Intestinal Parasitic Infections

Forman Erwin Siagian Departemen Parasitologi FKUKI Senin, 8 April 2013 Email:formanerwin@yahoo.com

agents
Helminths Ascaris lumbricoides, Trichuris trichiura, Schistosoma japonicum, Fasciolopsis buskii, hookworm, Taenia spp Protozoans Entamoeba histolytica, Entamoeba coli, Balantidium coli, Giardia lamblia, Blastocystis hominis Yeast Candida spp

Host-parasite Interaction
(Markell , Voge, John)

Adaptations to parasitism
The possibility of adaptation of a parasitic mode of existence may depend on preadaption or evolutionary change that make possible existence in an environment that otherwise would be unsuitable (e.g increased resistance to enzymatic activities of the host)

Effect of the parasite on the host

Injury, invasion or even destruction of host tissue may happen as by interference with the vital processes of the host through the action of secretions, excretions, or other products of the parasite

Effect of the host on the parasite

Diet or nutritional status of the host, immune process/armamentarium (especially acquired immunity) that may be very important in modifying the severity of the disease in endemic areas (such as schistosomoasis, malaria, filaria), or Genetic constitution of the host (e.g duffy blood group for P. vivax or sickle cell for P. palcifarum)

Outcome of the host-microbe interaction in the context of the damage framework

Arturo Casadevall, Liise-anne Pirofski. Infect. Immun. 2000, 68(12):6511 (ref no 63)

The estimated number and percentage of children aged 59 years infected with the three main species of soil-transmitted helminths and the population at risk in 2002

Hall et al. A review and meta-analysis of the impact of intestinal worms on child growth and nutrition. Maternal and Child Nutrition (2008), 4, pp. 118236

Hotez et al. J. Clin. Invest. 118:13111321 (2008)

prevalence

Maizels et al. J. Exp. Med. 2009; 206 (10): 2059-2066

Examples of Emerging and Re-Emerging Diseases

http://www.thepoultrysite.com/articles/1166/emerging-animal-diseases-and-internationaltrade

The distribution of (a) Ascaris lumbricoides, (b) Trichuris trichiura and (c) hookworm in Indonesia, as indicated by province-level estimates based on available survey data. White indicates those provinces where no relevant data were located.

Dr Simon Brooker . Human helminth infections in Indonesia, East Timor and the Philippines . Report to UNICEF East Asia and Pacific Region Office 19 Phra Atit Road, Bangkok 10200, Thailand . UNICEF, 2002 (ref no 12)

Prevalence of infection by province in Indonesia during the 1970s and 1990s

Dr Simon Brooker . Human helminth infections in Indonesia, East Timor and the Philippines . Report to UNICEF East Asia and Pacific Region Office 19 Phra Atit Road, Bangkok 10200, Thailand . UNICEF, 2002 (ref no 12)

Harmful effects of the parasite on the host

Wasting (cachexia) Superinfections Production of toxic compounds Immunodepression Allergic reactions Anaphylactic shock ( e.g malaria) Mechanical damage (e.g malaria, ascariasis) Irritative reflexes (intestinal contractions: ascaris) Irritation of skin and tissues by ecto- and endoparasites

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Harmful effects of the parasite on the host

Many parasites cause harmful effects to their host, but in most cases these effects are not of such importance that the host is being killed. Such effects comprise: Wasting (cachexia, spoliatrices) African trypanosomiasis and leishmaniasis may lead to severe loss of weight in both animals and man. Superinfections In the case of (muco)cutaneous leishmaniasis ulcerations may lead to superinfections with bacteria Production of toxic compounds It is thought that the African trypanosome, when in the central nervous system, produces aromatic amino-acid analogues that may influence brain function. Immunodepression Malaria, bilharziosis, etc., lead to a certain degree of immune suppression which renders the infected host more susceptible to other diseases. Allergic reactions In the case of onchocerciasis (river blindness) the presence of the filarial worms under the skin may lead to depigmentation due to allergic reactions. Anaphylactic shock may be induced by the sudden release of large amounts of parasite internal antigens into the bloodstream. In malaria this occurs when the merozoites are released in waves from infected erythrocytes. In African trypanosomiasis or sleeping sickness this occurs when the immune response leads to the massive killing and lysis of the circulating parasites. Also drug treatment leading to a massive killing of the parasites may result in anaphylactic shock. Mechanical damage In the case of malaria the lysis of erythrocytes does lead to haemolysis and anaemia. In the case of ascaris infection the presence of the worms in the small intestine may lead to intestinal occlusions Irritative reflexes (intestinal contractions: ascaris) Irritation of skin and tissues by ecto- and endoparasites

HOST PARASITE RELATIONSHIPS www2.nau.edu

Risk factors
Children Pregnant women Immunocompromised? Refugee/urban dweller Handycapped? Food handlers Pets/zoonoses? Govermental policy?

