Jahs Reviewer for Parasitology

Ascaris lumbricoides
-Giant Round Worm -most common intestinal nematode of man -occurs most frequently in the tropics -soil-transmitted helminth infections like ascariasis are diseases of poverty; they contribute to impairment of cognitive performances and growth of children; they reduce work capacity and productivity of adults. Parasite Biology -polymyarian type of somatic muscle arrangement (cells are numerous and project well into body cavity) -whitish/pinkish worms w/ smooth striated cuticles -males: 10-31cm, slender, ventrally curved posterior end w/ 2 spicules, no copulatory bursa, have single (reproductive organ)long, tortuous tubule -females: 22-35cm, slightly larger, have paired reproductive organs in the posterior 2/3 -adults: reside, but do not attach, to small intestine mucosa

-infective stage: fully embryonated egg (when the larvae reach their 3rd stage, larvae molt within the egg and become embryonated) -larvae hatch in small intestine lumen penetrate intestinal wallenter venulesportal veinliverheart pulmonary vessels (break out of III-1 capillaries and enter air sacs) -in the lungs(7-10days): larvaemoltingmigration to larynx & oropharynx swallowed to digestive tract -prepatent period 60-70days -eggs are deposited in the soil when a person with Ascaris infection defecates indiscriminately; 2-3weeks of embryonation Pathogenesis and Clinical Manifestation -varied pathology of ascariasis: -tissue reaction to the invading larvae -intestinal irritation by the mechanical and toxic action of the adult -complications due to extraintestinal migration -10-20worms may be asymptomatic unless discovered by stool examination or spontaneous exit of worms -During lung migration host sensitization allergic manifestations: lung infiltration, asthmatic attacks, edema of the lips -penetration of lung capillaries pneumonia-like symptoms -most frequent complaint: vague abdominal pain -moderate infectionslactose intolerance in preschool children -heavy infectionsbowel obstruction -serious fatal effects due to erratic migration of adult worms: regurgitated and vomited; escape through nostrils; inhaled into trachea; invade bile ducts; enter gallbladder or liver; lodge in appendixacute appendicitis; occlude pancreatic ductpancreatitis; penetrate through intestinal wall into peritoneal cavityperitonitis -Ascarisinfection may also result to intestinal volvulus, intussusception and obstruction -Biliary ascariasis-severe colicky abdominal pain -high fever may cause Ascarismigration -continuous Ascarisbiting/pricking of the intestinal mucosairritate nerve endingsintestinal spasmintestinal obstruction Diagnosis -Direct Fecal Smear (DFS)=2mg fecesemulsified in a drop of NSS on a glass slide, + coverslipexamined under microscope -Kato technique or cellophane thick smear method = 20-60mg feces; qualitative method for mass examination -Kato-Katz technique = modified Kato technique; amount of feces is measure quantify number of eggs in fecal sample; quantitative method: number of eggs per gram of feces; to determine egg reduction rate after treatment; to determine intensity of Ascaris infection Treatment -Broad-spectrum antihelminthics Albendazole-DOC, 400mg single dose, 200mg for children under 2yrs old Mebendazole-500mg single dose Pyrantel pamoate-10mg/kg (max 1gm) as single oral dose Ivermectin-as effective as albendazole if given at a dose of 200g/kg single dose -Adverse reactions for all: epigastric pain, headache, diarrhea, nausea, vomiting and dizziness, teratogenicity

-infertile eggs: 88-94m, longer and narrower than fertile eggs, w/ a thin shell and irregular mammilated coating filled w/ refractile granules, are found not only in the absence of males

-fertile eggs: 45-70m by 35-50m, w/ an outer coarsely, mammilatedalbuminous coveringw/c may be absebt or lost in decorticated eggs -thick, transparent , hyaline shell with a thick outer layer as a supporting structure and a delicate vitelline, lipoidal, inner membrane, w/c is highly impermeable -oviposition: fertile eggs have an ovoid mass of protoplasm w/c will develop into larvae (14days)

