Nemathelminthes

Nematodes or Roundworms
Unsegmented, bilaterally symmetrical worms with

cylindrical bodies that are elongated Complete digestive tract, including mouth and anus Body is covered with cuticle They have separate sexes, with female worms larger than the male worms

Intestinal Nematodes

Ascaris lumbricoides (giant roundworm)

Important properties

- Largest intestinal roundworm infecting humans - infective stage is fertilized ova - mode of transmission is ingestion of contaminated food or water with fertilized ova - ova hatched to larvae in small intestine

Ascaris lumbricoides (giant roundworm)

Important properties

- larvae migrate through the wall of the intestines into the bloodstream and then to the lungs - larvae enter the alveoli, pass up the bronchi & trachea and swallowed - larvae mature into adult worms - adult female worms lay thousands of eggs each day

Ascaris lumbricoides (giant roundworm)

Important properties

- ova passed into feces and develop into embryos in warm, moist soil

Ascaris lumbricoides (giant roundworm)

Adult worms 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 . Fertile eggs embryonate and become infective after 18 days to several weeks , depending on the environmental conditions (optimum: moist, warm, shaded soil). After infective eggs are swallowed , the larvae hatch , invade the intestinal mucosa, and are carried via the portal, then systemic circulation to the lungs . The larvae mature further in the lungs (10-14 days), penetrate the alveolar walls, ascend the bronchial tree to the throat, and are swallowed . Upon reaching the small intestine, they develop into adult worms . 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.

Ascaris lumbricoides (giant roundworm)

Pathogenesis & epidemiology

- adult worms produce little damage in the intestine - adult worms may contribute to malnutrition - major damage may occur during larval migration

Ascaris lumbricoides (giant roundworm)

Pathogenesis & epidemiology

- very common in tropics where sanitation is poor - young children are mostly affected - endemic in Southeast Asia, Africa, Central & South America

Ascaris lumbricoides (giant roundworm)

Pathogenesis & epidemiology

- Factors affecting high level of transmission: 1. high density of human population 2. use of night soil for fertilizer 3. poor sanitation 4. poor health education on hygiene

Ascaris lumbricoides (giant roundworm)

Disease: Ascariasis

- most infections are asymptomatic - lung migration may induce allergic reactions, manifesting as asthmatic attacks accompanied by eosinophilia (Loefflers syndrome) - pneumonia may occur due to alveolar penetration of the larvae

Ascaris lumbricoides (giant roundworm)

Disease: Ascariasis

- vague abdominal pain is the most frequent complaint - heavy worms may give rise to abdominal tenderness, fever, distention & vomiting - Infections with a large number of worms may cause abdominal pain or intestinal obstruction

Ascaris lumbricoides (giant roundworm)

Disease: Ascariasis

- complications associated with the disease are quite significant - a single adult worm may cause obstruction to the appendix leading to appendicitis - can cause perforation of the intestine due to parasites tough, flexible body leading to peritonitis with secondary bacterial infection

Ascaris lumbricoides (giant roundworm)

Disease: Ascariasis

- a tangled bolus of mature worms in the intestines may result to bowel obstruction - migration of the worm into the bile duct, gallbladder & liver may cause substantial tissue damage

Ascaris Lumbricoides - round worm - human intestinal parasites

Ascaris lumbricoides (giant roundworm)

Laboratory diagnosis

- demonstration of ova in the stool - occasionally adult worms pass with the feces - pulmonary ascariasis may be diagnosed from the finding of larvae and eosinophils in the sputum

Ascaris lumbricoides (giant roundworm)

Treatment

- drugs proven to be effective in treating ascariasis: mebendazole, albendazole, pyrantel pamoate

Ascaris lumbricoides (giant roundworm)

Prevention

- control measures include: 1. proper disposal of human feces 2. health education of the population 3. improved personal hygiene among people who handle food 4. avoidance of human feces as fertilizer *mass chemotherapy is also recommended in endemic areas

Enterobius vermicularis (pinworm)

Enterobius vermicularis (pinworm)

Important properties

- life cycle confined in humans - infection can be acquired through ingestion of fertilized eggs of the worm - in small intestines, the ova hatch into larvae which mature to adult worms that migrate to the colon

