Dr.

Agnes Kurniawan, PhD, SpParK

1. To acquire knowledge on protozoa and worms which often leads to gastrointestinal disorders 2. To understand the life cycle, epidemiology, clinical symptoms, diagnosis, treatment and prevention of the protozoa and worms causing GI disorders

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Trichuris Taenia E.

trichiura
WORM

saginata

histolytica
cayetanensis

Cyclospora

PROTOZOA

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Whipworm, a roundworm/nematode, STH Commonly infect children Epidemiology : warm, humid climates, crowded Mode of infection : ingested of mature eggs Risk factor : poor hygiene, sanitation, raw vegetables Mature egg ingested hatch in the small intestine larvae adult worm in caecum/ascending colon egg adult female = 60-70 days egg infective stage:36 wks, soil eggs produced: 3000-10.000/day
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 Adult:
-

female 5 cm, male 4 cm anterior portion whip like live in colon ascendens and caecum no lung cycle: egg ingested hatch in the small intestine larvae adult worm in caecum/ascending colon

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10 worms asymptomatic Heavy infection diarrhea, dysentery, anemia, rectal prolapse, growth retarded
<
Note : dysentry : frequent, painful passage of stool that contains a mixture of mucus, water, and blood.

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 The

anterior part of the worm dip into the intestinal mucosa irritation trauma and inflammation of the intestinal mucosa and bleeding -- sucked by the worms anemia

Parasitology Lab Diagnosis

Microscopy : Wet smear : T. trichiura eggs in the stool

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Treatment
Mebendazol 2x100 mg for 3 days (>2 yo) 2x200 mg for 3 days (adult) - Albendazol 400 mg, single dose
-

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1. BREAK THE WORM LIFE CYCLE - environmental sanitation : use of toilet for defecation, not using stool for fertilizer - good personal hygine : handwashing with soap & water, wash well the fruits and vegetables - mass treatment when prevalence > 30% 2. HEALTH EDUCATION
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3m

Taenia sp

E400

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Definitive host: man Adult worm: in the middle third small intestine Intermediate host : cattle larva (cyst) in muscles Mode of infection: 1. in cattle: grazing on moist pasture contaminated with eggs of T. saginata from human stool 2. in man: consuming uncooked/rare cooked beef with larvae (cysticercus bovis)

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LIFE CYCLE

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LIFE CYCLE & PREVENTION

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Proglotid: crawling out of anus GI complaints: nausea, diarrhea, abdominal pain Systemic symptoms: fatigue, hunger, dizziness, moderate loss of weight Rare symptoms: vomiting of segments, obstruction of bile ducts, pancreatic ducts or appendix

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eggs

in stool proglotid crawling out of anus Treatment praziquantel 10mg/kg, single dose albendazole

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EVALUATION OF TREATMENT
-

Relieve of symptoms Parasitology lab examination : 1. 24 hours collected stool after th/: scolex + proglottids 2. stool, 3 months after th/: negative for eggs and or segments

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 E.

histolytica: histo=tissue ; Lysis = dissolve, destroyed Aetiology of intestinal and extra intestinal amebiasis Host : human Habitat : colon Distribution : cosmopolitan, in tropical and subtropical countries

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stages: trophozoite and cyst

TROPHOZOITE : - 2 forms : histolytica (pathogen) and minuta (apathogen). Size : 10-60 um, entameba nucleus Endoplasm: fine granules, contains bacteria or food metabolites If contains red blood cells erythrophagocytosis typical for E. histolytica infection Live 2 hours outside the host
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 Size:

10-20 um round/oval shape Structure: cyst wall, endoplasm with 1,2 or 4 nuclei Endoplasm : chromatoid body (cigar form) & glycogen vacuol (food storage) apathogenic Infective stage : mature cyst (cyst with 4 nuclei)
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 Ingestion

of mature cyst Excystation in the stomach with the help of gastric juice trophozoite release colon multiplication by binary fission invade the mucose ( cause symptoms ) or transform into cyst stage (encystation )

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 Trophozoites

express gal/gal nac lectins antigen on its surface stick to colonic epithelial cells present amoebapores and excrete cysteine proteinases (amebapain dan hystolisine) lyse extracellular protein matrix epithelial cell lysis tissue necrosis, further invasion to submucose flask shape ulcer