Epidemiology -cosmopolitan distribution -endemicin SEA countries, Africa, Central & South America -prominent parasite in both and temperate and tropical zones, more common in warm countries and more prevalent in areas where sanitation is poor -infection: presence of eggs in the feces with or without the symptoms -disease: infected w/ the parasite and shows signs and symptoms -factors affecting transmission: human population, involvement in agriculture (including use of night-soil as fertilizer), illiteracy, poor sanitation, poor health education on personal, family and community hygiene Prevention and Control -sanitary disposal of human feces -health education (personal, family, and community hygiene) -mass chemotherapy

Eggs 50- 54 um Lemon shaped with plug like translucent polar prominences Yellowish outer and transparent inner shell Fertilized eggs are unsegmented at oviposition and embryonic development takes place outside the host when eggs are deposited at clayish asoil Trichuris eggs are more susceptible to dessication than ascaris eggs Whip worms inhabit the large intestine Entire whip portion is embedded in the intestinal wall of the cecum There is NO heart-lung migration Pathogenesis and Clinical Manifestations Infective stage: Embryonated eggs Diagnostic stage: Eggs in the feces Petechial hemorrhage- caused by embedded anterior portion of the worm in the intestinal mucosa o Predisposes to amoebic dysentery presumably because the ulcer provides a suitable suitable site for tissue invasion by the E. hystolytica The mucosa in hyperemic, and edematous, enterorrhagia is common and there may even be rectal prolapsed among heavily infected individuals Appendicitis and granuloma- due to consequent irritation and inflammation of worm-filled lumen of the appendix infection of >5,000 eggs/gram of feces is usually symptomatic >20,000 eggs/gram of feces often develop severe diarrhea or dysenteric syndrome In Heavily infected individual, worms can be seen throughout the entire colon and rectum o In such, trichuriasis are often marked by frequent blood streaked diarrheal stool, abdominal pain and tenderness, nausea and vomiting and weight loss Diagnosis Clinical diagnosis is Possible only in very heavy chronic trichuris infections, where adult worms attached in the intestinal mucosa can be seen In light infection, where symptoms is absent, laboratory diagnosis is essential Direct fecal smear with a drop of saline Kato thick smear method is an alternative method using 20-60 mg of stool sample o Highly recommended in the diagnosis of the disease Kato katz technique- a quantitative method, used to determine egg count to know the Cure Rate (CR), egg reduction rate (ERR) and intensity of the infection o Used to assess the success of the control program o High specificity and and sensitivity for detecting trichuris eggs as well eggs of other soil transmitted helminthes

Trichuris trichiura
Whip worm Soil transmitted helminth Frequently occurring with Ascaris- they have similarities in their distribution and mode of transmission Holomyarian- based on the arrangement of somatic muscles in cross section where the cells are small, numerous, and closely packed in a narrow zone.

Parasite Biology Male Female 30-45 mm 35- 50 mm Coiled posterior with a Bluntly rounded posterior single spicule and end retractile sheath

Worms have attenuated anterior three fifths transverse by a narrow esophagus resembling a string of beads Robust posterior two fifths contains the intestines and a single set reproductive organs Females lay approx. 3,000- 10,000 eggs/ day Larvae not usually described probably because soon after the eggs are ingested, larvae escapes and penetrate the intestinal villi where they remain three to ten days

Treatment Mebendazole- DOC, given 500 mg single dose, in light infections, in heavy infections, 2-3 days of consequent medication may be required contraindicated to hypersensitivity and early pregnancy Albendazole- alternative drug, given 40 mg single dose. Contraindicated to pregnant Ivermectin + Albendazole- better cure and egg reduction than albendazole alone

Epidemiology Occurs in temperate (20- 30%) and tropical countries (60- 85%) Children ages 5- 15 are most often infected In the Philippines, the prevalence is 80- 84% Factors affecting transmission are the same as that of ascariasis Prevention and Control Mass treatment is indicated if the infection rate is >50% Due to high incidence of re-infection, periodic mass treatment is necessary 1. Treatment of infected individual 2. Sanitary disposal of human feces 3. Washing of hands 4. Health education on sanitation and hygiene 5. Thorough washing and scalding of uncooked vegetables especially in areas where night soil used as fertilizers