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transmission
oral oral
complications
hemorrhagic colitis perianal itch
Small intestine
Ascaris (round worm) oral percutaneous and Strongyloides (thread worm) autoinfection Ancylostoma & Necator percutaneous (hookworms) small intestine obstruction duodenitis, cutaneous larva currens, hyperinfection in immunocompromised iron deficiency anemia
Worm
Trichinella spiralis or nativa Toxocara canis (visceral larva migrans) Wuchereria bancrofti or Brugia malayi (lymphatic filariasis) Onchocerca volvulus (river blindness)
Diagnosis: stool examination for larvae (strongyloides) or eggs (the rest) Treatment: albendizole or ivermectin (strongyloides) or mebendazole (the rest)
Treatment:
Introduction
The helminths (from the Greek meaning worm) are higher, multicellular forms of parasite with specialized organs. There are two basic groups: Nematodes - roundworms Platyhelminths - flatworms - cestodes (tapeworm) - trematodes (fluke)
Nematodes
Characteristics - round in cross section - bilaterally symmetrical - variable size - 1 mm to 1 meter - organs - digestive, nervous, excretory, cuticle, muscle, sexual - develops by molting (shedding cuticle - separate sexes - reproduction and development: egg egg fertilization embryo in egg larva 4 molts adult Categories Bowel nematodes - with adults in bowel
Trichuris trichiura Ancylostoma duodenale and Necator americanus Enterobius vermicularis Strongyloides stercoralis
Tissue nematodes - adults or larval stage in tissue Trichinella spiralis, native etc Toxocara canis (visceral larva migrans) Filaria - Wuchereria bancrofti Brugia malayi Onchocerca volvulus Loa loa etc.
small intestine attaches to colonic epithelium and matures to egg laying in 3 months.
Clinical - clinical: 99% assymptomatic - heavy load gives diarrhea, dysentery, anemia, rectal prolapse Diagnosis - examine stool (standard techniques) - pathognomonic egg Treatment - mebendizole, albendizole
Problems - lack of cost effective control methods in LDC (least developed countries)
maturation in 15-43 days) . Female migrates onto perianal skin to lay eggs at night. - organism: adult female approx. 10 mm long; egg approx. 55 m long
Clinical - most asymptomatic <10% anal pruritus; rarely vaginitis Diagnosis -less then 10% found in stools, i.e. not a useful examination; -best is pinworm swab - cellophane tape swab, or sticky paddle Treatment - mebendizole, albendazole, pyrantel pamoate Problems - insensitivity of pinworm swabs (intermittent deposition of eggs) : eradication of infection from rest of family.
up trachea and are swallowed, taking up permanent adult residence in the small intestine; ~ 2 months from egg to mature adult
Adult worms1 live in the lumen of the small intestine. A female may produce up to 240,000 eggs per day, which are passed with the feces 2. Fertile eggs embryonate and become infective after 18 days to several weeks 3, depending on the environmental conditions (optimum: moist, warm, shaded soil). After infective eggs are swallowed 4, the larvae hatch 5, invade the intestinal mucosa, and are carried via the portal, then systemic circulation to the lungs 6 . The larvae mature further in the lungs (10 to 14 days), penetrate the alveolar walls, ascend the bronchial tree to the throat, and are swallowed 7. Upon reaching the small intestine, they develop into adult worms 1. Between 2 and 3 months are required from ingestion of the infective eggs to oviposition by the adult female. Adult worms can live 1 to 2 years. (CDC 1999)
Clinical - related to number of worms; small numbers asymptomatic - large numbers of adults in intestine -- obstruction, pains - at times adults migrate into bile duct, up esophagus or through surgical anastomoses of intestine - cause malnutrition if in large numbers Diagnosis: stool examination for eggs Treatment: mebendizole, albendazole
adult
