Académique Documents
Professionnel Documents
Culture Documents
01
January 6,
2017
INTESTINAL NEMATODES
Dr. Malijan
TOPIC OUTLINE
I.
Introduction: Metazoan parasites
II.
Overview: Intestinal Nematodes
a. Ascaris lumbricoides
b. Hookworms
c. Strongyloides stercoralis
d. Capilaria philippinensis
e. Enterobius vermicularis
f.
Trichuris trichiura
METAZOAN PARASITES
Aka roundworms
Intestinal
o Acaris lumbricoides
o Hookworms
o Strongyloides stercoralis
o Capilaria philippinensis
o Enterobius vermicularis
o Trichuris trichiura
Extra-intestinal
o Angiostrongylus cantonensis
o Filarial worms
o Trichinella spiralis
Phylum Cestoidea (Tapeworms)
Order Cyclophyllidea
o Dipylidium caninum
o Echinococcus spp.
o Hymenolepis spp.
o Raillientina garrisoni
o Taenia spp.
Order Pseudophyllidea
1
of
1
3
o Diphyllobothrium latum
o Spirometra
Phylum Trematoda (Flukes)
o Artyfechinostomum malayanum
o Clonorchis sinensis
o Echinostoma ilocanum
o Heterophyids
o Opistorchis spp.
o Paragonimus westermani
o Schistosoma spp.
Phylum Nematoda
Roundworms
Unsegmented, elongated and cylindrical
Sexes are separate females are larger than males
Posterior end of male usually curved
Class Aphasmidia lacking phasmids or caudal
receptor (Adenophorea)
o Trichuris
o Trichinella
o Capilaria
2. Class Phasmidia with phasmids or caudal
papillae (Secernentia)
1.
ORDER
Ascaridida
Strongylida
Rhabditida
Oxyurida
Spirurida
GENUS/ORGANISM
Ascaris
Angiostrongylus and
hookworms
Strongyloides
Enterobius
Filarial worms
INTESTINAL NEMATODES
Species which parasitize the small intestine
o Ascaris lumbricoides
o Necator americanus (hookworm)
o Ancylostoma duodenale (hookworm)
o Strongyloides stercoralis (threadworm)
o Capilaria philippinensis
Species which parasitize the large intestine
o Enterobius vermicularis (pinworm)
o Trichuris trichiura (whipworm)
Life cycle:
1. Egg stage
2. Four larval stages
3. Adult stage
Adult female may be:
Intestinal Nematodes
1.
2 of
x
Female
o Bigger and longer, tapered at both ends
o Large (22-35cm x 5mm) and may grow
up to 45 cm long
o Reproductive potential: 240,000
eggs/day
o With paired reproductive organs in
posterior 2/3
o Vulva in anterior end and comprises 1/3
of its whole length
Male
o Ventrally curved posterior end with two
spicules in tail
o 15-25cm x 3mm (10-31cm)
o Reproductive organ: single, long,
tortuous tubule
Fertilized egg
o Mostly oval or spherical, golden brown
o Capable of further development in soil
from single cell to embryonated eggs
o Shell (Corticated)
Intestinal Nematodes
Unfertilized eggs
o 1st two layers absent; shell is thinner with
irregular mammilated coating (only one
layer) filled with refractile granules
o Generally larger, narrower, more
elongated
o Can never undergo development in soil
o 88-94m x 39-44m (longer and
narrower)
Life Cycle
3 of
x
Intestinal Nematodes
Lactose intolerance
Eosinophilia
Allergic
Adult Stage
o Intestinal
Liver
Perforate the bowel and
into peritoneal cavity
Gallbladder
4 of
x
Complication
Intestinal obstruction
Acute appendicitis
Biliary ascariasis
presenting with severe
colicky abdominal pain
Multiple abscesses
Peritonitis
Diagnosis
Direct fecal smear:
o 2mg stool used
Kato Technique of Cellophane Thick Smear:
o 20-60mg stool, purely qualitative
method recommended for mass
examination
Kato-Katz Technique:
Epidemiology
Occurs most frequently in tropical and
subtropical regions (Asia, Central and South
America, Africa)
Estimated to infect 1.2 billion individuals (1/5
of the worlds population)
Thrives in areas with lack of sanitation,
poverty, and ignorance
Most common source of infection soilcontaminated foods esp. raw vegetables
Cosmopolitan distribution
20,000 die annualy, mostly young children
Risk of infection exist wherever fecal
disposal is improper
Factors contributing to transmission:
o High density of human population
Intestinal Nematodes
o
o
o
1.