Ayeh-Kumi et al. J Trop Med Parasitol. 2009;32:1-8.

(Michael O Harhay, John Horton, Piero L Olliaro)

Environmental factors as well as thehost-parasite relationships (compepid.tuskegee.edu)

Am. J. Trop. Med. Hyg. 2005;, 73(2): 38691 (ref no 23)

Modjarrad et al. Am. J. Trop. Med. Hyg., 73(4), 2005, pp. 77782 (ref no 32)

Schaible UE, Kaufmann SHE (2007) Malnutrition and infection: Complex mechanisms and global impacts. PLoS Med 4(5): e115.

Life cycle of Strongyloides stercoralis. Complete life cycle of Strongyloides stercoralis with both parasitic and free living cycles along with the cycle leading to autoinfection and hyperinfection syndrome. The cycle involving the mechanism of autoinfection is shown on the right side of the figure with the cycle elucidating the concept of hyperinfection and disseminated infection on the left side of the figure Vadlamudi et al.Clinical and Molecular Allergy 2006, 4:8

pathophysiology
The protozoan intestinal parasite Entamoeba histolytica remains a signicant cause of morbidity And mortality worldwide. E.histolytica causes two major Clinical syndromes, amebic colitis and amebic liver abscess.
Am J Physiol Gastrointest Liver Physiol 280:G1049G1054,2001 (ref no 3)

Cysts can remain alive outside the host for weeks or months, Especially under damp conditions,but are rapidly destroyed at temperatures under 5C and over 40C. Cysts are not invasive, but trophozoites can penetrate the gastrointestinal mucosa. From there,the trophozoites are able to migrate to other organs, causing extraintestinal infections.
Mehmet Tanyuksel and William A. Petri Jr. Clin. Microbiol. Rev.2003, 16(4):714 (ref no 4).

It is estimated that 10% of individuals with amebic Colitis will develop an amebic liver abscess after dissemination of amebic trophozoites from the bowel Through the portal circulation
Am J Physiol Gastrointest Liver Physiol 280:G1049G1054,2001 (ref no 3)

Scanning electron micrographs of experimental intestinal amebiasis in the guinea pig. (A) Trophozoites of E. histolytica adhere preferentially to the elevated interglandular epithelium. (B) A small interglandular region of microinvasion is observed in the early invasive lesion with superficial ulceration. (C) In a more advanced stage of invasion, numerous trophozoites are seen penetrating a colonic ulcer Adam RA.Clin. Microbiol. Rev. 2000, 13(2):318. (ref no 10)

adherence of trophozoites to colonic epithelial cells

destroy colonic epthelial cells (via direct contact or apoptosis)

host inflammatory responses induced by broken epthelial cells inflammation

Stanley Jr et al. Entamoeba histolytica: parasitehost interactions. Am J Physiol Gastrointest Liver Physiol; 2001: 280: G1049G1054, 2001 Ref no 3

amebiasis

The jejunal morphology ranges from normal to subtotal villus atrophy, and a correlation between the degree of villus damage and malabsorption has been reported . In humans, polymorphonuclear leukocytes and eosinophils have been detected Faubert, Clin. Microbiol. Rev. 2000, 13(1):35.

Life cycle of Giardia intestinalis. www.readcube.com

EFFECT OF LOW-LEVEL PATHOGENIC HELMINTH INFECTION ON ENERGY

Hypothetical model of the role of mucosal Langerhans cells (LC) in HIV infection. Oral mucosal Langerhans cells serve as an initial target for HIV infection. The cytopathic changes of Langerhans cells with a productive HIV infection contribute to selective depletion of Langerhans cells, which may impair mucosal immunologic protection against colonization by microorganisms causing HIVassociated oral mucosal lesions. de Repentigny et al. Clin. Microbiol. Rev. 2004, 17(4):729.

