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Nematodes Overview

intestinal-- Strongyloides larva

systemic-- microfilaria (Wuchereria)

Transmission and Clinical Complications Large Intestine


Trichuris (whipworm) Enterobius (pinworm)

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)

transmission clinical picture & diagnosis


raw pork, bear, walrus oral mosquito vector black fly vector horse fly vector myositis, diarrhea Dx. eosinophilia, raised CPK, serology eosinophilia, hepatomegaly, cough, fever Dx: serology elephantiasis, chyluria or hydrocoele Dx: microfilaria in blood, serology, antigen capture itchiness, persistant skin nodules, blindness Dx: adults in skin nodules, microfilaria in skin biopsies (snips) Calabar swellings (3-4 days), eye worm Dx: microfilaria in blood

Loa loa (eye worm)

Diagnosis: stool examination for larvae (strongyloides) or eggs (the rest) Treatment: albendizole or ivermectin (strongyloides) or mebendazole (the rest)

Systemic Diagnosis: blood or tissue examination for microfilaria; serology for


Trichinella and Toxocara

Treatment:

Wuchereria, Onchocerca, Loa- ivermectin, diethylcarbamazine, albendizole Trichinosis, Toxocara- albendizole

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.

Trichuris trichiura (Whipworm)


Epidemiology - about 350 million infected, in some areas 90-100% of population - restricted to warm climate by necessity for egg to embryonate on moist warm soil for10-14 days before becoming infective - spread: fecal - oral (esp. via foods and hands) Biology - life cycle: people infected by swallowing embryonated egg egg hatches in

small intestine attaches to colonic epithelium and matures to egg laying in 3 months.

adult female, approx. 45 mm

eggs approx. 52 mu long

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)

Enterobius vermicularis (Pinworm)


Epidemiology -very common in all geographic areas - 20%+ in Toronto's children - spread: fecal - oral; eggs can survive days to weeks in environment Biology - infected by swallowing egg which hatches after contact with stomach acid and matures to adult which then resides in lumen of caecum (from egg to adult

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

pinworm egg 50-60 m pinworm adult 8-13 mm

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.

Ascaris lumbricoides (Roundworm)


Epidemiology -About 650 million infected worldwide mainly tropics. Transmission is faecaloral; egg very resistant, can survive years Biology -egg ingested, hatches in duodenum; larvae penetrate intestine wall, enter blood vessels and embolize through liver to lungs. They then migrate into airspaces,

up trachea and are swallowed, taking up permanent adult residence in the small intestine; ~ 2 months from egg to mature adult

adult female 20-35 cm

eggs ~68 m long

adults from one child long

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

Strongyloides stercoralis (Threadworm)


Epidemiology The only important helminth that can complete its life cycle in the human host and hence increase its numbers. Special problem in immunocompromized because of this. Mainly a tropical parasite because requires warm moist soil for transmission. Transmission: skin contact with invasive larvae in soil. Biology Larvae passed into soil in human feces where mature in several days to skin invasive (filariform) larvae. Can exist for months in soil "free living" by completing life cycle without contact with human host man. Larvae penetrate skin, move via blood vessels to lung, invade airspace, move up bronchi, are swallowed, and then penetrate small intestinal mucosa where they mature to adults in submucosa. They deposit eggs in submucosa and these hatch and migrate into intestinal lumen. Small numbers of larvae get into blood vessels and circulate again to produce more adults (internal autoinfective cycle) or invade perianal skin and enter blood vessels to eventually produce new adults (external autoinfective cycle). Organism: female adult - 2.7 mm long, rhabditiform larvae approx. 0.38 mm, filariform larvae approx. 0.6 mm long

adult

filariform (invasive) larva

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

Ancylostoma duodenale and Necator americanus


(Hookworm) Epidemiology: transmission by contact of skin with soil contaminated with larvae. Biology: eggs in feces hatch and mature as larvae in warm moist soil; develops into to infective (filariform) larvae in 7 days. Filariform larvae penetrate skin of host (e.g. bare feet), circulate to lungs where they penetrate alveoli, move up

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

h mouth of Ancylostoma duodenale egg 60 x 40 m

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.

Treatment albendizole, ivermectin.

Laboratory procedures for diagnosing intestinal helminths


Stool ova and parasite (O & P) examination

1. Direct microscopic (without a concentration technique) examination: not very


sensitive 2. Kato technique: uses glycerin mixed with stool which "clears" (makes

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

4. Culture: Harada Mori or Baerman culture or charcoal culture - only

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

Trichinella spiralis, nativa (Trichinosis, Trichinellosis)

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

larva extracted from muscle

adult from intestine wall

Clinical Early (1-2 weeks) -

abdominal pain, diarrhea

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)

microscopic examination of muscle biopsy serology

larva in muscle cell at biopsy

Treatment: steroids and mebendizole or albendazole Problems: education of meat consumer lack of good drugs

Toxocara canis (Visceral Larva Migrans)


Epidemiology: This is a zoonotic roundworm with the dog as reservoir. Uncommon human infection but consequences serious. Transmission is dog fecal (dog)-oral (human) . Dog feces especially in sandboxes and parks where children play. Eggs in soil viable and infective for several months. Biology: Adult has cycle in dog the same as Ascaris in man. Man an accidental "dead end" host. Eggs ingested by man/child, hatch after stomach passage and larvae migrate through small intestinal wall into vasculature and then to liver and lungs and beyond. Do not mature to adults but cause local inflammation especially in liver. Organism: In man larvae are 0. 5 mm long; egg in dog feces, looks like a round Ascaris egg.

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

eosinophilic meningitis (mainly SE Asia).


3. Gnathostoma spinigerum: nematode of cat producing migratory local

subcutaneous swelling, and at times encephalomyelitis (mainly SE Asia).


4. Capillaria philippinensis: small intestine nematode producing diarrhea and malabsorption (Philippines).

5. Bayliascaris procyonis: Raccoon nematode in North America producing a

visceral larva migrans like Toxocaris (above) but with severe encephalitis

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