2.
3.
4.
Hookworms
Necator americanus: New world
hookworm/ American murderer
Ancylostoma duodenale: Old world
hookworm
Ancylostoma braziliense: Cat hookworm
Ancyclostoma caninum: Dog hookworm
Numbers 1 and 2
Adult
o Small, cylindrical, fusiform, gray-white
o Females > Males
o Males: posterior end broad
membranous caudal bursa with rib-like
rays used for copulation
o Hook-like head curved opposite to bodys
curvature
o Buccal capsule: ventral pair of
semilunar cutting plates
Filariform larva
o Buccal spears are conspicuous and
parallel to body
o Conspicuous transverse striations on
sheath of tail
o Infective stage to man
Egg
o 60-75m x 35-40m
o Bluntly rounded ends
o Single, thin, transparent, hyaline shell
o Unsegmented at oviposition
o Ovoidal, colorless, 4-8 cell stage
o Constipated stool: embryo inside shell
o Differentiation of N. americanus and A.
duodenale:
Ancylostoma duodenale
Adult
o Larger than N. americanus
o Single-paired male and female
reproductive organs
o Head continues in same direction as
body
o Buccal capsule: 2 pairs of curved
ventral teeth
5 of
x
Intestinal Nematodes
Life Cycle
Filariform larva
o Same but with inconspicuous buccal
spears and transverse striations on tail
region
1.
Egg
6 of
x
Intestinal Nematodes
5.
Lasts up to 2 weeks
Dermatitis
7 of
x
Petechial hemorrhages
Bronchitis or pneumonitis
Intestine
Eosinophilia 30-60%
Adult Stage
o Hookworm Anemia
N. americanus: 0.03-0.05mL
blood/day
A. duodenale: 0.16-0.34mL
blood/day
o Hypoalbuminemia
Combined loss of blood, lymph and
protein
o Other signs and symptoms
Exertional dyspnea, weakness,
dizziness and lassitude
Rapid pulse, edema, albuminuria
Diagnosis
Ground itch and creeping eruption:
characteristic lesion, history of contact with
soil
DFS: for heavy infection (cant detect <400
eggs/gm feces)
Kato/Kato-Katz
o Kato-Katz Technique (quantitative
method)
Concentration methods (ZnSO4
Centrifugal Floatation method or
Formalin Ether Concentration)
o Determining whether stool is positive or
negative of hookworm eggs
Culture method (Harada-Mori)
o Allowing hatching of larvae from eggs
on filter paper strips with one end
immersed in water
o Recommended for species
determination via filariform larvae
Concentration techniques improve likelihood
to find eggs
Culture methods help identify the species of
hookworm involved
N. americanus is of a more serious concern
in the Philippines
Intestinal Nematodes
o
Treatment
Treat all infections, except in high reinfection
(because it is impractical)
Priority is given to:
o Pregnant women
o Children with malnutrition, pulmonary
tuberculosis, and anemia
Severe anemia (Hgb=7-8g/dL) before
dealing with worm infection
Iron-deficiency anemia
o
diet and iron supplementation therapy
Severe hypoalbuminemia
o quick deworming
Broad anti-helminthic
o Albendazole
Drug of Choice
Chewable or suspension
Percutaneous
8 of
x
Egg
o 50-54m x 23m
Intestinal Nematodes
o
o
o
o
Life Cycle
9 of
x
Intestinal Nematodes
Epidemiology
Children 5-15 years old frequently infected
Philippines: 80-84% prevalence
Infection through ingestion of
embryonated eggs
Prevention and Control
Mass treatment if infection rate is >50%
Preventive measure
o Treatment of infected individuals
o Sanitary disposal of human feces by
constructing toilets and their proper
use
o Washing of hands with soap and
water before and after meals
o Health education on sanitation and
personal hygiene
o Thorough washing and scalding of
uncooked vegetables especially