Taenia solium and Taenia saginata

Life Cycles of

clem.mscd.edu

Immune cells against helminth infection

The role of parasite secreted proteins in modulating host immunity www.sciencedirect.com

Hypothetical framework for interaction of protective immune responses to Mycobacterium tuberculosis (Mtb) infection in the setting of mixed infection (a) Mtb/H. pylori coinfection may enhance pro-inflammatory signals (e.g., interferon (IFN)-) involved in control of TB infection, (b) Mtb/helminth co-infection may suppress pro-inflammatory responses to Mtb infection via the Th2 pathway.53, 54 The presence of all three infections (c) Triple infection (Mtb/helminth/Hp) would be expected to heighten proinflammatory and anti-inflammatory signals. Also, as shown in (d), H. pylori and helminth co-infection may suppress proinflammatory responses to H. pylori infection. IL, interleukin; TNF, tumor necrosis factor.

Mucosal Immunology 2011; 4: 246-51

Macrophage diversity and polarization: in vivo veritas_ bloodjournal.hematologylibr

Host-parasite relationship www.sbs.utexas.edu

Senet JM. Rev Iberoam Micol 1997; 14: 6-13

Major components of the granulomatous response to schistosome eggs in the host liver and the main cytokines and chemokines that regulate this response. Legend: Egg, Neutrophil, Eosinophil, Macrophage, Hepatic Stellate CellFibroblast, Collagen Fibres, CD4+ T-cell/B-cells, Hepatocytes
Burke et al.immunopathogenesis of human schistosomiasis. Parasite Immunology. 2009; 31: 163176 (ref no 9)

Burden of helminthiases Most helminth infections, if left untreated, result in multi-year, chronic inflammatory disorders that cause both concurrent and delayed-onset pathology to the afflicted human host
Journal of Clinical Investigation.2008; 118 (4):1313 (ref no 6)

Public Health Importance of Giardiasis Giardiasis exerts a signicant public health impact because Of the high prevalence and disease burden of the infection, its Propensity in causing major outbreaks and emergency responses, and its effects on growth and cognitive functions of Infected children
Clin. Microbiol. Rev. 2011, 24(1): 111 (ref no 8)

Cellular aspect of OPC The accumulated evidence suggests a number of hypothetical defects which may underlie the susceptibility to mucosal candidiasis in HIV-infection. The depletion of CD4 cells and a shift in expression From Th1 to Th2 cytokines may reduce the anticandidal activity of macrophages and PMNs and thus trigger the onset of OPC
Clin. Microbiol. Rev. 2004, 17(4): 749 9ref no 2)

Taenia solium taeniasis/cysticercosis is endemic in most developing countries,where it is an important Cause of epileptic seizures and other neurologic symptoms. In industrialized countries, cysticercosis results from travel or immigration of tapeworm carriers from endemic areas. In both endemic and nonendemic countries, housemaids Commonly immigrate from cysticercosisendemic areas and can transmit the infection if they carry the adult tapeworm
Huisa BN et al. Taeniasis and cysticercosis in housemaids working in affluent neighborhoods in lima,Peru. Am.J.Trop.Med.Hyg., 73(3),2005,pp.496

Unlike African schistosomiasis, schistosomiasis japonica is a zoonosis, naturally infecting more than 40 mammalian host species. Large mammals, such as bovines, excrete substantial Amounts of feces and, therefore, have a high contamination index. Daily fecal excretion rates have been estimated to be as high as 25 kg for cattle and $5060 kg for water buffaloes (Bubalis bubalis).In China, a number of drug intervention trials have Demonstrated the importance of bovines in the transmission of S. japonicum to humans. As a result, water buffaloes in China Are well recognized as the major reservoir hosts for schistosomiasis In the lake and marsh land areas, contributing up to 75% of Subsequent transmission to humans
Gordon CA,Acosta LP,Gray DJ,Olveda RM,Jarilla B,etal.(2012)HighPrevalence of Schistosoma japonicum Infection in Carabao from Samar Province,the Philipines: Implications for Transmission and Control.PLoS Negl Trop Dis. 2012; 6(9):e1778 (Ref no 22)

How to make diagnosis of intestinal parasites infection?