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 Form

: bottle shape, small opener at the top, wide at the bottom, irregular rim, slightly elevated Inflammation, with blood and secondary infection with bacteria Progression to submucose area along the lateral axis of colon Excretion of trophozoite into the lumen invade other healthy area of colon or excreted with stool dysentric stool (mucous and blood )
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1. Carrier state: - intestinal amebiasis - parasite multiplies in the body - stools : cysts ++ - clinical signs /symptoms : none - cause : low virulent strain, low number of infection, adequate immune status

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2. Intestinal amebiasis - dysentery, colitis, appendicitis, toxic megacolon, amebomas - Abdominal pain - Diarhoea with mucous and bloody stool , frequency up to 10 x/day - Fever, loss of appetite, decrease body weight

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3. Extraintestinal Amebiasis - most common: liver abscess - Symptoms : fever, abdominal pain upper right quadran - GIT symptoms : nausea, vomitus, abdominal cramp, diarrhea, constipation - other manifestations : peritonitis, pleuropulmonary abscess, cutaneous and genital amebic lesions
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 The

most common extraintestinal complication of amebiasis (8.5% of cases). Hepatic infection occurs because colonic trophozoites ascend via the portal vein invade the parenchyma Cause : toxin release & hepatocyte damage Usually develop within days - months after dysentri

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 Symptoms

: fever (>90% acute cases), dull pleuritic right upper quadrant pain radiating to the right shoulder, hepatomegali and pleural effusions. Acute form: often very high fever, continuous or intermittent + chills Chronic forms : fever is low, develops gradually, without chills or sweating Right / left lobe

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 Occasionally

spread into the overlying abdominal wall or form portal venous amebic thrombi. Hematogenous dissemination to the brain is rare Diarrhea (2%), with 4 - 5 x/ day,watery stool, with mucus and blood, tenesmus, abdominal cramping and distension due to potassium loss Jaundice is an unusual feature(5%)

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abscess extends upward the diaphragm, pleura empyema . Invasion of the lung parenchyma by E. histolytica development of interstitial pneumonitis, liquefaction & formation lung abscess
the

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1. Microscopic Faeces : trophozoite (invasive stage) and / cysts (non invasive stage) The 2 stages represent two separate species : E. histolytica & E. dispar which are morphologically indistinguishable unless E. histolytica is observed with ingested red blood cells Cysts: found in formed stool Trophozoites: found in diarrheal stool
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Body fluid: trophozoite Stool examination is best performed 3X in a week to exclude false negative

2. Serology test ( Antibody detection) IHA, ELISA To diagnose extraintestinal amebiasis Performed together with the microscopic examination of the abscess fluid and radio diagnostic
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3. Antigen Detection ELISA Specimens: stool, serum, abscess fluid, saliva Specific for E. histolytica ( cannot for E. dispar)
4. Polymerase chain reaction (PCR) to differentiate E. Histolytica from E. dispar

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TREATMENT
Drugs: - metronidazole (trophozoite & cyst form) - chloroquine (trophozoite form) - paromomycin (trophozoite form) Intestinal Amebiasis: paromomycin 25-35 mg/kgbb/hari, 3x/day, 7 days Extraintestinal Amebiasis : metronidazol 3x750 mg/hari 7-10 days + abscess drain

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 Improving

sanitation and hygine individuals Health education on mode of transmission Water treatment : chlorination and filtration

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 Coccidia Host:

man Epidemiology : developing countries

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 Oocyst:

8-10 um Immature (unsporulated) oocyst excreted in stools sporulation 1 several weeks in warm and humid climate Mature Oocyst : 2 sporocysts @ four sporozoites Infection : ingestion of mature oocysts Source of infection : contaminated food / vegetables, water such as raspberry Parasite lives intracytoplasmic develop in the jejunal enterocytes
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 Diare
anorexia,

flatulance, epigastric pain, nausea, vomitus, low grade fever Immune competent : acute, light diarrhea AIDS : chronic diarrhea, severe

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1. Microscopic : - oocyst in the stool, duodenal aspirates, duodenal/jejunal biopsy - 3 stools every 2-3 days - safranin / acid fast stainings 2. UV fluorecense microscope 3. PCR

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 Treatment

: trimetoprim + sulfametoksazol, metronidazol, siprofloksasin Prevention : Improving sanitation and hygine individuals, health education, water treatment, proper washing of raw vegetables and fruits

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THANK YOU

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