
• Occasionally reported in other sites: Liver and
• Retrofection = a type of autoinfection, involves
lungs
hatching of the embryonated eggs after their
deposition in the perianal area and subsequent
migration back into the rectum and large
intestine

Life Cycle:
• Mature egg ingested by human → egg hatch in
the duodenum → larva develops to maturity in S.
I. → proceed to L.I. (final habitat) → adult in large
L. I. (male and female)
Diagnosis:
• Recovery of the characteristic eggs Treatment:
Method: Scotch Tape Swab Technique • Albendazole = DOC
• Suspected in children with pruritus ani = single dose of 400mg or 200 mg in
• Occasionally, adult female worms seen children < 2 y.o.
crawling in the perianal region or in the = should be repeated in 2 weeks to kill any
feces worms that migrated and hatched from eggs present at
• Females do not ordinarily oviposit until the time of initial treatment
they leave the intestinal tract • Pyrantel pamoate = single dose of 11 mg/kg body
• Eggs: 50-60 um in length, 20-32 in weight and repeated in 2 weeks
breadth
Translucent shell of moderate thickness HOOKWORM INFECTIONS:
Flattened on one side = flattening, consequent ANCYLOSTOMA DUEDENALE
reduction in diameter and thicker shell – differentiates • Old World hookworm
from hookworm eggs • Adults : - grayish white or pinkish
- head slightly bent in relation to the rest of
the body
- Male = measures nearly 1 cm x 0.5 mm
- Female = longer and stouter
• Mouth is well developed = pair of teeth on either
side of the median line and a smaller pair in the
depths of the buccal capsule
• Male worm: provided with a prominent copulatory
bursa posteriorly
• Hookworm eggs when passed in feces =
unsegmented
• In sandy and moist soil, larvae develop and hatch
within 24 to 48 hours • Diagnosis: Depends on the recovery of the eggs
• Growth and development take place in the soil as from the stools
the larva feed on bacteria and organic material Eggs similar with Strongyloides: Ancylostoma
and undergo first molt = long buccal capsule between the oral opening and the
• After 7 days, worm stop feeding and molt the esophagus
second time, transforming from rhabditiform to Strongyloides = short buccal capsule
filariform or infective larvae Eggs = oval and 56-60 um long x 36 to 40 um in breadth
• Infective larvae do not feed and live for 2 weeks = shell is thin and colorless
and if cannot find a host, live in the upper layers
of the soil = contact with skin of suitable host
= can also enter percutaneous, oral,
transmammary and transplacental
• Humans = the only host
• Larvae enter adjacent venules and carried to the
lungs then to the alveoli – trachea ---
reswallowed --- small intestine where they mature
• Attach thru mouth parts and suck blood and
ANCYLOSTOMA CANINUM
tissue juices of the host = average
• Hookworm of dogs
period of 7-8 weeks
• Can cause abortive infection in humans
Life Cycle: • Larvae unable to complete the life cycle ---
migrate through the subcutaneous tissue
• Filariform larva on soil penetrate skin → blood
• Seen in an area heavily populated by dogs
stream → alveoli → via trachea, esophagus and
infected with the parasite
stomach to S. I. → adult worm attach to mucosa
• Treatment: Mebendazole
of S. I. → Hookworm egg in soil hatches to
produce rhabditiform larva → molts in about 3 NECATOR AMERICANUS
days to produce 2nd stage rhabditiform larva → • Resemble Ancylostoma but slightly smaller
molts in about a week to produce infective • Males : 5-9 mm in length
filariform larva • Females: about 1 cm long
• Head is slightly bent in relation to the rest of the
body= definite hook shape at the anterior end
• Buccal capsule is armed with a pair of cutting
plates while Ancylostoma has teeth
• Eggs slightly larger, averaging 64-76um by 36x40
um.
Manifestations: • Adult females = burrow into the mucosa of the
• Allergic reaction in penetrating the skin = “ intestinal tract where they lay eggs
ground itch” • Eggs similar in appearance with hookworms,
• Do not usually cause severe pulmonary hatch in the mucosa and liberate rhabditiform
larvae which make their way to the lumen of the
symptoms since larvae is smaller than
intestine
Ascaris
• Maturation of the worms may be marked by Life Cycle:
gastrointestinal discomfort or diarrhea Rhabditiform and filariform larve in feces → filariform
• Chronic infections = considerable blood loss--- larva may re-infect while in intestine or penetrate skin
Iron Deficiency Anemia from soil → rhabditiform larva may molt forming into
filariform larva → may molt twice to become free-living
• Pica = consequence of iron deficiency anemia
adult → under favorable conditions producing infective
• Eosinophilia is variable = up to 70% filariform larva