Examination of Stool specimen: 1. direct wet film (e.g Iodine, Lugol, KOH 10%) 2. concentration techniques: - sedimentation - flotation Serology Coproantigen note:preservation of stool specimen is best with polyvynil alcohol (PVA)

Predicted Effect on Ascaris and Trichuris Prevalence Following Frequent and Periodic Dewormings with Benzimidazole Anthelmintics
Hotez PJ et al. Helminth Infections: Soil-Transmitted Helminth Infections and Schistosomiasis. In Jamison DT, Breman JG, Measham AR, et al., editors.Disease Control Priorities in Developing Countries. 2nd edition. World bank 2006 (ref no 30)

Pre-departure albendazole therapy

In 1997, CDC and the International Organization for Migration (IOM) detected a 38% prevalence of potentially pathogenic intestinal parasite infections in a group of Somali refugees living in refugee camps in Kenya. In response, CDC recommended presumptive treatment for all non pregnant refugees over the age of 2 years with a single 600-mg dose of albendazole 3 days prior to departure to the United States. In May 1999, CDC extended this recommendation to refugees from throughout sub-Saharan Africa. Subsequently, some populations migrating from Southeast Asia also began receiving this presumptive therapy. Pre-departure albendazole treatment has dramatically decreased the prevalence of parasitic infections detected in stool samples in newly arrived refugees. A reduction from 24% to 4% in the prevalence of intestinal helminth infections has been documented in African refugees arriving in Massachusetts before and after May 1999, respectively

31 US dept of Health GUIDELINES intestinal-parasites-domestic medical examination. 2012

WHO. Monitoring Anthelmintic Efficacy for Soil Transmitted Helminths (STH). 2008

Therapeutic Regimens for the Treatment of Amebiasis

Vinod K Dhawan. Current Diagnosis and Treatment of Amebiasis TOUCHBRIEFINGS2008

Sekian dan terimakasih.

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Buku Ajar Parasitologi FKUI Edisi 4. Jakarta: Balai Penerbit FKUI de Repentigny et al. Candidiasis in Human Immunodeficiency Immunopathogenesis of Oropharyngeal virus infection.Clin. Microbiol. Rev. 2004, 17(4):729 Stanley Jr et al. Entamoeba histolytica: parasite-host interactions Am J Physiol Gastrointest Liver Physiol 2001; 280:G1049-G1054 Tanyuksel et al. Laboratory Diagnosis of Amebiasis Clin. Microbiol. Rev. 2003, 16(4):713 Arturo Casadevall and Liise-anne Pirofski. Host-Pathogen Interactions: Basic Concepts of Microbial Commensalism, Colonization, Infection, and Disease Infect. Immun. 2000, 68(12):65116. Hotez et al. Helminth infections: the great neglected tropical diseases J. Clin. Invest. 118:13111321 (2008) Adam RA. Biology of Giardia lamblia. Clin. Microbiol. Rev. 2001, 14(3):447 Yaoyu Feng, Lihua Xiao. Zoonotic Potential and Molecular Epidemiology of Giardia Species and Giardiasis. Clin. Microbiol. Rev. 2011, 24(1):110 Burke et al. Immunopathogenesis of human schistosomiasis. Parasite Immunology. 2009 (31): 16376 Hall et al. A review and meta-analysis of the impact of intestinal worms on child growth and nutrition. Maternal and Child Nutrition (2008), 4, pp. 118236 Markell and Voges Medical Parasitology Dr Simon Brooker . Human helminth infections in Indonesia, East Timor and the Philippines . Report to UNICEF East Asia and Pacific Region Office 19 Phra Atit Road, Bangkok 10200, Thailand . UNICEF, 2002Huisa BN et al. Taeniasis and cysticercosis in housemaids working in affluent neighborhoods in lima,Peru. Am.J.Trop.Med.Hyg., 73(3),2005,pp.496500 Salim L. et al. Seroepidemiologic Survey of Cysticercosis-Taeniasis in Four Central Highland Districts of Papua, Indonesia.A m. J. Trop. Med. Hyg., 80(3), 2009, pp. 384388 Huisa BN et al. Taeniasis and cysticercosis in housemaids working in affluent neighborhoods in lima,Peru. Am.J.Trop.Med.Hyg., 73(3),2005,pp.496-500 Guezala MC et al. Development of a Species-Specific Coproantigen ELISA for Human Taenia solium Taeniasis. Am. J. Trop. Med. Hyg., 81(3), 2009, pp. 433437