Enterobius vermicularis (pinworm)

Important properties

- mating of adults occur in the colon - at night, female worms migrate to the anus and release thousands of fertilized eggs - within six hours, eggs develop into larvae & become infectious

Eggs are deposited at night by the gravid females. Eggs are ingested via person-to-person transmission through the handling of contaminated surfaces (such as clothing, linen, curtains, and carpeting), or airbourne eggs may be inhaled and swallowed. Self-infection may also occur if eggs are transferred from to the mouth by fingers that have scratched the perianal area. After ingestion, larvae hatch from the eggs in the small intestine. The adults then migrate to the colon. The life span of the adults is about two months. Adults mate in the colon, and the males die after mating. Gravid females migrate nocturnally to the anus and ovideposit eggs in the perianal area. The females die after laying their eggs. The time period from ingestion of infective eggs to the ovideposition of eggs by females is approximately one month. The larvae develop and the eggs become infection within 4-6 hours. Newly hatched larvae may also migrate back into the anus, and this is known as retroinfection.

Enterobius vermicularis (pinworm)

Pathogenesis & epidemiology

- transmitted through hand to mouth by children scratching the perianal folds - worms may also find their way to clothing and play objects in daycare centers - they can survive for long periods in the dust that accumulates over doors, windowsills and under beds

Enterobius vermicularis (pinworm)

Pathogenesis & epidemiology

- transmission can be through inhalation of fertilized ova - autoinfection or retroinfection can also occur - can be transmitted through contaminated foods or drinks - exist worldwide but common in temperate regions

Enterobius vermicularis (pinworm)

Pathogenesis & epidemiology

- person-to-person spread is greatest in crowded conditions - infection is considered as group infection

Enterobius vermicularis (pinworm)

Disease: enterobiasis (oxyuriasis)

- hosts are asymptomatic & serve only as carriers - perianal pruritus (nocturnal pruritus ani) is the most prominent clinical manifestation - nocturnal pruritus ani may result to insomnia & fatigue & may lead to secondary bacterial infection due irritated area

Enterobius vermicularis (pinworm)

Laboratory diagnosis

- scotch tape method or cellophane test done in the perianal skin - eggs are not found in the stools

E. vermicularis (male adult)

E. vermicularis adult(female) showing esophageal bulb

Anterior part of E. vermicularis (female) showing cephalic alae

Anterior and posterior parts of female Enterobius vermicularis

Enterobius vermicularis (pinworm)

Treatment

- DOC: mebendazole or pyrantel pamoate - eggs are not killed by the drug so that retreatment in two weeks is recommended - entire family must be treated to avoid reintroduction of the worm or re-infection

Enterobius vermicularis (pinworm)

Prevention

- good personal hygiene - regular clipping of fingernails - thorough washing of beddings - prompt treatment - thorough housecleaning

Trichuris trichiura (whipworm)

Trichuris trichiura (whipworm)

Important properties

- infection is obtained by ingestion of embryonated eggs (fertilized ova) in contaminated food or water - eggs hatched in small intestine, differentiate into larvae & immature adults - immature adults migrate to the colon where maturation occur & mating

Trichuris trichiura (whipworm)

Important properties

- thousands of eggs are produced each day - ova are passed in the feces - eggs form embryos in warm, moist soil

Trichuris trichiura (whipworm)

Pathogenesis & epidemiology

- worldwide distribution, most specially in the tropics - prevalence is directly correlated with poor sanitation and the use of human feces as fertilizer - adult worms burrow their hair-like anterior ends into the intestinal mucosa, but do not cause significant anemia

Trichuris trichiura (whipworm)

Disease: trichuriasis

- clinical manifestations are related to the intensity of the worm burden - majority are asymptomatic - heavy infection may cause abdominal pain & distention, bloody diarrhea, weakness & wt. loss

Trichuris trichiura (whipworm)

Disease: trichuriasis

- appendicitis resulting from worms filling up the lumen of the appendix - in children, heavy infection may lead to rectal prolapse due to irritation & straining during defecation - anemia & eosinophilia is seen in heavy infection

Trichuris trichiura (whipworm)

Laboratory diagnosis

- finding the typical barrel-shaped eggs with bipolar plug in the stool

Trichuris trichiura (whipworm)