those areas where night soil is used
as fertilizer
Enterobius vermicularis
Human pinworm
Causes Enterobiasis or Oxyuriasis
characterized by perianal itching or pruritus
ani
Parasite Biology
Adult
o Small, whitish, or brownish in color
o Anterior end: posterior cuticular alar
expansions (lateral wings or cephalic
alae)
o Posterior esophageal bulb
o Female
8-13mm x 0.4mm
Long pointed tail (pinworm)
Females die after oviposition
10
of x
Egg
o 50-60m x 20-30m
o Elongated, ovoid, flattened on ventral
side
o Similar to letter D
o Translucent shell (two layers):
Outer, triple, thick hyaline
albuminous shell: mechanical
protection
Inner embryonic lipoidal membrane:
chemical protection
o Outside host, eggs become
infective/embryonated within 6 hours
o Ovum develops into tadpole-like embryo
o Resistant to putrefaction and
disinfectants but succumb to
dehydration in dry air within a day
o Cool and moist conditions: eggs
remain viable for several days
Intestinal Nematodes
Larvae
o Folded once within shell, creating a
visible line along eggs long axis
o Rhabditiform larvae
Characteristic esophageal bulb but
has no cuticular expansion on
anterior end
Life Cycle
Retroinfection
o Migration of newly hatched larvae from
anal skin back to rectum
Pathogenesis and Clinical Manifestations
11
of x
1/3 asymptomatic
Forms:
o Pathology at the site of attachment
of worm
Mild catarrhal inflammation of the
mucosa due to attachment of the
worms
Mechanical irritations and secondary
bacterial infection
Minute ulceration or abscesses in
cecal mucosa
o Pathology due to egg deposition in
perianal area
Intense itching or pruritus in
perianal region -> scarified
Pruritus ani -> hemorrhage,
eczema, bacterial infection of
anal and perianal regions and
perineum
o Pathology caused by migrating
adults
Migrating worms lay eggs in genital
organs causing vulvovaginitis,
worms enter fallopian tube causing
salpingitis
Pregnant female is responsible for
signs and symptoms
Children suffer insomnia due to pruritus
Hinahanap ni female yung pinagmulan niya
kaya kung saan-saang butas pumasok
vaginitis, endometriasis, salpingitis,
peritonitis, appendicitis
Other s/sx: poor appetite, weight loss,
irritability, teeth grinding, abdominal pain
Diagnosis
History and physical exam
Direct Fecal Smear
o Eggs are found only in 5% of infected
persons
Perianal Cellulose Tape Swab or
Grahams Scotch Adhesive Tape Swab
o D-shaped ova
o Best time: soon after patient awakens
and before bathing
Worms seen migrating out of childs anus at
right
Treatment
Pyrantel pamoate
o Drug of Choice
o 10mg/kg with second dose 2-4 weeks
later
Albendazole
o 400 mg, single dose
Mebendazole
o 500mg, single dose
A second dose is necessary for heavy
infection
Intestinal Nematodes
Femal
e
2.2mm x
0.04mm
Colorless, semitransparent with
a finely striated
cuticle
Slender tapering
anterior end and
a short conical
pointed tail
Short buccal
cavity with four
indistinct lips
Uteri with single
file of 8-12 thinshelled,
transparent,
segmented ova
Long, slender
esophagus
extends to the
anterior fourth of
the body
Intestine is
continuous
Subterminal
anus
Vulva located
1/3 of body from
posterior end
Gubernaculu
m but no
caudal alae
1mm x
0.06mm
Smaller than
parasitic
female
With
muscular
doublebulbed
esophagus
Intestine is a
straight
cylindrical
tube
Strongyloides stercoralis
Causes Strongyloides, Cochin-China
Diarrhea, threadworm infection
Epidemiology: infections run parallel with
hookworm infection
