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12-4-09 Parasitology 2 (Infections by Parasitic Worms) Overview: helminthes are worm-like parasites that can be divided into three

major groups: tapeworms (cestodes), roundworms (nematodes), and flukes (trematodes). Tapeworms and flukes are flatworm platyhelminths, while roundworms are understandably round. All helminthes develop through egg, larval, and adult stages, and can be both hermaphrodic and bisexual. They are large, long-lived, and can cause serious disease, though many infections remain asymptomatic. Examples form each group of helminthes: CESTODES: T. saginata (beef tapeworm) is characterized by gravid segments found on grass that is ingested by bovine. The segments break into thousands of eggs in the cows gut, and these eggs hatch into oncospheres that penetrate the gut wall into cow muscle, where they differentiate into cysticercus. Humans eating undercooked beef ingest the cyticerus, which attach to the wall of the small bowel and give off small gravid segments that begin to pass through the anus. Beef tapeworm is usually well tolerated and asymptomatic, but can cause abdominal distress, dyspepsia, anorexia, incrased appetite, nausea, localized pain, and diarrhea. Larvae can localize in tissues and produce systemic infection NEMATODES: inclue Ascaris lubricoides, Necator americanus, Ancyclostoma duodenale, and Enterobius vermicularis (Pinworm). Seem to cause a lot of diarrhea; however, little disease is associated with mild infections. Pinworm is the most common helminth in the US, and its believed that almost all Americans have been infected at one point. Pinworm is the only parasite that is not diagnosed with a stool sample; rather, it relies on Scotch-tape perianal swabs. TREMATODES (flukes): see below regarding Schistosoma. Have flattened, bilateral symmetrical body thats leaf-shaped. They have suckers (acetabula) for adhesion to host tissue) 1. Understand that diagnosis of infection with intestinal parasites is usually established by demonstration of the parasite or its characteristic eggs in stool. Demonstrating the eggs of the parasite in excreta provides the definitive diagnosis in all cases of fluke infection. The best method is the Kato thick smear method, where 50 mg of feces is placed on a slide covered with a coverslip soaked in glycerol. The three different species of schistosoma can be differentiated by their characteristic egg morphology (i.e. S. masoni eggs have a sharp lateral spine, S. haematobium eggs have a large terminal spine, and S. japonicum eggs have a smaller inconspicuous lateral spine. 2. Appreciate that infection with the schistosome parasite occurs in fresh water through skin-penetrating cercariae. Schistosoma eggs reach the freshwater from excreta. Miracidium hatches from the egg under optimal conditions of temperature, light, and freshwater. Miracidium penetrate the snails soft tissue and undergoes differentiation into a mother sporocyst, which produces a second order

daughter sporocyst. Daughter sporocysts migrate to the digestive gland of the snail where they produce thousands of cercariae. Cercariae emerge from the snail and seek contact with a vertebrate host, penetrating the host skin. Within the host, the cercariae differentiate into schistosomulum and subsequently migrate to vasculature. Juvenile worms reside in the hepatic portal system continuing maturation into male and female adults. 3. Recognize that during shistosomiasis, disease results primarily from the hosts immune presponse to the eggs. Male and female adult worms mate in the hepatic portal vessels and lay 300-3000 eggs daily for 4-35 years!! Some eggs are swept into the precapillary sinusoids of the liver, where they become the nidus of a granulomatous reaction. Chronic hyper-responsiveness to soluble egg antigens leads to the immunopathological consequence of clay pipe-stem fibrosis. Mature eggs pass out of blood vessels into gut lumen or the urinary bladder for excretion into freshwater. 4. Use antihelminthic drug praziquantel as the appropriate treatment of choice for patients with schistosomiasis. Treatment of all fluke infections is accomplished by a one day course of Praziquantel, with the exception of Fasciola hepatica, which requires Bithional orally for 15 days. Note that Praziquanel will eliminate the parasite, but does not affect lesions caused by eggs already deposited in tissues. Additional notes: There are three major disease syndromes of schistosomiasis: 1. schistosome dermatitis: pruritic rash that appears after skin penetration by cerariae, due to immediate + delayed hypersensitivity reaction to parasite antigens 2. acute schistosomiasis (Katayamas syndrome): begins 1-2 months after primary exposure and lasts >3 months, usually caused by S. japonicum. Symptoms include fever/chills, cough, urticaria, arthralgia, lymphadenopathy, splenomegaly, and abdominal painall caused by massive release of parasite antigen from immune complex formation. 3. chronic schistosomiasis: characterized by hepatomegaly, portal hypertension, and esophageal varices when infected by S. japonicum or S. mansoni; characterized by inflammation and fibrosis of bladder and ureters followed by hydroneprhosis when infected by S. haematobia. End result of chornic schistosomiasis is usually granulomas and fibrosis. The severity of disease relates to the intensity of infection. The mature embryo (miracidium) secretes antigenic molecules that destroy tissue to make room for eggs to pass through mucosa into the lumen of the bowel and bladder. Approximately 50% of eggs make it to the environment; the rest remain to elicit inflammation in the host, forming focal granulomatous lesions from delayed hypersensitivity cell-mediated reactions. These granulomas result in portal venous obstruction, causing portal hypertensionhepatomegaly, splenomegaly, and esophageal

varices. The aforementioned clay pipstem fibrosis refers to the enlarged fibrous triads surrounding the portal vein lumina. Keep in mind that the majority of infected patients are asymptomatic (only 5-10% present with clinical disease!). Younger people can regain heavy infections after treatment and re-exposure, while older people tend not to get re-infected. IgE is anti-parasitic and correlates with lower egg output. Epidemiologically, schistoomes are seen mainly in S. America, the Caribbean and Africa, w/ S. japonicum seen particularly in the Far East. Distribution is limited by the snail as the intermediate host.