Treatment

- DOC mebendazole Prevention - health education - proper sanitation - good personal hygiene - avoidance of night soil as fertilizer

Ancylostoma duodenale (Old World Hookworm Necator americanus (New World Hookworm)

Important Properties
Infection is due to penetration of the skin by the

filariform larvae found in moist soil Feet or legs are usual site for penetration Larvae are carried by the blood to the lungs, migrate to alveoli, pass up the bronchi and trachea then swallowed Larvae develop into adults in the small intestines

Important Properties
Adult worms attach to the wall either by cutting

plates (Necator) or teeth (Ancylostoma) Adult feed on blood from the capillaries of the intestinal villi Female worm lays thousands of eggs each day which are passed in the feces

Ancylostoma duodenale adult

Hookworm ova

Necator americanus adult

Filariform larvae

Pathogenesis & epidemiology

Major damage is due to blood loss at the site of

attachment in small intestines Irritation of the skin Inflammatory reaction in the lungs during larval migration Found worldwide, especially in tropics Walking barefoot on soil predisposes to infection

Disease: Hookworm infection

Penetration of skin by infective filariform larvae

produces a pruritic papule or vesicle ground itch Pneumonia with eosinophilia on lung larval migration Adult worms in small intestines can be manifested by nausea, vomiting & diarrhea Microcytic, hypochromic anemia (chronic infection) Secondary bacterial infection

Laboratory diagnosis
Stool exam shows characteristic thin-shelled ova

Occult blood in the stools is a frequent finding

Eosinophilia is typical Occult blood smear shows microcytic,

hypochromic anemia

Normal RBC
The RBC's here are smaller than normal and have an increased zone of central pallor. This is indicative of a hypochromic (less hemoglobin in each RBC) microcytic (smaller size of each RBC) anemia. There is also increased anisocytosis (variation in size) and poikilocytosis (variation in shape).

Treatment
DOC mebendazole

Alternative drug pyrantel pamoate

Iron therapy to manage anemia Severe cases, blood transfusion may be

necessary

Prevention
Education

Improved sanitation
Proper disposal of human feces Wearing shoes or any protective footwear

Strongyloides stercoralis (threadworm)

Strongyloides stercoralis (threadworm)

Important properties

- has two distinct life cycles (free-living in soil, within the host) - life cycle within the host begin with skin penetration by the filariform larvae (like the hookworm) - adult worms form in small intestines

Strongyloides stercoralis (threadworm)

Important properties

- adult worms enter the mucosa and produce eggs - eggs differentiate to rhabditiform larvae, which are passed in the feces - some of the larvae differentiate to filariform larvae which can penetrate the wall of the intestines directly without leaving the host (autoinfection)

Strongyloides stercoralis (threadworm)

Important properties

- larvae passed in the feces & that enter warm, moist soil mature into female & male worms - adult worms mate & entire life cycle of egg, larva & adult can occur in the soil (free-living) - several cycles occur before filariform larvae are formed

Rhabditiform (L1) larva of Strongyloides stercoralis is about 0.3 mm long. (1 m = 0.001 mm)

Filariform larva of Strongyloides stercoralis is about 0.6 mm long.

Strongyloides stercoralis (threadworm)

Pathogenesis & epidemiology

- adult female worms cause inflammation in the wall of small intestines resulting to diarrhea - autoinfection, penetrating larvae may cause significant damage to intestinal mucosa which can lead to secondary bacterial infection and sepsis

Strongyloides stercoralis (threadworm)

Pathogenesis & epidemiology

- larvae in lungs can produce an inflammatory reaction similar to Ascaris - irritation at the site of penetration - found primarily in the tropics - same geographic distribution as that of the hookworms

Strongyloides stercoralis (threadworm)

Disease: strongyloidiasis (Cochin-China diarrhea)

- larval migration to lungs lead to pneumonitis - presence of adult worms in intestines are asymptomatic - heavy worm burden can involve biliary & pancreatic ducts the entire small intestines and the colon

Strongyloides stercoralis (threadworm)

Disease: strongyloidiasis (Cochin-China diarrhea)

- manifestations: epigastric pain, abdominal tenderness, vomiting, watery diarrhea, malabsorption - symptoms mimicking peptic ulcer and accompanied by eosinophilia strongly suggest parasitic infection