Infective stage: filariform larvae via skin
penetration
Parasite Biology
Adults
Male
12
of x
PARASITIC
None
FREE LIVING
0.7mm x
0.04mm
Smaller than
female
With
ventrally
curved tail, 2
copulatory
spicules
Rhabditiform larvae
o 225m x 16m
Intestinal Nematodes
o
o
o
Filariform larvae
o Infective stage
o Non-feeding, slender, 550m
o Usually smaller than hookworm
filariform larvae, with distinct cleft at
tip of tail
Egg
o Clear thin shell
o Similar to egg or hookworm but is only
50-58m x 30-34m
Life Cycle
13
of x
Free-living cycle
o The rhabditiform larvae passed in the
stool
Parasitic cycle
o Begins when filariform larvae in
contaminated soil penetrate the human
skin -> lungs -> alveolar spaces ->
bronchial tree -> pharynx -> swallowed
-> small intestine
o Duodenum: molt twice, become adult
female worms
o The females live threaded in the
epithelium of the small intestine and by
parthenogenesis produce eggs, which
yield rhabditiform larvae
o The rhabditiform larvae can either be
cause autoinfection
o In autoinfection, the rhabditiform
larvae become infective filariform larvae,
which can penetrate either:
Strongyloides stercoralis
Intestinal Nematodes
o
Eosinophilia as a clue
Harada mori culture
o For use in field
Baermann funnel, Bealess string Test,
Duodenal aspiration, Small bowerl
biopsy
Serology
14
of x
Epidemiology
Found throughout the world with same
distribution pattern as hookworms
More of a fecally-transmitted worm than
soil-transmitted helminth because it is
infective shortly after passage with the feces
Low local prevalence
More frequently found among male children
7-14 years old than among females and
adults
Prevention and Control
Proper waste disposal
Protection of the skin from contact with
contaminated soil
Early detection and treatment of cases
Capilaria philippinensis
Family Trichuroidea
o Thin filamentous anterior end and
slightly thicker and shorter posterior
end
Adults have subterminal anus
Parasite Biology
Adult
o Female
2.3-5.3mm
Esophagus has rows of secretory
cells (stichocytes)
Entire esophageal structure
(stichosome)
Vulva at the junction of anterior and
middle third
o Male
1.5-3.9mm
Spicule 230-300m long and has
unspined sheath
Chitinized spicule and a long spicule
Egg
o Peanut-shaped with striated shells,
flattened bipolar plugs
o 36-45m x 20m
o Passed in feces, embryonated in soil or
water
o In water, ingested by freshwater or
brackish water fish
Intestinal Nematodes
Hyperinfection: massive number of
adult worms
7. Definitive natural hosts: migratory fisheating birds
Pathogenesis and Clinical Manifestations
Sypmtoms:
o abdominal pain,
o gurgling stomach (borborygmus)
o chronic diarrhea
o
weight loss, malaise
o anorexia
o
vomiting
o
edema
Lab findings:
o sever protein-losing enteropathy
o malabsorption of fats and sugars
o decreased excretion of xylose
o low electrolyte (K+) levels
o high IgE levels
Histology
o Flattened and denuded villi
o dilated mucosal glands
o lamina propria infiltrated with plasma
cells
o lymphocytes, macrophages, neutrophils
No invasion of intestinal tissue but with
micro-ulcers in epithelium and
compressive degeneration and
mechanical compression of cells
Life Cycle
15
of x
Diagnosis
Finding rhabditiform larvae
o Feces or duodenal aspirate direct or
concentration methods
Eggs only obtained by drastic purge/NGY
duodenal aspirates
Treatment
Electrolyte replacement and high protein
diet
Anti-diarrheal agents
Antihelminthic drugs
o Albendazole
Intestinal Nematodes
16
of x