Pathogenesis:
• Anemia = Microcytic hypochromic type • Larvae molt once before being passed out in the
• Bone marrow is markedly hyperplastic feces
• Erythroid and myeloid hyperplasia of the spleen • Once filariform larvae is formed, it penetrate
immediately into the wall of the gut and enter the
• A. duodenale = lives 1-5 years
bloodstream
• N. americanus = as long as 18 years
• Diagnosis: Demonstration of characteistic larvae in
Epidemiology: the stools= larvae resemble those hookworm but
• Widespread infection in significant parts of which can be distinguished by their very short buccal
cavity
defecate directly onto the soil and do not
Embyonated eggs = present in severe
customarily wear shoes
diarrhea
• Factors: appropriate ambient temperature
= differentiated with hookworm eggs since
Sufficient rainfall
they contain always well-developed
Loose sandy loam soil
larvae
Treatment:
• Larvae may be concentrated with zinc sulfate
• Albendazole = single oral dose of 400 mg (200
• Duopdenal Aspiration = occasionally reveal larvae
mg in children under 2 years old)
= drug of choice in both Ancylostoma and • String Capsule method or Enterotest
Necator
• Mebendazole = equally effective
= 100 mg BID for 3 days
• Pyrantel Pamoate = also effective
• Ferrous sulfate = in severe infection
= 200 mg daily TID
= start at the time of anti helminthic teratment and
continued 3 months after the hemoglobin value returns to
normal

STRONGYLOIDES STERCORALIS
• Exist as free living nematode
• Adult: very small = about 1 mm long
• Filariform larvae = infective stage
= incapable of further development in the soil
and must penetrate skin of host to continue
life cycle
• Rhabditiform larvae that pass out from the stool
of the host can directly transform into filariform
larvae without developing into free living adults
• Penetration to the skin and migration to the lungs
and eventually to the small intestine also takes
place
• Adult males = eliminated from the body in early
infection
• Causes “swollen belly sickness” = abdominal
distention, respiratory distress, generalized
edema, and hypoproteinemia
• Therapy as recommended for S. stercoralis is
curative if begun early

CAPILLARIA PHILIPPINENSIS
• Intestinal capillariasis = first observed in 1962 in
Ilocos Sur
• Adult worms: slender, 4-5 mm long
• Live in intestinal mucosa primarily jejunum
• Finding of larval stages, and of oviparous and
larviparous females in the bowel, suggests that
the parasite multiplies in the intestine and
overwhelming infections are the result of
autoinfection
• Eggs seen in infected persons = measures 45 x
Symptoms: 21 um --- ingested by fresh water and brackish
• Pneumonitis may be produced by the larvae but water fish where larval stages are found
less severe than Ascariasis • Complete life cycle is not known
• Moderate to severe diarrhea • Laboratory diagnosis is made by finding the
• Malabsorption syndrome with steatorrhea characteristic eggs
• In heavy infections, involve the large and small
bowels = give rise to ulceration of the intestinal
mucosa suggestive of duodenal ulcer or
ulcerative colitis
• Melena may be present in massive lower
gastrointestinal bleeding with passage of bright
red blood per rectum
• If only GIT and lungs are involved =
Hyperinfection syndrome - fever, GI symptoms,
dyspnea, wheezing, hemoptysis, cough and
weakness Symptoms:
• When migrating larvae are many = Disseminated • Abdominal pain, borborygmus (gurgling), and
strongyloidiasis – commonly affects malnourished diarrhea
children, immunocompromised (AIDS), • Diarrhea may be accompanied by anorexia,
malignancy, taking high doses of corticosteroids nausea, vomiting and hypotension
• Patient may become cachectic with generalized
Pathogenesis: anasarca
• Patchy Pneumonitis in heavy infections = larvae • Visible peristaltic waves may be seen over the
may be found in the sputum distended abdomen
• Adult female worm may be found in all parts of
the intestinal tract but more common in the Pathogenesis:
jejunum • Pathologic picture : Hypoproteinuria, low blood
calcium, potassium, and cholesterol levels,
Treatment: features of protein wasting enteropathy
• Albendazole and Ivermectin = both are effective
• In hyperinfection syndrome = 400mg daily for 15 Epidemiology:
days • Recently redescribed as Paracapillaria
• Ivermectin = 100% cure rate when given at 200 philippinensis
mcg/kg body weight daily for 2 days • Natural life cycle is not known