Strongyloides stercoralis (threadworm)

Disease: strongyloidiasis (Cochin-China diarrhea)

- autoinfection can lead to chronic infection, increasing the risk of developing a severe, lifethreatening hyperinfection syndrome, especially with immunocompromised patients

Strongyloides stercoralis (threadworm)

Disease: strongyloidiasis (Cochin-China diarrhea)

- intestinal symptoms of hyperinfection syndrome: diarrhea, malabsorption, electrolyte abnormalities - fatal complications of the syndrome include: bacterial sepsis, meningitis, peritonitis and endocarditis

Strongyloides stercoralis (threadworm)

Laboratory diagnosis

- finding larvae in stool - ova are not seen in stools - collection of stools must be 3 consecutive days is recommended - larvae may occur in showers, with many present in one day or few or none in the next

Strongyloides stercoralis (threadworm)

Laboratory diagnosis

- when absent in stool, larvae may be demonstrated in duodenal aspirates or in sputum in the case of massive infection -striking eosinophilia

Strongyloides stercoralis (threadworm)

Treatment

- DOC ivermectin with thiabendazole with mebendazole as alternative drugs Prevention - education - proper sanitation & sewage disposal - wearing of shoes - prompt treatment of existing infections

Capillaria philippinensis

Capillaria philippinensis
Important properties

- first described in Philippines in 1963, when the first human case died from the infection - epidemic occurred in 1967-1968 which led to the death of almost 100 individuals - infection can be obtained through ingestion of undercooked or raw freshwater fish called bagsit that contains infective larvae

Capillaria philippinensis
Important properties

- larvae in small intestines mature into adults - eggs are laid then passed out in feces - eggs embryonate in soil or water - once in water, embryonated ova are ingested by fish then develop into infective larvae

Capillaria philippinensis
Pathogenesis & epidemiology

- large number of worms is responsible for pathology in humans - produce micro-ulcers in the intestinal tissues - ulcerative & degenerative lesions account for malabsorption of fluid, protein and electrolytes

Capillaria philippinensis
Pathogenesis & epidemiology

- intestinal capillariasis was first noted in Northern Luzon - parasites can be found also in Zambales & Southern Leyte - infection is due to ingestion of freshwater/brackish water fish bagsit, which eaten raw, especially by the Ilocano population - migratory fish-eating birds are the natural hosts

Capillaria philippinensis
Disease: intestinal capillariasis

- characterized by abdominal pain, chronic diarrhea and a gurgling stomach (borborygmus) - patient develop wt loss which aggravated by the accompanying anorexia, nausea & vomiting - malabsorption of fat & sugars, severe protein-losing enteropathy & low electrolyte levels (potassium)

Capillaria philippinensis
Laboratory diagnosis

- finding ova in feces - various larval stages as well as adult worms may also be seen in feces

Capillaria philippinensis
Treatment

- electrolyte replacement & high protein diet - DOC albendazole - alternative drug mebendazole - relapses may occur if treatment regimen is not followed

Capillaria philippinensis
Prevention

- discourage eating raw fish - good sanitary practices - health education - prompt treatment of infection

Blood and Tissue Nematodes

Wuchereria bancrofti (Bancroft's filarial worm)

Brugia malayi (Malayan filarial worm)

W. bancrofti & B. malayi

Important properties

- both are mosquito-borne parasite found in the lymphatics of humans - B. malayi are also found in animals, as reservoir hosts - humans are infected through mosquito bites (Anopheles and Culex species)

W. bancrofti & B. malayi

Important properties

- vector deposits larvae on the skin while biting - larvae penetrate the skin, enter the lymph node, after one year, mature into adults & produce microfilariae - microfilariae circulate in the blood, especially at night (noctural periodicity), are ingested by biting mosquito - humans are the only definitive hosts

W. bancrofti & B. malayi

W. bancrofti

B. malayi

W. bancrofti & B. malayi

Pathogenesis & epidemiology

- manifestations are due to the obstruction of lymphatic vessels by the adult worms, causing edema - most widest filarial parasite is W. bancrofti and common in tropical areas - in Phils. Bancroftian filariasis is found in Camarines, Albay, Sorsogon, Quezon, Mindoro, Masbate, Romblon, Marinduque, Bohol, Samar, Leyte, Palawan, Mt. Province and all provinces of Mindanao - Vector is Anopheles mosquito