Clinical most asymptomatic GI - peptic ulcer like symptoms, diarrhea rarely, cutaneous larvae currens (trunkal itchy dermatitis) hyperinfection (disseminated strongyloides) in immunocompromised; spread of larvae to peritoneum, lung, CNS with contamination of those organs with gram negative bacteria; transmural small intestine spread of larvae and bacteria with necrosis of intestine Diagnosis stool examination . NB: difficult to find strongyloides duodenal aspirate or Enterotest duodenal string test serology (the most sensitive) culture of stool (Harada-Mori or Baerman) allows "free living" strongyloides to multiply agar plate tracking Treatment: albendazole, ivermectin Problems: diagnostic techniques not sensitive untreated it persists for life
bronchi and are swallowed. Then, as adults, they attach by mouth to small intestinal mucosa and suck blood. (Necator 0.03 ml/day, Ancylostoma 0.15 ml/day). Prepatent period (time from skin penetration to egg production) is 4-5 weeks. Adults can live 5-15 years. Organism Adult female 12 mm long (A.d); ova approx. 60 mu long Adult female 10 mm long (N.a); ova approx. 65 mu long
filariform larva
Clinical usually assymptomatic 90% heavy infections (20 - 100 worms) iron deficiency anemia malnutrition from protein loss rarely itch at skin entry site Diagnosis: Stool examination for ova Treatment: mebendizole, albendazole
Problems: Lack of cost effective LDC (least developed country) control Cutaneous Larva Migrans Ancylostoma caninum, Ancylostoma braziliensis etc. Non-human (dog, cat etc) hookworms that penetrate human skin (as does human hookworm) but cannot go further. Migrate and produce serpiginous itchy traits in subcutaneous tissue.
transparent) fecal debris making eggs visable. Can be used for counting eggs/gram feces.
3. Concentration techniques:
i. zinc sulfate solution flotation - eggs float to top of solution ii. formal ethyl acetate sedimentation
Strongyloides will multiply in an incubated stool specimen - increases numbers of larvae and sensitivity of microscopy.
Eosinophilia
Increased blood eosinophil counts are normal host response to helminth infection; not seen in protozoan infections very high (30-80% of WBC) Trichinella Toxocara Fasciola moderate (10-30% of WBC) hookworm Strongyloides low or absent (0-10% of WBC) Enterobius Ascaris Trichuris
Epidemiology Common in geographic areas where undercooked pork is eaten, in the Arctic where raw walrus is eaten and among bear hunters in North America; 5-15% of North American population infected at some time.This is a zoonosis infecting most carnivorous mammals; especially pigs, bear, walrus, and rats. Man infected by eating Trichinella infected uncooked meat.
Biology Encysted larvae in meat, when eaten, excyst (hatch) and penetrate into small intestine submucosa where they mature to adults in 1-2 weeks producing larvae which penetrate blood vessels and diseminate to all muscles. There, they cause inflammation and encyst in muscle cells (not cardiac), remaining viable and quiet for many years. Adult female is 5 mm.long
Midterm (2-6 weeks) - myalgia, muscle weakness, facial and periferal edema, rash; sometimes encephalitis and myocarditis Long term (months) - usually assymptomatic despite presence of trichinella "cysts" Diagnosis clinical picture with laboratory support (eosinophilia and raised creatine phosphokinase (CK)
Treatment: steroids and mebendizole or albendazole Problems: education of meat consumer lack of good drugs
Toxocara eggs
Clinical Hepatomegaly, pneumonitis, encephalitis, fever and eosinophilia in heavy infections Retinal lesion (similar to retinoblastoma) or focal retinitis when single larva reaches retina. Diagnosis Clinical syndrome with very high eosinophilia Serology Nothing in stools Treatment: Steroids and albendizole Problems: - Control of dog and cat feces in parks and sandboxes - Diagnosis difficult because of nonspecificity of symptoms
Other Nematodes
1. Anisakis sp: Salt water fish (cod, herring etc) roundworm that when ingested
produces a nematode inflammatory mass in stomach of raw fish consumer or eosinophilic gastritis (mainly Japan, Holland).
2. Angiostrongylus cantonensis: nematode of amphibians producing
visceral larva migrans like Toxocaris (above) but with severe encephalitis