STRONGYLOIDES FULLEBORNI
• Experimentally: eggs hatch and develop into
• A parasite of monkeys but also infect humans larvae if fed to fresh and brackish water fish and
to adult stage if the infected fish are fed to
• Common in infants under 6 months of age
monkeys --- fresh and brackish water fish are
• Eggs are found in the feces
eaten raw --- humans acquire infection
• Larvae found in the milk of nursing mothers
• Two other capillarias causing human infections with their attenuated anterior ends embedded in
(rare): the mucosa
1.C. hepatica = causing hepatic capillariasis • Worms found in the rectum in heavy infections
2.C. aerophila = causing pulmonary capillariasis
Diagnosis:
Treatment: • Demonstration of the characteristic barrel or
• Mebendazole = DOC football-shaped eggs in the feces
= 200 mg BID for 20 days • Each female worm produces 3,000 to 7,000 eggs
• Albendazole = alternative drug daily
= 400 mg for 10 days • Eggs measure 50 to 54 um in length with
• In acute illness = fluid and electrolyte refractile prominences at both ends= Polar
replacement and high protein diet plugs
• Zinc sulfate flotation method = very efficient in
demontrating the eggs
TRICHURIS TRICHIURA
• Whipworm
• Trichuris = hair tail
• Common in tropical areas and in regions where
sanitation is poor
• Thick posterior part of the body forming the stock
and long thin anterior portion the lash
• Adult worm : 3-5 cm long Symptoms:
• Females are larger than males
• Usually asymptomatic in light infections
• Thin almost colorless anterior three fifths of the
body consists of the esophagus • In heavy infections : abdominal pain and
• Expanded posterior part is pinkish gray and distention, bloody or mucoid diarrhea,
tenesmus, weight loss and weakness
contains the intestine and reproductive organs
• Prolapse of the rectum = usual complication
in chronic heavy infections
• Anemia and moderate eosinophilia and
nutritional deficiencies may be seen in heavy
infections

Pathogenesis:
• Appendicitis = brought by blockage of the
lumen by worms
• Edema of the rectum produced by numbers of
worms embedded = rectal prolapse
Life cycle: • Blood loss per worm is calculated to be
• Infection acquired by ingesteion of fully approximately 0.005 ml/worm/day
embryonated eggs ---- passed in unsegmented • Infections of 200 worms or more may cause
condition and require 10 days or more outside the chronic dysentery = profound anemia and
body to reach the infective stage ---- larvae pass growth retardation
to the cecal area where they attach permanently
• Mimics inflammatory bowel disease but is
readily curable
• Human infections results from ingestion of third-
Treatment: stage larvae belonging to genera Anisakis or
• Albendazole = DOC Pseudoterranova
• Mebendazole = alternative drug • Larvae reach a length of 50 mm and a diameter
• Loperamide hydrochloride = may help by of 1-2 mm
increasing contact time between drug and parasites • Classification is difficult but generally identified
by “type” on the basis of the structure of the
TRICHOSTRONGYLUS SPECIES
digestive tract
• T. orientalis
• Larvae of Anisakis usually found in mackerel and
• Related to hookworms and the adults are similar salmon
in appearance • Larvae of Pseudoterranova = usually parasitize
• Species infecting humans are smaller than the cod, halibut, rockfish (Pacific red snapper),
hookworms but the eggs are larger sardine, and squid
• Eggs: Symmetrical and thin shelled and differ • Most human infections have been reported from
from hookworm egg in size ( 73 to 95 by 40 – 50 Japan and Netherlands = consumption of sushi
um) and their more pointed ends and sashimi in Japan and pickled herring in
Netherlands
Symptoms and Pathogenesis: • Invades the gastric mucosa and intestinal tract
• Eggs hatch in soil --- hatched larvae contaminate
foodstuff --- ingested
• Larvae do not undergo pulmonary migration but Symptoms:
when reswallowed attach themselves to the • Abrupt onset 1-5 days after ingestion of raw fish,
intestinal mucosa and grow to adulthood in 3-4 abdominal pain, nausea, and sometimes vomiting
weeks or diarrhea, with signs of peritoneal irritation and
• They ingest blood = clinically apparent blood loss incomplete ileus of the small intestine
only seen in heavy infections • Perforation of the bowel has been reported =
finding of an anisakid larva in an inflammatory
Epidemiology: omental mass
• Use of human feces as fertilizer = human to • Gastric anisakiasis = severe epigastric pain,
human spread of the infection nausea, and vomiting sometimes within a few
hours after ingestion of contaminated raw fish
Treatment: • Gastroscopic removal of the worm is usually
• Mebendazole = DOC needed
• Albendazole = equally effective
Diagnosis:
• A presumptive diagnosis can be made on the
basis of the patient’s food habits
• Definitive diagnosis: Demonstration of worms
obtained by gastroscopy, or vomited by the
patient
• If vomited larvae are well preserved, they may be
cleared in glycerin and identified by the structure
of the digestive tract which differs in three types
of anisakid larvae

Epidemiology:
• Human infections results from the consumption of
raw or insufficiently smoked or salted or
marinated fish
• Fish kept frozen at –20°C for at least 5 days are
considered safe for consumption in dishes such
ANISAKIASIS as sashimi and sushi
• Parasites of the gastrointestinal tract of animals • Smoking fish kills the parasite only if the
( seals, sea lions, whales and dolphins) temperature of the flesh reaches 65°C during the
• Found in marine fish infected with the larval process
stages of nematodes
• Salting or marinating fish cannot be depended on
to kill the parasites
• Larvae may be found in the gut, visceral cavity
and the flesh of the fish
• When fish are iced ( but not frozen) for
transportation to harbor processing plants, larvae
may migrate from the gut into the muscles

Treatment:
• No treatment needed in transient anisakiasis
• Albendazole = 400mg BID for 21 days

Comparative morphology of the digestive tracts of the


three types of anisakine larvae