W. bancrofti & B. malayi

- in the Phils, the major mosquito vector is Anopheles minimus flavirostris; in urban areas, parasites are transmitted by Culex mosquito species.
Disease: Filariasis (Elephantiasis)

- 3 stages: Asymptomatic, Acute, Chronic - Asymptomatic: presence of thousands of microfilariae in the peripheral blood; adult worms are found in lymphatic system without clinical manifestations

W. bancrofti & B. malayi

- Acute (adenolymphangitis): marked by fever with lymphadenitis (particularly of the male genital organs usually due to Wuchereria) and of the extremities (due to Brugia) : in females, breasts involvement may be present : recurrent attacks are characterized by epididymitis, orchitis, retrograde lymphangitis of the lower extremities, localized inflammation of the arms and legs

W. bancrofti & B. malayi

- Chronic: develops slowly after several years of infection. : chronic edema, repeated acute inflammatory episodes; obstruction will lead to edema and fibrosis of the legs and genitalia, especially in the scrotum. : hardening of the enlarged parts over the years with loss of skin elasticity and fibrosis, producing ELEPHANTIASIS. Hydrocele results from obstruction of the lymphatics of the tunica vaginalis (common in bancroftian

W. bancrofti & B. malayi

W. bancrofti & B. malayi

W. Bancrofti & B. malayi

Laboratory diagnosis

- thick blood smears taken between 8pm to 4am - best collection of specimen is at night - antigen detection techniques - Ultrasound to detect live worms in lymphatics
Treatment

- DOC diethylcarbamazine (6mg/kg/day for 12 days in divided doses, preferably after meals) bancroftian filariasis

W. Bancrofti & B. malayi

Treatment

- DOC diethylcarbamazine (6mg/kg/day for 12 days in divided doses, preferably after meals) bancroftian filariasis - 3-6mg/kg/day brugian filariasis - Ivermectin in a single oral dose of 200-400ug/kg as alternative drug

W. Bancrofti & B. malayi

Prevention

- as per recommendation of WHO Division of Control of Tropical Diseases involve the development of safe, effective, well-tolerated, single-dose annual microfilaricidal drug treatments, especially in endemic areas - DEC-medicated table and cooking salts - vector control

Trichinella spiralis

T. spiralis
Important properties

- pigs are the most important reservoirs - transmitted by ingestion of raw or undercooked meat containing larvae encysted in muscle - larvae excyst in the small intestine then matures to adult worms - eggs hatch within the adult females, and larvae are released and enter the bloodstream, to be carried to different organs - larvae develop only in striated muscle cells, where they encyst and remain viable for several years - HUMANS are end-stage host

T. spiralis

T. spiralis
larva

Male T. spiralis in muscles

T. spiralis
Pathogenesis and epidemiology

- severity of symptoms depend on the intensity of infection - those harboring 100 or more larvae show symptoms - trichinosis is zoonosis - humans are infected after eating raw or undercooked meat of infected animals - infection is usually maintained in pig-pig or pigrat-pig cycle

T. spiralis
Disease: trichinosis

- 3 phases: Enteric phase incubation and intestinal invasion diarrhea or constipation, vomiting, abdl cramps, malaise, nausea Invasion phase larval migration and muscle invasion fever, periorbital edema, urticaria, pain, swelling, and weakness larval migration leads to cardiac and nervous system disease cause of death congestive heart failure or

T. spiralis
Convalescent phase encystment and encapsulation of larvae signs and symptoms start to decline disease is self-limiting so full recovery is expected

T. spiralis
Laboratory diagnosis

- muscle biopsy revealing larvae within striated muscles

cyst

Encysted larva

T. spiralis
Treatment

- no treatment - managed through bed rest and supportive measures - analgesics/antipyretics - corticosteroids in severe cases - thiabendazole for first week to kill adult worms, however, drug has no effect in migrating larva

T. spiralis
Prevention

- Health education - Thorough adequate cooking of meat - Freezing meat may kill encysted larvae - Strict meat inspection